am a Korean-born woman and a Registered Nurse whocame to the United States as an adult, and gave birthduring the 1990s in the United States. My birth experi-

ences brought up many unexpected cultural conflicts be-tween the postpartum beliefs of my home culture and thoseof the United States. This led me to consider what otherforeign-born women feel after giving birth in the UnitedStates, and how much American nurses know about cultur-al beliefs other than those of American-born women. I de-cided to learn more about this, and work toward educatingAmerican nurses along the way. This article is the result ofwhat I have learned.

Every year the population of the United States becomesincreasingly ethnically diverse. According to Census 2000,75.1% of the U.S. population is White, 12.3% is AfricanAmerican, 3.6% is Asian, 0.9% is American Indian/AlaskaNative, 0.1% is Native Hawaiian/other Pacific Islander,5.5% is “other” races, and 2.4% consists of people describ-ing themselves as two or more races. About 13% have His-panic origin; this population is expected to grow rapidlyover the coming years (U.S. Bureau of Census, 2001). Of theRegistered Nurses in the United States, 87.7% are White,

erences or expectations might be neglected due to health-care providers’ lack of cultural competence (Lauderdale,1999). Although considerable diversity exists among non-Western cultures, there are also many common postpar-tum practices that nurses can learn to recognize in provid-ing maternity healthcare. The two common non-Westernpostpartum beliefs described in this article are (1) hot-cold beliefs and (2) postpartum confinement beliefs.These beliefs will be examined for cultures fromGuatemala, China, Jordan, Lebanon, Egypt, Palestine, In-dia, and Mexico.

Hot and Cold BeliefsOne common belief in many non-Western cultures is thenecessity of maintaining a “hot-cold balance” within thebody and with the environment after the birth of a baby.Hot-cold concepts of healthcare (also called humoral theo-ries) are centuries old in the traditional cultures of LatinAmerica, Asia, and Africa (Manderson, 1987; Spector,2000). In many non-Western cultures, blood is considered“hot.” Therefore, after giving birth, when the woman haslost blood she is considered to be in a cold state. Accord-

March/April 2003 MCN 7574 VOLUME 28 | NUMBER 2 March/April 2003

Postpartum Beliefs & PracticesAmong Non-Western Cultures

Yeoun Soo Kim-Godwin, PhD, MPH, RN

4.9% are African American, 3.5% are Asian, 2.0% are His-panic, and 0.5% are Native American (U.S. Department ofHealth and Human Services, 2001).

Beliefs and practices surrounding the postpartum peri-od are culturally patterned (Brettell & Sargent, 1997),and marked differences exist between Western and non-Western cultures. A lack of cultural knowledge on thepart of registered nurses can make appropriate care diffi-cult to deliver (Lauderdale, 1999). Although womenfrom non-Western cultures may wish to preserve theirown traditional postpartum practices, their cultural pref-

ingly, postpartum care in these cultures is aimed at keepingthe new mother warm; it is believed that this will restoreher humoral balance.

In rural Guatemala, traditional midwives emphasize theapplication of heat in the postpartum period (Lang &Elkin, 1997). New mothers are instructed to use heatedwater to preserve their warmth; they might take a sweat-bath, a sitz bath, or an herbal bath, according to region.Guatemalans believe that a hot bath increases the flow ofmilk, “lowers” the milk into the breasts, and preventsbreast milk from becoming “cold.” Although Western-edu-

ABSTRACT

Postpartum health beliefs and practices among non-Western cultures are

each distinct, but have many similarities. Two common belief systems sur-

round 1) the importance of hot and cold, and 2) the necessity of confine-

ment during a specific period of time after giving birth. This article de-

scribes common postpartum health beliefs among women in Guatemala,

China, Jordan, Lebanon, Egypt, Palestine, India, and Mexico, and offers an

exemplar from the author’s experiences as a Korean woman giving birth in

the United States. Cultural competence in the provision of postpartum

care is essential for nurses in the healthcare world of the 21st century.

Key Words: Cultures; Non-Western; Postpartum; Practices.

I

A Korean Woman’s Postpartum Experience in the United StatesI came to the United States in 1992, was married to anAmerican in 1995, and gave birth in the United Statestwice in the late 1990s. My first experience giving birthwas difficult and included a third degree laceration and sig-nificant pain after giving birth. Nevertheless, approximately30 minutes after giving birth, my nurse suggested that Itake a shower, explaining that a shower would refresh andstrengthen me. I felt a certain degree of conflict, for Koreanculture prohibits bathing immediately after giving birth.However, I followed her instruction, largely because myculture also teaches respect for authority.

After the shower, the nurse brought an ice container fullof bottles of juice, explaining that because I had lost a lotof blood and fluids, I needed to drink as much liquid as Icould. Again, I felt a conflict, for Korean practice (whichfollows the humoral theory) dictates that a new mother isnot supposed to drink cold liquids.

Circumstances required that my husband and I had tostay at a home other than our own for a few days after mydischarge from the hospital; the homeowner kept the tem-perature of the home very low. Again, according to Koreanpractice, a new mother is supposed to cover up with blan-kets and keep warm to protect her loose bones; accordingto this belief, if I failed to do so, I would suffer from bonepain or rheumatism in my old age. Although as a nurse Ihad been educated in Western postpartum practices, Ifound I still believed in the traditional Korean postpartumpractices, whether or not they had grounding in Westernmedical theory.

Another frustration was food. After I gave birth, my hus-band brought me the same meals that Americans usually eatat home, such as bagels or muffins for breakfast, and sand-wiches for lunch. I wondered why my husband and his fami-ly did not prepare special foods for me, since I was a newmother. I sorely missed miyuk-kuk, the hot and smelly sea-weed soup, which is routinely served to every new mother inKorea. Other American attitudes and behaviors also con-fused and disappointed me. Approximately 7 days after Igave birth to our baby daughter, my husband’s family gath-ered to celebrate her arrival. I felt that all their concern wasfor the baby, rather than for me, the new mother. In Korea,very elaborate consideration and attention is granted to thenew mother after birth. As a Korean, I also looked forwardto enjoying the role of a patient until my full recovery, usual-ly lasting 1 month. I remembered my sister’s postpartum pe-riod in Korea. After having her baby, she came to our hometo receive postpartum care from our mother. For about amonth, my sister’s only duties were to eat and sleep to re-store her health. In contrast, my American husband and hisfamily treated me as a healthy person who could resumenormal activities almost immediately. For example, my hus-band expected me to drive to the pediatrician’s clinic for thebaby’s first physical checkup 7 days after giving birth.

After my second birth experience 3 years later I felt lessconflict, for I had learned how to negotiate differences be-tween my culture and my husband’s. Because I had become

more acculturated, I felt less conflict with American prac-tices, but nevertheless, I still felt that a new mother receivesinadequate consideration in the United States. Within anhour of giving birth, a nurse brought me my baby andasked me to sleep with her, explaining that this would in-crease infant-mother attachment. During the night, I calledmy nurse twice and asked her to take the baby to the nurs-ery, because I was still tired, and wanted to sleep withoutinterruption. Korean culture had taught me that maternalrest is crucial to recovery. But the nurse’s comments mademe feel guilty—as if I were an incompetent and lazy moth-er—so I held the baby thorough the night. The next morn-ing, when I told my husband about the experience, he wasdelighted that our new daughter had slept with her mother.Again, I saw that in America less consideration is given formaternal rest than in Korea.

Clinical ImplicationsGiven the extent of ethnic and racial diversity in the UnitedStates, it is not possible to know details about each non-Western country’s postpartum practices. However, a rudi-mentary knowledge of the most common non-Westernpostpartum beliefs and practices will enable nurses andmidwives to avoid unnecessary conflicts and provide moreappropriate and effective care.

Galanti (1997) gave an example of conflicts when de-scribing a Vietnamese woman who returned to the hospitalwith a high fever and abdominal pain 12 days after givingbirth. During her stay, she rejected most of the food andliquids prepared by the hospital, refused to take a showeror wash her hair, and would not get out of bed except touse the bathroom. When she insisted on covering up withmany blankets in spite of her high temperature and sweat-ing, the nurses feared for her health. In this case, a familiar-ity with non-Western “hot-cold” beliefs and practiceswould have made the nursing care plan easier to devise. Arefusal by an Asian mother to have a full shower should be

March/April 2003 MCN 77

cated healthcare providers generally discourage hot baths,such baths provide ritual as well as physical cleansing inGuatemala culture (Lang & Elkin, 1997).

According to the Chinese custom of zuo yue zi (“doingthe month”), the new mother should not go out into thesunshine, walk about, read, cry, bathe, wash her hair, touchcold water, or engage in sexual intercourse (Galanti, 1997;Holroyd et al., 1997). After giving birth, the mother is ex-pected to be kept warm, and to be protected from “thewind.” It is important to keep the room warm, lest cold orwind enter the new mother’s joints. No matter how hot theweather, the traditional Chinese woman will want the win-dows closed and the air conditioning off. Bathing is consid-ered dangerous. Southeast Asian women observe very simi-lar postpartum practices (Davis, 2001).

In a phenomenological study exploring experiences ofpostpartum depression among 45 Middle Eastern women(Lebanese, Egyptian, and Palestinian), Nahas, Hillege, andAmashen (1999) reported that the interviewees believedthat their “bones are still open” after birth, and havingcold food and drink would result in health problems suchas arthritis and rheumatism. The interviewees also believedthat hot meals keep new mothers warm and increase theirmilk supply (Nahas et al., 1999). Jordanian women main-tain this same belief (Nahas & Amashen, 1999).

In a study of contemporary Mayan Indian culture in Yu-catan, Mexico, Jordan (1993) reported that for the firstweek following childbirth, the Mayan mother and infantare considered “hot” and must remain secluded in thehouse to protect them from “cold” evil wind. AmongMexican Americans, the postpartum preference for a warmenvironment may restrict full bathing or hair washing forup to 40 days after giving birth (Purnell, 1998).

Postpartum ConfinementAlthough the length of the postpartum period varies cross-culturally, the notion of a 40-day postpartum is common inmany non-Western cultures (Lauderdale, 1999; Nahas etal., 1999). In almost all non-Western societies, 40 days af-ter birth is seen as necessary for recuperation. Among mostnon-Western cultures, family members (especially femalerelatives) provide strong social support, help new mothersat home during that period. The new mother’s activities arestrictly limited, and her needs are taken care of by (typical-ly) female relatives and midwives (Holroyd et al., 1997;Nahas & Amashen, 1999).

For example, in Guatemala, a traditional midwife visitsthe mother every day or two, for up to 2 weeks after birth,to check the baby’s cord, to massage the mother, and towash the families’ clothes and linens, so that the newmother may rest (Lang & Elkin, 1997).

Chinese women believe rest is essential after birth. Dur-ing the customary 30-day postpartum confinement, femalerelatives or live-in helpers perform household activities forthe new mother (Holroyd et al., 1997). The new mothermust be confined to her home during a 30-day postpartumperiod and must perform a variety of avoidance rituals(Holroyd, Katie, Chun, & Ha, 1997).

In India, postpartum confinement typically lasts up to 40days. This seclusion is to protect the new mother and her in-fant not only from evil spirits, but also from exposure to ill-ness, because both are considered to be in a vulnerable stateafter birth (American Public Health Association, 2001).

In the Middle East, resting 40 days after having a baby iscustomary in Jordan, Lebanon, Egypt, and Palestine (Nahas& Amashen, 1999; Nahas et al., 1999). During this 40-dayperiod, someone comes to the house or stays with the newmother to take care of the baby, the house, and the otherchildren, so that “all new mothers have to do is rest” (Nahas& Amashen, 1999, p. 42).

Although not a 40-day prohibition, in Mayan Indianculture in Mexico, a new mother and infant must remaininside for 7 days and have limited contact with non-house-hold visitors. After the first week, the mother may increaseher activities. She resumes her full, normal activities onlyafter the 20th-day sobada, a postpartum massage by amidwife, which constitutes the formal termination of thechildbirth process (Jordan, 1993).

Some Differences Between Westernand Non-Western Postpartum PracticesIn the traditional non-Western view, birth is part of a holisticand personal system, involving moral values, social relations,and relation to the environment, as well as the physical as-pects. Birth ceremonies often are used to recognize the im-portance of the event in the culture (Leininger, 1995). Specialfoods are prepared to express the reward of motherhood, aswell as to symbolize a new baby’s entry into the family andcommunity (Callister & Vega, 1998; Leininger, 1995).

In contrast, Western postpartum practices are based onthe biomedical model. In a Western framework, pregnancymight be “managed” by a physician who performs a spe-cial medical or obstetrical role (Lauderdale, 1999). Accord-ing to Davis-Floyd (1997), the message conveyed to Ameri-can women is that the role of the woman is less importantthan that of the physician during giving birth. Gifts andcelebrations are centered around the newborn rather thanthe mother (e.g., baby showers, christenings, visits fromfriends and relatives to see the baby) (Lauderale, 1999). Itis interesting that women’s status has been considered rela-tively higher in Western cultures than in non-Western cul-tures, yet paradoxically less recognition seems to be givento new mothers in the United States.

76 VOLUME 28 | NUMBER 2 March/April 2003

Suggested Clinical Implications■ Non-western new mothers may be reluctant

to have a full bath or shower after giving birth.Consider substituting a sponge bath or sitzbath.

■ Non-western new mothers may feel especiallysensitive to cold. Respect their preference for a warm environment by providing blankets ormonitoring room temperature.

■ In non-Western cultures, cold foods and colddrinks are often prohibited for new mothers.Warm tea, coffee, broth, or other foods may be substituted for ice water or cold juices.

■ Non-western new mothers often anticipate enjoying a recuperative role for an extendedtime after giving birth. Do not expect them toresume regular activities soon.

Non-Western new mothers may lackthe extensive familial and social support that they enjoyed in their owncountries. Nurses and midwives can help provide this extra support.

March/April 2003 MCN 79

understood in terms of the belief that cold temperatures aredetrimental to recuperation after childbirth. Flexibility onthe part of nurses who work with new mothers needs to beincorporated into the “routine” postpartum care we feel isnecessary. Nurses can ask new mothers about their culturalbeliefs, and incorporate those preferences into the plan ofher care. Sometimes, generic (folk) practices may be com-bined with Western healthcare practices for the provisionof effective healthcare. In the case of the Vietnamesewoman, a sponge bath could be substituted for the routineshower, and additional clean bed blankets might be offered.

Because culturally specific dietary prescriptions are com-mon in the postpartum period among non-Western coun-tries, the choice of certain cultural foods by non-Westernwomen should be respected, if there are no dietary restric-tions for health reasons (Lauderdale, 1999). Although pre-scribed foods differ among non-Western countries, general-ly there is a very strong emphasis on “heating” food duringthe postpartum period, while at the same time “cooling”food is prohibited. Therefore, the routine distribution of icewater or cold juices can be modified by offering warm tea,coffee, or broth.

Nurses and midwives can assess the new mother’s levelof acculturation and assimilation, linguistic abilities, andeducation level. Less acculturated women may feel an in-tense level of stress when confronted with cultural beliefs ofhealthcare in the United States (Balcazar, Peterson, & Krull,1997). In my case, my second childbirth experience wasmuch less stressful than my first, because I had becomemore acculturated to Western practices.

In conclusion, nurses and midwives need to recognizethat cultures reflect life experiences; they should be sensi-tive to cultural differences in postpartum beliefs and prac-tices as the first step toward developing their cultural com-petence. Many professional sources of information areavailable to increase cultural competence, as well as in-ser-vice education programs related to non-Western postpar-tum beliefs and practices (Moore & Moos, 2002). ✜

Yeoun Soo Kim-Godwin is an Assistant Professor, Schoolof Nursing, University of North Carolina, Wilmington NC.She can be reached at 3204 Bougainvillea Way, Wilming-ton NC 28409 (e-mail: kimy@uncw.edu).

ReferencesAmerican Public Health Association (2001). South Asia case study-India:

Norms of maternal care in India and impact on utilization onmaternal health services in the U.S. Retrieved June 14, 2001 fromhttp://www.apha.org/ppp/red/indiaPostpartum.htm.

Balcazar, H., Peterson, G., & Krull, J. L. (1997). Acculturation and familycohesiveness in Mexican American pregnant women: Social andhealth implications. Family and Community Health, 20(3), 16-31.

Brettell, C. B., & Sargent, C. F. (1997). Gender in cross-cultural perspective(2nd ed.). Upper Saddle River, NJ; Prentice Hall.

Callister, L. C., & Vega, R. (1998). Giving birth: Guatemalan women’s voice.Journal of Obstetric, Gynecologic and Neonatal Nursing, 27, 289-295.

Callister, L. C. (2001). Culturally competent care of women and newborns:Knowledge, attitude, and skills. Journal of Obstetric, Gynecologic andNeonatal Nursing, 30, 209-215.

David-Floyd, R. E. (1997). Gender and ritual: Giving birth the American way.In C. B. Brettell & C. F. Sargent (Eds.), Gender in cross-cultural perspec-tive (2nd ed., pp. 403-415). Upper Saddle River, NJ: Prentice Hall.

Davis, R. E. (2001). The postpartum experience for Southeast Asianwomen in the United States. MCN, The American Journal of Mater-nal Child Nursing 26(4), 208-213.

Galanti, A. (1997). Caring for patients from different cultures: Case studiesfrom American hospitals (2nd ed.). Philadelphia: University of Penn-sylvania Press.

Holroyd, E., Katie, F. K. L., Chun, L. S., & Ha, S. W. (1997). “Doing themonth”: An exploration of postpartum practices in Chinese women.Health Care for Women International, 18, 301-313.

Jordan, B. (1993). Birth in four cultures: A cross-cultural investigation ofchildbirth in Yucatan, Holland, Sweden, and the United States (2nded.). Montreal, Canada: Eden Press Women’s Publications.

Lang, J. B., & Elkin, E. D. (1997). A study of the beliefs and birthing prac-tices of traditional midwives in rural Guatemala. Journal of Nurse-Midwifery, 42(1), 25-31.

Lauderdale, J. (1999). Childbearing and transcultural nursing care issues.In M. M. Andrews & J. S. Boyle (Eds.). Transcultural concepts in nurs-ing care (3rd ed., pp. 81-106). Philadelphia: Lippincott.

Leininger, M. (1995). Transcultural nursing (2nd ed.). New York: McGraw-Hill.Manderson, L. (1987). Hot-cold food and medical theories: Overview and

introduction. Social Science and Medicine, 25, 329-330.Moore, M. L., & Moos, M. K. (2002). Cultural competence in the care of child-

bearing families. New York: March of Dimes Birth Defects Foundation.Nahas, V., & Amashen, N. (1999). Culture care meanings and experiences

of postpartum depression among Jordanian Australian women: Atranscultural study. Journal of Transcultural Nursing, 10(1), 37-45.

Nahas, V., Hillege, S., & Amashen, N. (1999). Postpartum depression: Thelived experiences of Middle Eastern migrant women in Australia.Journal of Nurse-Midwifery, 44(1), 65-72.

Purnell, L. D. (1998). Mexican-Americans. In L. D. Purnell & B. J. Paulanka(Eds.), Transcultural health care: A culturally competent approach (pp.397-421). Philadelphia: F. A. Davis.

Spector, R. (2000). Cultural diversity in health and illness (5th ed.). UpperSaddle River, NJ: Prentice Hall Health.

Stewart, S., & Jambunathan, J. (1996). Hmong women and postpartumdepression. Health Care for Women International, 17, 319-330.

U.S. Bureau of Census (2001, May). Overview of race and Hispanic origin.Retrieved June 7, 2001, from http://www.census.gov/prod/2001pubs/.

U.S. Department of Health and Human Services (DHHS). (2001). Factsheet: National sample survey of registered nurses 2000. Rockville,MD: Division of Nursing, Bureau of Health Professions.

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It is interesting that women’s status in Western cultures has been consid-ered relatively higher than the statusof women in non-Western cultures, yetparadoxically less recognition seems to be given to new mothers in theUnited States.

Birth and Postpartum Practices and Hot-cold Theorywww.nurseweek.com/ce/ce220a.htmlwww.iejhe.org/PAID/2001/pdf/merritt.pdfwww.hmonnet.org

www.unescap.org/pop/jounral//1993/v08n2aa.htmA Cross-Cultural Maternal Health Information Catalog-APHAhttp://www.apha.org/ppp/red/index.htmWHO (World Health Organization) Headquarters Site Searchhttp://www.who.int/site-search/data-who-hq-live/search.shtml

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CE TestPostpartum Beliefs and Practices Among Non-Western Cultures

CE TEST QUESTIONSGeneral PurposeTo provide registered professional nurses with adescription of common postpartum health beliefsamong women in non-Western cultures.

Learning ObjectiveAfter you read this article and take this test, youwill be able to:

1. Describe at least four typical postpartum beliefscommon among non-Western cultures andcontrast them with those of Western cultures.

2. Discuss the expected postpartum confinementamong various non-Western cultures, as wellas the supportive activities provided to newmothers during that time.

3. Plan three interventions for postpartum womenfrom non-Western cultures.

Questions

1. Beliefs about maintaining a hot-coldbalance within the body are calleda. caloric theories.b. humoral theories.c. thermal theories.

2. Due to the blood loss associatedwith delivery, a woman in theimmediate postpartum period isconsidered by many non-Westerncultures to bea. in a cold state.b. in a neutral state.c. in a feverish state.

3. In Guatemala, a hot bath givenafter delivery is believed toa. increase blood loss.b. help restore fertility.c. lower breast milk into the breasts.

4. Chinese customs encourage thepostpartum woman toa. wash her hair.b. sit outdoors in the sunshine.c. avoid touching cold water.

5. In keeping with tradition, aChinese postpartum woman willkeep her room warm because shebelieves that cold willa. affect her joints.b. weaken her baby.c. cause gastrointestinal distress.

6. Middle Eastern women believe thathaving a cold drink after childbirthwill causea. migraine headaches.b. rheumatism.c. ulcers.

7. The expected postpartum confine-ment for Chinese women isa. 20 days.b. 30 days.c. 40 days.

8. During the 2 weeks afterGuatemalan women give birth, amidwife visits every other day toperform several functions, includinga. washing the family’s clothes.b. taking the baby outdoors.c. washing the mother’s hair.

9. The traditional postpartum periodin the Mayan Indian culture lastsa. 20 days.b. 30 days.c. 40 days.

10. In India, women are confined for 40days after childbirth to protectthem froma. the cold.b. evil spirits.c. the heat.

11. Unlike non-Western cultures, child-birth-related practices in Westerncultures focus primarily ona. the newborn.b. the household chores.c. the new mother’s need for rest.

12. Studies by Davis-Floyd (1997) inthe area of postpartum practicesindicate that the typical woman inthe United States is made to feelthat her role during birth is lessimportant than that ofa. the newborn.b. her partner.c. the physician managing her care.

13. Which of the following is a goodexample of a compromise betweenWestern and non-Western post-partum practices?a. allowing the newborn to sleep in the new

mother’s bedb. giving the new mother a sponge bathc. offering the new mother plenty of chilled fruit

14. Korean women expect their post-partum recovery to take approxi-matelya. 2 weeks.b. 3 weeks.c. 1 month.

15. Of the following, which would bethe most appropriate interventionfor a postpartum woman from anon-Western culture?a. offering her extra blanketsb. encouraging her to resume her normal

activities as soon as she canc. providing plenty of cold water and juice to

drink

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