Immigrant Southeast and East Asian mothers' transnational postpartum cultural practices: A meta-ethnography.

OBJECTIVE: Southeast and East Asian mothers experience the postpartum period differently than that of the general population. Despite the documented difference, there is limited representation of postpartum cultural practices in nursing and midwifery research. The purpose of this meta-ethnography is to synthesize qualitative findings from studies that examined postpartum cultural practices of Southeast and East Asian mothers globally to ensure better maternal health outcomes.
METHODS: Noblit and Hare's seven-step meta-ethnographic approach was used. We analyzed constructs, concepts, themes, and metaphors using Krippendorff's content analysis. The guidelines for preferred reporting the synthesis of qualitative research were adhered to enhancing transparency (Preferred Reporting Items for Systematic Reviews and Meta-Analyses).
RESULTS: The collaborative search process in the following databases, PsycINFO, CINAHL, and Scopus, resulted in eight high quality research studies published between January 2017 and February 2020. Five studies discussed postpartum traditions of immigrant mothers (n = 67) living in North America (n = 67), while three studies explored that of mothers living in Southeast and East Asian. Mothers (n = 132) from China, Hong Kong, Taiwan, Korea, Vietnam, and Hmong participated.
FINDINGS: Three themes emerged: (1) importance of maintaining postpartum cultural practices; (2) barriers of "doing-the-month"; and (3) modification: practicality over tradition. Although participants recognized value in postpartum traditions, the lack of social support deterred more immigrant than non-immigrant Southeast and East Asian mothers from "doing-the-month." Due to the influence of western medicine, clinicians' postpartum care suggestions, and use of modern technology (e.g., Internet), Southeast and East Asian mothers had informed choices to adapt, modify, or "break with tradition."
CONCLUSION: Similarities and differences existed in how each Southeast and East Asian mother accepted and engaged with postpartum cultural practices, a process which aligned with one's definition of health. Maternity care providers should further elicit Southeast and East Asian mothers' needs based on individualized assessments beginning in prenatal care with emphasis on social support for mothers who have recently immigrated and given birth in their adopted countries.

Introduction

Postpartum cultural practices among mothers of Southeast and East Asian (SEEA) descent have been well documented.[1-3] An example of postpartum cultural practices is conscientiously eating yang-associated foods, resting, reducing physical activity while staying indoors for a maximum of 30–45 days after giving birth. In Asian cultures, postpartum cultural practices are referred to as “doing-the-month,” a ritualized time after birth giving underpinned by the ancient Chinese philosophy of yin-yang. Yin-yang is influenced by Traditional Chinese Medicine (TCM) that has evolved over thousands of years. To this day, the term yin symbolizes cold, black, darkness, and femininity, while yang signifies warmth, white, light, and masculinity.

According to tradition, giving birth breaks the yin-yang balance and is viewed as a transient illness. Mothers’ bodies are considered to be in extreme yin after birth giving due to blood loss (blood as a symbol of heat).[4,5] To restore this imbalance, postpartum practices were usually performed with the supervision and assistance of female elders (i.e., mothers and mothers-in-law). Due to traditional lore and multigenerational transmission of culture, these practices can vary on an individual basis. For example, Chinese postpartum mothers engaged in zuo yue zi, which translates to “sit moon” or “sitting month,” meaning “to stay home for 1 month while being fully taken care of by one’s social support system.” Similarly, Cambodian female elders had four primary responsibilities: establish infant care, encourage rest, facilitate self-care possibilities, and pass down postpartum traditions as their daughters transitioned into motherhood.

Today, SEEA mothers still value the benefits of participating in postpartum cultural practices. According to Chen, contemporary mothers are more likely to observe postpartum cultural practices today than in their parents’ generation, as financial stability, social support, and accessible resources increase. Given the rising birth rates to SEEA mothers and for the fact that first-time Asian mothers have almost twice the maternal mortality rate compared to white women, this systematic review will help maternity care providers better understand the complex, underlying meanings behind postpartum cultural practices and how they impact maternal outcomes for immigrant Asian mothers. The aim of this systematic review with a meta-ethnographic approach is to assess, analyze, and synthesize qualitative data from different research studies that examined postpartum cultural practices of SEEA mothers in different parts of the world. Results will provide opportunities for maternity care providers to better support mothers with culturally appropriate and affirming care.

Theoretical framework

A transnational and decolonial feminist nursing analytic was used for this article. The objective of transnational and decolonial feminist nursing is to go beyond the binaries of the terms “modern” (i.e., European or the United States and therefore advanced and better) and “traditional” (i.e., SEEA or other countries from the Global South and therefore less advanced and somehow lacking or inferior) when referring to a specific phenomenon, such as postpartum cultural practices. A transnational, decolonial perspective questions both inter- and intranational determinations of not only gendered oppression but also can capture varying experiences of culturally diverse people, particularly ethno-racialized people, whose postpartum cultural practices remain largely hidden and underestimated in maternal health outcomes. The framework has evolved overtime to go beyond the use of the terms “modern” and “traditional,” to more culturally appropriate terms when caring for vulnerable subpopulations, in particular, immigrants, limited English speakers, and childbearing people who suffer in greater silence than the general white Euro/U.S.-born population.[11,12] Maternity care providers will likely resonate with this theory when caring for SEEA mothers as it provides a more holistic approach when examining class, race, gender, nation, and different social identities while incorporating both “traditional” and “modern” aspects of maternity health care to support SEEA mothers to improve better outcomes for mothers and babies.

The purpose of utilizing a transnational and decolonial feminist lens for this systematic review with a meta-ethnographic approach was not only to simultaneously visibilize the domination of the Euro/U.S.-centric postpartum cultural practices but also to critically examine why some mothers return to, and thus, revitalize the term “traditions” into “postpartum cultural practices” as a result. Long’s study confirms this for Hmong and Vietnamese American mothers who have sought to employ cultural practices overtime as a form of “progressive retrieval of a repressed woman’s culture, rather than as a sign of a retrograde society” (p. 5). Through this counter-discourse, this article sought to discuss how SEEA mothers expose, reveal, contradict, and/or adapt to the dominant culture that they live in, and whether or not they had observed varying “traditions” and engaged in SEEA cultural practices after childbirth.

We recognize that differences among SEEA mothers, based on their class, region, ethnicity, religion, among others, will impact the extent to which they are able to and interested in observing postpartum cultural practices. Some SEEA mothers will desire to engage in postpartum cultural practices to assert their cultural identity and heritage or to pay homage to their familial ancestors. For example, sociologist Vo found that Vietnamese college students who grew up in the United States redefined what it meant to be Vietnamese American because their identity was influenced by both cultures, not just their own ethno-racial group nor the dominant group. By keeping these transnational ties, immigrant people expand their “horizons” by moving back and forth in the “in-between” space of living with the intentionality and expression of a bicultural identity. Thus, this systematic review with a meta-ethnographic approach will provide a theoretical contribution to the literature of how SEEA mothers’ transnational identities combined with the differences among them of race, class, ethnicity, religion, and nation shape the way they talk about and engage in postpartum cultural practices today.

Research design

We used Noblit and Hare’s seven-phase meta-ethnographic approach to selecting, appraising, summarizing, interpreting, synthesizing, and reporting the synthesis of findings. First, the authors identified an intellectual interest that qualitative research might inform, selected studies that were relevant to such intellectual interest, and read the studies. According to Noblit and Hare, relevant studies have themes, metaphors, and/or constructs which can be (a) refutational, (b) line-of-argument, or (c) reciprocal. “Refutational” means the accounts stand in relative opposition to each other; “line-of-argument” assembles like studies together that naturally follow a theory-laden “trail”; and “reciprocal” means key metaphors between two or more studies are directly comparable, can translate into one another, and thus, be synthesized. All included articles reported obtaining ethical approval before commencing their respective studies, of which their data are readily available to the public, so ethics approval for this systematic review was not sought. We followed a methodologically inclusive design for conducting a systematic review which includes reflexivity, informed criteria for searching and selecting records, and audience-appropriate transparency. In addition, this systematic review with a meta-ethnographic approach has been written in adherence to guidelines for Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) to enhance transparency in reporting the synthesis of qualitative research (see Supplementary File 1).

Reflexivity

To enhance the trustworthiness of this systematic review with a meta-ethnographic approach, the first author reflexively considered their prior beliefs before commencing the study. A senior researcher in Sociology and Asian and Asian American Studies supervised the study. Both have a firm philosophy of culturally centered care, dignity, and respect and believe it is crucial to support and facilitate mothers in informed decision-making, which reflect their cultural orientation, ethno-racial identities, and childbirth preferences, even if these decisions fall outside of standard procedures and guidelines. In addition, the authors were attentive to differences among inter-, intra-, and subgroup variations.

Search strategy and selection criteria

Studies of postpartum cultural practices of SEEA mothers were reviewed using the following databases pertinent to nursing and midwifery: PsycINFO, CINAHL, and Scopus. Original research articles were searched using pre-determined criteria: full-text, peer-reviewed and English language studies that investigated participation in postpartum cultural practices. MeSH terms and exploded controlled vocabulary terms included Southeast Asian, East Asian, mothers, postpartum customs, postpartum cultural traditions, postpartum rituals, “doing-the-month,” or postpartum cultural practices. Combined search terms were also used, for example, “Southeast Asia*” or “East Asia*” and “postpartum” or “postnatal” and cultural practice* or tradition*. The first author consulted with an academic librarian to further expand on the rigor of the search. We searched a mix of terms which initially resulted in 438 articles. Once duplicates were removed (n = 129), 309 abstracts and article titles were scanned for relevance. Of these, 159 articles were excluded because they addressed the wrong population. A total of 142 further studies were inappropriate because they were quantitative studies, clinical research studies, cohort studies, or focused primarily on maternal health outcomes, and breastfeeding. Nine studies were published more than 5 years ago and thus, removed, resulting in the final eight studies. The search process for included studies was further provided with PRISMA Flow Diagram (see Figure 1).

Figure 1.

PRISMA flow diagram.

Preferred reporting items of systematic reviews and meta-analyses, 2020.

The first author critiqued the level of evidence of the included studies utilizing the John Hopkins Nursing Evidence-Based Practice (JHNEBP) research appraisal tool. This checklist guides the evaluation of quality of evidence for experimental, quasi-experimental, or non-experimental studies. There are three different levels of evidence (I = experimental study, II = quasi-experimental study, III = non-experimental study) for any specific study, which can have a (“Low” = C) or (“High/Good” = A/B) quality rating. Since the included studies were all qualitative in design, they had Level III evidence. The articles received a “B” grade or higher.

Synthesis

Initial data extraction involved identifying and tabulating each studies’ key characteristics, that is, author, country, aims, sample, setting, data collection method, data analysis method, adherence to ethics, reflexivity discussion, key findings, and quality grade (see Table 1). The first author was guided by the literature in extracting demographic and contextual information selected to aid in the analysis. These included the participants’ characteristics, such as age, parity, marital status, country of origin/destination, and type of birth.

Table 1.

Methodological characteristics of included studies.

Author	Year	Sampling	Research design	Data collection	Data analysis
Chang et al. 5	2018	Snowball	Phenomenology	Individual, face-to-face interviews	Content analysis
Han et al. 19	2020	Convenience and snowball	Mixed-methods (qualitative strand)	Individual, face-to-face interviews	Thematic analysis
Saito and Lyndon 20	2017	Convenience and snowball	Grounded theory approach	Individual, face-to-face interviews	Constant comparative approach
Ta Park et al. 21	2019	Convenience and snowball	Mixed methods	Face-to-face interviews	Content analysis
Ta Park et al. 22	2017	Convenience and snowball	Mixed-methods (qualitative strand)	Individual, face-to-face interviews	Content analysis
Tsai and Wang 23	2019	Purposive and snowball	Phenomenology	Face-to-face interviews	Thematic analysis
Wang et al. 24	2019	Purposive	Ethnography	Face-to-face interviewsParticipant observation	Thematic analysis
Yeh et al. 4	2017	Purposive	Phenomenology	Face-to-face interviews	Thematic analysis

The synthesis method used the inductive meta-ethnographic approach of Noblit and Hare and included multiple readings of each study, translation, and synthesis. According to Noblit and Hare, meta-ethnography operates on the conceptual level, whereby, the familiarization stage comprised each article being read individually to identify authors’ constructs, concepts, themes, and metaphors. Quotes, metaphors, and central concepts that vividly captured SEEA mothers’ experiences with postpartum cultural practices were recorded. This systematic review with a meta-ethnographic approach generated “reciprocal translations,” that were further synthesized into overarching themes. The iterative process of reading, highlighting, lifting key findings, and clustering thematic elements that spoke on participants’ postpartum cultural practices was repeated until no raw data were left uncovered. To assess the risk of bias among individual studies, the second author reviewed the final tables based on her research expertise in Sociology and Asian and Asian American Studies. Questions were addressed in weekly meetings by extensive group discussion and consensus.

Results

Eight studies met the inclusion criteria; three mixed methods studies; and five qualitative studies. The total sample comprised 132 participants from different SEEA ethnic groups: Vietnamese, Chinese, Hong Kong Chinese, Taiwanese, Korean, and Hmong. The mean age of participants ranged from 20 to 45 years. Level of education ranged from middle to graduate school, with most SEEA mothers completing high school education. All mothers were married. Primiparas (n = 94) accounted for more than double the multiparas (n = 38). A majority of mothers (n = 79) gave birth vaginally (60%). Five studies focused on the postpartum experience of SEEA immigrant mothers. These mothers’ length of stay in their adopted countries ranged between 1 month and 35 years (see Table 2).

Table 2.

Participant characteristics of included studies.

Study	Origin country	N	Destination country	Sample size	Age range (years)	Parity	N	Marital status	N	Type of birth	N	Length of stay
Ta Park et al. 21						Multiparas	5			Vaginal	12
	China	8	USA	15	29–39			Married	15			2–35
	Taiwan	5				Primiparas	10			Cesarean	3
	Hong Kong	1
	USA	1
Saito and Lyndon 20	Taiwan	10				Multiparas	4			Vaginal	Not specified
	Hong Kong	2	USA	13	28–45			Married	13			1 month–15 years
	China	1				Primiparas	9			Cesarean	Not specified
Yeh et al. 4						Multiparas	0			Vaginal	18
	Taiwan	27	Taiwan	27	25–39	Primiparas	27	Married	27	Cesarean	9	-
Tsai and Wang 23	China	20	China	20	25–39	MultiparasPrimiparas	020	Married	20	VaginalCesarean	128	-
Chang et al. 5						Multiparas	4			Vaginal	9
	China	12	Canada	13	25–34			Married	13			1–6
	Taiwan	1				Primiparas	9			Cesarean	4
Wang et al. 24						Multiparas	13	Married	18	Vaginal	8
	China	18	China	18	20–40	Primiparas	5			Cesarean	10	-
Ta Park et al. 22	Vietnam	15	USA	15	27–40	MultiparasPrimiparas	69	Married	15	VaginalCesarean	123	5–35
Han et al. 19	Korea	11	USA	11	22–44	MultiparasPrimiparas	65	Married	11	VaginalCesarean	83	5–20

Findings

Of the eight articles, six focused on postpartum cultural practices in the home setting. Two articles assessed how new mothers employed postpartum cultural practices within Postpartum Nursing Centers (PNCs) both located in China and Taiwan. These culturally centered facilities acted as maternity homes for new mothers to live in for 20 days, on average, following their hospital stay of 3–5 nights.[4,23] As shown in evidence (Table 3), each study’s sample, number of themes, and specific examples were described at the individual level and supported by information, including characteristics (e.g., marital status, parity, age, number of years living in destination country), type of postpartum cultural practices observed, metaphors, and converging quotes of the participants. Three themes emerged: (1) importance of maintaining postpartum cultural practices; (2) barriers of “doing-the-month”; and (3) modification: practicality over tradition.

Table 3.

Results summary.

Author, date and discipline	Evidence type, level, and quality	Results	Findings that help answer the question	Limitations
Ta Park et al. 21 Nursing	Mixed methodsLevel of evidence: III Quality rating: B	Three themes identified:● Culture-specific postpartum traditions● Perceptions of sadness or depression after birth● Help-seeking for mental health issues	● Family instills cultural values and postpartum traditions● Stay indoors, rest, hot foods/drinks, avoid cold● Desire for westernization considered a deterrent● Lack of social support, hormonal changes● Confide in spouse first, then other family and friends● Costs, unaware of services, language and cultural barriers	Mixed methods typology not specified
Ta Park et al. 22 Public Health	Mixed methodsLevel of evidence: III Quality rating: B	Two themes emerged:● Strong cultural identity● Practice and examples of postpartum traditions	● Postpartum cultural practices maintain cultural values● Specific heating practices, postpartum diet, and rest● Lack of social support related to stress or high workload	Mixed methods typology not specified
Chang et al. 5 Nursing	QualitativeLevel of evidence: IIIQuality rating: B	Two themes identified:● Novel encounters with zuo yue zi ● Expectations, catalysts, and deterrents of zuo yue zi	● The availability and quality of social support from family members, friends, culturally consistent providers, paid doulas, and resources in the social system of women’s new country impact their postpartum cultural practices	Linguistic differences between translator and participants
Han et al. 19 Social Work	Mixed methodsLevel of evidence: IIIQuality rating: A	One core theme emerged:● Importance of keeping postpartum traditions	● Family reinforces postpartum cultural practices● Growth of social network with ethnically similar women	Low generalizability and transferability
Saito and Lyndon 20 Nursing	QualitativeLevel of evidence: IIIQuality rating: A	Two core themes identified:● Acceptance of postpartum traditions● “Valuing comfort over tradition”	● Family pressure, past experiences, nature of available options, teaching from doctors, and comfortAvailability and costs of special regional traditional foods● Indoor heating, hot water, weather impacts adherence	Use of Corbin and Strauss “grounded theory” approach
Tsai and Wang 23 Nursing	QualitativeLevel of evidence: IIIQuality rating: B	Two core themes emerged:Motherhood burdenMotherhood adaptation	Motherhood stereotypes, fatigue, and frustrationCompromising in the face of reality“Being practical” and “realistic”	Low diversity from mothers with less than college degree
Wang et al. 24 Nursing	QualitativeLevel of evidence: IIIQuality rating: B	Three themes identified:● Gaining yin-yang (shady-sunny) balance● Preventing “xie” (pathogenic factor) entering body● Enhancing breastmilk production	● Eating hot food to improve yang (light, masculine energy)● Staying in room to avoid xie (diseases)● Dietary practices to improve breastmilk productionVisitors believed to decrease breastmilk production	Linguistic differences between translator and participants
Yeh et al. 4 Nursing	QualitativeLevel of evidence: IIIQuality rating: B	Four themes emerged:● Need to increase energy to gain more yang forceNeed to internalize mothering● Need to be supported by family and friends● Need to be understood	● Getting proper rest, nutrition, and carePsychological support and assistance with infant care from husbands and midwives invaluable● Constant need for confirmation from hospital staff to inspire confidence in abilities through motherhood	Single setting, low diversity from mothers with less than college degree

Theme 1: importance of maintaining postpartum cultural practices

Across the eight studies, all participants valued “doing-the-month” rituals after birth giving to restore the yin-yang balance. One Chinese Canadian mother said,

For women giving birth to babies, zuo yeu zi is essential . . . Despite receiving education in the West these years, I still feel that I am Asian; on the physical and other levels, I still have the traditional concepts.

Most participants observed postpartum cultural practices to prevent illness later on in life:[22,24]

They told me I should be careful with wind and food but did not follow the advice. I regret that. A few months after my bones ached and even my teeth were loose. So that’s when I thought, Oh this is why my mom and mother-in-law were worried.

Therefore, focus was placed on eating specially prepared yang foods during the postpartum period. For example, hot tea, broth, and soups, such as miyuk guk (Korean seaweed soup) were consumed in large portions immediately after birth. It was uncommon to consume “cold” food as it was believed to inhibit breastmilk production, and “cause gong hang (cold uterus) which could slow down lochia discharge.”

SEEA mothers made conscious decisions about their dietary practices in postpartum, as not only what they ate mattered but also when and how often they did. For example, one Chinese mother declared how she incorporated meats as a source of protein in every meal to ensure a strong sense of health after birth giving:

Delivery is an incomparable event because of the great loss of qi (physical vitality) that occurs, and I need something supplementary for health. For instance I have chicken soup, pig liver, and meat at every meal. I believe these nutritious foods are beneficial for my physical recovery.

However, some mothers found that their postpartum diet in confinement resulted in physical consequences for both mother and baby, such as heat rash, “You see my baby is ‘shang huo’ (getting fire or suffering from excessive internal heat) with a red rash full on his face, neck, and chest.”

Thus, a postpartum diet varied among SEEA individuals, where a few participants considered holding off on spicy, fatty, or oily foods until the second week after childbirth as they could produce excessive yang (heat) in the body, contributing to heartburn.

Theme 2: barriers of “doing-the-month”

All SEEA mothers recognized the importance of engaging in postpartum cultural practices for 1 month; however, there were social barriers that emerged as deterrents to “doing-the-month.”

Social barriers

Participants viewed maternity care providers as part of their social support system after childbirth, a time of great dependence and fulfillment. However, for SEEA immigrant mothers, maternity care providers in the new country were unaware of participants’ birth culture, values, and belief systems, which made them feel alienated.[26,27] Hence, a few mothers reported nurses’ lack of culturally affirming care:

The nurse said . . . “Why do you not take a shower?” I felt I was being judged and thought of as “How come you’re so dirty?” Not only was her facial expression clear, her tone of voice was quite obvious to make me feel very uncomfortable.

However, a few mothers found the “assistance from midwives and nursing staff was invaluable.” Their culturally sensitive care which included checking vital signs, breastfeeding support, and teaching how to take care of the newborn’s umbilical cord helped bring meaning to non-immigrant Taiwanese mothers’ physical recovery and helped improve their psychological well-being.

There were limitations in social support where first-time SEEA mothers sought exclusive maternity health care at a regional PNC, an example of westernization in the form of an institutional structure that most SEEA countries have developed to meet the culturally safe maternity care needs of their people. Since 2007, PNCs have been growing across Southeast and East Asia, such as in China and Korea, which represents a renewed perspective of clinical and cultural value toward “doing-the-month” practices. SEEA mothers reported having the opportunity to engage in rest and relaxation (with the exception of breastfeeding) coupled with 24/7 nursing care over the course of 1 month after giving birth. On average, these centers charge 70,000 to 580,000 Yen (US$618–US$5117) for 1-month stay and 2 to 4 million South Korean Won (US$1672–US$3344) per 2-week stay, respectively. Therefore, PNCs are generally suited for the upper class, from which 47 new mothers who elected to stay at a PNC could possibly afford.

Within the PNC, participants described learning about the “baby’s sleep patterns, getting through the night, understanding baby language, and bathing” from the direction of the nurses and midwives. Despite not having their social support system nearby, one non-immigrant Taiwanese mother learned how to successfully grow in confidence and adjust to her new maternal role while both finding time to rest and learn infant care:

Staying at the [PNC] gives me a buffer period to learn to care for the baby. I have already learned so much more about baby care. I still have classes to attend though, because it is quite important to know how to nurse the umbilical cord and bathe the body.

One Chinese mother reflected on her experience at the PNC and how she found a sense of social support in the clinical staff to help combat against postpartum depression:

At this [doing the month] stage, physical recovery is essential. I don’t want to keep my baby with me. I believe if I have enough support from midwives I would become a happy and healthy mother. It also would offer protection against postpartum depression.

However, most participants across the eight studies, particularly SEEA immigrant mothers, neither had access to contemporary long-standing institutional structures, such as PNCs, in their destination country nor in-person support from their mothers or mothers-in-law because they were geographically distant.[19,21,22] Consequently, a few participants sought further alternative support from their local communities:

The reason we also want to hire a nanny is that my mom cannot come, the whole, a long time . . . we don’t want her to be too tired. . . . she needs to take care of the baby, or all the stuff.

Across four studies, SEEA individuals reported that they could not adhere to postpartum traditions consistently during the critical 1-month period following childbirth due to the demands of their work obligations. A few non-immigrant Chinese mothers were able to work from home “doing e-business online” and “in the cities outside the villages,” while some non-immigrant Hmong participants held different occupations, such as farming, and had to labor from dusk to dawn every day. Despite the occupation, more immigrant than non-immigrant SEEA mothers feared losing their jobs or being demoted given their work-related responsibilities, which would detract them from their more recent responsibilities and roles in motherhood. Several Chinese immigrant mothers reported they could not afford unpaid maternity leave to care for a new child while trying to incorporate zuo yue zi practices into their lives. Although many working SEEA mothers were expecting cultural understanding and sensitivity from their employers, they were also faced with the difficult choice to continue working up until and beyond childbirth as opposed to taking time off without pay. As the cost of living in Western countries continues to rise, SEEA mothers in this systematic review felt that they had little to no time to engage in postpartum cultural practices as much as they would have liked, in part because of the need to work to provide for their growing family and contribute to the household income.[24,28]

To make matters worse, it was particularly difficult for many immigrant SEEA mothers to follow a traditional postpartum diet without the proper support system (i.e., sisters, mothers, and mothers-in-laws) who would typically cook postpartum meals to help with the transition from being a childless adult to new mother. For immigrant SEEA mothers in this systematic review, their social support system usually comprised of only the husband; while sisters, mothers, and grandmothers were often times geographically distant or remained living in their origin country. In addition, immigrant SEEA mothers reported that neither they nor their spouses had the time to cook yang-associated foods because of their work schedules or were too exhausted from taking turns looking after their infant and additional children. And although specially prepared postpartum meals were available at local Asian grocery stores, the weekly costs of these carryout entrées, platters, and soups could range up to thousands of U.S. dollars over the course of just 1 month. According to one Chinese mother living in Canada,

For me the home meal delivery was a little expensive! The problem with new immigrants is that over here, they cannot do the work that they previously did, so my salary is not very high. Therefore, I feel that $3500 is a little expensive! Actually my parents gave me a sum of money, like a red envelope, money for zuo yue zi . . . Nevertheless I still feel the cost is quite burdensome.

Theme 3: modification: practicality over tradition

Participants across the eight studies modified their postpartum cultural practices in light of “being practical” and “realistic.” One Chinese immigrant mother wanted to have visitors and considered herself to be removed from the idea of “postpartum isolation for the first month after delivery.” She did not believe that house guests who visit the mother were believed to “decrease breastmilk production.” However, she found that a visit from a friend actually provided much needed sociocultural relief, ultimately helping her see herself through a less distressing lens, “A friend of mine came to see the baby just last Sunday . . . I felt I wasn’t in a bad mood that day at all but the visit made things better.”

Though most mothers acknowledged specific traditions, such as no showers for 1 month, this maternal practice changed to accommodate the physical and sociocultural needs of one first-time mother:

In the US system, they will tell you have to take shower as soon as possible because it’s dirty, because I sweat and the bottom part, it bleeds, so it’s dirty, you have to clean yourself so you have a clean body to take care of your baby, to nurse baby.

By stepping outside of the “traditional box,” this newly immigrated Chinese mother of two also had to find different ways to adapt when she realized she did not have proper social support in postpartum:

Starting from about the tenth day after I gave birth to the second baby, I took my daughter to school every day. I waited for one hour and brought her home after classes finished. I had to go out every day and touch the cold air. It is considered that I had no zuo yue zi.

Discussion

This is the first systematic review with a meta-ethnographic approach that sought to synthesize postpartum cultural practices among contemporary SEEA mothers globally. Five studies examined how SEEA immigrant mothers engaged in “doing-the-month” in North America, while three studies explored postpartum cultural practices of mothers living in Southeast or East Asia. SEEA immigrant and non-immigrant mothers continue to move away from an extended family structure to a more nuclear one. A majority of births occur in hospitals today, and hospital policies only permit clients to stay for, on average, 3 to 5 days. There are also no mandatory home visits from nurses or midwives after hospital discharge. Hence, the acceptance of and adherence to postpartum cultural practices have also changed overtime.

For example, some immigrant and non-immigrant SEEA mothers were not fully wedded to postpartum cultural practices. Several participants considered it too cumbersome to follow the strict rules involved in “doing-the-month” (e.g., wearing multiple layers, staying indoors). However, they acknowledged specific heating practices were important and made perfect sense in their parents’ generations. For example, heating/cooling systems were not widely available 20 or 30 years ago in SEEA countries or were generally unaffordable to persons of limited means. Today, a majority of SEEA mothers in the studies live in technologically advanced societies with standard heating/cooling systems, and therefore, facilitate mothers to be in more control of both their environment and bodies in the context of postpartum. Thus, some SEEA mothers stated that it was no longer necessary to practice postpartum traditions in these modern times. For example, when the weather was too hot, a Korean-speaking mother and Californian resident thought there was no need to wrap her body up with clothes or heat up the room.

Some found that they could not withstand the discomfort of not washing their hair, doing laundry, or having intercourse for that long. So, they adopted practices of their own by washing themselves with warm clothes, steaming the body with Chinese herbs, or showering quickly with warm running water and then using a blow dryer to dry wet strands of hair. In a previous study, Lee reported that first-time Korean mothers in the United States felt that purposively engaging in postpartum cultural practices was a personal choice rather than an expectation, unbreakable bond or duty.

Son’s study found that Korean mothers who came to the United States in their adolescence and twenties reinforced the need to engage in Sanhujori (Korean term for “doing-the-month”) because it contributed to mothers’ overall state of health. This finding was consistent with previous research in postpartum Indonesian mothers which reported major “postpartum maternal needs were obtained from the family and community through traditional interventions.” Likewise, Chinese mothers who underwent doing-the-month rituals, such as prolonged rest and reduction in physical activity, had a greater sense of restfulness, mindfulness, maternal self-esteem, and confidence to breastfeed and learn about infant care than mothers who did not. In addition, researchers confirmed doing-the-month was negatively associated with postpartum depression among Vietnamese and Chinese mothers living in Taiwan.[35,36]

Despite the positive maternal health outcomes mothers reported after engaging in postpartum cultural practices, previous research described higher levels of psychological distress among immigrant Chinese mothers following zuo yue zi compared with those who were not following zuo yue zi. In total, 18% of participants felt “ambivalent and or negative” about following postpartum cultural practices; due to the influence of western medicine, clinicians’ postpartum care suggestions and use of modern technology, including the Internet, to participate in online communities (e.g. WeChat, KakaoTalk) and chat forums to find perinatal-related information.[5,19,22,24] Thus, these SEEA mothers had informed choices to adapt, modify, or “break tradition” with some of the postpartum cultural practices (e.g. refraining from washing hair, brushing teeth and intercourse). Among other reasons were the stressful family dynamics as grandmothers interfered with the father’s bonding with the infant. By pressuring new mothers to adhere to their rules of zuo yue zi, grandmothers deterred immigrant Chinese postpartum mothers from engaging in them at all. These findings resonate with those of immigrant Japanese postpartum mothers who were aware of the cultural differences but desired westernization, and therefore, followed the Australian ways of caring for their baby.

Implications for practice

Some SEEA mothers, immigrant and non-immigrant alike, still observe postpartum cultural practices to the extent that it is practical and affirms their cultural identity. Therefore, before maternity care providers meet with SEEA perinatal mothers, they should first attempt to understand the cultural background, including their history, social structure, cosmology, and traditional healing practices. In addition, SEEA postpartum mothers who identify with specific heating practices, such as sitting by a coal-lit fire, should be educated about carbon monoxide poisoning, and those who reduce physical activity significantly should be advised about blood clot formation. Alternative heating practices should be recommended to promote culturally congruent care that is safe. Some examples include, but are not limited to: deep breathing, arm and leg exercises in bed, application of hot packs, warmed towels and linen, peri-bottles filled with warm water to roll on the mid-section, space heaters from home, and heated blankets from the unit warmer.

It is also imperative to make critical assessments of the mother’s social, economic, and environmental needs beginning in prenatal care. Assess what mothers, including their partners, do for work and whether or not they can afford to take time off to engage in postpartum cultural practices to the extent they would like. It is important to note that young, immigrant SEEA mothers who have lived in their destination country for less than 3 years may have fewer sources of social support than those living in their origin country. Yet, this subpopulation is more likely to observe in postpartum cultural practices but may find themselves unable to engage in them fully due to lacking social support. Therefore, maternity care providers should make critical assessments of mothers’ social support systems and make referrals as necessary. Research have shown that mothers who received support from a doula during and after birth giving had higher maternal role confidence, maternal self-esteem, and breastfeeding intent and initiation than mothers who did not.

Limitations

This systematic review with a meta-ethnographic approach included ethnic groups from six of the largest SEEA-origin communities, representing 3% of the US population. Results have some transferability and invite readers to make connections between elements of participants’ stories and their own experience. However, this study is limited as only English language publications were sought, which resulted in a small sample size. Findings may not be generalized to the experience of mothers from other cultures and regions.

Conclusion

Some mothers in this study were not fully wedded to the cultural practices while a majority of mothers modified them to remain practical. Modifications aligned with one’s definition of health, social support network, and financial situation. Participants made choices that transformed some aspects of their cultural identity. Maternity care providers should further assess SEEA immigrant and non-immigrant mothers’ cultural needs beginning in prenatal care, with emphasis on social support, and make referrals based on those comprehensive assessments. Future research could examine “doing-the-month” experiences between US-born and SEEA-born mothers. It is also worth investigating SEEA mothers’ birthing experiences and childbirth customs, as little information is known about infant rituals (e.g. placental burial).

Click here for additional data file.

Supplemental material, sj-docx-1-whe-10.1177_17455065211060640 for Immigrant Southeast and East Asian mothers’ transnational postpartum cultural practices: A meta-ethnography by Timothea Vo and Manisha Desai in Women’s Health