Chinese women

Many Chinese women, to avoid complications in pregnancy, will observe traditional customs and may assume “special treatment” when they are pregnant, such as relying on family to assist them to lift heavy items or to reach up for objects. They may need as much rest as possible and are not expected to be active or to do routine house chores. It is customary for pregnant women to avoid negatively affect their pregnancy by not looking at ugly things and not sitting on the corners of tables. Health care providers who encourage independence rather than dependence may be seen as uncaring (Queensland Health, 2009).

Traditional Chinese women may believe that some types of food disturb the balance of the “hot and cold” elements required for good health. Therefore, there are customary dietary and behavioural practices to keep the mother and baby physically healthy, for example, drinking special soups and chicken broth to maintain body balance (yin and yang). Some traditional Chinese women may not eat certain types of food or fruits they consider “cold” or “yin” food, or food that has a “wind” element, for example, food that is salty, lean, rich in potassium, or soft and wet such as lettuce and watermelon (Queensland Health, 2009).

• Women may become distressed when they are not offered the option of following cultural birth practices.
• Women may prefer sitting or squatting when giving birth.
• Traditionally, the labouring woman’s mother or mother-in-law attends the birth, rather than the father of the child. This practice varies among the Chinese communities. Nowadays, husbands are expected to stay with their wife during labour to show support and love.

• In contemporary Chinese societies, women who have recently given birth are still regarded as vulnerable. The custom of “doing the month” called Zuò yuè zi (in Mandarin) or Cho Yuet (in Cantonese) is the traditional Chinese practice where women are relieved of most work duties for a month (30 days) or more after giving birth in order to recuperate. Women are required to follow certain restrictive prescriptions, such as remaining indoors and following a strict diet (Bina, 2008).
• There is also the cultural practice of peiyue (in Mandarin) or pui yuet (in Cantonese) carried out by an elder female family member, (usually the woman’s mother or mother-in-law) who assumes most of the responsibility for the baby’s care and housework for the month. During this time child-rearing knowledge is transferred to the mother and she is protected from exhaustion and sleep deprivation (Lee, Yip, Leung & Chung, 2004). These days, Chinese families may hire a nanny or peiyue or pui yuet, also called yue sao for the month following birth to look after the mother and baby. The peiyue or pui yuet or yue sao cooks special food for the mother during that month.
• Traditionally, it is generally believed that postnatal women are weak and ‘toxic’ as evidenced by the presence of postpartum discharge. Postnatal discharge or lochia is thought to be contagious and for that reason other women are discouraged from coming into contact with it. It is a belief that the follicles expand during birth, leaving the new mother weak and vulnerable to “cold”, “air”, “wind” or “rain”, and thus she is discouraged from going out of the house.
• It is believed that postpartum women are deficient in “Yin” (internal heat) and for this reason new mothers must observe dietary restrictions and have minimal physical activity (Thai, 2005). Some women will be required to rest, dress warmly, take no showers or limit showering, and avoid hair washing during the postpartum period. Such practices and beliefs around postnatal rest often conflict with birthing unit routines (such as staff requesting mothers to shower postpartum and giving them cold water to drink). It is important for the birthing unit staff to explain to Chinese mothers who practice the postnatal rest period, that they understand the different postpartum practices and to ask women whether they wish to shower. If women do not wish to shower, ask if they would like a sponge with warm tap or pre-boiled water. This would avoid stereotyping behaviours, making assumptions, and would be a culturally appropriate way of offering an acceptable alternative to showering.
• New mothers who observe stringent dietary restrictions are expected:
  • Not to eat certain types of food or fruits they consider “cold” or “yin” foods. These are described earlier under the Pregnancy section).
  • Not to drink cold water, and, some may be encouraged by their families to restrict their fluid intake.
• Foods new mothers are encouraged to eat are:
  • Rice, pork, black-skinned chicken soup, bean curd, glutinous rice, garlic, ginger, and sometimes rice wine (Mi Jiu). These are considered “yang” foods, neutral or warm and are beneficial for restoring the body to its natural balance of “yin” and “yang”.
  • All foods must be well cooked and served hot including water.
    NB: Some of the special soups or foods may have a strong smell that may not be appealing to westerners. It is important to ask the women or mothers/mothers-in-law what is in the food they are eating or soup they are drinking, particularly if there is any alcohol content.
• Traditional postpartum practices are also influenced by the belief that they help women rejuvenate, rehabilitate, recover and regain their energy. The practices as well are believed to prevent the ailments of old age such as: poor vision, digestive disorders, uterine prolapse, back pain, aching joints , headaches, varicose veins, wrinkling of the skin and premature aging.

(Queensland Health, 2009)

Many Chinese women are expected to follow certain traditional practices advocated by older female relatives. However, many women opt for an approach which combines traditional and western neonatal care practices. For example:

• Babies may be over-wrapped and sleep in a prone position.
• Babies may be separated from their mother for at least the first 24 hours, to allow the postpartum mother to rest.
• Some women believe that if newborn babies are praised, bad spirits will take the baby away or the child will fall ill.
• Grandmothers, particularly the father’s mother, are often very involved with the new baby and the new mother’s recovery. Their authoritative position should be acknowledged when caring for the mother and during teaching sessions.
• The ‘Mongolian blue spot’ (a bluish pigmentation) is common at birth amongst Indo-Chinese and other Asian babies, and persists until the age of 18 months or two years.
• Babies in some Asian cultures may not be named for 1-3 months. For example, in Chinese culture, the baby may initially be given a nickname to be used until a formal name is given. A child's formal name is usually picked by its grandparents. A baby’s naming ceremony is very important because Chinese people believe that one's name can influence everything that happens in life. How this ritual is celebrated depends more on each specific family than on traditional rules.
• Some mothers who observe traditional postpartum practices may be expected by older family members not to leave the house during the period of postnatal rest. Women, therefore may not visit their baby who is in the Neonatal Intensive Care Unit (NICU). To avoid misunderstanding between NICU staff and mothers, staff need to explain to women their expectation that mothers breastfeed and bond with their baby while they are in the care of the NICU. It is important for staff to ask the mother if she will be observing a postnatal rest period, if so what does it involve, and will she be able to come to the NICU to breastfeed and bond with her baby.

• In contemporary Chinese society, women are educated about the importance of colostrum for the health of their baby. However, some Chinese women or older family members may consider colostrum to be stale and dirty and to be discarded.
• Babies may be fed with boiled rice water or formula during the first two days. NB: Staff need to explain the benefits of colostrum feeding and encourage women to breastfeed.
• Some mothers believe that formula provides more nutritional content than breast milk and supplement breastfeeding. Staff need to explain that breast milk is sufficient for all their baby's nutritional needs.

While some studies have suggested that the custom of peiyue may prevent social isolation and postnatal depression, other studies have found that the continual presence of a mother-in-law is not necessarily perceived as supportive by new mothers (Bina, 2008; Chan et al, 2002; Chen, 1999; Lee et al., 2004). Heh et al’s (2004) study of culture and postpartum depression in Taiwanese women showed that too much emotional support from in-laws, which was less wanted by the women, and too little support from parents, which was more wanted, contributed to depressive symptomatology. Heh et al (2004) suggested that the ritual of “doing the month” protects women from postpartum depression if support during this month meets the woman’s true needs. In another study, Lee (2000) explored women’s subjective perceptions of cultural traditions as fulfilling or not fulfilling their needs. The peiyue care was found to influence depressive symptoms by improving the psychological well-being of the women. On the other hand, negative relationships with the mother-in-law as well as not receiving peiyue care increased depressive symptoms.

Where there is a harmonious relationship between the ‘new’ mother and the woman providing the peiyue the risk of postpartum depression is reduced (Lee et al., 2004). Postnatal depression may still occur (and rates are similar to non-Asian population rates) especially when Asian women are isolated from their families (Lee et al., 2004). Good family support reduces the risk of postnatal depression. Due to the stigma around mental illness, family will go to some lengths to avoid seeking professional support.

"Doing the Month"
(Lee et al., 2004)

• The relationship between a mother-in-law and daughter-in-law is as important as the marital relationship in shaping the emotional well-being of the daughter-in-law in Chinese society.
• Women who are continually supported by a designated female relative or friend in the first postpartum month reported better social support, and have a slightly lower risk of postnatal depression.
• The ritual of “doing the month” protects women from the risk of postpartum depression only if support during this month meets the women’s true needs.
• If the mother-in-law was the peiyue support and the new mother did not get along well with her mother-in-law, the in-law tension can offset the potential benefit of the peiyue or pui yuet arrangement.
• During assessments, it is important to be aware that in Asian families the extended family is the main form of family life, and that in-laws are commonly defined as being inside the family boundary. 

Siu et al. (2012) studied risk factors for postnatal depression in the antenatal period in a cohort of Chinese women in Hong Kong. The risk factors for postnatal depression identified in the study were: marital dissatisfaction; dissatisfied relationship with mother-in-law; antenatal depressive symptomatology; and anxiety-prone personality. The study found that Chinese women tended to keep their feelings to themselves and to not admit that they had depressive symptoms. It is important to identify early Chinese women at risk so that they can be supported and monitored more closely.

Marital dissatisfaction has been consistently found to be an important determinant of postnatal depression among Chinese women (Siu et al., 2012). As well, an unsatisfactory relationship with a mother-in-law is a salient risk factor for postnatal depression (Chan et al, 2002; Chen, 1999; Lee et al., 2004). In traditional Chinese culture, after marriage a woman would live with her husband’s family. The woman becomes the “subordinate daughter” of her mother-in-law and is responsible for the care of her husband’s family members. As the “subordinate daughter”, the woman is expected to respect and obey the opinions and advice of her mother-in-law in all aspects of her life including the ways to take care of the family and the newborn child (Siu et al., 2012). Overt and covert conflicts emerge if the woman has different views from her mother-in-law and this can cause significant distress in the daughter-in-law.

For women who do not live with their mother-in-law after marriage, the traditional Chinese beliefs that a woman would be “subordinate” to her mother-in-law still prevails in some Chinese families. After the birth of a child, a woman has increased contact with her mother-in-law if she provides peiyue support or if she visits the newborn child at the woman’s home. Because of the increased contact, there may be conflicts about child rearing practices which will be exacerbated if the woman is not supported by her husband.

Studies show that conflicts with a mother-in-law, marital dissatisfaction, past depression and antenatal depressive symptomatology are independent antenatal risk factors for postnatal depression in Chinese women (Lee et al., 2004; Siu et al., 2012).

In Lee et al’s study (2000), spouse dissatisfaction with the female gender of the baby increased the risk for PND. In traditional Chinese culture, a boy is more treasured than a girl as a boy signifies the perpetuation of the family to the next and subsequent generations.

Persistent wound (episiotomy wound or caesarean section wound) pain for more than 2 weeks was found to be a significant risk factor for PND. Postnatal Chinese women with the presence of persistent wound pain need adequate wound care and pain control (Lee et al., 2000).

Clinical Implications: Antenatal Depression
(Lee et al., 2004; Siu et al., 2012)

• Studies highlight the importance of assessing antenatal depressive symptomatology and close monitoring of Chinese women with significant antenatal depressive symptomatology (eg those with antenatal EPDS score > 9 or PHQ-9 score > 16) during the postnatal period for PND.
• Chinese women with an anxiety-prone personality and relationship problems with their husband and/or mother-in-law also warrant close follow up.
• Antenatal interventions aimed at reducing these risk factors may serve to lower the chance of developing PND.
• Provide the woman with information about New Mother’s Support Groups in her local community and/or Parent Education groups to reduce isolation and increase support.

Helpful tips for engagement
(Hoai, 2000)

When an interpreter is needed, it is essential to identify the dialect in order to find an appropriate interpreter. The following are some tips for health practitioners when doing HOME VISITS:

• Give a clear introduction of your role and the purpose of the visit.
• Check whether it is appropriate to remove your shoes before entering the home (notice whether there is a collection of shoes at the front door).
• If food or drink is offered, it is acceptable to decline politely even though the offer may be made a few times.

A woman may expect her family members to be involved in her maternity care and decisions about treatment. The following are some cultural nuances to consider when engaging with Chinese women and their family members:

• Addressing women and their family members using their title and surname (premature familiarity may be considered disrespectful).
• Shaking hands with men may be an acceptable greeting.
• Greeting women with a smile and a ‘hello’ or traditional greeting to avoid any offense as not all women are comfortable with hand shaking.
• A nod or slight bow is also a customary greeting.
• Avoiding eye contact, shyness and passivity are cultural norms.
• Many Chinese people will avoid saying ‘no’ as it is considered impolite.
• Silence (listening) is a sign of politeness; interrupting is considered rude.
• To summon someone using your finger is considered extremely rude (hands palm facing downwards and moving fingers together in a scratching motion is acceptable).
• ‘Yes’ can be an ambiguous response, sometimes used to indicate that the listener is paying attention. It does not necessarily indicate agreement (ask open-ended questions).
• Showing respect, especially for elders, is appreciated (eg greeting the elders first, the health practitioner being on time for an appointment, and greeting them in their traditional way).
• Showing an interest in the family’s culture and practices will likely enhance the relationship with the health practitioner and compliance.
• Health practitioners are usually highly regarded and women and family members may not ask questions as it is considered disrespectful. It would be helpful to invite the woman and her family to ask questions.
• ‘Saving Face’ is a strong principle and will be used over confrontation or questioning of those in authority. It is also important not to put a woman or her family members in a position where they will be seen to ‘lose face’.