Indian women

Pregnancy is sometimes the first encounter a migrant woman has with the health system in a new country. Indian migrants often find pregnancy and childbirth a stressful and isolating time without family and community to support them with nurturing and traditional practices. Indian men do not usually know much about these practices and so cannot substitute for kindred women.

The social context of childbirth and marriage

• Arranged marriage is a common practice, in which the status and reputation of both families play a part. Couples are usually expected to start a family immediately, and when a bride becomes pregnant, this is an event celebrated by the couple’s extended families and neighbours.
• Becoming a mother elevates a woman’s status within her family and community and is considered crucial for leading a fulfilling life.
• Older female members have important roles. They are considered the source of knowledge concerning diet, conduct and taboos during pregnancy; and the main source of support after birth taking over household chores and baby care so that the new mother can rest.
• Pregnancy is believed to be a "hot state," or a time of increased body heat. A woman’s diet is adjusted to accommodate this.

Diet based on Ayurveda

In Ayurveda, perfect health is defined as a balance between body, mind, spirit, and social wellbeing. Since childbirth is seen as a life event that interrupts the balance of doshas (energies), Ayurvedic medicine recommends certain herbs, diet and yoga to restore the balance.

• Indian cultures recognise the influence of the concepts of ‘heat’ and ‘cold’ and the effect of wind and air on health status (Gatrad et al., 2005).
• Pregnancy is an over-heated state, thus ‘hot’ foods, such as high protein, acidic, salty and spicy foods and some fruits are avoided (Gatrad et al., 2005).
• Indian women attempt to attain balance and avoid miscarriages during pregnancy by eating ‘cold’ food. However, ‘hot’ foods are encouraged during the last stages of pregnancy to facilitate the expulsion of the fetus (Choudhry, 1997).
• Many taboos on diet are based on the belief that dietary indiscretions by the mother would later cause sickness in the newborn.
• Certain foods are believed to have a ‘cooling’ or ‘heating’ effect on the function of various organs of the body.
• It should be noted that some Ayurvedic medicine is high in lead, mercury and other heavy metals.

Hindu rituals and other customs

• Hindu sacraments are part of an ancient Code of Law set up to help individuals to achieve ‘purity’ and ‘perfection’. There are eight sacraments related to the period between pregnancy and the baby’s first birthday reflecting the importance Hindus ascribe to pregnancy and birth. Each sacrament has its own set of rituals. Apart from the washing of the baby immediately after birth, the timing of the ritual bath varies from five to nine days or up to three months.
• To ward off evil spirits, a black dot is applied to the forehead or elsewhere on the face/body and a small pocket knife is pinned to baby’s clothing.
• An oil massage is a popular practice, believed to improve strength and maintain general health in mothers and their babies.

(Queensland Health, 2009)

• Women are expected to be stoic during labour and the birth process. Indian women in labour will follow instructions from health care providers or family members. Men are not usually present in the birthing room at the time of birth. Often, an older female family member assists the mother in the birth process. Women prefer not to use pain-relieving medication as this is believed to complicate the birth. Midwives can suggest non pharmocological methods of pain relief such as relaxation and breathing techniques and support women to use these.
• Traditionally, labouring women are isolated due to birth-related pollution beliefs.
• Women usually cry out in pain as the birth approaches.
• Some women may prefer lying on a bed during the birth, while others may prefer to squat, either on the floor or on a stool.
• Profuse bleeding after the birth may be viewed as a good sign linked to the purification of the uterus.
• Traditionally, the umbilical cord and placenta were considered polluted and their disposal was carried out by a certain social caste.

• The concept of ritual pollution remains strong in contemporary India. Temporary states of impurity occur due to menstruation, birth or death, and rituals are required for people to revert to a pure state (Waller, 2016).
• Traditionally, the woman and her baby were considered polluted and were touched only by the traditional birth attendant (dai), grandmother and mother-in-law.
• The custom of postnatal rest following childbirth stems from pollution beliefs.
• The benefits of such a tradition are that it ensures a good rest for the new mother who is exempted from housework; it avoids potential infection from visitors; and it allows the woman to concentrate on bonding with her baby.
• The period of postnatal rest for Indian women is up to 40 days. Postnatal rest is practiced to protect mother and child, who are believed to be in a ‘cold’ state after childbirth and therefore should avoid draughts, water, cold drinks and cold food. In hospital, air conditioning, daily showers and cold drinks and food in the maternity ward are problematic. A woman may accept a warm bath but decline a warm shower. The new mother is required to cover her head and ears and wear socks in order to keep warm.
• Indian cultures also maintain the postpartum belief that childbirth depletes the mother of heat, blood and air and therefore women are vulnerable to cold, wind and disease (Manderson, 1981).
• Dietary practices are instituted to address the ‘cold’ postpartum state in many traditional cultures. Indian women take “hot” food and drink, such as garlic, coffee and spicy dishes of chili, coriander and fish. They avoid “cold” foods including most fruit and vegetables (Choudhry, 1997; Manderson, 1981).
• Postpartum practices are usually upheld by and enforced by mothers-in-law, aunts and other older female relatives.
• While Indian women value western maternity care, some traditional beliefs and practices associated with childbirth endure regardless of women’s level of acculturation (Wells & Dietsch, 2014). This may cause conflict between the advice received from health professionals and that received from older female family members.
• Indian women may follow traditional practices for a variety of reasons including: respect for elders, maintaining family harmony, and fear of adverse consequences for themselves and their babies.
• In New Zealand and Canadian studies, the most frequently mentioned issues while in the birthing unit are the conflict between resting and being active. Indian traditions prescribe strict bed rest, whereas western midwifery practice encourages early ambulation and self-care after birthing.
• Indian women report needing to negotiate between maintaining traditional customs in New Zealand and being practical (DeSouza, 2005; Grewal, Bhagat & Balneaves, 2008). They became flexible in their expectations and shorten the postnatal rest period if circumstances require it.
• When possible, family members are brought from India for support. Where extended family support is lacking, husbands can become actively involved in domestic responsibilities and childcare.
• When family support is not available, the lack of attentiveness expressed through having special food prepared, oil massages, and having housework done by extended female family members is a painful loss (DeSouza, 2005).
• It is important for midwives and other clinicians to find out an individual’s cultural beliefs without making assumptions about the level of importance Indian women may or may not give to traditional practices.
• Women’s cultural preferences should be accommodated unless obviously hazardous.
• It is helpful to consider postnatal rituals as rites of passage for new mothers that promote physical recovery, emotional stability and spiritual protection (Wells & Dietsch, 2014).

• When the baby’s cord falls off, a purifying social and religious ceremony is performed. Only then is the baby considered pure and is dressed in new clothes (Waller, 2016).
• Amrit - holy water. Some families insert a few drops of specially prepared sweetened water into the mouth of the baby as a blessing, and for its ‘cleansing’ properties the mother also drinks some.
• It is believed that newborns are highly susceptible to nujur or nazar (evil eye). Admiring a newborn is discouraged because it may cause envy and cast the evil eye.
• To ward off evil spirits, a black dot (kohl) is applied to the forehead or elsewhere on the face, head or body and a small pocket knife is kept with baby.
• Mother and child stay together for up to 40 days. It is important to discourage co-sleeping and to explain to the mother and other significant family members, the link to sudden unexpected infant death (SUDI).
• An oil massage is a popular practice, believed to improve strength and maintain general health in mothers and their babies.
• Religious ceremonies are practiced during neonatal care, for instance:
  • In many Hindu families, a ritual is performed on the sixth day after birth and the baby is officially named on the eleventh day.
  • In Muslim families, it is common for the father or the grandfather of the child to recite the Azan in the child’s right ear and the Iqama in the child’s left ear just after birth to confirm that the child is Muslim.
  • In Christian families they may wish to pray or anoint the infant for blessings and health.

• Initiation of breastfeeding by Indian women is usually prolonged and starts when colostrum is fully expressed. Inform women of the benefits of colostrum.
• Babies are usually fed when they cry at any time during the day or night.
• Crying babies may not be tolerated well by elder family members and the mother may be pressured to introduce complementary feeds due to the perception that the baby is still hungry and therefore not settling. The baby may also be given honey and water (with the aim of cleansing the baby’s stomach and aiding digestion). Health professionals need to discuss New Zealand breastfeeding recommendations with the mother and older family members.

Patel and colleagues (2002) examined the effect of risk factors, particularly related to baby gender bias which is deeply embedded in Indian cultures, on the occurrence and outcome of postpartum depression.

A significant risk factor for postpartum depression was women’s sadness about their babies’ female gender. Additionally, risk for postnatal depression in women who had experienced marital violence was significantly greater if the baby was a girl, but it was significantly lower if the baby was a boy. These results suggest that the preference for male children is a significant risk factor for postnatal depression. The high expectation that the next child be a boy may place a pregnant woman who already has a daughter under considerable stress.

For some Indian women, the shortened timeframe for postnatal rest in a new country can lead to postnatal distress (Waller, 2016).

Social support from family

• Older female family members in Indian society have important roles (Wells & Dietsch 2014). They are:
  • Considered to be the source of knowledge concerning diet, conduct and taboos during pregnancy.
  • The chief supporters of the woman after birth, taking over household chores.
  • The providers of baby care so that the new mother can rest.
• A universal theme that emerges in the literature is the reliance that women place on their own mothers (Amma) for support, advice, presence and help (Raman et al, 2014). When mothers or other family members are not available, women feel very isolated and alone and this may lead to ongoing distress (Raman et al, 2014).
• In some cases in-laws provide the nurturing and care usually provided by the woman’s mother but not always. Tension with in-laws (including sisters-in-law) may be the single biggest source of stress for women (Raman et al, 2014).
• Limited involvement from husbands in childcare and the perinatal period has been shown to be a risk factor for maternal depression in India (Rodrigues et al., 2003). Women at particular risk are those whose support is exclusively from their husband as family are not in New Zealand or when the marriage is a “love” match (Waller, 2016).
• Research has demonstrated the positive association between social support and maternal mental health and breast feeding (Barona-Vilar et al, 2009).

• Indian women and their families tend to perceive the health care provider as the authority. They may not question the health practitioner as it is considered disrespectful and so there is the need to explain how services work and to ask the woman and her family if she has any questions or concerns.
• If Western treatment is at odds with the traditional treatment in Indian communities, the family may ignore the provider and continue with traditional practices.
• It is important for the health provider to find out what traditional treatments may be being followed and try to incorporate these where possible.
• Women may not be accustomed to being informed of all the side effects of a prescribed treatment. The western model of informing patients can lead to confusion and fear, so in explaining a procedure, providers should balance discussion of the risks with realistic assurances.
• Family members are usually involved in a woman’s treatment decisions. The woman and her family members need to be given a detailed description of recommended tests and treatments, and postnatally, that they may bring ethnic foods to replace or supplement the hospital meals.
• Privacy and modesty are important to Indian women. Women prefer female health care providers and interpreters.

For 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.

Tips for LMCs engaging with Indian women (Waller, 2016)

• Be sure to explain to the woman the LMC system in New Zealand. Remind women of the need to book early with an LMC.
• Facilitate women’s access to social and support networks where they are absent or weak.
• Tailor the information provided to each woman according to her nutritional needs (eg vegetarian, halal) and the cultural and religious customs and rituals she may use during childbirth.
• Be aware of the cultural (and somatic) presentation of the symptoms of anxiety and depression and where to seek support for the women eg GP.
• Encourage the woman to have contact with other new mothers postnatally and prevent isolation, particularly when there is a belief that going outside the home will cause illness.