ISPUB.COM Volume 9 Number 2

ISPUB.COM The Internet Journal of Third World MedicineVolume 9 Number 2

1 of 9

Belief and Practices of Traditional Post Partum CareAmong a Rural Community in Penang Malaysia”M Hishamshah, M bin Ramzan, A Rashid, W Wan Mustaffa, R Haroon, NBadaruddin

Citation

M Hishamshah, M bin Ramzan, A Rashid, W Wan Mustaffa, R Haroon, N Badaruddin. Belief and Practices of TraditionalPost Partum Care Among a Rural Community in Penang Malaysia”. The Internet Journal of Third World Medicine. 2010Volume 9 Number 2.

Abstract

Introduction: In developing countries, 70% of new mothers do not receive postpartum care. In Malaysia there are a number oftraditional postpartum practices commonly practiced by new mothers.Aim: To describe the beliefs and practices related to thetraditional postpartum care among women who had given live births in a village in Penang, Malaysia. Methodology: Adescriptive cross sectional study was conducted among 68 women residents of a village who had given live births. Besides thebaseline demographic data, information was collected on the postpartum confinement period and the aspects of traditionalpostpartum care. The data was analysed using the SPSS version 18.0.Results: All the 68 eligible women responded. All of themwere aware of and practised postpartum ‘pantang’. The mean perceived confinement period was 53 days. Most respondentspractice the confinement period due to self-belief (86.8%), others due to convenience (4.4%) and family pressure (4.4%). Mostwomen in this village were aware of and practiced the common postpartum regimens except for the encouragement of morefood intake and the limitation of contact with others. Older women were more likely to consume or use traditional herbs (χ² =9.468, 4, P = 0.050) and to restrict their water intake (χ² = 18.827, P < 0.001). Most of them claimed that they would repeat thesame traditional postpartum care regimens in their subsequent pregnancies and would advise their children the importance ofdoing so despite the presence of complications.Conclusion: This study revealed a high awareness and practice of traditionalpostpartum care.

INTRODUCTION

Postpartum maternal health care influences the health ofboth the mothers and their children greatly. Like prenatalcare, the postpartum health care that is typically providedduring the six-week period after childbirth is very important

to the mothers' health.1 In developing countries, over 60% ofmaternal deaths occur during the postpartum period. A greatnumber of postpartum complications can be avoided.Physical as well as psycho-social problems can be detectedearly via an effective postpartum care. Effective postpartumcare is essential to maximize survival of mothers and newborn regardless of where a woman delivers. Ironically, indeveloping countries, about 70% of women do not receive

any postpartum care.2

In general, Western postpartum practices are based on thebiomedical model, whereby the role of the woman is lessimportant than that of the physician. In contrast, thetraditional non-Western perspective emphasizes that birth is

part of a holistic and personal system, involving moralvalues, physical aspects, social relations, and relation to theenvironment. Postpartum health beliefs and practices amongnon-Western cultures are each distinct, but have manysimilarities.

In general, most Asian traditional practices of postpartumcare aim to restore the balance in the body elements i.e. soil,water, wind and fire. These practices aim at restoring thenormal function of sex and reproductive organs, increasingwellbeing and energy of the mothers, encouraging woundhealing, weight loss and aesthetic reasons. Giving birth is aperiod that is described as ‘cold’ hence proper care is givento balance this. These postpartum care practices are

practiced throughout the whole confinement period.3 Twomost common belief systems in traditional postpartum careincludes the importance of balancing hot and cold elementswithin the body mostly via modification of food intake,clothing and sanitary habits as well as the necessity of

Belief and Practices of Traditional Post Partum Care Among a Rural Community in Penang Malaysia”

2 of 9

confinement during a specific period of time after giving

birth.4

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

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

How and whether or not the traditional postpartumconfinement period and care actually have any effects onwomen’s health has still not been fully understood.Especially for the fact that even though in general, the namesand tools used are same, different families inherit differentlevel of practice and technique making it hard to objectivelyasses its effects. Due to the dearth in research conducted ontraditional postpartum care practices health careprofessionals are not able to understand the existing healthbenefits of the practices nor are they able to detect thepotential harm of these practices.

The objective of this study was to describe the beliefs andpractices related to the traditional postpartum care amongwomen in a village in Penang, Malaysia.

METHODOLOGY

Setting: the study was conducted in a village located in theisland of Penang in Malaysia. Most of the villagers wereMalay Muslims working as fisherman or employed in thetourism industry.

Sampling: all the women in the village who had given birthwere eligible to participate. Those who did not consent or

were unable to communicate effectively were excluded.

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

Tools: Trained research assistants collected the data in therespondent’s homes. Besides the baseline demographic date,information was collected on the post-partum confinementperiod and the aspects of traditional post-partum care such asdietary modification, massage, hot compress, corset, herbalapplication and lifestyle changes. For these practices therespondents were asked whether they were aware of it butdid not practice, they were aware of it and practiced, or ifthey were not aware of it at all.

Analysis: Data was analysed using PASW (PredictiveAnalysis Software) version18.0. Results were tabulated anddepicted graphically.

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

RESULTS

All the 68women who were eligible out of the total 300villagers agreed to participate. The age of respondentsranged from 21 to 80 years old with the mean age of 46.1years old. Most of them were in the age group of51-60followed by 41-50. Most of the respondents wereMalays, Muslims, married, housewives and the highest levelof education up to secondary school as shown in table 2.


3 of 9

Figure 1

Table 1: Demographic profile of the respondents

The confinement period ranged from 30 to 150 days. Themean perceived confinement period was 53 days. This isdepicted in figure 1. Irrespective of the number of days mostbelieved that it was important to strictly follow theconfinement period. The most common reason given for thepractice of confinement was self-belief (59) followed byconvenience i.e. they were housewives hence they canpractice it (3) and family pressure (3).

Figure 2

Figure 1: Perceived minimum confinement period

As shown in Table 2, irrespective of the age group,education level and employment, most perceived theconfinement period to be more than 45 days. However the

findings were not statistically significant.

Figure 3

Table 2: Crosstabulation between the demographic profileand the perceived minimum confinement period

Figure 2 shows the practice of some of the more commonbeliefs and practices of post-partum care regimens amongstthe Asian community. Most women in this village wereaware and practiced these common postpartum regimensexcept for the encouragement of more food intake and thelimitation of contact with others. Use of corset which ispopular among Malaysian women during postpartum is lessused in this community.

Figure 4

Figure 2: Awareness and practices of common traditionalpostpartum care regimens

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


4 of 9

Figure 5

Table 3:Cross tabulation between the demographic variablesand the postpartum diet practice

Figure 6

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

Figure 7

Figure 3:Sources of awareness for traditional postpartumpractices

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

Figure 8

Figure 4:Level of perceived importance of each aspect inpostpartum care

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

Figure 9

Figure 5:Reasons for the practices of postpartum care

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

The only reported complications due to the practice oftraditional postpartum care or ‘pantang’ were caused by dietand traditional herbs. The complications were constipationand haemorrhoids. As shown in Figure 6, even when therewere complications the possibility of practicing theseregimens again in the future was still high. Most womenclaimed that they would repeat the same regimens oftraditional postpartum care in subsequent pregnancies andthey would advise their children on the importance ofpractising it.


5 of 9

Figure 10

Figure 6:Complications and possibility of future practice

DISCUSSION

The very strong level of belief and practice in the traditionalpractices with regards to postpartum care in this communityis consistent with previous studies on the same topic.

The traditional Malay belief in terms of confinement periodis consistent with the number of maximum days that can beregarded as ‘nifas’ i.e. lochia, as defined by Islamicjurisprudence as the maximum postpartum confinementperiod which is 44 or 45 days. In the Islamic Women HealthRules (‘FiqhWanita’), it is believed that, per vaginalbleeding that exceeds 44, 45 or 60 days (depending on thescholar) is considered ‘istihadhah’ i.e. diseased blood whichalerts for some pathological bleeding hence differentregulations apply in terms of acts of worship e.g. prayers,

fasting and pilgrimage.6 This is then adopted in the Malaycommunity as the confinement period perhaps for the sakeof convenience in monitoring mothers during the postpartumcare. In the classic Hindu mystic beliefs, 44 is a mysticalnumber believed to represent the 4 elements that needs to bebalanced after the imbalanced act of giving birth i.e. soil,water, wind and fire. 44 days is also the traditional belief forthe number of days for the process of creation and death ofhumans. There are also 44 angels believed to be guardingthese 4 elements and the four galaxies traditionally believed

to be present in the universe.3 One hundred days is also quitecommon however, it is more exclusively attributed toprohibition of sexual intercourse rather than the full practice

of traditional postpartum care.3

Irrespective of the number of days, in most Asian cultures,family members (especially female relatives) or midwivesprovide strong social support and help new mothers at home

during this period.4 The experience and observations of thepractice especially among the elder family members are veryinfluential. Many believe that women who are not strictabout confinement period suffer ill health and infertility in

later years.7 This could be a reason why many women inMalaysia still practise postpartum confinement religiously

regardless of socio-economic status.3 However it isimportant to remember that a very big majority of those whopractice these postpartum regimens do so on their ownaccord without the pressure from family members. Due towork commitment especially among the educated womenliving in urban areas in Malaysia, it is quite common thesewomen, including traditional midwives and masseuses whoprovide care services during the confinement period are

rather lenient about the number of confinement days.8 InMalaysia most employers provide 60 consecutive days as

confinement leave.9

In a biomedical perspective however, all functions of thereproductive organ i.e. the uterus, vagina and cervix in anuncomplicated delivery will become relatively back to itspre-gestational state by two weeks and hence there isn’t aneed for restriction in any activity of daily living unless the

mother complains of any unusual symptoms.10

Generally, the women in this community were aware,emphasised the importance and practiced these commonpostpartum care regimens with the exception of practiceslike increasing food intake (which is only common amongthe Chinese) and limiting contact with others. This isconsistent with the claim that postpartum care is one aspectof women health that is largely influenced by the traditionalstandards. This indicates the importance of taking intoaccount traditional practices and belief when assessing andmanaging mothers in maternal and child health services,which is not yet emphasized in the standard care provided bythe country’s health services.

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

The discussion on the traditional postpartum care comparingwith the documented health effects based on western healthmodel and the implication on health is tabulated for easyunderstanding (tables 5-8).

As shown in Table 5, prohibition of gassy food and theencouragement of food intake are consistent with westernbelief although the limitation of water and certain foods likevegetable and fruit intake may form a risk for dehydration,constipation and malnutrition. Although there are studieswhich reported the benefits of the traditional herbs especiallyfor constipation and jaundice but the potential side effects ofthese need to be further explored to avoid potential dangers


6 of 9

as shown in table 6.

As shown in table 7 and 8,hot compress, massage and use ofcorset although have no scientific evidence in their benefitshowever there are no recorded complications of on thesepractices. Limitation of movement is encouraged in bothwestern and traditional practice but the contention is theperiod of immobilization. Prolonged immobilization shouldbe discouraged to avoid possible complications especiallydeep vein thrombosis.

By understanding the practices and the reasons, thestakeholders of maternal and child health in the communitywill be able to provide a holistic approach which is crucial inthe management of postpartum mothers who will benefitfrom both biomedical and traditional health services asopposed to the conflicts which usually occur between

biomedical, traditional and alternative medicine.11

The commonly believed superiority of the modern and thedevaluation of indigenous cultures and knowledge systemsresults in incomplete healthcare delivery. Mothers in thispart of the world are still inclined towards traditionalpractices in postpartum care. The modern healthcareproviders should encourage good practices and adviceagainst the hazardous practices.

Figure 11

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


7 of 9

Figure 12

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

Figure 13

Table 7: Physical aspect of traditional postpartum carecompared with the documented health effects based onwestern health model and its implication on health

Figure 14

Table 8: Lifestyle aspect of traditional postpartum carecompared with the documented health effects based onwestern health model and its implication on health

CONCLUSION

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

Acquired health education influences lifestyle changes,which is valuable in promoting healthy habit duringpostpartum period. Education should be targeted to theirfamilies especially the female family members to change anypotential harmful practices which may adversely affectmaternal and child health.

Health professionals should be aware of the patients’ cultureand which traditional belief complements professional care.Healthcare providers should also advise and educate women


8 of 9

about the importance of adhering to the standard practice ofpostpartum care while outlining appropriate strategies forintegration of mothers’ traditional beliefs and modernapproaches of postpartum care.

LIMITATION

Because of the small sample size the results obtained maynot truly reflect the true level of belief and practice oftraditional postpartum confinement period and care in thepopulation. However this study can be used as a foundationfor larger studies in this field. Future studies on a multiracialand more urbanised population would yield interestingresults.

References

1. Ching-Yu Cheng, Eileen R. Fowles, Lorraine O. Walker.Postpartum Maternal Health Care in the United States: ACritical Review. The Journal of Perinatal Education2006;15(3):34–422. Global Health Technical Brief.The Maximizing Accessand Quality Initiative.[Online]http://www.maqweb.org/techbriefs/postp.shtml[Cited March 20, 2011]3. Barakbah, Anisah.Ensiklopedia Perbidanan Melayu -Encyclopedia of the pregnancy,births,and maternal healthcare according to traditional Malay culture. KualaLumpur :UtusanPublication. 2007.4. Kim-Godwin YS. Postpartum Beliefs and PracticesAmong Non-Western Cultures. The American Journal ofMaternal/Child Nursing 2003;28(2): 74-785.Sternhttp://www.google.com/url?q=http%3A%2F%2Fwww.ncbi.nlm.nih.gov%2Fpubmed%3Fterm%3D%2522Stern%2520G%2522%255BAuthor%255D&sa=D&sntz=1&usg=AFQjCNEdJMJPgpIASkfqY2Y5ksay29xRPwG,Kruckmanhttp://www.google.com/url?q=http%3A%2F%2Fwww.ncbi.nlm.nih.gov%2Fpubmed%3Fterm%3D%2522Kruckman%2520L%2522%255BAuthor%255D&sa=D&sntz=1&usg=AFQjCNGCSqBPkmyUi8N3-UwnLJg5Y94kLgL.Multi-disciplinary perspectives on post-partum depression:an anthropological critique. PubMed, social science andmedicine 1983;17(15):1027-41.6. Talha, Abu.Fiqh Of Menstruation. [Audio CD] London :Qadimoon, 2008.7. Joanna H Raven, Qiyan Chen, Rachel J Tolhurst, PaulGarner. Traditional beliefs and practices in the postpartumperiod in Fujian Province, China: A Qualitative Study.Liverpool. PubMed Central;BMC Pregnancy and Childbirth,2007;7(8)8. Zamani A, Traditional Practices in Postnatal Care: TheMalay Community in Malaysia. Trinity Student MedicalJournal 2001;29. A Guide to Malaysian Labour Law.PNMB Lawnet, 2008[Online]http://www.lawnet.com.my/lawnetpublic/LegalInformation/

LegalAwareness/AGuideToMalaysianLabourLawsPart1of2/tabid/69/Default.aspx.[Cited March 10, 2011]10. Beckmann CRB, Ling FW, Barzansky BM et al.Obstetrics and Gynecology.6th Edition. Baltimore:Lippincott Williams & Wilkins; 2009.11. Davis-Floyd R. Daughter of Time: The PostmodernMidwife. Rev Esc Enferm USP, 2007, Vol. 41.[Online]http://www.davis-floyd.com/userfiles/Daughter%20of%20Time%20-%20postmodern%20midwife.pdf. [cited on CitedMarch 10, 2011]12. Laderman C, Symbolic and Empirical Reality: A NewApproach to the Analysis of Food Avoidances. AmericanEthnologist 1981; 8(3):468-493.13. Duyff RL.American Dietetic Association Complete Foodand Nutrition Guide. John Wiley and Sons Ltd, 2006.[Online] http://www.ajcn.org/content/85/3/926.full[citedMar 22 2011]14. Nutrition and healthy eating: Water: How much shouldyou drink every day?April 17 2010. Mayo Foundation forMedical Education and Research (MFMER), [Online]http://www.mayoclinic.com/health/water/NU00283[citedMar 22 2011]15. American Society of Nephrology. Evidence Lacking OnHealth Benefits of Drinking Lots of Water, According ToReview of Literature. ScienceDaily. April 3, 2008[online]http://www.sciencedaily.com¬/releases/2008/04/080402120522.htm[Cited March 20, 2011]16. Stevensen C. JAMU: an Indonesian herbal tradition witha long past, a little known present and an uncertain future.Complementary therapies in nursing & midwifery 1999;5(1):1-3.17. Laderman C.Wives and Midwives: Childbirth andNutrition in Rural Malaysia. California: University ofCalifornia Press. 1987.18. Mendelssohn K, Evans D S. The Physical Basis ofRadiant Heat Therapy. Oxford : Royal Society of Medicine,1945.[online]http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2180957/pdf/procrsmed00555-0040.pdf[cited Mar 22 2011]19. Lydon-Rochelle MT, Albers L, Teaf D.Perinealoutcomes and nurse-midwifery management. J NurseMidwifery 1995;40(1):13-820. Magnussona M, Pope MH, Hansson T.Does a backsupport have a positive biomechanical effect? AppliedErgonomics 1996;27(3):201-521. Stress management: Massage: Get in touch with its manyhealth benefits [Online]. Jan 30 2010 [cited Mar 22 2011].Mayo Foundation for Medical Education and Research(MFMER), [Online]http://www.mayoclinic.com/health/massage/SA0008224.[cited Mar 22 2011]22. Zuradatolakma Din.Berpantang Secara RawatanTradisional Bagi Masyarakat Melayu. s.l. : FPEND, 1999.23. Azidah AK, Shaiful BI, Rusli N et al. PostnatalDepression and Socio-Cultural Practices Among PostnatalMothers in Kota Bahru, Kelantan.Med J Malaysia.2006;61(1):76-83.24. Chen PC. Incorporating the Traditional Birth Attendantinto the Health Team: The Malaysian example. Tropical andGeographical Medicine1977;29(2):192-6


9 of 9

Author Information

Munirah HishamshahFinal Year Medical Student, Penang Medical College

Muhammad Sirri 'Ammar bin RamzanFinal Year Medical Student, Penang Medical College

Abdul Rashid, MBBS, MHScAssociate Professor, Department of Public Health Medicine, Penang Medical College

Wan Nur Hidayah bt Wan MustaffaFinal Year Medical Student, Penang Medical College

Raihanah HaroonFinal Year Medical Student, Penang Medical College

Nur Baizura bt BadaruddinFinal Year Medical Student, Penang Medical College

Documents

ISPUB.COM Volume 9 Number 2