Elsevier

Midwifery

Volume 114, November 2022, 103463
Midwifery

A descriptive qualitative study exploring the postpartum confinement experiences among first-time mothers from the three major ethnic groups in Singapore

https://doi.org/10.1016/j.midw.2022.103463Get rights and content

Abstract

Objective

Modern Singaporean mothers still embrace traditional confinement practices after childbirth, which often marks a significant milestone in maternal experiences. However, limited studies have explored in-depth the collective confinement experiences of mothers in Singapore. This study hence aimed to explore the postpartum confinement experiences of first-time mothers from the three major ethnic groups in Singapore, namely Chinese, Malay, and Indian.

Design

A descriptive qualitative study was conducted. Purposive sampling was adopted to recruit participants. Individual semi-structured face-to-face/telephone interviews were used to collect data, which were analysed using thematic analysis.

Setting and participants

Sixteen first-time mothers were recruited from two obstetric clinics in a tertiary hospital in Singapore.

Findings

Five themes emerged: “Specific diets adopted and avoided for different purposes”, “Complexity of various traditional confinement practices (TCPs) adopted”, “Reasons for adopting TCPs”, “Reasons for modifying TCPs”, and “Postpartum challenges”.

Key conclusions

Our study provided unique insights about Singapore's Chinese, Malay and Indian first-time mothers’ postpartum confinement experiences. While confinement practices were still observed, many mothers no longer subscribed to guidelines followed by previous generations and were modifying or forgoing practices they deemed impractical. Mothers faced challenges adapting to new motherhood and often felt restrained or stressed by confinement practices.

Implications for practice

Healthcare professionals should take the lead to educate mothers and their families on harmful traditional confinement practices and their misconceptions. Future studies could explore alternative methods of postpartum check-up to improve first-time mothers’ confinement experiences, and focus specifically on lower-income families to explore their unique confinement experiences.

Introduction

Postpartum confinement is a convalescence period with various lifestyle restrictions lasting about one month after childbirth (Naser et al., 2012). During this period, mothers usually spend the majority of time in a room and adhere to strict traditional confinement practices (TCPs), defined as any conventional practice performed during postpartum confinement by the mother or their family to promote maternal recovery and baby growth. Examples include dietary regulations (Chen et al., 2014; Leung, 2017), cloistering indoors (Fok et al., 2016), bathing abstinence (Fok et al., 2016), and traditional postpartum massages (Naser et al., 2012).

Most TCPs are centred around the common belief amongst Chinese, Malay, and Indian cultures of the ‘hot-cold’ concept (Naser et al., 2012). It is believed that the physiological changes that happened during antepartum and intrapartum alter the body's hot-cold harmony. Antepartum is deemed as the ‘hot’ state and during childbirth, energy is thought to be lost together with blood loss, resulting in the ‘cold’ or vulnerable body state (Fok et al., 2016). Therefore, the postpartum period is considered crucial for regaining this balance.

In most Asian cultures, TCPs persist due to the belief that the rituals guarantee the health of the mother and baby, and that failure to comply will lead to dire consequences for both (Chang et al., 2018). Hence, many are motivated to endure the inconveniences of TCPs. However, a local qualitative study had reported that new mothers felt unprepared and overwhelmed by the changes experienced postpartum (Ong et al., 2014). Common biological changes included breastfeeding, fatigue, and aches (Mao et al., 2016; Wang et al., 2009), while psychological changes included motherhood adaptation, infant care, inadequate spousal support, and conflict with confinement caregivers (Nayak and Shetty, 2017; Ngai et al., 2012). Such negative confinement experiences were highly correlated with postpartum depression (PPD) (Liu et al., 2014; Wan et al., 2009). Yet, limited studies have discussed how TCPs may influence these challenges differently during confinement, undermining efforts to develop effective maternal postpartum programmes.

Some studies have suggested that the strict adoption of TCPs is declining among mothers. As the restrictive nature of TCPs is associated with PPD (Wan et al., 2009), many mothers are, therefore, modifying or avoiding TCPs to accommodate their needs (Chang et al., 2018). According to Fok et al. (2016) intra-cultural differences in TCPs are increasingly observed in urban societies, whereby restrictive rituals are less likely to be practised by contemporary mothers. Naser et al. (2012) proposed globalisation of knowledge as the critical reason for modern mothers’ selective behaviour in adopting certain TCPs. Other studies (Chin et al., 2010; Fok et al., 2016) have found the cross-cultural influences of TCPs that reported an increasing number of mothers adopting TCPs from other ethnic cultures.

A cohort study reported that 96.4% of Chinese mothers, 92.4% of Malay mothers, and 85.6% of Indian mothers still adhered to some TCPs postpartum (Fok et al., 2016), despite modernised understanding and social expectations about health and postpartum confinement (Leung et al., 2005). A deeper understanding of first-time mothers’ postpartum confinement experiences is thus crucial to promote positive maternal experiences and to better support mothers undergoing postpartum confinement.

Limited studies have focused specifically on first-time mothers’ postpartum confinement experiences. A local qualitative study by Naser et al. (2012) explored the traditional birthing practices of Chinese, Malay, and Indian mothers in Singapore, but lacked focus on postpartum confinement experiences and instead explored mothers’ collective experiences from pregnancy to postpartum. Moreover, most previous studies on postpartum confinement focused on only a particular ethnic group from their country, which lacked exploration of cross-cultural influences, with most literature focusing on Chinese TCPs. Therefore, this study is imperative in filling those gaps and contributing to literature for future interventional studies that may improve maternal postpartum experiences through TCPs.

This study aimed to explore the postpartum confinement experiences of first-time mothers from the three major ethnic groups in Singapore, namely Chinese, Malay, and Indian. The research question was: What are the postpartum confinement experiences of Chinese, Malay and Indian first-time mothers in Singapore?

Section snippets

Conceptual framework

Figure 1 illustrates a conceptual framework of components influencing mothers’ postpartum confinement experiences, including TCP components that usually influence or are practised during confinement: ‘Beliefs’, ‘Dietary practices’, ‘Physical activities’, ‘Hygiene practices’, ‘Massage’ and ‘Support’. The components are extracted based on a review of the literature (Chen et al., 2014; Fok et al., 2016; Naser et al., 2012) and are believed to influence first-time mothers’ confinement experiences.

Study design

A descriptive qualitative study design was adopted. This design has been widely postulated to be an invaluable methodological approach in qualitative nursing study (Sandelowski, 2010). It allowed the gathering of rich data constructed by unique individuals, like personal experiences, to be displayed in an understandable and relatable manner that clearly describes the phenomena of interest (Colorafi & Evans, 2016). The Consolidated Criteria for Reporting Qualitative Research (COREQ) (

Findings

Participants’ data were summarised in Table 2. Among the 16 first-time mothers who completed their postpartum confinement, 8 were Chinese, 5 were Malays, and 3 were Indians aged 26 to 44 years old. Majority were Singaporeans (n=12, 75.0%), exclusively breastfeeding their babies (n=12, 75.0%), employed (n=12, 75.0%), had acquired higher education (n=11, 68.8%), living with their spouse (n=11, 68.8%), had normal vaginal delivery (n=13, 81.3%), and a monthly household income >US$1,508 (n=15,

Discussion

This study aimed to explore the postpartum confinement experiences of first-time Chinese, Indian, and Malay mothers in Singapore. Our findings suggest that mothers conformed to certain dietary restrictions or recommendations for three main reasons: Promoting post-delivery recovery, improving breastmilk supply, and ensuring the baby's well-being. Many participants accredited their success to their special confinement diet, affirming similar findings from previous studies (Mukhopadhyay and

Conclusion and recommendations for further studies

Our study has provided unique insights into Singapore's Chinese, Malay and Indian first-time mothers’ postpartum confinement experiences. Future studies should explore the costs and benefits of alternative methods of postpartum check-up and lactation counselling, such as home visitations by nurses/midwives or teleconsultation, to facilitate mothers’ confinement. Research is required to evaluate the safety of certain TCPs. Studies should also focus specifically on lower-income families to

Ethical approval

This study received ethics approval from the National Healthcare Group Domain Specific Review Board (NHG DSRB) on 19 September 2018 (NHG DSRB Ref: 2018/00780). All participants provided informed written consent to participate in this study.

Funding sources

This study received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Clinical trial registry and registration number (if applicable)

Not applicable.

Authorship statement

All authors listed meet the criteria according to the latest guidelines of the International Committee of Medical Journal Editors, and all authors are in agreement with this manuscript.

Author contributions

Study Design: H.G.H., M.L.T., W.W.

Data Collection and Analysis: M.L.T., L.W.L.L., H.G.H.

Manuscript Preparation: K.L.N., M.L.T., H.G.H., W.W., L.W.L.L., G.H.

Availability of data and material

The datasets generated and analysed are not publicly available as ethical and legal restrictions related to the confidentiality of study participants prohibit publicly available datasets.

CRediT authorship contribution statement

Meng Lynn Tan: Conceptualization, Methodology, Investigation, Formal analysis, Project administration, Writing – original draft. Kai Lin Ng: Formal analysis, Writing – original draft. Leta Wei Ling Loh: Validation, Resources, Writing – review & editing. Gørill Haugan: Writing – review & editing. Wenru Wang: Supervision, Writing – review & editing. Hong-Gu He: Supervision, Conceptualization, Methodology, Visualization, Formal analysis, Writing – original draft, Writing – review & editing.

Conflict of Interest

The authors declare no potential conflicts of interest with respect to the research, authorship, and/or the publication of this article.

Acknowledgements

We are deeply grateful to all the participants who had shared their invaluable experiences with the research team. We also appreciate the Nurse Manager and nurses from the Obstetric and Gynaecology clinics of the study hospital for their great support and kind assistance during the recruitment process.

References (47)

  • S.H. Chang et al.

    Experiences of Chinese immigrant women following “Zuo yue zi” in British Columbia

    J. Clin. Nurs.

    (2018)
  • L.-W. Chen et al.

    Dietary changes during pregnancy and the postpartum period in Singaporean Chinese, Malay and Indian women: The GUSTO birth cohort study

    Public Health Nutr.

    (2014)
  • Y.M. Chin et al.

    Zuo yuezi practice among Malaysian Chinese women: tradition vs modernity

    Br. J. Midwif.

    (2010)
  • J. Christie

    Hurry less, worry less for moms

    (2011)
  • K.J. Colorafi et al.

    Qualitative descriptive methods in health science research

    HERD

    (2016)
  • L.M. Connelly

    Trustworthiness in qualitative research

    Medsurg. Nurs.

    (2016)
  • D. Fok et al.

    A comparison of practices during the confinement period among Chinese, Malay, and Indian mothers in Singapore

    Birth

    (2016)
  • Report of the Joint FAO/WHO Expert Consultation on the Risks and Benefits of Fish

    (2011)
  • X. Fritel et al.

    Stress urinary incontinence 4 years after the first delivery: a retrospective cohort survey

    Acta Obstet. Gynecol. Scand.

    (2004)
  • P.I. Fusch et al.

    Are we there yet? Data saturation in qualitative research

    Qual. Rep.

    (2015)
  • K. Harris et al.

    Counseling single mothers of multiple heritage children: what is the difference?

    Fam. J.

    (2013)
  • WOG Healthier Catering Policy

    (2017)
  • An Eating Guide for Breastfeeding Mothers

    (2018)
  • 1

    Contributed equally to the preparation of the manuscript.

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