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The puerperium
Vol. 13 No 2 | Winter 2011
Feature
New life begins with 40
Dr Kenneth J Nathan
MB ChB BAO MRCOG


This article is 9 years old and may no longer reflect current clinical practice.

Historically and culturally, each society’s practices during the puerperal period vary greatly, but one number keeps recurring.

The variation of puerperal practices across cultures and centuries is too broad to contemplate in a single article. While there are many models of care in New Zealand and Australia today, encompassing everything from traditional care of Indigenous and migrant women, through to private obstetric care, the majority of women in these countries give birth in a hospital setting. Older patients will often recount long hospital stays with bed rest following uncomplicated births, while today’s new mothers may be offered early discharge to a luxury hotel, supported by their hospital.

For the majority of obstetricians in day-to-day practice, the management of the puerperium is left largely to our midwifery colleagues. It can be seen that current practice in the Western world is based, in some aspects, on biblical and historical attributes, with adaptations being made with the advancement of medical science and an understanding of the complications that can arise during this period. However, we live in a changing society, where the impact of cultural and religious beliefs from non-Western societies will have to be taken into account to cater for the diversity of modern society.

Beliefs and practices surrounding the postpartum period are culturally patterned and marked differences exist between Western and non-Western cultures. A lack of cultural knowledge on the part of caregivers can make appropriate treatment difficult to deliver. Although women from non-Western cultures may wish to preserve their own traditional postpartum practices, their cultural preferences or expectations might be neglected due to healthcare providers’ lack of cultural competence. Although considerable diversity exists among non-Western cultures, there are also many common postpartum practices that midwives and obstetricians can learn to recognise in providing maternity healthcare.

Confinement

All cultures recognise a period of recovery and bonding with the baby for women after they have given birth. Although the length of the postpartum period varies cross-culturally, the notion of a 40-day postpartum is common in many non-Western cultures. In almost all non-Western societies, 40 days after birth is seen as necessary for recuperation. Among most non-Western cultures, family members  (especially female relatives) provide strong social support and help new mothers at home during this period.

The importance of the 40 days following childbirth is also seen in the Christian tradition of ‘churching’. The usual date of churching was the 40th day after giving birth, in accordance with the Biblical date and Jewish practice. For example, under Mosaic law, as found in the Old Testament, a mother who had given birth to a male-child was considered unclean for seven days; moreover she was to remain for 33 days ‘in the blood of her purification’. This was reflected in the commemoration of the presentation of Jesus at the temple (also called Candlemas) 40 days after Christmas. Western belief up until quite recent times followed this 40-day rule.

The recurrence of ‘40 days’ for the puerperium in so many diverse cultures from around the world raises the question of whether there is a common link across them. It is remarkable that each passing solar year can very effectively (even perfectly) be measured and metered out by keeping track of every 40th day. Ancient writings and artifacts (including certain monuments) make it clear that a cycle of 40 days was once carefully time tracked. Early astronomers appear to have once time tracked a cycle of 40 days for calendar purposes. The ancients appear to have also revered and celebrated this cycle in the practice of religion.

The early time track of 40 days can be recited from the book of Exodus where it is shown that Moses was in the mount for 40 days and 40 nights (refer to Chapter 24: 10-18). The calendar term ‘40 days and 40 nights’ is again recorded in the book of Deuteronomy, where Moses wrote: ‘And I stayed in the mount … to the rishown yowm [or to the 1st day, or the beginning day], 40 days and 40 nights… ‘(refer to Chapter 10:10).

In the traditional non-Western view, birth is part of a holistic and personal system, involving moral values, social relations and relation to the environment, as well as the physical aspects. In contrast, Western postpartum practices are based on the biomedical model. In a Western framework, pregnancy might be ‘managed’ by a physician who performs a special medical or obstetrical role.

Changes to practices of recovery from childbirth in secular societies are often related to motivations that are not spiritual. The USA Centers for Disease Control and Prevention (CDC), in 1995, reported that between the years of 1970 and 1995 the average length of stay in hospital after a vaginal delivery decreased from 3.9 to 2.1 days, and for caesarean delivery from 7.8 to 4.0 days. They attribute this reduction not to improvements in medical care, but rather to the savings in the health budget resulting from fewer days in hospital.

While there is recognition that a period of recuperation, bonding and protection is essential following childbirth, there is also an economic imperative that most women return to other duties when appropriate. Spiritual, medical and economic factors have again played their part in this decision. On a prosaic note, Australian readers will probably see the effect of the introduction of paid parental leave in extending the time before women return to paid work following childbirth.

Although considerable diversity exists among non-Western cultures, there are also many common postpartum practices. One such belief is the necessity of maintaining a ‘hot-cold balance’ within the body and with the environment after the birth of a baby. Hot-cold concepts of healthcare (also called humoral theories) are centuries old in the traditional cultures of Latin America, Asia, and Africa.

In rural Guatemala, traditional midwives emphasise the application of heat in the postpartum period. New mothers are instructed to use heated water to preserve their warmth; they might take a sweat bath, a sitz bath or an herbal bath, according to region. Guatemalans believe that a hot bath increases the flow of milk, ‘lowers’ the milk into the breasts and prevents breast milk from becoming ‘cold’.

According to the Chinese custom of zuo yue zi (‘doing the month’), the new mother should not go out into the sunshine, walk about, read, cry, bathe, wash her hair, touch cold water or engage in sexual intercourse. After giving birth, the mother is expected to be kept warm and to be protected from ‘the wind’.

In Mayan Indian culture in Yucatan, Mexico, in the first week following childbirth, the Mayan mother and infant are considered ‘hot’ and must remain secluded in the house to protect them from ‘cold’ evil wind. Among Mexican Americans, the postpartum preference for a warm environment may restrict full bathing or hair washing for up to 40 days after giving birth.

In India, postpartum confinement typically lasts up to 40 days. This seclusion is to protect the new mother and her infant not only from evil spirits, but also from exposure to illness, because both are considered to be in a vulnerable state after birth.

In the Middle East, resting 40 days after having a baby is customary in Jordan, Lebanon, Egypt and Palestine. During this 40-day period, someone comes to the house or stays with the new mother to take care of the baby, the house and the other children, so that all new mothers have to do is rest.

When assimilating the historical diversity of the cultural beliefs of our modern society, today’s obstetrician, with the wealth of current research and advancements in health provision, can easily draw parallels to the associated causes of morbidity and mortality in the postpartum period to the practices of the past which have led to those beliefs, which have become ingrained in certain cultures without questioning the fundamental reasons behind them. Our recognition and understanding of it, however, may help us in bridging that chasm.

References

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