Zuo yuezi (ZYZ)—which, by direct translation, means ‘sitting the month’ or sometimes ‘doing the month’—is a traditional Chinese practice of confinement and convalescence for women for a full month after giving birth. During ZYZ, the new mother is expected to follow a collective set of ‘restrictive prescriptions and proscriptions’ (Pillsbury, 1978: 11). The origins of ZYZ date back millennia and the practice broadly follows the logic of classical Chinese medicine and folk traditions, to restore the body's ‘imbalance’ during pregnancy and childbirth through the diet and daily hygiene practices, as well as a preventive measure against future ailments (Pillsbury, 1978). Fok (1996) explained that perceptions of health among Chinese people are based on the ‘yin and yang’ health theory, informed by the Taoist concept of balance.
When a woman gives birth, her body is believed to be depleted of the ‘hot’ element through blood loss and inner energy (‘chi’), placing her in a ‘cold’ state for around 40 days while her womb heals. This is generally regarded as the first and second stages of the postpartum period (Romano et al, 2010). As a result, the new mother is advised to observe certain restrictions to her diet and movements, to keep her body warm and rest as much as possible. The consumption of confinement foods of the ‘yang’ properties is seen as particularly important to restore the woman's lost energies through birth and balance, alongside restricted consumption of ‘yin’ foods, based on five categories (Fok, 1996):
Similar forms of postpartum confinement and associated practices are also followed in other Asian populations, such as among Malaysian and Indian women, to various extents (Choudhry, 1997; Koon et al, 2005; Chen et al, 2014; Fok et al, 2016). Among the few studies that have examined the dietary intake of Asian women during the postpartum confinement period, even fewer have looked at the nutritional intake for Chinese mothers during this time. In the Singaporean birth cohort study (GUSTO: Growing Up in Singapore Towards healthy Outcomes), which surveyed 1220 Chinese, Malay and Indian women 3 weeks postpartum, most respondents reported having adhered to traditional restrictions, increasing their consumption of fish and milk-based drinks, which reflects modern dietary recommendations, while decreasing their intake of noodles, seafood, chocolates and sweets (Chen et al, 2014). Using a 24-hour dietary recall with 134 Chinese mothers surveyed in Kuala Lumpur who were practising ZYZ, Koon et al (2005) found that the women's mean energy intake was 19% below the recommended nutrient intake (RNI) for Malaysia (Ministry of Health Malaysia, 2005), while mean protein and iron intakes were 93% and 222% above RNI, respectively; this reflects the increased intakes of chicken and pork during this time. Mean intakes of the B vitamins thiamine, riboflavin and niacin were above 75% of RNI, while intakes of vitamins A and C were less than 50% of the RNI, owing to restricted consumption of fruit and vegetables.
The reasons behind women's decision to practise ZYZ are manifold, and have been shown to be largely driven by sociocultural factors. Raven et al (2007) identified a respect for tradition and strong influences from family elders in ZYZ among new mothers in Fujian, China, but recognised that they had adapted some of the practices to reflect modern health beliefs influenced by the media, which may lead to conflict in the family. However, some new mothers also responded to elders' advice to give honeysuckle to the infant to calm skin rashes (Raven et al, 2007).
The literature on ZYZ is sparse, and little has been published on its practice in different geographical settings and among migrant families to Western countries. This is despite being a key element of postpartum care adopted by many Asian mothers around the world (Koon et al, 2005; Chen et al, 2014; Fok et al, 2016). In a comparative study of Chinese and Scottish women in their experience of postnatal care in Scotland, Cheung (1997) reported that women follow ZYZ for five reasons:
A more recent study which investigated the effects of cultural beliefs on infant and childcare practices among Chinese-American mothers in New York, USA, suggested that ZYZ is associated with the early introduction of solids and maternal reporting of a delay in lactation. It also highlighted the importance of the husband and family elders in a woman's decision to breastfeed and duration of breastfeeding (Lee and Brann, 2015).
Chinese people represent a diverse population in London with backgrounds from different Far Eastern regions, such as Hong Kong, mainland China, Taiwan, Singapore and Malaysia. According to the latest census information from the Office for National Statistics (2011), in 2010, 1.7% of live births in England and Wales were to mothers who were born in Eastern and Southeast Asia, a majority of whom were of Chinese ethnicity (where ethnicity is self-defined). The importance of cultural awareness among health professionals in enhancing postpartum care has been highlighted in the sparse studies on confinement (Cheung, 1997; Choudhry, 1997; Tien, 2004).
Aims
This qualitative study aimed to explore how cultural beliefs influence postpartum dietary choices and infant feeding practices among Chinese women living in London, to inform improved understanding of the needs of new Chinese mothers for health visitors, midwives and GPs in the community.
Methodology
Inclusion criteria were mothers of Chinese ethnicity who lived in London and had given birth in the previous 12 months. Women were recruited via posters at ‘well baby’ health clinics, Chinese community centres in London and the author's community networks. As with the national census, ethnicity was self-identified (Office for National Statistics, 2012). Consideration was given to respondents who may not be able to travel long distances with a young baby, so the respondents them selves selected locations that were convenient to them for their interviews.
Each woman was interviewed by the author through a semi-structured questionnaire based on a set of questions focusing on her infant feeding practices and postpartum dietary choices, and a discussion of her own background, her partner and wider family unit. The women's experience with health visitors and midwives after birth was also included. Each interview lasted up to 1 hour and was conducted either in English or Chinese (in Putonghua, or the Cantonese dialect), or a mix of both languages. All interviews were translated into English and transcribed verbatim. The results were analysed according to the knowledge and practice of ZYZ and infant feeding. The women's perceptions of the cultural considerations of health professionals were also discussed.
Results
Ten women of self-identified Chinese ethnicity who had given birth in the previous 12 months were interviewed during June–September 2015. The average age of respondents was 36 years. Most of them were firsttime mothers (n = 8), professionals (n = 9) and were born outside of the UK (n = 9). On average, the women had lived in the UK for 13 years at the time of the inter view (Table 1).
| Criteria | n | % | |
|---|---|---|---|
| Parity | One | 8 | 80 |
| Two | 1 | 10 | |
| Three | 1 | 10 | |
| Occupation | Employed | 9 | 90 |
| Homemaker | 1 | 10 | |
| Place of birth | Australia | 1 | 10 |
| Canada | 1 | 10 | |
| Hong Kong | 3 | 30 | |
| Mainland China | 3 | 30 | |
| Taiwan | 1 | 10 | |
| UK | 1 | 10 |
The knowledge and practice of ZYZ
All respondents reported that they knew of the practice of ZYZ, and a majority of them practised aspects of ZYZ to various extents—mainly through dietary approaches—for up to 1 month after birth. There was uncertainty and confusion over how ZYZ was defined, as some women could not say for sure whether they had practised ZYZ as the custom was not fully observed. The duration and practice of ZYZ varied according to personal circumstances, mostly convenience, practicality and the availability of help and support.
Some respondents reported that they did not practise ZYZ but considered the consumption of foods and drinks for recovery and to produce breast milk:
‘I don't really agree with the perception of ZYZ. My understanding is the mum will need to stay in bed… that's all… Also eating chicken and fish prepared in a certain way… there's not much evidence to support its usefulness, [but] I drink [Chinese] soup as it helps mums to produce breast milk.’ (R2)
‘Strictly speaking, I did not practise ZYZ. There are lots of constraints [living in the UK]. I need to take care of the baby myself. I do not have enough time to practise ZYZ completely. In general, I would adopt some specific foods and dishes due to my cultural background to eat more or eat less of.’ (R5)
‘It seems impossible to not wash your hair, or to not shower for a month, and also, in terms of the herbs, it's not as popular in the UK… it might be more of an inconvenience to everyday life after birth…’ (R10)
Diet (food and drink) was the main element through which the women regarded themselves to have practised ZYZ. Respondents recalled following a regular meal pattern based on rice, plenty of meat, some vegetables and lots of fluid. The consumption of special foods and drinks was also reported (Table 2).
| Food or drink | More or less consumed | Reason reported for increased consumption or restriction |
|---|---|---|
| Pork knuckles with vinegar | More | Nourishment, replenish collagen |
| Chicken cooked in wine | More | Energy |
| Meat- or or egg-based dishes | More | Energy |
| Soup broths such as pork ribs with vegetables and fish with papaya | More | Production of breast milk |
| Water infused with herbs or dried fruit, such as red dates and gogi berries | More | Hydration |
| Ginger | More | Relieving wind |
| Golden needles and black fungus | More | Ridding of lochia |
| Water infused with roasted rice grains | More | Ridding of lochia |
| Shangkua soup | More | Ridding of lochia |
| Cherries | More | Replenish blood loss |
| Raw and cold foods, such as salads | Less | Protect the body from catching ‘cold’ |
| Salt | Less | Keep the kidneys healthy |
| Deep-fried foods | Less | Protect the body from ‘harm’ and balance the ‘yin and yang’ |
| Shellfish | Less | Prevent the development of allergies in infant |
All fresh ingredients were bought locally in mainstream supermarkets or specialist Chinese shops, such as foods of a particular variety or cut e.g. pork knuckles. Soup packs and dried herbal ingredients were brought over by visiting mothers or sent from mainland China, Hong Kong or Taiwan, as these were not readily available in London.
‘We live quite close to a Chinese superstore, so it was convenient for us to get the traditional ingredients, my husband got a lot of the dry ingredients beforehand and the rice wine. My mum also sent me a pack of “postpartum tea” [to] which I add rice wine, goji berries and red dates to make into a drink.’ (R9)
‘I bought a ZYZ package from Taiwan [online], with around 30 days of supply. These are herbal remedies [ingredients] for soup… you only need to add meat.’ (R11)
Reasons to practise ZYZ
When asked to reflect on the main reasons to practise ZYZ, most respondents regarded their cultural background and the influence of the wider family unit and peers. Women's own mothers and their experience of childbirth have been shown to play a crucial role in informing the practice of ZYZ. Three of the respondents' mothers had travelled from mainland China to visit their daughters before or shortly after they gave birth, to prepare special dishes for them. One respondent, whose mother lived in London, said:
‘She would cook my evening meals, every day, so she would have soup every day ready, rice with ginger, chicken and rice wine, that sort of thing. She had basically decided for me, what I was going to eat.’ (R3)
The mothers who were unable to visit ensured that special ingredients and soup packs were sent to their daughters, and that they follow the dietary advice on ZYZ. One respondent reported her father as the person who influenced the way she ate by making dishes for her. The women's partners were also important in informing whether ZYZ was practised, supporting the women physically to help prepare the traditional recipes and/or emotionally by approving of the practice or disapproving of it owing to the lack of scientific evidence. One respondent had the help of a hired ‘confinement nanny’, and another that of a relative who helped her prepare special dishes to be given away to friends as a gift to announce the birth of a baby.
‘I don't think midwives have specific cultural considerations for us, but if we explained the reason to them, they might understand. When I gave birth… the midwife asked me to take a shower. I explained that it is a cultural tradition [not to], which she understood‘
‘After birth, I avoided the cold foods, such as salads… I mainly ate Chinese-style dishes because [the confinement nanny] helped us prepare these. She loves cooking… and made lots of soup, steamed fish, beef, soup noodles and chicken as well.’ (R9)
‘I have a grand-auntie, who lives in Holland, who came over to help make the ginger and pork knuckles dish. This was mainly for friends [as a gift], I did not really do much on ZYZ…’ (R7)
The fulfilment of a cultural requirement for the women's own family and peers was also discussed, which helped shape postpartum dietary preferences.
‘I have listened to the advice by my parents, also my friends, what are some of the appropriate things to do or not to do [in the period after birth]…’ (R5)
‘[The main reason was] because my parents think it is important, and asked me to take care and not to do this or that… so that they will feel happy… after birth, I slowly accepted [eating] ginger… my sister asked me to eat more chicken and pork… she hired a confinement nanny and some of the advice she still remembers, so relayed these to me…’ (R6)
Infant feeding practices
All participants breastfed their infants, either exclusively (n = 4) or occasionally supplemented with infant formula (n = 6), until solids were introduced. For those who had introduced solids at the time of the interview, most prepared weaning foods in a Chinese style:
‘Because many Chinese foods are cooked via steaming, I think this is an appropriate way to prepare foods for the baby, so it works perfectly.’ (R1)
All the women who had started giving their babies solids made a dish called ‘congee’, which is a rice-based porridge, either on its own or mixed with other ingredients such as carrots and sweet potatoes. One respondent expressed confusion over the local weaning guidelines contradicting the advice given by her family:
‘It's mostly congee, I went to some weaning groups and they said start weaning at 6 months but my family said start earlier at 4 months, but I followed the local advice here in the end as I live here.’ (R6)
Views on health professionals with respect to ZYZ
Overall, the respondents' experiences of health care were positive. In line with government advice, there was a general consensus that health-care practitioners did not endorse any special diets to aid breast milk production. However, one woman felt she received dietary advice contradictory to her own culture:
‘[One of the midwives] advised me to drink Guinness mix with milk [to produce breast milk], I was stunned. She asked me to have a glass a day. I was really perplexed as this was not something I would normally drink… They also asked me to eat some breakfast cereals, but I am not used to just drinking cold milk.’ (R6)
Another woman considered that any misunderstanding may be the result of a lack of opportunities to learn about Chinese women's cultural beliefs and practices:
‘I don't think they have specific cultural considerations for us, but if we explained the reason to them, they might understand. For example, when I just gave birth, we were still in the maternity ward and the midwives asked me to take a shower. I explained that it is a cultural tradition that we don't take showers right after birth to avoid contact with water, which she understood.’ (R1)
‘I told [the midwives] that I cannot go out as I have to practise ZYZ, and they accept it, showing at least they understood the situation.’ (R11)
While the women found mainstream UK websites, such as NHS Choices and BabyCentre, useful to inform them of dietary needs following birth, most reported that they also looked for recipe ideas to make special ZYZ dishes—either from Chinese books via the Charing Cross Library or purchased online, or via blogs and social media. It was suggested that a web-based resource that comprises ZYZ materials and recipes, available both in Chinese and English, would be a useful platform for Chinese women following childbirth, to engage with new mothers who are ethnic Chinese but may not speak or write the language:
‘I would have liked to follow ZYZ more, as my mum passed it down, perhaps similar to a lot of British-born Chinese (BBC) people… it's more like a Chinese folklore… most BBCs… cannot write Chinese, so it is more difficult to look it up on the internet and see what the proper procedure is in some ways.’ (R10)
Discussion
The postpartum period is a special time when many Chinese women consider traditional cultural beliefs that may influence their dietary choices, to aid recovery after birth and boost the production of breast milk, as well as weaning practices for the baby. Cheung (1997) found that Scottish women attended to a well-balanced diet in terms of the balance of nutrients, whereas Chinese women tried to maintain the cosmologically balanced concept of yin and yang through their diet to support lactation and maternal recovery from childbirth, and reduce the risk of future illnesses. In the current study, women reported that certain dishes provide specific nutrients such as collagen from pork knuckles to replenish body tissues, carbohydrates in rice for energy and water for hydration; this reflects the intertwining of knowledge in nutritional science with the women's cultural beliefs.
While all of the respondents were aware of ZYZ, suggesting that it is a deep-rooted Chinese custom irrespective of where the women were born, most of them only practised it to varying degrees in the period following childbirth. It was found to be particularly challenging to uphold the full set of ZYZ customs while living in London owing to limited availability of specific ingredients and the lack of physical help to prepare the dishes while caring for a newborn. Lack of knowledge about how to prepare these dishes has also been reported to be a reason that affects the practice of ZYZ. The involvement of the women's immediate and wider family to inform their dietary choices after birth suggests that the postpartum period is a time to foster social bonds, and by following the custom of ZYZ a woman can help to fulfil a cultural requirement as a way to pay respect to her own and her partner's parents (Cheung, 1997; Raven et al, 2007; Lee and Brann, 2015).
The women in this study indicated that they only followed aspects of ZYZ that were reasonable and practical, most of which involved dietary adjustments, confirming the importance of the theory of Chinese food therapy (‘shiliao’). This awareness and receptiveness of the weeks following birth as being a critical period for new mothers to improve their diet may serve as an opportunity for nutritional intervention among Chinese and some other Asian communities. Improved understanding of these needs may help midwifery practi tioners to work across cultural boundaries that influence health during the perinatal and postpartum periods (Raman et al, 2016).
‘By fostering greater awareness and understanding of various cultural groups, including consideration of the practice of zuo yuezi, health professionals such as midwives can play a key role in building rapport with new mothers’
This qualitative study has confirmed previous findings (Cheung, 1997; Choudhry, 1997; Tien, 2004) on the need to couple Western medical advice and cultural sensitivity when working with women from different ethnic groups. By fostering greater awareness and understanding of various cultural groups, including consideration of the practice of ZYZ, health professionals such as midwives and health visitors can play a key role in building rapport with new mothers. This could be achieved by working in collaboration with nutritionists to understand the needs of different cultural groups, with the aim of improving women's postpartum experience. Implementing such an initiative would require the provision of appropriate training and educational resources on specific ethnic groups, which may include recipe cards and ideas for weaning and the introduction of solids.
Limitations
As a small qualitative study, this project has many limitations. A sample of 10 respondents provided insight into the practice of ZYZ within a tight timeframe; however, interviewing more women would give rise to a greater depth of data and help increase its validity. Owing to the specificity of the inclusion criteria and Chinese women being considered as a hard-to-reach community group (Whitnell, 2004), a majority of respondents were recruited via convenience sampling, mainly in southwest London and through personal contact, which may have introduced a level of bias and generalisation of the women's experience. Additionally, transcriptions of interviews were undertaken by the author alone, as there was no other bilingual colleague available to check for accuracy.
In future studies, a 24-hour dietary recall and an exhaustive questionnaire could be used to better examine the dietary intakes of new mothers at the time of the interview, as well as comparing their postpartum dietary practice quantitatively against demographic information e.g. age, country of birth and years living in the UK (Koon et al, 2005; Fok et al, 2016). Given that the postpartum period is a crucial time for many Asian women to be more concerned about their diet, and frequently through the practice of ZYZ, this could be used as a tracker to record food and nutritional intakes and evaluate their influence on the future health of the women and their children, similar to the GUSTO birth cohort study in Singapore (Chen et al, 2014; Fok et al, 2016).
Conclusion
Culture plays an important part in what Chinese mothers in London choose to eat following childbirth for recovery or breastfeeding. This is often manifested through the practice of ZYZ and the consumption of specific foods and drinks. The woman's family, particularly her partner and her own mother, have been found to play a crucial role in her dietary choices, which often include foods that support recovery and the production of breast milk, along with restricting foods considered ‘harmful’ based on principles of traditional Chinese medicine to balance the ‘hot’ and ‘cold’ properties of the new mother.
Despite ZYZ being a key element of postpartum practice among many Chinese women, health professionals in the UK do not appear to have a strong cultural awareness of ZYZ, which may sometimes result in the provision of advice contrary to the practice. The women in this small study have suggested that the availability of English-language materials about ZYZ online, and as part of the training for professionals, may help to improve understanding of such cultural considerations and enhance health professionals' rapport with Chinese women in the perinatal and postpartum periods.