Midwifery 56 (2018) 158–170

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Midwifery
journal homepage: www.elsevier.com/locate/midw

Traditional beliefs and practices in pregnancy, childbirth and postpartum: MARK

A review of the evidence from Asian countries
⁎
Mellissa Withers, PhD, MHS Associate Professor , Nina Kharazmi, MPH MPH Student,
Esther Lim, MPH Clinical Research Coordinator
University of Southern California Keck School of Medicine, 2001 North Soto Street SSB 318G, Los Angeles, CA 90089, USA

A BS T RAC T

INTRODUCTION: Asian women suffer the largest proportion of the world’s maternal deaths. To reduce this,
policymakers and healthcare providers must encourage women with traditionally low rates of maternal health
care utilization to access services.
OBJECTIVE: The purpose of this study is to provide a comprehensive review of the most common traditional
practices in Asia relating to pregnancy, childbirth and the postpartum period.
DESIGN: We conducted a literature search of articles: a) focusing on Asia; b) relating to pregnancy,
childbirth or postpartum, c) relating to traditional beliefs and/or cultural practices; and 4) published in English
in the year 2000 or more recently.
FINDINGS: A total of 74 articles are included in this review; 20 articles related to pregnancy, 44 to
childbirth, and 45 to postpartum. More than one-half (38) of the articles focused on South Asia and 13 related to
China. In the pregnancy category, the majority of the studies focused on dietary recommendations and
behavioral taboos. For the childbirth category, many articles examined beliefs and practices that helped to
explain women’s aversion to institutional births, such as preference for traditional birth positions, and fear of
medical interventions. In the postpartum period, confinement was common because postpartum women were
perceived to be weak, fragile and vulnerable to illness. Other prevalent beliefs and practices across Asian
countries included massage, the state of pollution after childbirth, the use of traditional healers and traditional
medicine and herbs, beliefs relating to hot/cold imbalance, behavioral taboos, magic, and superstition.
KEY CONCLUSIONS: Many Asian women continue to practice a wide range of traditional beliefs and
practices during pregnancy, childbirth, and the postpartum period. More information is needed on the benefits
of formal maternal healthcare services; such educational programs should be geared towards not only women
but also husbands, parents, and in-laws. By recognizing and appreciating common local beliefs, providers can be
better positioned to provide culturally competent care. Instead of reducing the choices available to women
during the birth experience, providers should understand, respect, and integrate cultural interpretations of
childbirth and the needs of women and their families.

Introduction
Maternal mortality, deaths during pregnancy, birth or the post-
partum period, is a key indicator of women's health and status (World
Health Organization (WHO), 2015a). The top three direct causes of
maternal mortality worldwide are hemorrhage, postpartum infections,
and pre-eclampsia (Say et al., 2014; WHO, 2015a). One of the
Sustainable Development Goal (SDG) targets is to reduce the current
global maternal mortality ratio of 216 per 100,000 live births to less
than 70 per 100,000 live births by 2030 (WHO, 2015b). Asia suffers the
largest proportion of the world's maternal deaths. Of the 302,000
global maternal deaths that occurred in 2015, more than one-third
took place in the Asian region (WHO, 2015a). In fact, the Southern
Asia region, consisting of nine countries,1 accounted for about 66,000
of these deaths, while about 4800 occurred in the four countries in
Eastern Asia,2 and about 13,000 occurred in the 11 countries of South-

⁎
Corresponding author.
E-mail addresses: mwithers@usc.edu (M. Withers), kharazmi@usc.edu (N. Kharazmi), esther.lim@med.usc.edu (E. Lim).
1
Afghanistan, Bangladesh, Bhutan, India, Iran (Islamic Republic of), Maldives, Nepal, Pakistan, Sri Lanka.
2
China, Democratic People's Republic of Korea, Mongolia, Republic of Korea.

https://doi.org/10.1016/j.midw.2017.10.019
Received 17 March 2017; Received in revised form 22 October 2017; Accepted 23 October 2017
0266-6138/ © 2017 Elsevier Ltd. All rights reserved.
M. Withers et al.
Eastern Asia3 (Alkema et al., 2015; WHO, 2015b).
Overwhelming evidence demonstrates that prenatal care, skilled
attendance at birth, and adequate postpartum care could dramatically
reduce maternal (and infant) mortality rates (Bale et al., 2003;
Oyerinde, 2013; The United Nations Children’s Fund (UNICEF),
2015; WHO, 2016). However, the use of these services is low among
some Asian populations. For example, the United Nations (UN)
estimates that only 42% of women in South Asia receive the recom-
mended four or more antenatal care visits and only 49% give birth with
a skilled birth attendant (WHO, 2016). Put into perspective, antenatal
care coverage (four or more visits) in Laos is only at 37%, while it is
much higher for Cambodia and Indonesia, at 72% and 84% respec-
tively. Rates of birth with a skilled attendant is another example of
inadequate care, reaching 42% in Laos, 92% in Cambodia, 87% in
Indonesia, and 73% in the Philippines (WHO, 2016).
The utilization of formal maternal healthcare also varies greatly
within countries. Studies have documented the considerable disparities
in use of maternal healthcare services among women living in the Asia
region, demonstrating that the lowest rates of maternal healthcare
utilization often belong to the most marginalized groups, such as ethnic
minorities, women living in rural areas, women with little formal
education, and women with low economic status (White, 2004;
Liamputtong, 2004a, 2004b; Wellhoner et al., 2011; Metcalfe and
Adegoke, 2012; Sein, 2013; Culhane-Pera et al., 2015).
In recent decades, significant progress has been made in reducing
maternal mortality primarily by addressing supply-side barriers, such
as the lack of skilled birth attendants or financial constraints
(Thaddeus and Maine, 1994; Geller et al., 2006; Gil-González et al.,
2006; Piane, 2009). However, evidence demonstrates that even when
skilled formal healthcare is accessible, not all women utilize these
services, suggesting that demand-side barriers, including cultural
beliefs, women's preferences, and other factors which influence the
demand for maternal healthcare services, play an important role in
determining the likelihood that women will use formal services
(Okafor, 2000; Chapman, 2003; Kyomuhendo, 2003; Maimbolwa
et al., 2003; Rööst et al., 2004; Sibley et al., 2007b; Berry, 2006; Gil-
González et al., 2006; Piane, 2009; Sibley et al., 2009; Wellhoner et al.,
2011).
While childbirth is a biological event, the pregnancy and birth
experiences surrounding it are mostly social constructs, shaped by
cultural perceptions and practices (Steinberg, 1996; Liamputtong
2000a, 2000b; Kaphle et al., 2013). Scholars have argued that the
medical view of pregnancy and birth often fails to appreciate the
influence that traditional beliefs and practices have on maternal
healthcare service utilization (Johnson, 2008; McCourt, 2009; Titaley
et al., 2009, 2010; Benoit et al., 2010; Haines et al., 2011; Sawyer et al.,
2011; Teman, 2011). For one, beliefs surrounding a routine, uncom-
plicated pregnancy may paint a different picture than that commonly
shared within Westernized institutional medical practices. Medical
risks or problems during pregnancy may therefore go undiagnosed
for longer, the different view point delaying women from seeking care
at institutional practices while favoring more familiar informal health-
care practitioners (White et al., 2012; Morrison et al., 2014).
Considering the significant role that demand-side barriers pose to
alleviating maternal mortality, cultural competency has been garnering
greater support as a means to improving the utilization rates of
maternal healthcare services (White, 2002, 2004; Syed et al., 2008;
Agus et al., 2012; Kaphle et al., 2013; Sein, 2013; Raman et al., 2014;
Culhane-Pera et al., 2015; Fadzil et al., 2015). Often times, simplistic
analyses have blamed women and their family members for their poor
utilization of medical services during pregnancy and childbirth (Thapa
et al., 2000; Regmi and Madison, 2009; Ahmed et al., 2010; Brunson,
3
Brunei Darussalam, Cambodia, Indonesia, Lao People's Democratic Republic,
Malaysia, Myanmar, Philippines, Singapore, Thailand, Timor-Leste, Viet Nam.
159
Midwifery 56 (2018) 158–170
2010; Cindoglu and Sayan-Cengiz, 2010; Harris et al., 2010; Brown
et al., 2011; Koolenga and Stewart, 2011; Moore et al., 2011; Basnyat,
2011; Coxon et al., 2012). However, studies from around the world
demonstrate that when services are culturally competent, women and
their families express higher levels of satisfaction and have higher rates
of utilization (Choudhury et al., 2012; Sharma et al., 2013; Kaphle
et al., 2013; Culhane-Pera et al., 2015).
In order to achieve the SDG target, policymakers and health care
providers must find ways to encourage women from groups with
traditionally low rates of maternal healthcare utilization to access these
services. By recognizing and appreciating prevailing local beliefs,
maternal healthcare providers can be better positioned to provide
culturally competent care to women and their families, thereby
improving maternal and infant health outcomes when possible. The
purpose of this study is to provide a comprehensive review of the
evidence regarding the most common traditional practices in Asia
relating to pregnancy, childbirth, and the postpartum period. We
provide an account of the beliefs and practices that persist in Asian
cultures despite the modernization that has occurred in the past 15
years, examining a broad range of beliefs in three categories (preg-
nancy, childbirth, and the postpartum period) and by geographic
concentration.
Methods
We conducted a search of PubMed and Web of Science using the
following keywords: maternal, antenatal, prenatal, pregnancy, preg-
nant, childbirth, births, postnatal, postpartum, traditional, traditions,
beliefs, practices, culture, cultural, and Asia. The search resulted in a
total of 7183 citations. Three reviewers (the co-authors) independently
screened the abstracts focusing on published articles: a) relating to
Asia; b) focusing on pregnancy, childbirth or postpartum, c) relating to
cultural practices; d) in English; and e) from the year 2000 or more
recently. Duplicates and Masters theses were excluded. Eligible papers
must also have focused on traditional beliefs and practices surrounding
maternal care. While many structural factors- including cost, perceived
quality of care, transportation, and gender-related factors, such as lack
of decision-making ability by women, or lack of freedom of mobility-
are major barriers to the use of maternal health care services, they were
outside of the scope of this paper. In addition, articles on infant care
and breastfeeding were excluded, as well as articles relating to Asian
immigrants in non-Asian countries, or Asian-Americans. After this
process, the full text of 364 articles was reviewed to ensure eligibility
and a total of 74 articles were determined to fit the inclusion criteria.
See Fig. 1 for the flow of methods.
Data were extracted according to the following domains: study
setting, data collection method, study population, themes and conclu-
sions. Using thematic analysis methods, the articles were coded using
open coding during the first round and grouped into three broad
categories: pregnancy, childbirth, postpartum. They were then further
classified into themes according to the beliefs and practices discussed
in the article.
Findings
Overview
Of the 74 total articles shown in Fig. 2, 22 related to more than one
of the three categories. Upon further classification, the final review
included 20 articles that related to pregnancy, 44 articles on childbirth,
and 45 articles on postpartum practices.
Geography
The articles covered a total of 22 Asian countries. Not all countries
in Asia were represented in the articles that fit the inclusion criteria for
M. Withers et al. Midwifery 56 (2018) 158–170

PubMed & Web of Science search criteria for

published articles: a) from Asia; b) relating to
pregnancy, childbirth or postpartum; c) relating to
cultural practices; d) in English; and e) from the year
2000 or later. Masters theses excluded

Records identified through

database searching Duplicates excluded
(n = 7,183)

Records excluded focused on:

a) structural factors as barriers to
maternal health care (i.e. costs,
Abstracts screened by three reviewers quality of care, and gender-related
for inclusion factors)
b) infant care or breastfeeding
c) Asian immigrants in non-Asian
countries or Asian-Americans

Full-text articles assessed

for eligibility Full-text articles excluded for not
(n = 364) meeting inclusion criteria
(n = 290)

Studies included
(n = 74)

Fig. 1. Flow chart of processes and criteria used in the literature review selection of 74 studies on maternal health beliefs and practices in Asian countries.

this study. As shown in Fig. 3, 60.8% of articles related to South Asian

countries, including India, Nepal, and Bangladesh. A further 15
featured China, 11 featured Thailand, and nine featured Lao PDR.
Seven articles focused on several countries in one article (Syed et al.,
22 24 2008; Callister et al., 2010; Metcalfe and Adegoke, 2012; de Boer and
Childbirth
Cotingting, 2014; Van Andel et al., 2014; Downe et al., 2016; Raman
Post-Natal
et al., 2016). Many of the articles focused on a specific ethnic group
Maternal He alth
within a country, such as the Kry in Laos (Lamxay et al., 2011), Katang
5 Multiple Ca tegories
in Laos (Chithtalath and Earth, 2001), Tibetan women in China
25
(Wellhoner et al., 2011), tribal women in Gujarat, India (Sharma
et al., 2013), and the Hmong women in Thailand (Srithi et al., 2012;
Culhane-Pera et al., 2015) and Vietnam (White et al., 2012). Study
Total articl es: 74 participants included women, mothers-in-law, and healthcare provi-
ders.
Fig. 2. A breakdown of articles by section. Note that the categories are mutually Table 1 gives an overview of the major beliefs and practices found in
exclusive for clarity. this review.
We found that traditional beliefs and practices regarding pregnancy
V
Vietnam, 6
and childbirth are generally passed down inter-generationally from
Bangladesh, 12 Cambodia, 5
mothers and mothers-in-law to daughters and daughters-in-law
Thailand, 11
1 (Lundberg and Thu, 2011; Kaewsarn et al., 2003; Leung et al., 2005;
South
S Korea, 3
Callister et al., 2011; Naser et al., 2012). Women reported continuing
w Guinea,
Papua New
3 these customs in order to follow tradition, or out of a sense of familial
Pakisstan, 4 C
China, 15 duty and pressure from family members or elders, even when the
Other, 2 women themselves reported that they did not want to participate (Ali
et al., 2004; Leung et al., 2005; Raven et al., 2007; Callister et al., 2011;
Other: Cook
C Islands, pal, 12
Nep
mor, Japan,
East Tim Agus et al., 2012; Choudhury et al., 2012). Studies have found that
Palau, Samoa,
Singapo
S
ore, Tahiti, India , 17 women followed traditional practices even though they did not
Vanuatu necessarily appreciate their importance because they worried about
Myanmaar, 5 potential negative consequences (to both the infant and mother) if they
Lao PDR, 9
Malaysia,
M 4 did not adhere to these customs (Agus et al., 2012; Naser et al., 2012).
Indonesia, 6
Several studies found that older women, women with educated
Fig. 3. A geographical comparison of articles. Note that articles may apply to multiple husbands, and those living in urban areas were less likely to participate
countries. in these customs or did so for shorter periods of time when practised
(Cheung, 2002; Liamputtong et al., 2005; Chien et al., 2006; Liu et al.,
2006; Wang et al., 2009; Fadzil et al., 2015). Ethnic minority groups, as
well as women living in rural areas, were also more likely to take part in

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M. Withers et al. Midwifery 56 (2018) 158–170

Table 1
A comparison of traditional childbirth, post-natal, and maternal health practices presented in the literature.

Practice Country Description Author/year

Behavioral taboos China The following precautions are taken during pregnancy (to avoid miscarriage or • Callister et al. (2011)
India stillbirth) and/or postpartum: lifting heavy objects in farm work (i.e. rice bag or • Corbett and Callister (2012)
Myanmar water buckets); lying on one's abdomen; driving a car; and sexual intercourse. Some • Iyengar et al. (2016)
Thailand women also avoid bathing during the first month after childbirth. • Kaewsarn et al. (2003a)
Vietnam • Kaewsarn et al. (2003b)
• Lee et al. (2009)
• Leung et al. (2005)
• Liamputtong et al. (2005)
• Lundberg and Thu (2011)
• Mao et al. (2016)
• Raven et al. (2007)
• Sein (2013)
Birth Position India Women give birth at home in a squatting or kneeling position with assistance by • Afsana and Rashid (2001)
Lao PDR their family members. In Laos, women often sit with their knees to their chest, • Culhane-Pera et al. (2015)
Nepal holding onto a rope hanging from the ceiling while a traditional birth attendant puts • Iyengar et al. (2008)
Thailand abdominal pressure during childbirth. In India, women often give birth in a seated • Liamputtong (2004a, 2004b)
Vietnam position or lying supine on the floor. In Nepal, women give birth during the second • Sagdopal (2009)
stage of labor on their hands and knees. • Sychareun et al. (2012)
• Thapa et al. (2000)
• White et al. (2012)
Confinement China Home confinement practices during the postpartum period help to prevent health • Callister et al. (2011)
Malaysia problems and future complications (e.g. back or knee pain). • Fadzil et al. (2015)
Myanmar • Fok et al. (2016)
Nepal • Leung et al. (2005)
Singapore • Liamputtong (2004a, 2004b)
Thailand • Liu (2006)
• Poh et al. (2005)
• Raven et al. (2007)
• Sein (2013)
• Thapa et al. (2000)
• Tien (2004)
Fear of Medical India Many women avoid hospitals to give birth due to the fear of medical interventions, • Afsana and Rashid (2001)
Interventions Lao PDR such as a cesarean section and episiotomy. Some women feel dehumanized in the • Barnes (2007)
Nepal hospital setting, which further exacerbates their fear. • Corbett (2012)
• Regmi and Madison (2009)
• Sreeramareddy et al. (2006)
• Sychareun et al. (2012)
Food Taboos Cambodia Cold foods are avoided and hot foods are encouraged during the first month • Agus et al. (2012)
China postpartum. For the Malays, food taboos include avoiding “cold” vegetables (e.g. • Barennes et al. (2009)
India water spinach, spinach, and pumpkins). By comparison, some foods (e.g. beef, • Callister (2006)
Indonesia mutton, rice with black pepper, anchovies, and salted fish) and certain drinks (e.g. • Callister et al. (2011)
Lao PDR coffee and milk) are considered “hot” and thus suitable for postpartum mothers. In • Corbett and Callister (2012)
Malaysia China, women must refrain from consuming “cold” food, as it is believed to create an • Diamond-Smith et al. (2016)
Myanmar imbalance of qi, resulting in sore back muscles, poor circulation, and a weaker • Fadzil et al. (2015)
Nepal bladder and uterus. “Cold” foods includes fruit and raw or cooked vegetables such as • Fok et al. (2016)
Singapore cabbage, bamboo shoots, and turnips. Additional dietary precautions (and beliefs): • Iyengar et al. (2008)
Thailand spicy hot food (baby may be born hairless); coffee and tea (decreases child's • Iyengar et al. (2016)
Vietnam intelligence); consuming more than half of a banana (eating a whole banana may • Kaewsarn et al. (2003b)
result in birth obstruction); shell fish and northern Thai relishes (prevent the • Lee et al. (2009)
perineum from drying out after giving birth); and Thai eggplant (will cause anal pain • Leung et al. (2005)
after giving birth or during yu duan). • Liamputtong et al. (2005)
• Liu et al. (2006)
• Liu et al. (2009)
• Lundberg and Thu (2011)
• Mao et al. (2016)
• Mukhopadhyay
(2009)
and Sarkar

• Poh et al. (2005)

• Raman et al. (2014)
• Raven et al. (2007)
• Sein (2013)
• Thapa et al. (2000)
• White (2004)
Hot/Cold imbalance Cambodia Mothers often visit steam rooms or baths in order to promote hygiene, healing and • Barennes et al. (2009)
Lao PDR recovery after childbirth. During postpartum, women lie atop beds with fire • dede Boer and Lamxay (2009)
Thailand underneath to restore heat ("roasting"). • Kaewsarn
Boer et al. (2011)
Vietnam • Kaewsarn etet al.al. (2003a)
• Lundberg and Thu (2003b)
• (2011)
(continued on next page)

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Table 1 (continued)

Practice Country Description Author/year

• Sychareun et al. (2012)

• White (2004)
Magic and mantra Bangladesh Magical healers conduct blessings and rituals to promote an easy birth. Rituals will • Downe et al. (2016)
Cambodia also be conducted during difficult births and prolonged labor. Many spiritual acts • Haq (2008)
India involve offerings of specially prepared food, beverages, and household items to • Liamputtong et al. (2005)
Indonesia deities and spirits. Ceremonies may also involve music, prayers, and ritualistic • Raman et al. (2016)
Lao PDR chanting. • Sarfraz et al. (2015)
Nepal • Sychareun et al. (2012)
Pakistan • Syed et al. (2008)
Papua New Guinea • Thapa et al. (2000)
Taiwan • Vallely et al. (2015)
Thailand
Vietnam
• White (2004)
Massage Cambodia Prenatal and postpartum massage is commonly performed and viewed as beneficial • Agus et al. (2012)
Indonesia in many countries. In Nepal, childbirth often starts with a birth-attendant massaging • Fadzil et al. (2015)
Malaysia a woman's abdomen. • Fok et al. (2016)
Singapore • Kaewsarn et al. (2003b)
Thailand • Lewis et al. (2015)
• Liamputtong et al. (2005)
• Naser et al., (2012)
• Sagdopal (2009)
• Thapa et al. (2000)
• White (2002)
• White (2004)
State of pollution India Women are secluded during menstruation, childbirth, and postpartum. They are not • Chithtalath and Earth (2001)
Nepal allowed to prepare food, tend to the garden or crops, or collect water from the river. • Haq (2008)
Pakistan This is due to the belief that vaginal blood can cause sickness, poor health, and • Kaphle et al. (2013)
Papua New Guinea possibly death. • Metcalfe and Adegoke (2012)
• Syed et al. (2008)
• Thapa et al. (2000)
• Vallely et al. (2015)
Traditional Medicine & Lao PDR Plants and herbs are used for a range of conditions during pregnancy, childbirth, and • Abe and Ohtani (2013)
Herbs Malaysia Philippines the postpartum period. • Barennes et al. (2009)
South and Southeast • Callister et al. (2011)
Asia * • dede Boer and Cotingting (2014)
Thailand • de Boer and Lamxay (2009)
Vietnam • Fadzil
Boer et al. (2011)
• Lundberg et al. (2015)
• Poh et al. (2005)
and Thu (2011)
• Srithi et al. (2012)
• Sychareun et al. (2012)
• Van Andel et al. (2014)
•
*
South East Asia and the surrounding countries includes the following: Bangladesh, Cambodia, China, Cook Islands, East Timor, India, Indonesia, Japan, Laos, Malaysia, Myanmar,
Nepal, Palau, Papua New Guinea, Philippines, Samoa, South Korea, Tahiti, Thailand, Tonga, Vanuatu, and Vietnam.

traditional rituals (Thapa et al., 2000; Sychareun et al., 2012).
However, other studies have found that these beliefs and practices
are still widely observed even among educated urban women. For
example, Raven et al. (2007) found that confinement was reportedly
common in both urban and rural families in China. Sein et al. (2013)
found in Myanmar that traditional postpartum practices were widely
followed, regardless of area of residence or educational level.
Results by category
Pregnancy
Table 2 shows the 20 articles included in the pregnancy category,
which included 11 studies that were qualitative only, seven that were
quantitative only, and two that were both.
Several studies documented that pregnancy is widely viewed as a
natural phenomenon and not as a risky condition (Syed et al., 2008;
Brunson, 2010; Thapa et al., 2000; Agus et al., 2012). In some cases,
this belief contributed to delayed recognition of dangerous pregnancy
complications (White, 2002; Syed et al., 2008; Brunson, 2010; Agus
et al., 2012). However, the majority of the traditional beliefs and
practices were innocuous.
A majority of the studies in this category focused on food
recommendations and taboos to be observed during pregnancy.
Studies found that pregnant women generally avoided “hot” foods.
For example, Pakistanis considered foods like sugar, nuts, beans and
maize as hot and abortifacient (Ali et al., 2004). Alternatively, studies
found that “cold” foods, such as buttermilk, oranges, and curd were
avoided during pregnancy because they were believed to harm the
fetus. Others found that “cold” foods were restricted only during
lactation (Ali et al., 2004; Agus et al., 2012). For example, women in
Indonesia believed that eating fish would make their breast milk smell
and taste bad (Agus et al., 2012). Food recommendations and restric-
tions were also sometimes based on beliefs regarding the effects they
had on the growth of the baby (Ali et al., 2004; Mukhopadhyay and
Sarkar 2009; Culhane-Pera et al., 2015). For example, Culhane-Pera
et al. (2015) noted that prenatal vitamins were often avoided because
they were thought to promote excessive fetal growth, discouraging an
easy birth. Some Chinese women believed that eating shrimp would
cause skin allergies, eating rabbit meat led to the development of cleft

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Table 2 Table 3
A comparison of demographic and methodological characteristics of studies relating to A comparison of demographic and methodological characteristics of individual studies in
pregnancy. the meta-synthesis.

Pregnancy Childbirth

No. Authors/year Country Research Design No. Authors/year Country Research Design

1 Agus et al. (2012) Indonesia Qualitative study 1 Afsana and Rashid Bangladesh Qualitative study
2 Brunson (2010) Nepal Qualitative and (2001)
quantitative study 2 Barnes (2007) India Qualitative study
3 de Boer and Cotingting Southeast Asia and Quantitative study 3 Brunson (2010) Nepal Qualitative and
(2014) surrounding countries quantitative study
*
4 Callister et al. (2011) China Qualitative study
4 de Boer and Lamxay Lao PDR Qualitative study 5 Chithtalath and Earth Lao PDR Qualitative study
(2009) (2001)
5 Downe et al. (2016) Indonesia, Taiwan Qualitative study 6 Choudhury et al. Bangladesh Qualitative and
and Vietnam (2012) quantitative study
6 Lamxay et al. (2011) Lao PDR Qualitative study 7 Corbett and Callister India Qualitative study
7 Lee et al. (2009) China Quantitative study (2012)
8 Mukhopadhyay and India Quantitative study 8 Culhane-Pera et al. Thailand Qualitative study
Sarkar (2009) (2015)
9 Raman et al. (2014) India Qualitative study 9 de Boer and Cotingting Southeast Asia and Quantitative study
10 Raman et al. (2016) Asia † Qualitative study (2014) surrounding countries*
11 Rees and Yoneda India Qualitative study 10 de Boer and Lamxay Lao PDR Qualitative study
(2013) (2009)
12 Sarfraz et al. (2015) Pakistan Qualitative study 11 Deepak et al. (2013) India Qualitative study
13 Sreeramareddy et al. Nepal Quantitative study 12 Diamond-Smith et al. Myanmar Qualitative study
(2006) (2016)
14 Srithi et al. (2012) Thailand Quantitative study 13 Fronczak et al. (2007) Bangladesh Qualitative study
15 Sychareun et al. (2012) Laos Qualitative study 14 Haq (2008) India Qualitative study
16 Syed et al. (2008) Bangladesh, Nepal Quantitative study 15 Iyengar et al. (2008) India Qualitative study
and Pakistan 16 Kamal (2013) Bangladesh Quantitative study
17 Thapa et al. (2000) Nepal Qualitative and 17 Kaphle et al. (2013) Nepal Qualitative study
quantitative study 18 Lamxay et al. (2011) Lao PDR Qualitative study
18 Titaley et al. (2010) Indonesia Qualitative study 19 Lewis et al. (2015) Nepal Qualitative study
19 Wellhoner et al. (2011) China Quantitative study 20 Liamputtong et al. Thailand Qualitative study
20 White (2002) Cambodia Qualitative study (2005)
§
Total Qualitative studies: 13 Quantitative studies: 9 21 Liamputtong (2004a) Thailand Qualitative study
22 Liamputtong (2005) Thailand Qualitative study
Palau, Papua New Guinea, Philippines, Samoa, South Korea, Tahiti, Thailand, Tonga, 23 Metcalfe and Adegoke Bangladesh, India, Nepal Qualitative and
Vanuatu, and Vietnam. (2012) and Pakistan quantitative study
*
South East Asia and the surrounding countries includes the following: Bangladesh, 24 Mirzabagi et al. (2013) India Qualitative study
Cambodia, China, Cook Islands, East Timor, India, Indonesia, Japan, Laos, Malaysia, 25 Morrison et al. (2014) Nepal Qualitative study
Myanmar, Nepal, 26 Naser et al. (2012) Singapore Qualitative study
†
Article examines the following regions: South Asia – Bangladesh, India, Nepal, and 27 Raman et al. (2016) Asia† Qualitative study
Pakistan; Asia – Indonesia, Cambodia, China, Laos, Myanmar, Philippines, and Vietnam. 28 Regmi and Madison Nepal Qualitative study
§
Qualitative and quantitative studies are not mutually exclusive. (2009)
29 Sagdopal (2009) India Qualitative study
30 Sarfraz et al. (2015) Pakistan Qualitative study
palates, and eating any meat was generally negative for fetal health. 31 Sharma et al. (2013) India Qualitative study
Several studies also documented the widespread use of traditional 32 Sreeramareddy et al. Nepal Quantitative study
medicines and herbs among pregnant women in Asian cultures. Taken (2006)
orally, used in medicinal baths, enemas, or as ointments, most were 33 Srithi et al. (2012) Thailand Quantitative study
34 Story et al. (2012) Bangladesh Qualitative study
commonly used to combat nausea during pregnancy or to stimulate
35 Sychareun et al. (2012) Lao PDR Qualitative study
labor (de Boer and Lamxay, 2009; Srithi et al., 2012; Agus et al., 2012; 36 Syed et al. (2008) Bangladesh, Nepal, and Quantitative study
Rees and Yoneda, 2013; de Boer and Cotington, 2014; Raman et al., Pakistan
2014). Others discussed the importance of traditional practitioners, 37 Thapa et al. (2000) Nepal Qualitative and
such as spiritual healers and religious leaders, as protectors of the quantitative study
38 Titaley et al. (2010) Indonesia Qualitative study
pregnant (Syed et al., 2008; Wellhoner et al., 2011; Rees and Yoneda, 39 Vallely et al. (2015) Papua New Guinea Qualitative study
2013). Syed et al. (2008) found that women in Pakistan preferred to 40 Van Andel et al. (2014) Southeast Asia and Quantitative study
use amulets and holy water to solve problems rather than seek out surrounding countries*
formal healthcare services. Prenatal massage, often given by a tradi- 41 Van Hollen (2003) India Qualitative study
42 Wellhoner et al. (2011) China Quantitative study
tional healer, was also noted as a common practice believed to promote
43 White et al. (2012) Vietnam Qualitative study
maternal and infant health (White, 2002; Liamputtong et al., 2005; 44 White (2002) Cambodia Qualitative study
Agus et al., 2012). Total§ Qualitative studies: 37 Quantitative studies: 11

Childbirth
For childbirth, as seen in Table 3, a total of 44 studies were
included. This included 33 studies that were only qualitative, seven that
were only quantitative, and four that featured both.
Many of the articles in this category examined reasons behind the
preference for a home birth (Liamputtong, 2005; Sreeramareddy et al.,
Palau, Papua New Guinea, Philippines, Samoa, South Korea, Tahiti, Thailand, Tonga,
Vanuatu, and Vietnam.
*
South East Asia and the surrounding countries includes the following: Bangladesh,
Cambodia, China, Cook Islands, East Timor, India, Indonesia, Japan, Laos, Malaysia,
Myanmar, Nepal, Palau, Papua New Guinea, Philippines, Samoa, South Korea, Tahiti,
Thailand, Tonga, Vanuatu, and Vietnam.
†
Article examines the following regions: South Asia – Bangladesh, India, Nepal, and
Pakistan; Asia – Indonesia, Cambodia, China, Laos, Myanmar, Philippines, and Vietnam.
§
Qualitative and quantitative studies are not mutually exclusive.

163
M. Withers et al.
2006; Haq, 2008; Sagdopal, 2009; White et al., 2012; Choudhury et al.,
2012; Sychareun et al., 2012; Kaphle et al., 2013; Culhane-Pera et al.,
2015). In some South Asian cultures, especially among lower-caste
populations, women have traditionally given birth in a cowshed (Thapa
et al., 2000; Regmi and Madison, 2009; Sharma, 2013; Kaphle et al.,
2013) or a special hut constructed for birthing (Vallely et al., 2015;
Lamxay et al., 2011). Commonly seen as a time of impurity, any contact
with a pregnant woman's bodily fluids was avoided (Thapa et al., 2000;
Brunson, 2010; Choudhury et al., 2012; Kaphle et al., 2013; Sharma,
2013; Vallely et al., 2015). In Papua New Guinea, notably, it is a
woman's responsibility to dispose of the “contaminated” placenta,
which abides by cultural and spiritual beliefs regarding pregnancy
and birth as “polluting” in contrast to the “holiness” of the home
(Vallely et al., 2015; Thapa et al., 2000; Metcalfe and Adegoke, 2012;
Kaphle et al., 2013). However, Brunson's (2010) study in Nepal
suggests that the influence of such beliefs on “pollution” is fading,
with more women opting to dismiss the practice of postpartum
seclusion for pragmatic reasons, or sustain it since it is easier to clean
the area afterwards (Vallely et al., 2015).
Since childbirth is seen as a natural and normal occurrence in many
Asian cultures, hospital births were generally deemed unnecessary if
not for complications (Afsana and Rashid, 2001; Thapa et al., 2000;
Liamputtong, 2004, 2005; Syed et al., 2008; Titaley et al., 2010;
Sychareun et al., 2012; White et al., 2012; Kaphle et al., 2013; Culhane-
Pera et al., 2015). Health clinics and hospitals were commonly
perceived to be places for treating health problems and disease,
therefore, women who were treated there were unwell and had
complicated pregnancies. In Bangladesh, for example, women reported
that they would suffer stigma if they gave birth at a hospital or clinic
because they would be perceived as being “sick” and having a defective
body (Afsana and Rashid, 2001). Mirzabagi et al. (2013) found that
obstetric complications, including prolonged and obstructed labor,
were perceived by some in India to be modern-day phenomena and
that medical interventions are due to sedentary lifestyles, which cause
difficulties in labor and birth.
Another common reason for choosing a home birth was the
perception that it allowed greater control over the birth experience.
Women reported fear or anxiety regarding institutional births for
several reasons. First, the medicalization of birth at hospitals and
clinics was viewed as being prohibitive (Afsana and Rashid, 2001;
Liamputtong, 2005; Iyengar et al., 2008; Kaphle et al., 2013; Morrison
et al., 2014; Culhane-Pera et al., 2015). As an example, when women or
family members thought health centers would not allow them to bury
the placenta, a common practice, they often avoided giving birth at a
health center (Barnes, 2007; White et al., 2012; Culhane-Pera et al.,
2015). The position for giving birth was also important. Women often
desired birthing positions such as sitting, kneeling, or squatting, which
all contradict the position of lying on one's back that is routinely
practised in many hospitals and other formal healthcare settings
(Thapa et al., 2000; Afsana and Rashid, 2001; Liamputtong, 2004,
2005; White et al., 2012; Sychareun et al., 2012; Morrison et al., 2014;
Culhane-Pera et al., 2015). Moreover, Nepali women reported that they
avoided institutional births because there was no warming system for
their babies, referring to traditional beliefs regarding the need to
restore lost heat after birth (Thapa et al., 2000).
Obstetric interventions were also a source of fear, with women often
believing that they would be forced to undergo one at a hospital or
institution. Episiotomies, the induction of labor through drugs, sutur-
ing after birth, and caesarean sections (with or without their consent)
were all reported concerns (Afsana and Rashid, 2001; Liamputtong,
2004a, 2005; Barnes, 2007; Regmi and Madison, 2009; Naser et al.,
2012; Sychareun et al., 2012; Sharma, 2013; Culhane-Pera et al.,
2015). Afsana and Rashid (2001) found that Bangladeshi women
reported that they would suffer stigma if they gave birth at a hospital
because they would be forced to undergo surgery; any form of incision,
whether abdominal or perineal, was regarded negatively. Women also
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Midwifery 56 (2018) 158–170
mentioned that if the scar remained unhealed, it affected their regular
household chores, sexual relations with their husbands and eventually
their social status. Sychareun et al. (2012) found that women in Laos
reported not wanting to be sutured after birth because this would
interfere with the hot bed rituals postpartum. Similarly, the importance
of warmth being available in the birthing room has been reported in
Nepal as well (White et al., 2012; Thapa et al., 2000; Sreeramareddy
et al., 2006). Although meant to alleviate pain and facilitate birth,
clinical interventions diminished a woman's birth experience (Van
Hollen, 2003; Sharma, 2013; Deepak et al., 2013; Mirzabagi et al.,
2013). In contrast, several studies from India found the unmonitored
use of uteronics, such as oxytocin, to be commonly practised as a
means to increase labor pains and speed birth, even in home births
(Sreeramareddy et al., 2006; Iyengar et al., 2008; Deepak et al., 2013;
Mirzabagi et al., 2013; Sharma, 2013).
Many women also felt that hospital-based care was very imperso-
nal, a setting where they felt "reduced to an object" and "observers to
their own childbirth" (Regmi and Madison, 2009). Several studies
found that women felt mistreated by healthcare workers at clinics
(Afsana and Rashid, 2001). In addition, numerous studies from a range
of Asian cultures reported that women felt embarrassment, shyness, or
shame regarding having to bare themselves to strangers, and that a lack
of privacy violated their modesty (Afsana and Rashid, 2001; Brunson,
2010; Story et al., 2012; Sychareun et al., 2012; Morrison et al., 2014;
Culhane-Pera et al., 2015). Yet at the same time, it was culturally
unacceptable for them to speak out regarding these feelings. In
Thailand, women were mostly passive and accepted a healthcare
provider's advice without question, even when it contradicted their
own preferences, because they believed the dynamic demanded the
woman's compliance rather than an open discussion (Liamputtong,
2004a). Chinese women similarly did not repudiate a care provider's
decision with respect to their own preferences or beliefs because of
concern for “saving face (lian)” (Lau and Wong, 2008).
As childbirth is considered to be a family affair in many Asian
cultures, most women were found to prefer their husbands and/or
other family members to be present at birth, which was often in
opposition to a birthing institution's isolation policies (Thapa et al.,
2000; Afsana and Rashid, 2001; Chithtalath and Earth, 2001;
Liamputtong, 2004a; Barnes, 2007; Haq, 2008; Naser et al., 2012;
Sychareun et al., 2012; White et al., 2012; Sharma, 2013; Morrison
et al., 2014; Culhane-Pera et al., 2015; Lewis et al., 2015). The presence
of family members and the community at large gave women comfort
and psychological support during home births (Sharma, 2013;
Culhane-Pera et al., 2015). However, not all family members were
equally involved across different Asian societies. In our analysis, male
involvement during childbirth greatly varied, where some traditions
designated childbirth as solely within a woman's domain. As such, only
females could be present beside a birthing bed. In others, male partners
were encouraged to take part, undertaking such duties as cutting the
umbilical cord (Brunson, 2010; Lewis et al., 2015). Only two studies
(both from Nepal) reported that some women believed that a husband's
presence during birth could cause complications (Lewis et al., 2015) or
put them at risk of “pollution” (Thapa et al., 2000).
Superstitious beliefs about pregnancy and childbirth were found in
several countries, including Nepal, Bangladesh, India and Papua New
Guinea (Thapa et al., 2000; Barnes, 2007; Regmi and Madison, 2009;
Choudhury et al., 2012; Kaphle et al., 2013; Vallely et al., 2015).
Purifications and rituals were considered to protect a birthing woman
from evil spirits complicating childbirth (Vallely et al., 2015). Hmong
women in Thailand found that the presence of household spirits
ensured safe birth (Culhane-Pera et al., 2015). Bangladeshi women
found that malevolent spirits could cause excessive, forceful and
continuous bleeding, as well as blood clots, and that women would
seek help from a traditional healer if this occurs (Sibley et al., 2009).
Traditional birth attendants (TBAs) or healers were also widely
favored compared to formal healthcare providers (Regmi and Madison,
M. Withers et al.
2009; Cheung and Pan, 2012; Choudhury et al., 2012; Sychareun et al.,
2012; Kamal, 2013; Culhane-Pera et al., 2015). Numerous reasons
were cited for this preference, including cultural beliefs and practices
regarding the use of traditional medicines, as well as the personal
support that TBAs offered. In Laos (Sychareun et al., 2012), the
predominant role of TBAs was to administer traditional medicines
and “magic water” that has been prayed over by a healer or by lay
people, believed to relieve pain, treat abnormal discharge, and energize
the mother for a smooth birth. TBAs also often performed what was
seen as important natural interventions during childbirth. In studies
from India, Laos, Bangladesh, and Nepal, women desired the strong
massages that TBAs provided, who would also push down on the
abdomen during birth, and in some cases, further encourage the
expulsion of the placenta after birth by pulling on the umbilical cord
or making the mother gag (Thapa et al., 2000; Fronczak et al., 2007;
Iyengar et al., 2008; Titaley et al., 2010; Sychareun et al., 2012).
Furthermore, TBAs were often responsible for ritually burying the
placenta where birth took place, usually at home (Barnes, 2007).
Used for everything from inducing labor and placental delivery to
preventing uterine prolapse, medical plants and herbs were often seen
as essential (de Boer and Lamxay, 2009; Lamxay et al., 2011; Srithi
et al., 2012; Van Andel et al., 2014; de Boer and Cotingting, 2014). For
example, a string of bamboo fiber could be used to tie the umbilical
cord and a piece of freshly cut sugarcane to sever the umbilical cord
(Lamxay et al., 2011). In one study from India, women in labor were
fed clarified butter, ginger, lentils, milk, or tea, which are believed to
facilitate labor by promoting warmth (Mirzabagi et al., 2013). Laotian
women drank blessed or coconut water, along with placing holy water
or eggs on their abdomens, to ease birth (Sychareun et al., 2012). Two
other studies from Nepal described women drinking cumin seed soup
and glucose water to gain strength for birth, as well as using mustard
oil or turmeric for childbirth, rubbing it on the stump of the umbilical
cord and/or the newborn at times (Thapa et al., 2000; Sreeramareddy
et al., 2006).
Food taboos continued on from pregnancy up to the very moment
of birth. As mentioned previously, physiological changes during
pregnancy are believed to cause a hot/cold imbalance in the body,
with pregnancy itself considered to be an over-heated state. “Cold”
foods were believed to help correct this imbalance and avoid a
miscarriage (Callister et al., 2011; Naser et al., 2012). In India,
however, women would use “hot” foods to encourage labor towards
the end of pregnancy (Naser et al., 2012). In China, it was reported that
some women believed that “sour” foods increased the likelihood of a
male child, while “hot” foods were associated with female children
(Callister et al., 2011).
In addition, more general taboos were reported in numerous
studies from across Asia. In studies from China, sex had to be avoided
to prevent miscarriages and pregnant women were expected to remain
mostly immobile, as well as avoid frightening experiences or negative
emotions that could stress the unborn child (Callister et al., 2011).
Other common taboos were to avoid wearing high-heels, hammering
nails into walls, and moving heavy furniture (Lee et al., 2009). In
contrast, Indian mothers were encouraged to continue on with normal
work schedules and to be more active in order to physically prepare for
a normal birth. They were also advised to never sleep on their backs,
always sit up to turn over, and never sit in a cross-legged position
(Corbett and Callister, 2012).
Postpartum
For the postpartum category, as seen in Table 4, a total of 45 studies
were included. This included 26 studies that were only qualitative, 10
that were only quantitative, and nine that featured both.
Traditional postpartum practices persist in many Asian cultures
based on the belief that they assure the health of the mother and baby,
with failure to comply widely believed to result in long-lasting health
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Midwifery 56 (2018) 158–170
problems for both (Liamputtong, 2004b; Syed et al., 2008; Liu et al.,
2009; Callister et al., 2011). Women in China, Cambodia, Laos, Nepal,
Thailand, Myanmar, Singapore, and Vietnam similarly believe that the
first few days up to 40 days postpartum is a time for isolation and
confinement (Thapa et al., 2000; Syed et al., 2008; Naser et al., 2012).
In China, this period of vulnerability is called the “sitting month” or
“doing the month” (Leung et al., 2005; Callister, 2006; Liu et al., 2009),
in Thailand it is called Yu Duan (Liamputtong, 2004b), and sawsaye in
Cambodia (White, 2004).
The exact procedure associated with confinement practices vary
considerably across cultures, but all focus on the placement of
restrictions on a woman's movement after giving birth. The purpose
of this confinement is mostly to aid the mother in resting and building
back strength, as postpartum women are considered to be weak, fragile
and vulnerable to illness. It also helps to minimize the risk of any
infections passing onto the woman and newborn within this sensitive
period (Thapa et al., 2000; Raven et al., 2007). However, in countries
like Nepal, Bangladesh, Papua New Guinea, and Pakistan, the main
motivation for this isolation is to protect others from their “polluted”
states for up to one month postpartum (Thapa et al., 2000; Syed et al.,
2008; Lewis et al., 2015; Vallely et al., 2015). The Chinese in particular
consider this practice important to provide social support, which
ensures physical and emotional recovery, facilitating the transition to
motherhood. More recently, there has been a modification made to the
more than 2000-year-old Chinese tradition of “doing the month”
(zuoyuezi), which now integrates the maternal or paternal grand-
mother in providing maternal/newborn care for the first month at
postpartum (Cheung et al., 2006).
The most common rationale for postpartum susceptibility is
thought to be due to a loss of body heat during childbirth, which again
results in an imbalance between the hot and cold forces in women's
bodies (Liu et al., 2009; Syed et al., 2008). Symptoms attributed to this
imbalance include shortness of breath, anemia, dizziness, headaches,
diarrhea, heart palpitations, sore back muscles, poor circulation, a
weak bladder, and headaches (White, 2004; de Boer et al., 2011). In
Cambodia however, it was the influence of ghosts or spirits called priey
krawlah pleung, which would attack women left exposed after birth,
causing symptoms such as seizures, fainting, altered consciousness, or
other similar behaviors (White et al., 2002; White, 2004).
The accepted method of treatment for postpartum temperature
imbalance is heat therapy. In many countries such as Cambodia, Laos,
Vietnam, China, and Malaysia, for several days or even weeks after
birth, women would be wrapped in blankets and/or herbs (White,
2004; Fadzil et al., 2015) and, similar to a steam placed atop beds with
fire and medicinal leaves burning underneath to restore lost heat
(White et al., 2002; White, 2004; Lundberg and Thu, 2011; de Boer
et al., 2011; Kaewsarn et al., 2003b; Barennes et al., 2009; Fadzil et al.,
2015; de Boer and Cotingting, 2014; Sychareun et al., 2012). de Boer
et al. (2011) in Laos identified ten plant species that were commonly
used for steam saunas and baths, hotbeds, and “roasting”. In
Cambodia, White (2004) found that injecting “hot” medicines instead
of “roasting” is being increasingly favored for its efficiency. Thai women
would also have heat lamps placed on the perineum (Kaewsarn et al.,
2003b; Liamputtong, 2004b).
Protecting the body from additional heat loss after birth was
thought to be just as critical as restoring it. Studies from China,
Vietnam, Cambodia, Thailand, Laos and Myanmar found that most
people believed women should be kept covered and kept inside for
protection from the cold, rain, and especially the wind (White et al.,
2002; Kaewsarn et al., 2003; White, 2004; Leung et al., 2005; Syed
et al., 2008; Barennes et al., 2009; Liu et al., 2009; Lundberg and Thu,
2011). Massages were also routinely practised at postpartum with hot
compresses or body wraps using medicinal plants (Barnes, 2007; Fadzil
et al., 2015). Interestingly, Cambodian women utilized strong mas-
sages, with or without heat, to dislodge “leftover” blood remaining
stuck to the uterus during birth (White, 2004).
M. Withers et al. Midwifery 56 (2018) 158–170

Table 4
A comparison of demographic and methodological characteristics of studies relating to postpartum.

Post-Natal

No. Authors/year Country Research Design

1 Abe and Ohtani (2013) Philippines Quantitative study

2 Barennes et al. (2009) Lao PDR Qualitative study
3 Barnes (2007) India Qualitative study
4 Brunson (2010) Nepal Qualitative and quantitative study
5 Callister (2006) China Background of post-partum traditions
6 Callister et al. (2010) China, India, South Korea, and Thailand * Qualitative study
7 Callister et al. (2011) China Qualitative study
8 Choudhury et al. (2012) Bangladesh Qualitative and quantitative study
9 Culhane-Pera et al. (2015) Thailand Qualitative study
10 de Boer and Cotingting (2014) Southeast Asia and surrounding countries † Quantitative study
11 de Boer et al. (2011) Lao PDR Qualitative study
12 de Boer and Lamxay (2009) Lao PDR Qualitative study
13 Diamond-Smith et al. (2016) Myanmar Qualitative study
14 Fadzil et al. (2015) Malaysia Qualitative and Quantitative study
15 Fok et al. (2016) Singapore Quantitative study
16 Fronczak et al. (2007) Bangladesh Quantitative study
17 Iyengar et al. (2016) India Qualitative study
18 Kaewsarn et al. (2003a) Thailand Qualitative study
19 Kaewsarn et al. (2003b) Thailand Qualitative study
20 Lamxay et al. (2011) Lao PDR Qualitative study
21 Leung et al. (2005) China Qualitative study
22 Liamputtong (2004b) Thailand Qualitative study
23 Liu et al. (2006) China Qualitative study
24 Liu et al. (2009) China Quantitative study
25 Lundberg and Thu (2010) Vietnam Qualitative study
26 Mao et al. (2016) China Quantitative study
27 Mukhopadhyay and Sarkar (2009) India Quantitative study
28 Poh et al. (2005) Malaysia Qualitative and quantitative study
29 Raman et al. (2016) Asia § Qualitative study
30 Raven et al. (2007) China Qualitative study
31 Sarfraz et al. (2015) Pakistan Qualitative study
32 Sein (2013) Myanmar Qualitative and quantitative study
33 Sibley et al. (2009) Bangladesh Qualitative and quantitative study
34 Sibley et al. (2007a) Bangladesh Qualitative study
35 Sreeramareddy et al. (2006) Nepal Quantitative study
36 Sychareun et al. (2012) Laos Qualitative study
37 Syed et al. (2008) Bangladesh, Nepal, and Pakistan Quantitative study
38 Thapa et al. (2000) Nepal Qualitative and quantitative study
39 Tien (2004) China Qualitative and quantitative study
40 Titaley et al. (2010) Indonesia Qualitative study
41 Vallely et al. (2015) Papua New Guinea Qualitative study
42 Wang et al. (2009) China Qualitative and quantitative study
43 Wellhoner et al. (2011) China Quantitative study
44 White (2004) Cambodia Qualitative study
45 White (2002) Cambodia Qualitative study
Total¶ Qualitative studies: 35 Quantitative studies: 19

Europe, Uganda, and Latin America. Only China, India, South Korea and Thailand were included for this paper.
Palau, Papua New Guinea, Philippines, Samoa, South Korea, Tahiti, Thailand, Tonga, Vanuatu, and Vietnam.
*
Article examines the following regions: United States, Canada, the United Kingdom, Western Europe, New Zealand and Australia, Thailand, Korea, China, India, Mexico, Nigeria,
Eastern.
†
South East Asia and the surrounding countries includes the following: Bangladesh, Cambodia, China, Cook Islands, East Timor, India, Indonesia, Japan, Laos, Malaysia, Myanmar,
Nepal.
§
Article examines the following regions: South Asia – Bangladesh, India, Nepal, and Pakistan; Asia – Indonesia, Cambodia, China, Laos, Myanmar, Philippines, and Vietnam.
¶
Qualitative and quantitative studies are not mutually exclusive.

An extension of the concept regarding heat imbalances found in
the body, dietary beliefs and practices were redundantly found in
most of the countries examined. Again, “hot” foods and drinks were
encouraged to promote circulation of energy in the body, such as
ginger and eggs marinated in black vinegar, while “cold” foods like
fruit and raw or cooked vegetables are to be avoided (Cheung, 2002;
Kaewsarn et al., 2003; White, 2004; Leung et al., 2005; Liu et al.,
2006, 2009; Callister, 2006; Raven et al., 2007; Syed et al., 2008;
Mukhopadhyay and Sarkar, 2009; Barennes et al., 2009; Lamxay
et al., 2011; Naser et al., 2012; Fadzil et al., 2015). Alternatively,
Fadzil et al. (2015) found in Malaysia that “sharp” foods, such as
watermelons, pineapples, and carbonated vegetables, were believed to
be harmful during the postpartum period. In Myanmar, sour and
spicy foods, pork, seafood, beef, sticky rice, and duck were all to be
avoided postpartum (Syed et al., 2008). Meanwhile, Bangladeshi
women were advised to eat dry foods (cooked without water), as well
as rice with mashed potatoes and cumin seeds, in order to cool the
stomach and promote breast milk production (Choudhury et al.,
2012). Moreover, green vegetables, pumpkins, and apples were
restricted from the diet for 2–3 months after birth because they were
believed to cause diarrhea for the baby through breast milk (Thapa
et al., 2000). Teas of medicinal herbs were further used in the many
countries in Asia to aid healing, reduce abdominal pain, protect and
reduce fever, dizziness, promote breast milk production, and reduce
bleeding (Kaewsarn et al., 2003b; de Boer and Lamxay, 2009;
Barennes et al., 2009; Lamxay et al., 2011; Van Andel et al., 2014).

166
M. Withers et al.
In terms of postpartum taboos, sexual abstinence for 30–40 days
postpartum was almost practised universally in China, Thailand,
Vietnam, and Myanmar (Leung et al., 2005; Lundberg and Thu,
2011; Kaewsarn et al., 2003a, 2003b; Syed et al., 2008). Bathing or
hair washing, especially with cold water, was strictly prohibited for
varying days postpartum to avoid blood clots, sore bones and joints,
and generally to hasten bodily heat restoration (Kaewsarn et al., 2003;
Leung et al., 2005; Callister, 2006; Chien et al., 2006; Raven et al.,
2007; Syed et al., 2008; Lee et al., 2009; Liu et al., 2009; Lundberg and
Thu, 2011; Lamxay et al., 2011). In China, even dental hygiene was
traditionally avoided during this period (Raven et al., 2007). With
regards to “pollution”, women in Nepal, India, Bangladesh, and Papua
New Guinea were not allowed to prepare or serve food, tend to crops,
or even collect water at postpartum (Syed et al., 2008; Vallely et al.,
2015). A step further, Laotian husbands with wives who had given birth
up to five days prior, were barred from entering anyone's home in a
village since he would be “polluted” by proximity (Lamxay et al., 2011).
Other common postpartum taboos found in review were an exten-
sion of those found during pregnancy, which included reading (Syed
et al., 2008), eating or drinking while standing, moving around
excessively (Leung et al., 2005), doing housework (Leung et al.,
2005; Callister, 2006; Lundberg and Thu, 2011; Syed et al., 2008),
and experiencing strong emotions (White, 2004). Some women in
China also drank only black bean water, as unflavored water was
thought to cause excessive weight gain or edemas (Callister et al.,
2011).
Any postpartum issues also elicited the help of traditional healers or
TBAs instead of professional healthcare providers in countries like
Bangladesh, China, and Nepal (Sibley et al., 2007a; Syed et al., 2008;
Sibley et al., 2009; Wellhoner et al., 2011). TBAs were also responsible
for providing a bulk of the postpartum care for both mother and child
(Barnes, 2007; Sharma, 2013). This was especially important to women
in places which practised isolation after birth, since TBAs were often
one of the very few people allowed to interact with them (Thapa et al.,
2000; Haq, 2008).
Discussion
A comprehensive review of the traditional beliefs and practices
relating to pregnancy, childbirth, and the postpartum period has been
presented; some may be reasons for the chronically low use of formal
healthcare found in some Asian populations. While structural factors,
such as distance to the health center or financial constraints, are
barriers to the use of maternal healthcare, this review demonstrates
that traditional beliefs and practices around pregnancy and childbirth
could greatly influence the likelihood of service use. We found that
many women in Asian societies continue to practise a wide range of
traditional beliefs and practices during pregnancy, childbirth, and the
postpartum period. While there is evidence to suggest that maternal
practices are being adapted to fit the current context of modern
women's lives, our review demonstrates that traditional beliefs and
practices still hold meaning and significance in many Asian cultures. In
addition, we have noted that most of the traditional beliefs and
practices are not harmful to women or their babies. In fact, many
could have psychological and physical benefits for women, such as birth
position and confinement practices. Therefore, healthcare providers
should recognize and appreciate these widespread practices when both
promoting and providing care in order to increase utilization and boost
service-user's satisfaction.
In terms of the existing research, a vast majority of the 74 studies
reviewed from 22 Asian countries related to South Asian countries,
while studies from China also featured prominently. Our review
suggests a dearth of studies relating to many other Asian cultures,
including Southeast Asian countries such as Indonesia, Malaysia,
Myanmar, Sri Lanka, and the Philippines. Considering the high levels
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Midwifery 56 (2018) 158–170
of maternal complications documented in many Asian countries, more
research is needed to document the current prevalence of such beliefs
and practices, and how they interact with more formal means of
maternal healthcare services.
Since pregnancy and childbirth have been found to be considered a
woman's natural rite of passage, in some cultures it is thought that
formal healthcare services should be sought only in cases of obstetric
complications. More information could help raise awareness about the
benefits of formal maternal healthcare services, while dispelling myths
and misconceptions surrounding the more dangerous practices that are
currently being undertaken outside of a hospital setting. Such educa-
tional programs should be geared towards not only women but also
husbands, parents, and in-laws, as these family members also have
important influence on women's use of maternal healthcare services. In
addition, it is important to train local providers on the most widespread
beliefs and practices in their own contexts, as well as cultural sensitivity
to such beliefs and practices.
In addition, numerous studies from a range of Asian cultures
reported that many women were generally reluctant to engage in
institutional births. In many Asian cultures, women and their families
preferred a more natural childbirth experience, with minimal medical
intervention. Many studies reported a common perception that child-
birth has become over-medicalized, which serves as a barrier to
encouraging women to have institutional births. In addition, women
reported not being comfortable with showing any parts of their body,
especially to providers who were essentially strangers. With this
sentiment in mind, providers should cautiously approach interactions
with women, particularly when asking them to expose themselves for
examination. Furthermore, rigid procedures that run counter to
traditional cultural practices, such as having women lie on their backs
or prohibiting husbands from witnessing births, act as subtle deter-
rents to the use of formal care among mothers. In fact, many western
societies are now adopting such practices as mainstream options for
women who want a less “medicalized” birth experience (Thies-
Lagergren et al., 2013). In fact, Fahy and Parratt (2006), Hatem
et al. (2008), and many others have argued that the benefits associated
with birthing environments such as birth centres, may be due not to the
environment itself, but to the model of care provided within the setting,
which is more respectful of the preference for a traditional birth
experience.
Governments and health care providers should prioritize how to
provide culturally appropriate maternity care at all times. Numerous
other studies from around the world have found that women felt often
mistreated by healthcare workers at clinics, but that they were unable
to express their discontent (Jewkes and Penn-Kekana, 2015; Bohren
et al., 2015). This could be related to providers’ lack of awareness
regarding such beliefs or their unwillingness to respect traditional
beliefs and practices. Providers may even be actively discouraging
women and their families from practising such traditions. Providers
should therefore foster a communicative relationship with women and
their families, to encourage open articulation of their desires, facilitat-
ing greater retention of women and ensuring future use of services.
When it comes to the involvement of spiritual and traditional
healers, their greater presence and reliance could be useful as a link
between informal and formal maternal healthcare, bridging the cultural
gaps between the two. Greater efforts to incorporate these healers could
prove more beneficial to the conventional medical care model. Laos for
example, has been successful in integrating the traditional birth
ceremonies performed by spiritual healers into the hospital setting,
presenting that option to women and their families and managing to
lower medical risks while ensuring greater overall satisfaction
(Eckermann, 2006).
Increasing the acceptability of male involvement in the birth
process may additionally prove to be a successful approach in increas-
ing formal healthcare use. Brunson's study (2010) in Nepal showed
M. Withers et al.
that young men personally desired greater involvement in maternal
healthcare but needed more initiatives to reduce the stigma associated
with male involvement in a largely woman's matter. Therefore,
healthcare providers and associated personnel could be called upon
to foster an environment which welcomes the engagement of men in
the entire pregnancy process. In particular, strategically focusing on
the positive role that men could play by supporting their partners
during childbirth to ensure a safer birth could be very effective
(Mullany, 2006).
Conclusions
While childbirth is a biological event, how women perceive a
successful pregnancy and birth experience are shaped by culture.
Providers play a crucial role in helping to support women to have
healthy pregnancies and births. As this review has shown, many of the
barriers to increased use of formal maternal healthcare services are
related to cultural beliefs and practices. Providing culturally competent
maternal health care will improve the quality of the birth experiences
for women and their families. Despite significant variability in the
Asian cultural beliefs and practices and increased modernization across
the region, this review has demonstrated that numerous similarities
also exist in beliefs and practices that persist in many Asian cultures,
including food and behavioral taboos, preferred birthing positions, and
the importance of the inclusion of family members as part of the
childbirth experience.
It is important for providers to be aware of the most common
practices in their own contexts in order to improve the care that they
offer to their patients. Inviting women and their families to discuss
their preferences and expectations for their pregnancy and childbirth
experiences with maternal health care providers can be an empowering
process and can improve women's self-confidence. Increasing the
dialogue around such beliefs and practices also offers providers the
opportunity to better align services with the needs and priorities of
women, enhancing the quality of care that they receive. Such discus-
sions can also help dispel the common myth that formal healthcare
services should be sought only in cases of obstetric complications.
Providers should be aware of the perception that institutional births are
overly, unnecessarily medicalized. Providing assurance to women and
their families that decisions regarding medical interventions will be
made by women and their families in consultation with their providers
could also enhance the likelihood of increased maternal healthcare
utilization, especially among groups with low rates of utilization.
Instead of reducing the choices available to women regarding the birth
experience, providers should understand, respect, and integrate cultur-
al interpretations of childbirth and the needs of women and their
families.
Acknowledgements
We would like to thank the following people for their assistance
with this study: Evan Pye, Meghan Stephens, Celia Herreros, and
Natalie Mata.
Ethical Statement
(1) Conflict of Interest-none declared
(2) Ethical Approval-not applicable
(3) Funding Sources-none declared
(4) Clinical Trial Registry and Registration number-not applicable.
Appendix A. Supporting information
Supplementary data associated with this article can be found in the
online version at doi:10.1016/j.midw.2017.10.019.
168
Midwifery 56 (2018) 158–170
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