Applied Nursing Research 27 (2014) 121–126
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Comparing Taiwanese women's biopsychosocial features by location of postpartum recovery Chich-Hsiu Hung, PhD, RN, Joel Stocker, PhD ⁎, Hsin-Tien Hsu, PhD, RN School of Nursing, Kaohsiung Medical University
a r t i c l e
i n f o
Article history: Received 1 December 2012 Revised 4 November 2013 Accepted 4 November 2013 Keywords: Health status Location of postpartum recovery Postpartum ritual Postpartum stress Social support
a b s t r a c t Background: In Taiwan, a culturally sanctioned ritual of maternal rest and recuperation has been traditionally practiced patrilocally during the first postpartum month. However, in recent years, the places where women may observe the ritual have become more diverse. Aim: Our goal was to compare women's psychosocial features based on where they stayed during their postpartum recovery. Methods: Using proportional stratified quota sampling of 18 hospitals and clinics in Taiwan by birth rate, we recruited 784 postpartum women. Results: Women stayed in their own home (17.1%), with their parents-in-law (33.3%), with their parents (36.0%), or in a postpartum nursing center (13.6%). Women who stayed in their own residence or who stayed in their parents' residence perceived greater social support than women who stayed with their parents-in-law. Conclusions: Further research should compare women's adjustment to motherhood and their competence in childcare based on where they stay during postpartum recovery. © 2014 Elsevier Inc. All rights reserved.
The postpartum is a time of transition and, therefore, of potential stress in a woman's life (Hung & Chung, 2001) that can have an adverse influence on maternal health (Hung, 2004). However, cultural practices during postpartum recovery may decrease postpartum stress and significantly improve maternal health (Hung, Yu, Ou, & Liang, 2010). The social support provided by the traditional postpartum rituals practiced in eastern cultures appears to play an essential role in protecting mothers from many of the negative physical and emotional conditions common in the postpartum period (Stern & Kruckman, 1983).
1. Background In Taiwan, the postpartum ritual doing the month is a culturally sanctioned time in the first month after childbirth, when a woman is expected to go into relative seclusion in order to recover and guarantee her future well-being by achieving harmony with the natural environment (Pillsbury, 1978). In doing the month, traditionally a senior family member facilitates a woman's recovery by encouraging rest, providing nutrition, and promoting her physical well-being (Pillsbury, 1982). In the past, the mother-in-law was the ⁎ Corresponding author at: School of Nursing, Kaohsiung Medical University, No. 100, Shih-Chuan 1 st Road, Kaohsiung City 80708 Taiwan. Tel.: + 886 7 312 1101X2617; fax: + 886 7 321 8364. E-mail addresses: [email protected] (C.-H. Hung), [email protected] (J. Stocker), [email protected] (H.-T. Hsu). 0897-1897/$ – see front matter © 2014 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.apnr.2013.11.010
postpartum woman's principal helper in the patrilocal household (Hung, Chang, & Chin, 1993). Contemporary Taiwanese mothers are still usually assisted by relatives during the month-long postpartum recovery period (Hung, 2005; Hung, Yu, Liu, & Stocker, 2010; Hung, Yu, Ou, et al., 2010). However, in the post-war era of urbanization and economic development, there was a shift toward the postpartum woman's own mother serving as her helper in either woman's (nonextended family) home (Hung & Chung, 2001; Hung, Lin, Stocker, & Yu, 2011). In addition to taking care of the postpartum woman, the woman's mother-in-law or mother generally helps with infant care, the household, and any of the infant's siblings (Hung, 2005). The mother-in-law or mother also tries to provide maternal wisdom and assistance regarding the woman's own physical care as well as the newborn's care (Hung, 2005). This kind of family-based support for postpartum women appears to play an important role in keeping stress levels relatively low in Taiwanese women during the postpartum (Hung et al., 2011). The decline of the close-knit, extended family has led to changes in family relationships, including a decrease in the likelihood that a postpartum woman's mother-in-law or mother will be available to assist her or that the woman would want such assistance (Hung, 2005). Although nearly all Taiwanese postpartum women still observe doing the month in some form, more and more women are opting to observe the ritual in postpartum nursing centers. These centers have emerged as a commercial means of meeting the demands brought about by the changes in family structure and
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relations. Postpartum nursing centers are professional, home-like health care facilities that are enabling the doing the month ritual to continue (Hung, Yu, Liu, et al., 2010; Hung, Yu, Ou, et al., 2010). Operated by registered nurses, these facilities for month-long recovery-in-residence are privately managed or partnered with local hospitals or obstetrical clinics (Hung, Yu, Liu, et al., 2010; Hung, Yu, Ou, et al., 2010). Postpartum nursing centers therefore perform many of the duties customarily fulfilled by the mother or mother-in-law during the month-long ritual of seclusion and those formerly carried out by public health nurses who would visit postpartum mothers in their homes (Hung, Yu, Liu, et al., 2010; Hung, Yu, Ou, et al., 2010). 2. Research purpose In the last 20 years, postpartum nursing centers have thrived even though national health insurance in Taiwan does not cover the cost, which is relatively high. The number of postpartum nursing centers in Taiwan has been steadily increasing, from only 4 postpartum nursing centers in 1997 to 33 in 2003, and 103 in 2010 (Department of Health, 2011). Despite the rising popularity of postpartum nursing centers and other shifts in postpartum residency pattern, there is a dearth of studies comparing women's biopsychosocial features by place of recovery. Thus, our study aimed to compare postpartum women's level of postpartum stress, level of social support, and health status by residence during the postpartum ritual period of recovery. 3. Research methods 3.1. Design This was a cross-sectional study design. 3.2. Sample We used proportional stratified quota sampling to sample 11 general hospitals and 7 obstetrical clinics by birth rate in southern Taiwan's Kaohsiung metropolitan area. The sample's inclusion criteria were as follows: married woman who had a singleton birth, could read Chinese and speak Mandarin, agreed to be interviewed via telephone during her postpartum period, and stayed in only one place—her own home where neither parents nor parents-in-law also resided, her parents-in-law's home, her parents' home, or a postpartum nursing center during the postpartum ritual period. Among 859 potential participants, 75 women were excluded because 14 were unmarried; 1 was divorced; 16 had twins; 13, including 1 twin, stayed in places other than the aforementioned; and 34, including 2 twins, stayed in two places. There were 784 participants in total, who participated in the study within their first 6 postpartum weeks.
level of postpartum stress. The score ranged between 62 and 310. The coefficient alpha for Hung PSS was .95. The SSS comprises the Family Adaptation, Partnership, Growth, Affection, and Resolve (Family APGAR) (Smilkstein, 1978) and Friend APGAR (Smilkstein, Ashworth, & Montano, 1982). It measures how often “a woman accepts social support from family and friends” (Smilkstein, 1978; Smilkstein et al., 1982). The construct validity of the SSS regarding the dimensions of family- and friend-support was verified through factor analysis (Hung & Chung, 2001). The SSS is a 10-item, 5-point Likert-type scale (1 = never and 5 = always). The score ranges between 10 and 50. A high total score indicates a high level of social support. The coefficient alpha for the SSS was .92. The culture-specific CHQ-12 was developed to measure the expression of anxiety, depression, sleep disturbance, somatic symptoms and somatic concerns, and interpersonal issues (Cheng, 1985; Cheng & Williams, 1986). The sensitivity and specificity of the CHQ-12 are 91.9% and 66.7%, respectively. Internal consistency with coefficient alpha has ranged from .75 to .84 (Hung & Chung, 1998, 2001). Coefficient alpha for this study was .72. On a 4-point scale (1 = not at all and 4 = most of the time), respondents indicate how often they have experienced minor psychiatric morbidity symptoms. Ratings of 1 and 2 are counted as 0, and ratings of 3 and 4 as 1. The sum of a total score rates from 0 to 12 (Chong & Wilkinson, 1989). The cut-off scores for judgments of ‘case’ or ‘non-case’ for minor psychiatric morbidity are 3 and 2, respectively, within community samples. 3.4. Procedure A research assistant approached each recruit during the woman's stay in a postpartum ward. The research assistant, an RN trained in the study's methodology by the primary researcher, explained the study to each recruit using standardized scripts. If she signed the consent form, the participant was asked to fill out the demographic questionnaire. Participants were systematically assigned to be interviewed by the research assistant by phone at her postpartum place of recovery during one of the 6 weeks after childbirth. The research assistant interviewed each participant over the phone. The institutional review board at the researchers' university approved this study. 3.5. Data analysis We analyzed the data using Statistical Product for Service Solutions (SPSS) version 17.0. A one-way analysis of variance (ANOVA) was used to determine four mean score differences for postpartum stress and social support by type of postpartum residence. If a p value was less than .05, a Scheffe posttest was conducted to compare each of the four mean scores. A chi-square test was used to determine participant's differences in health status by type of postpartum residence.
3.3. Instruments
4. Results
We conducted the study using three instruments: the Hung Postpartum Stress Scale (Hung PSS), the Social Support Scale (SSS), and the Chinese Health Questionnaire (CHQ-12). The 62-item Hung PSS was developed to assess “women's stress during the 42-day postpartum period” (Hung, 2007c). The significance of three dimensions of postpartum stress—namely, concerns about maternal role attainment, negative body changes, and lack of social support— has been backed by exploratory factor analysis (Hung, 2007c). Hung (2007c) shows that the Hung PSS is generalizable and possesses high coefficients of congruence. Respondents rank each item on a 5-point Likert scale (1 = not at all and 5 = always) based on the frequency with which they have perceived stress in their current postpartum period. All ratings were added, and a higher value signified a higher
A sample of 784 postpartum women participated during their first 6 postpartum weeks. The number of women who stayed in their own home was 134 (17.1%); with their parents-in-law was 261 (33.3%); with their own parents was 282 (36.0%); and in a postpartum nursing center was 107 (13.6%) (Table 1). The average age of participants ranged from 27.8 years to 31.3 years. In each category of recovery location, most women had obtained an associate degree or higher except for the women who stayed with their parents-in-law. Fulltime employment among the women ranged from 42.1% to 56.0%. With the exception of those mothers who stayed in a postpartum nursing center, most of the women in the study had a household income of less than 50,000 New Taiwan dollars (NTD) or 1667 US dollars per month.
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Table 1 Women's Demographic and Perinatal Characteristics (N = 784). Demographic characteristics
Own
Parents-in-law
Parents
Nursing center
Mean (SD)
Mean (SD)
Mean (SD)
Mean (SD)
Fp
or
or
or
or
or
n
%
(n = 134) Age (years) Education Senior high school or less Junior college or above Employment status Full-time Housewife or part-time Total household income per month Less than NTD 50,000 NTD 50,001–NTD 75,000 More than NTD 75,001 Length of marriage (months) This pregnancy was Planned Unplanned Gestational period (weeks) Type of delivery Vaginal delivery Caesarean section This childbirth experience Satisfied Unsatisfied Baby's body weight (kg) Sex of this baby Boy Girl Preferred sex of this baby Boy Girl Didn't matter Para Primipara Multipara Number of sons 0 1 or above Number of daughters 0 1 or above Method of this baby's feeding Breast feeding Formula feeding Mixed Key helper Mother Mother-in-law Husband Others/Two more helpers Postpartum week Postpartum day 0–7 8–14 15–21 22–28 29–35 36–42
n
%
n
(n = 261) 27.8
%
(n = 282)
30.8
(4.8)
(4.2)
61 73
45.5 54.5
156 105
59.8 40.2
57 77
42.5 57.5
110 151
42.1 57.9
29.0
n
%
χ2
(n = 107) (4.3)
31.3
(3.8)
132 150
46.8 53.2
32 75
29.9 70.1
158 124
56.0 44.0
56 51
52.3 47.7
67 29 38 54.8
50.0 21.6 28.4 (41.8)
148 81 32 33.6
56.7 31.0 12.3 (28.1)
133 94 55 36.9
47.2 33.3 19.5 (31.8)
32 32 43 46.6
29.9 29.9 40.2 (35.6)
51 83 38.5
38.1 61.9 (1.6)
86 175 38.6
33.0 67.0 (1.9)
101 181 38.5
35.8 64.2 (1.5)
43 64 38.6
40.2 59.8 (1.2)
57 77
42.5 57.5
117 144
44.8 55.2
52.3 47.7
88.1 11.9 (0.5)
235 26 3.2
90.0 10.0 (0.5)
36.5 63.5 .41 92.9 7.1 (0.5)
56 51
118 16 3.2
103 179 2.9 262 20 3.2
97 10 3.2
90.7 9.3 (0.5)
62 72
46.3 53.7
152 109
58.2 41.8
149 133
52.8 47.2
57 50
53.3 46.7
28 27 79
20.9 20.1 59.0
64 50 147
24.5 19.2 56.3
64 56 162
22.7 19.9 57.4
24 17 66
22.4 15.9 61.7
54 80
40.3 59.7
137 124
52.5 47.5
149 133
52.8 47.2
50 57
46.7 53.3
50 84
37.3 62.7
80 181
30.7 69.3
102 180
36.2 63.8
39 68
36.4 63.6
41 93
30.6 69.4
113 148
43.3 56.7
110 172
39.0 61.0
38 69
35.5 64.5
39 13 82
29.1 9.7 61.2
67 33 161
25.7 12.6 61.7
95 23 164
33.7 8.2 58.2
26 10 71
24.3 9.3 66.4
48 20 48 18 3.2
35.8 14.9 35.8 13.4 (1.7)
33 159 48 21 3.6
12.6 60.9 18.4 8.0 (1.8)
240 3 20 19 3.5
85.1 1.1 7.1 6.7 (1.7)
29 8 57 13 3.4
27.1 7.5 53.3 12.1 (1.7)
28 29 19 21 21 16
20.9 21.6 14.2 15.7 15.7 11.9
44 41 41 41 42 52
16.9 15.7 15.7 15.7 16.1 19.9
48 46 47 52 48 41
17.0 16.3 16.7 18.4 17.0 14.5
18 19 20 15 19 16
16.8 17.8 18.7 14.0 17.8 15.0
25.6 28.9
.00⁎⁎ .00⁎⁎
13.2
.00⁎⁎
47.0
.00⁎⁎
14.4 2.1
.00⁎⁎ .55
0.5 8.9
.72 .03⁎
0.0 5.2
.99 .16
1.7
.95
7.0
.07
2.7
.44
6.5
.09
7.7
.26
492.5
1.5 9.6
.00⁎⁎
.21 .84
⁎ p b .05. ⁎⁎ p b .01.
The average length of marriage ranged from 33.6 months to 54.8 months, and 33.0% to 40.2% of the women revealed that they had had a planned pregnancy. The mean gestational age ranged from 38.5 weeks to 38.6 weeks. Participants who resided in the three types of “home” residence, compared to participants in postpartum nursing centers, had a higher rate of caesarean section than of vaginal delivery, and 88.1% to 92.9% of these women expressed satisfaction with this childbirth experience.
The average birth weight of the babies was 3.2 kilograms, and 46.3% to 58.2% of the newborn babies were male. More than half of the women in each category indicated no gender preference regarding their infant. Primiparas ranged from 40.3% to 52.8%, while women with one or more sons comprised 62.7% to 69.3% and women with one or more daughters comprised 56.7% to 69.4% of participants. Over half breastfed and supplemented with formula. Women who breastfed ranged from 24.3% to 33.7%, and those who exclusively formula fed
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ranged from 8.2% to 12.6%. The women's key helper was the mother, mother-in-law, or husband, which varied by postpartum residence. The telephone interview was conducted an average of 3.2 weeks postpartum to 3.6 weeks postpartum. The women's age, education, employment status, household income, length of marriage, type of delivery, and key helper showed significant differences by type of postpartum residence (Table 1). The Scheffe posttest indicated that older women tended to stay in either their own home or in a postpartum nursing center, compared to women who stayed with their own parents or with their parents-inlaw. Moreover, the women who stayed with their own parents were older than those who stayed with their parents-in-law. The length of marriage was longer for those women who stayed in their own home than those women who stayed with their own parents or stayed with their parents-in-law. Women who stayed in a postpartum nursing center had been married longer than the women who stayed with their parents-in-law. Seven of the top ten perceived postpartum stressors were the same for all women in the study despite their different choices of postpartum recovery. These stressors were women's worries about their body soreness, the flabby flesh of their bellies, interrupted sleep, the baby suddenly falling sick, recovering their prenatal figures, the unpredictable schedule of the baby, and the baby's head shape due to its sleeping position. There were differences by postpartum residence within the top five items of social support. For women who stayed in their own home and those who stayed with their parents, three of the top items came from family support and two from friend support. Women who stayed with their parents-in-law had two top items from family support and three from friend support. Interestingly, for those women who stayed in a postpartum nursing center, one top item was from family support and four were from friend support. Women's postpartum stress involved concerns about maternal role attainment, negative body changes, and lack of social support. The results indicated no significant differences in concerns about maternal role attainment (F = .68, df = 3, 780, p = .57), negative body changes (F = .68, df = 3, 780, p = .56) or lack of social support (F = .24, df = 3, 779, p = .87) among the women who stayed in one of the four types of postpartum residence studied (Table 2). Women's social support included support from both family and friends. The results showed that there were significant differences in family support (F =12.32, df = 3, 779, p b .00) and friend support (F = 4.13, df = 3, 780, p b .01) among women by location of recovery (Table 2). The Scheffe posttest showed that women who stayed in their own home and women who stayed in their own parents' home perceived
more family support than women who stayed with their parents-inlaw. Women who stayed in their own parents' home also perceived greater family support than women who stayed in the nursing postpartum centers. In addition, women who stayed in their own parents' home perceived greater friend support than women who stayed with their parents-in-law. Differences in mean scores for postpartum stress and social support across the four types of postpartum residence were analyzed by one-way ANOVA and Scheffe posttest (Table 2). The mean scores for postpartum stress were not significantly different (F = .56, df = 3, 780, p = .65), but the mean scores for social support were significantly different (F = 9.69, df = 3, 780, p b .00) over the four types of postpartum residence. The Scheffe posttest showed that women who resided in their own home and women who stayed with their parents perceived a higher level of social support than women who stayed with their parents-in-law. We categorized participants who had a CHQ score greater than or equal to 3 as ‘cases’ for minor psychiatric morbidity; otherwise they were categorized as ‘non-cases’. The chi-squared tests indicated that women's health status did not differ significantly by postpartum residence (χ 2 = 3.39, df = 3, p = .34).
5. Discussion We found that women's age, education, employment status, household income, length of marriage, type of delivery, and key helper differed significantly among the four types of postpartum residence. Traditionally, a woman would reside with her parents-inlaw following the custom among ethnic-Chinese Taiwanese of patrilocality in an extended family residence after marrying. Alternatively, she would stay with her own parents in order to have assistance from her mother during the traditional postpartum period. However, we found that older women and women who had been married longer tended to choose their own home, if they owned one, or they chose the postpartum nursing center as a place for the month-long postpartum ritual. It suggests that a woman's autonomy and independence might increase with her age and the length of her marriage, enabling her to choose a place other than the mother-in-law's or mother's home while observing the month-long postpartum period. Postpartum nursing centers aim to facilitate postpartum recovery and newborn care in a calming, familial environment that includes wholesome meals and, commonly, Chinese herbal therapies (Hung, Yu, Liu, et al., 2010; Hung, Yu, Ou, et al., 2010). During their stay, women are provided with information on self-care and newborn care,
Table 2 Mean Scores of Women's Postpartum Stress and Social Support, and Percentages of Health Status (N = 784). Own home
Parents-in-law
Parents
Nursing center
Mean (SD)
Mean (SD)
Mean(SD)
Mean (SD)
or n
or %
(n = 134) Postpartum stress Maternal role attainment Negative body changes Lack of social support Social support Family support Friend support Health status Non-case Case
2.01 2.04 2.10 1.90 3.55 3.58 3.51 80 54
or
n
%
(n = 261) (.52) (.63) (.62) (.53) (.87) (.96) (1.01) 59.70 40.30
2.06 2.07 2.21 1.92 3.30 3.27 3.34 170 91
Case: minor psychiatric morbidity; non-case: none minor psychiatric morbidity.
or
n
%
n
(n = 282) (.57) (.63) (.73) (.60) (.83) (.89) (1.02) 65.13 34.87
2.04 2.07 2.16 1.89 3.66 3.71 3.61 193 89
%
(n = 107) (.58) (.66) (.70) (.59) (.74) (.86) (.85) 68.44 31.56
2.10 2.15 2.18 1.94 3.47 3.38 3.56 67 40
(.56) (.62) (.70) (.59) (.64) (.78) (.79) 62.62 37.38
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assistance, and support. The postpartum nursing center option is a luxury as it is expensive and not covered by health insurance (Hung, Yu, Liu, et al., 2010; Hung, Yu, Ou, et al., 2010). No doubt this is why older women with more economic independence were more likely to utilize their services in this study. We found that a higher proportion of women who stayed in the postpartum nursing centers had a high education level, full-time employment status (except for the women who stayed in their own parents' home), and higher household incomes compared with women who stayed in other places. Interestingly, compared with other women who stayed in the other three places for their postpartum ritual, women who stayed with their parents-in law were the youngest of the participants and had the lowest proportion of high education level and full-time jobs, and tended to have lower household income. With the exception of women in the postpartum nursing centers, we found that the proportion of women who had caesarean sections was higher than those who had a vaginal delivery regardless of the location of their postpartum recovery. Pre-planned caesarean sections have been very high in Taiwan. The high caesarean birth rate occurs in Taiwan for a long list of reasons, including people's concerns about the safety of natural childbirth; obstetricians' impatience; obstetrician's fear of malpractice suits; women who have had previous caesarean sections and are not aware of or interested in vaginal birth after caesarean (VBAC); some women's fear of a long, painful labor; the opportunity to avoid stretching the vagina (which they believe could negatively affect sexual intercourse after childbirth); higher medical reimbursement; and controlling the date and length of labor and delivery, e.g., to fit doctors' busy schedules or to coincide with what the family believes will be an auspicious birth date (Lin & Xirasagar, 2004; Lo, 2003). Our results indicate that the mother or mother-in-law was the primary helper in the postpartum period if a woman stayed in her parents' or her parents-in-law's home, respectively, for the postpartum ritual period. However, if the woman resided in her own home, the woman's husband or her own mother was her primary helper. Moreover, a woman's own mother, compared to the woman's motherin-law, was more likely to stay with her in her (i.e., the daughter's) own home for a full month to tend to her and the newborn; otherwise, the woman's husband would was the primary helper. Hung, Yu, Liu, et al. (2010), Hung, Yu, Ou, et al. (2010) found that most women who chose a postpartum nursing center did so because they wanted quality care, were reluctant to trouble others, or did not have adequate help. The implication is that a woman's mother-in-law or mother was unavailable during her daughter-in-law or daughter's postpartum ritual period, or that her husband's availability was limited. In the postpartum nursing centers, although staff nurses were responsible for caring for the women and their newborns' physical and emotional needs, and offered a series of maternal and infant wellness programs, most of the postpartum women did not consider the staff nurse to be her key helper. The services offered by the staff nurse might have been regarded as a business arrangement; moreover, either the woman's husband or they as a couple were the primary source of payment for the stay (Hung, Yu, Liu, et al., 2010; Hung, Yu, Ou, et al., 2010). We found in this study that women who stayed in the postpartum nursing centers indicated their husband as their key helper. The stressors ‘body soreness’, ‘the flabby flesh of their bellies’, ‘interrupted sleep’, ‘the baby falling sick suddenly’, ‘recovering their prenatal figures’, ‘the baby's unpredictable schedule’, and ‘the shape of the baby's head because of its sleeping position’ were considered by the women to be among the top ten postpartum stressors regardless of location of postpartum recovery. These stressors were also consistently perceived by women as the highest-ranking postpartum stressors regardless of their parity or postpartum week (Hung, 2005, 2006, 2007a, 2007b). In Taiwan, facial structure is considered a key element in predicting one's fortune (Hung, 2006). As a consequence, postpartum women pay a lot of attention
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to adjusting their infants' sleeping position in order to keep their infants' head well-formed. David, Brucker, & MacMullen (1988) found that ‘infant illnesses’ was the infant care topic of highest priority in postpartum education. Moreover, postpartum women need to face the unrelenting demands of infant care, which do not follow a schedule. As a result, most women will complain of fatigue and physical exhaustion, and will experience unease concerning changes in their postpartum bodies (Russell, 1974). Thus, postpartum women should be assisted in relaxation, diet instruction, and progressive exercises. Postpartum exercises that strengthen the pelvic and abdominal muscles particularly need to be emphasized (Hung, 2007a). Our study indicated that women's mean scores for postpartum stress and for its three dimensions—concerns about maternal role attainment, negative body changes, and lack of social support—were low despite the women's different postpartum residences. Moreover, the levels of postpartum stress, the three components of postpartum stress, and their health status did not differ significantly among the four postpartum locations. Our findings are congruent with the established literature, which suggests that the still-observed Taiwanese custom of doing the month has a direct bearing on women's familial relationships and well-being (Pillsbury, 1978, 1982). We found that postpartum women perceived receiving a high level of social support regardless of postpartum location. It is consistent with the prior results of Hung (2007a) that Taiwanese postpartum women perceive a high level of social support and their greatest amount of support is from family members. We found that women who stayed with their own parents or in their own home had higher levels of social support and family support than women who stayed with their parents-in-law. A woman's mother, rather than her mother-in-law or postpartum nursing center staff, is usually the person who offers the most effective family support—including higher levels of care—during the ritual of doing the month. In this study, participants were those married woman who had a singleton birth, could read Chinese and speak Mandarin, agreed to receive an interview via telephone during her postpartum period, and stayed in only one place—her own home where neither parents nor parents-in-law also resided, her parents-in-law's home, her parents' home, or a postpartum nursing center during the postpartum ritual period. Thus, our study's results cannot be generalized to postpartum women who do not meet the inclusion criteria of this study. 6. Conclusion In Taiwan today, doing the month is a postpartum ritual practiced in a variety of places; it plays a role in supporting postpartum women, reducing postpartum stress, and improving maternal health. The postpartum nursing centers are home-like health care facilities. Their security, staff qualifications, food and nutrition supplies, hygiene, nurse–bed ratio, and record-keeping should be regulated and brought under an accreditation process. The postpartum has been recognized in the ethnographic literature as a highly ritualized period of risk commonly mediated by seclusion as well as sexual and food taboos for the mother (Sargent, 2004). The results of this study can provide a framework for future longitudinal studies of immediate childbirth to 1 year postpartum in order to compare possible fluctuations in postpartum stress, social support, and maternal health for women who stay in their permanent residence or some other place during the postpartum period. Further research should also compare women's transition to motherhood and differences in their childcare competence based on the different types of postpartum residence in Taiwan and elsewhere. Acknowledgments Funding for this study was supported in part by a grant from the National Science Council, Taiwan (NSC 95-2314-B-037-085).
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Comparing Taiwanese women's biopsychosocial features by location of postpartum recovery Chich-Hsiu Hung, PhD, RN, Joel Stocker, PhD ⁎, Hsin-Tien Hsu, PhD, RN School of Nursing, Kaohsiung Medical University
a r t i c l e
i n f o
Article history: Received 1 December 2012 Revised 4 November 2013 Accepted 4 November 2013 Keywords: Health status Location of postpartum recovery Postpartum ritual Postpartum stress Social support
a b s t r a c t Background: In Taiwan, a culturally sanctioned ritual of maternal rest and recuperation has been traditionally practiced patrilocally during the first postpartum month. However, in recent years, the places where women may observe the ritual have become more diverse. Aim: Our goal was to compare women's psychosocial features based on where they stayed during their postpartum recovery. Methods: Using proportional stratified quota sampling of 18 hospitals and clinics in Taiwan by birth rate, we recruited 784 postpartum women. Results: Women stayed in their own home (17.1%), with their parents-in-law (33.3%), with their parents (36.0%), or in a postpartum nursing center (13.6%). Women who stayed in their own residence or who stayed in their parents' residence perceived greater social support than women who stayed with their parents-in-law. Conclusions: Further research should compare women's adjustment to motherhood and their competence in childcare based on where they stay during postpartum recovery. © 2014 Elsevier Inc. All rights reserved.
The postpartum is a time of transition and, therefore, of potential stress in a woman's life (Hung & Chung, 2001) that can have an adverse influence on maternal health (Hung, 2004). However, cultural practices during postpartum recovery may decrease postpartum stress and significantly improve maternal health (Hung, Yu, Ou, & Liang, 2010). The social support provided by the traditional postpartum rituals practiced in eastern cultures appears to play an essential role in protecting mothers from many of the negative physical and emotional conditions common in the postpartum period (Stern & Kruckman, 1983).
1. Background In Taiwan, the postpartum ritual doing the month is a culturally sanctioned time in the first month after childbirth, when a woman is expected to go into relative seclusion in order to recover and guarantee her future well-being by achieving harmony with the natural environment (Pillsbury, 1978). In doing the month, traditionally a senior family member facilitates a woman's recovery by encouraging rest, providing nutrition, and promoting her physical well-being (Pillsbury, 1982). In the past, the mother-in-law was the ⁎ Corresponding author at: School of Nursing, Kaohsiung Medical University, No. 100, Shih-Chuan 1 st Road, Kaohsiung City 80708 Taiwan. Tel.: + 886 7 312 1101X2617; fax: + 886 7 321 8364. E-mail addresses: [email protected] (C.-H. Hung), [email protected] (J. Stocker), [email protected] (H.-T. Hsu). 0897-1897/$ – see front matter © 2014 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.apnr.2013.11.010
postpartum woman's principal helper in the patrilocal household (Hung, Chang, & Chin, 1993). Contemporary Taiwanese mothers are still usually assisted by relatives during the month-long postpartum recovery period (Hung, 2005; Hung, Yu, Liu, & Stocker, 2010; Hung, Yu, Ou, et al., 2010). However, in the post-war era of urbanization and economic development, there was a shift toward the postpartum woman's own mother serving as her helper in either woman's (nonextended family) home (Hung & Chung, 2001; Hung, Lin, Stocker, & Yu, 2011). In addition to taking care of the postpartum woman, the woman's mother-in-law or mother generally helps with infant care, the household, and any of the infant's siblings (Hung, 2005). The mother-in-law or mother also tries to provide maternal wisdom and assistance regarding the woman's own physical care as well as the newborn's care (Hung, 2005). This kind of family-based support for postpartum women appears to play an important role in keeping stress levels relatively low in Taiwanese women during the postpartum (Hung et al., 2011). The decline of the close-knit, extended family has led to changes in family relationships, including a decrease in the likelihood that a postpartum woman's mother-in-law or mother will be available to assist her or that the woman would want such assistance (Hung, 2005). Although nearly all Taiwanese postpartum women still observe doing the month in some form, more and more women are opting to observe the ritual in postpartum nursing centers. These centers have emerged as a commercial means of meeting the demands brought about by the changes in family structure and
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relations. Postpartum nursing centers are professional, home-like health care facilities that are enabling the doing the month ritual to continue (Hung, Yu, Liu, et al., 2010; Hung, Yu, Ou, et al., 2010). Operated by registered nurses, these facilities for month-long recovery-in-residence are privately managed or partnered with local hospitals or obstetrical clinics (Hung, Yu, Liu, et al., 2010; Hung, Yu, Ou, et al., 2010). Postpartum nursing centers therefore perform many of the duties customarily fulfilled by the mother or mother-in-law during the month-long ritual of seclusion and those formerly carried out by public health nurses who would visit postpartum mothers in their homes (Hung, Yu, Liu, et al., 2010; Hung, Yu, Ou, et al., 2010). 2. Research purpose In the last 20 years, postpartum nursing centers have thrived even though national health insurance in Taiwan does not cover the cost, which is relatively high. The number of postpartum nursing centers in Taiwan has been steadily increasing, from only 4 postpartum nursing centers in 1997 to 33 in 2003, and 103 in 2010 (Department of Health, 2011). Despite the rising popularity of postpartum nursing centers and other shifts in postpartum residency pattern, there is a dearth of studies comparing women's biopsychosocial features by place of recovery. Thus, our study aimed to compare postpartum women's level of postpartum stress, level of social support, and health status by residence during the postpartum ritual period of recovery. 3. Research methods 3.1. Design This was a cross-sectional study design. 3.2. Sample We used proportional stratified quota sampling to sample 11 general hospitals and 7 obstetrical clinics by birth rate in southern Taiwan's Kaohsiung metropolitan area. The sample's inclusion criteria were as follows: married woman who had a singleton birth, could read Chinese and speak Mandarin, agreed to be interviewed via telephone during her postpartum period, and stayed in only one place—her own home where neither parents nor parents-in-law also resided, her parents-in-law's home, her parents' home, or a postpartum nursing center during the postpartum ritual period. Among 859 potential participants, 75 women were excluded because 14 were unmarried; 1 was divorced; 16 had twins; 13, including 1 twin, stayed in places other than the aforementioned; and 34, including 2 twins, stayed in two places. There were 784 participants in total, who participated in the study within their first 6 postpartum weeks.
level of postpartum stress. The score ranged between 62 and 310. The coefficient alpha for Hung PSS was .95. The SSS comprises the Family Adaptation, Partnership, Growth, Affection, and Resolve (Family APGAR) (Smilkstein, 1978) and Friend APGAR (Smilkstein, Ashworth, & Montano, 1982). It measures how often “a woman accepts social support from family and friends” (Smilkstein, 1978; Smilkstein et al., 1982). The construct validity of the SSS regarding the dimensions of family- and friend-support was verified through factor analysis (Hung & Chung, 2001). The SSS is a 10-item, 5-point Likert-type scale (1 = never and 5 = always). The score ranges between 10 and 50. A high total score indicates a high level of social support. The coefficient alpha for the SSS was .92. The culture-specific CHQ-12 was developed to measure the expression of anxiety, depression, sleep disturbance, somatic symptoms and somatic concerns, and interpersonal issues (Cheng, 1985; Cheng & Williams, 1986). The sensitivity and specificity of the CHQ-12 are 91.9% and 66.7%, respectively. Internal consistency with coefficient alpha has ranged from .75 to .84 (Hung & Chung, 1998, 2001). Coefficient alpha for this study was .72. On a 4-point scale (1 = not at all and 4 = most of the time), respondents indicate how often they have experienced minor psychiatric morbidity symptoms. Ratings of 1 and 2 are counted as 0, and ratings of 3 and 4 as 1. The sum of a total score rates from 0 to 12 (Chong & Wilkinson, 1989). The cut-off scores for judgments of ‘case’ or ‘non-case’ for minor psychiatric morbidity are 3 and 2, respectively, within community samples. 3.4. Procedure A research assistant approached each recruit during the woman's stay in a postpartum ward. The research assistant, an RN trained in the study's methodology by the primary researcher, explained the study to each recruit using standardized scripts. If she signed the consent form, the participant was asked to fill out the demographic questionnaire. Participants were systematically assigned to be interviewed by the research assistant by phone at her postpartum place of recovery during one of the 6 weeks after childbirth. The research assistant interviewed each participant over the phone. The institutional review board at the researchers' university approved this study. 3.5. Data analysis We analyzed the data using Statistical Product for Service Solutions (SPSS) version 17.0. A one-way analysis of variance (ANOVA) was used to determine four mean score differences for postpartum stress and social support by type of postpartum residence. If a p value was less than .05, a Scheffe posttest was conducted to compare each of the four mean scores. A chi-square test was used to determine participant's differences in health status by type of postpartum residence.
3.3. Instruments
4. Results
We conducted the study using three instruments: the Hung Postpartum Stress Scale (Hung PSS), the Social Support Scale (SSS), and the Chinese Health Questionnaire (CHQ-12). The 62-item Hung PSS was developed to assess “women's stress during the 42-day postpartum period” (Hung, 2007c). The significance of three dimensions of postpartum stress—namely, concerns about maternal role attainment, negative body changes, and lack of social support— has been backed by exploratory factor analysis (Hung, 2007c). Hung (2007c) shows that the Hung PSS is generalizable and possesses high coefficients of congruence. Respondents rank each item on a 5-point Likert scale (1 = not at all and 5 = always) based on the frequency with which they have perceived stress in their current postpartum period. All ratings were added, and a higher value signified a higher
A sample of 784 postpartum women participated during their first 6 postpartum weeks. The number of women who stayed in their own home was 134 (17.1%); with their parents-in-law was 261 (33.3%); with their own parents was 282 (36.0%); and in a postpartum nursing center was 107 (13.6%) (Table 1). The average age of participants ranged from 27.8 years to 31.3 years. In each category of recovery location, most women had obtained an associate degree or higher except for the women who stayed with their parents-in-law. Fulltime employment among the women ranged from 42.1% to 56.0%. With the exception of those mothers who stayed in a postpartum nursing center, most of the women in the study had a household income of less than 50,000 New Taiwan dollars (NTD) or 1667 US dollars per month.
C.-H. Hung et al. / Applied Nursing Research 27 (2014) 121–126
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Table 1 Women's Demographic and Perinatal Characteristics (N = 784). Demographic characteristics
Own
Parents-in-law
Parents
Nursing center
Mean (SD)
Mean (SD)
Mean (SD)
Mean (SD)
Fp
or
or
or
or
or
n
%
(n = 134) Age (years) Education Senior high school or less Junior college or above Employment status Full-time Housewife or part-time Total household income per month Less than NTD 50,000 NTD 50,001–NTD 75,000 More than NTD 75,001 Length of marriage (months) This pregnancy was Planned Unplanned Gestational period (weeks) Type of delivery Vaginal delivery Caesarean section This childbirth experience Satisfied Unsatisfied Baby's body weight (kg) Sex of this baby Boy Girl Preferred sex of this baby Boy Girl Didn't matter Para Primipara Multipara Number of sons 0 1 or above Number of daughters 0 1 or above Method of this baby's feeding Breast feeding Formula feeding Mixed Key helper Mother Mother-in-law Husband Others/Two more helpers Postpartum week Postpartum day 0–7 8–14 15–21 22–28 29–35 36–42
n
%
n
(n = 261) 27.8
%
(n = 282)
30.8
(4.8)
(4.2)
61 73
45.5 54.5
156 105
59.8 40.2
57 77
42.5 57.5
110 151
42.1 57.9
29.0
n
%
χ2
(n = 107) (4.3)
31.3
(3.8)
132 150
46.8 53.2
32 75
29.9 70.1
158 124
56.0 44.0
56 51
52.3 47.7
67 29 38 54.8
50.0 21.6 28.4 (41.8)
148 81 32 33.6
56.7 31.0 12.3 (28.1)
133 94 55 36.9
47.2 33.3 19.5 (31.8)
32 32 43 46.6
29.9 29.9 40.2 (35.6)
51 83 38.5
38.1 61.9 (1.6)
86 175 38.6
33.0 67.0 (1.9)
101 181 38.5
35.8 64.2 (1.5)
43 64 38.6
40.2 59.8 (1.2)
57 77
42.5 57.5
117 144
44.8 55.2
52.3 47.7
88.1 11.9 (0.5)
235 26 3.2
90.0 10.0 (0.5)
36.5 63.5 .41 92.9 7.1 (0.5)
56 51
118 16 3.2
103 179 2.9 262 20 3.2
97 10 3.2
90.7 9.3 (0.5)
62 72
46.3 53.7
152 109
58.2 41.8
149 133
52.8 47.2
57 50
53.3 46.7
28 27 79
20.9 20.1 59.0
64 50 147
24.5 19.2 56.3
64 56 162
22.7 19.9 57.4
24 17 66
22.4 15.9 61.7
54 80
40.3 59.7
137 124
52.5 47.5
149 133
52.8 47.2
50 57
46.7 53.3
50 84
37.3 62.7
80 181
30.7 69.3
102 180
36.2 63.8
39 68
36.4 63.6
41 93
30.6 69.4
113 148
43.3 56.7
110 172
39.0 61.0
38 69
35.5 64.5
39 13 82
29.1 9.7 61.2
67 33 161
25.7 12.6 61.7
95 23 164
33.7 8.2 58.2
26 10 71
24.3 9.3 66.4
48 20 48 18 3.2
35.8 14.9 35.8 13.4 (1.7)
33 159 48 21 3.6
12.6 60.9 18.4 8.0 (1.8)
240 3 20 19 3.5
85.1 1.1 7.1 6.7 (1.7)
29 8 57 13 3.4
27.1 7.5 53.3 12.1 (1.7)
28 29 19 21 21 16
20.9 21.6 14.2 15.7 15.7 11.9
44 41 41 41 42 52
16.9 15.7 15.7 15.7 16.1 19.9
48 46 47 52 48 41
17.0 16.3 16.7 18.4 17.0 14.5
18 19 20 15 19 16
16.8 17.8 18.7 14.0 17.8 15.0
25.6 28.9
.00⁎⁎ .00⁎⁎
13.2
.00⁎⁎
47.0
.00⁎⁎
14.4 2.1
.00⁎⁎ .55
0.5 8.9
.72 .03⁎
0.0 5.2
.99 .16
1.7
.95
7.0
.07
2.7
.44
6.5
.09
7.7
.26
492.5
1.5 9.6
.00⁎⁎
.21 .84
⁎ p b .05. ⁎⁎ p b .01.
The average length of marriage ranged from 33.6 months to 54.8 months, and 33.0% to 40.2% of the women revealed that they had had a planned pregnancy. The mean gestational age ranged from 38.5 weeks to 38.6 weeks. Participants who resided in the three types of “home” residence, compared to participants in postpartum nursing centers, had a higher rate of caesarean section than of vaginal delivery, and 88.1% to 92.9% of these women expressed satisfaction with this childbirth experience.
The average birth weight of the babies was 3.2 kilograms, and 46.3% to 58.2% of the newborn babies were male. More than half of the women in each category indicated no gender preference regarding their infant. Primiparas ranged from 40.3% to 52.8%, while women with one or more sons comprised 62.7% to 69.3% and women with one or more daughters comprised 56.7% to 69.4% of participants. Over half breastfed and supplemented with formula. Women who breastfed ranged from 24.3% to 33.7%, and those who exclusively formula fed
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ranged from 8.2% to 12.6%. The women's key helper was the mother, mother-in-law, or husband, which varied by postpartum residence. The telephone interview was conducted an average of 3.2 weeks postpartum to 3.6 weeks postpartum. The women's age, education, employment status, household income, length of marriage, type of delivery, and key helper showed significant differences by type of postpartum residence (Table 1). The Scheffe posttest indicated that older women tended to stay in either their own home or in a postpartum nursing center, compared to women who stayed with their own parents or with their parents-inlaw. Moreover, the women who stayed with their own parents were older than those who stayed with their parents-in-law. The length of marriage was longer for those women who stayed in their own home than those women who stayed with their own parents or stayed with their parents-in-law. Women who stayed in a postpartum nursing center had been married longer than the women who stayed with their parents-in-law. Seven of the top ten perceived postpartum stressors were the same for all women in the study despite their different choices of postpartum recovery. These stressors were women's worries about their body soreness, the flabby flesh of their bellies, interrupted sleep, the baby suddenly falling sick, recovering their prenatal figures, the unpredictable schedule of the baby, and the baby's head shape due to its sleeping position. There were differences by postpartum residence within the top five items of social support. For women who stayed in their own home and those who stayed with their parents, three of the top items came from family support and two from friend support. Women who stayed with their parents-in-law had two top items from family support and three from friend support. Interestingly, for those women who stayed in a postpartum nursing center, one top item was from family support and four were from friend support. Women's postpartum stress involved concerns about maternal role attainment, negative body changes, and lack of social support. The results indicated no significant differences in concerns about maternal role attainment (F = .68, df = 3, 780, p = .57), negative body changes (F = .68, df = 3, 780, p = .56) or lack of social support (F = .24, df = 3, 779, p = .87) among the women who stayed in one of the four types of postpartum residence studied (Table 2). Women's social support included support from both family and friends. The results showed that there were significant differences in family support (F =12.32, df = 3, 779, p b .00) and friend support (F = 4.13, df = 3, 780, p b .01) among women by location of recovery (Table 2). The Scheffe posttest showed that women who stayed in their own home and women who stayed in their own parents' home perceived
more family support than women who stayed with their parents-inlaw. Women who stayed in their own parents' home also perceived greater family support than women who stayed in the nursing postpartum centers. In addition, women who stayed in their own parents' home perceived greater friend support than women who stayed with their parents-in-law. Differences in mean scores for postpartum stress and social support across the four types of postpartum residence were analyzed by one-way ANOVA and Scheffe posttest (Table 2). The mean scores for postpartum stress were not significantly different (F = .56, df = 3, 780, p = .65), but the mean scores for social support were significantly different (F = 9.69, df = 3, 780, p b .00) over the four types of postpartum residence. The Scheffe posttest showed that women who resided in their own home and women who stayed with their parents perceived a higher level of social support than women who stayed with their parents-in-law. We categorized participants who had a CHQ score greater than or equal to 3 as ‘cases’ for minor psychiatric morbidity; otherwise they were categorized as ‘non-cases’. The chi-squared tests indicated that women's health status did not differ significantly by postpartum residence (χ 2 = 3.39, df = 3, p = .34).
5. Discussion We found that women's age, education, employment status, household income, length of marriage, type of delivery, and key helper differed significantly among the four types of postpartum residence. Traditionally, a woman would reside with her parents-inlaw following the custom among ethnic-Chinese Taiwanese of patrilocality in an extended family residence after marrying. Alternatively, she would stay with her own parents in order to have assistance from her mother during the traditional postpartum period. However, we found that older women and women who had been married longer tended to choose their own home, if they owned one, or they chose the postpartum nursing center as a place for the month-long postpartum ritual. It suggests that a woman's autonomy and independence might increase with her age and the length of her marriage, enabling her to choose a place other than the mother-in-law's or mother's home while observing the month-long postpartum period. Postpartum nursing centers aim to facilitate postpartum recovery and newborn care in a calming, familial environment that includes wholesome meals and, commonly, Chinese herbal therapies (Hung, Yu, Liu, et al., 2010; Hung, Yu, Ou, et al., 2010). During their stay, women are provided with information on self-care and newborn care,
Table 2 Mean Scores of Women's Postpartum Stress and Social Support, and Percentages of Health Status (N = 784). Own home
Parents-in-law
Parents
Nursing center
Mean (SD)
Mean (SD)
Mean(SD)
Mean (SD)
or n
or %
(n = 134) Postpartum stress Maternal role attainment Negative body changes Lack of social support Social support Family support Friend support Health status Non-case Case
2.01 2.04 2.10 1.90 3.55 3.58 3.51 80 54
or
n
%
(n = 261) (.52) (.63) (.62) (.53) (.87) (.96) (1.01) 59.70 40.30
2.06 2.07 2.21 1.92 3.30 3.27 3.34 170 91
Case: minor psychiatric morbidity; non-case: none minor psychiatric morbidity.
or
n
%
n
(n = 282) (.57) (.63) (.73) (.60) (.83) (.89) (1.02) 65.13 34.87
2.04 2.07 2.16 1.89 3.66 3.71 3.61 193 89
%
(n = 107) (.58) (.66) (.70) (.59) (.74) (.86) (.85) 68.44 31.56
2.10 2.15 2.18 1.94 3.47 3.38 3.56 67 40
(.56) (.62) (.70) (.59) (.64) (.78) (.79) 62.62 37.38
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assistance, and support. The postpartum nursing center option is a luxury as it is expensive and not covered by health insurance (Hung, Yu, Liu, et al., 2010; Hung, Yu, Ou, et al., 2010). No doubt this is why older women with more economic independence were more likely to utilize their services in this study. We found that a higher proportion of women who stayed in the postpartum nursing centers had a high education level, full-time employment status (except for the women who stayed in their own parents' home), and higher household incomes compared with women who stayed in other places. Interestingly, compared with other women who stayed in the other three places for their postpartum ritual, women who stayed with their parents-in law were the youngest of the participants and had the lowest proportion of high education level and full-time jobs, and tended to have lower household income. With the exception of women in the postpartum nursing centers, we found that the proportion of women who had caesarean sections was higher than those who had a vaginal delivery regardless of the location of their postpartum recovery. Pre-planned caesarean sections have been very high in Taiwan. The high caesarean birth rate occurs in Taiwan for a long list of reasons, including people's concerns about the safety of natural childbirth; obstetricians' impatience; obstetrician's fear of malpractice suits; women who have had previous caesarean sections and are not aware of or interested in vaginal birth after caesarean (VBAC); some women's fear of a long, painful labor; the opportunity to avoid stretching the vagina (which they believe could negatively affect sexual intercourse after childbirth); higher medical reimbursement; and controlling the date and length of labor and delivery, e.g., to fit doctors' busy schedules or to coincide with what the family believes will be an auspicious birth date (Lin & Xirasagar, 2004; Lo, 2003). Our results indicate that the mother or mother-in-law was the primary helper in the postpartum period if a woman stayed in her parents' or her parents-in-law's home, respectively, for the postpartum ritual period. However, if the woman resided in her own home, the woman's husband or her own mother was her primary helper. Moreover, a woman's own mother, compared to the woman's motherin-law, was more likely to stay with her in her (i.e., the daughter's) own home for a full month to tend to her and the newborn; otherwise, the woman's husband would was the primary helper. Hung, Yu, Liu, et al. (2010), Hung, Yu, Ou, et al. (2010) found that most women who chose a postpartum nursing center did so because they wanted quality care, were reluctant to trouble others, or did not have adequate help. The implication is that a woman's mother-in-law or mother was unavailable during her daughter-in-law or daughter's postpartum ritual period, or that her husband's availability was limited. In the postpartum nursing centers, although staff nurses were responsible for caring for the women and their newborns' physical and emotional needs, and offered a series of maternal and infant wellness programs, most of the postpartum women did not consider the staff nurse to be her key helper. The services offered by the staff nurse might have been regarded as a business arrangement; moreover, either the woman's husband or they as a couple were the primary source of payment for the stay (Hung, Yu, Liu, et al., 2010; Hung, Yu, Ou, et al., 2010). We found in this study that women who stayed in the postpartum nursing centers indicated their husband as their key helper. The stressors ‘body soreness’, ‘the flabby flesh of their bellies’, ‘interrupted sleep’, ‘the baby falling sick suddenly’, ‘recovering their prenatal figures’, ‘the baby's unpredictable schedule’, and ‘the shape of the baby's head because of its sleeping position’ were considered by the women to be among the top ten postpartum stressors regardless of location of postpartum recovery. These stressors were also consistently perceived by women as the highest-ranking postpartum stressors regardless of their parity or postpartum week (Hung, 2005, 2006, 2007a, 2007b). In Taiwan, facial structure is considered a key element in predicting one's fortune (Hung, 2006). As a consequence, postpartum women pay a lot of attention
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to adjusting their infants' sleeping position in order to keep their infants' head well-formed. David, Brucker, & MacMullen (1988) found that ‘infant illnesses’ was the infant care topic of highest priority in postpartum education. Moreover, postpartum women need to face the unrelenting demands of infant care, which do not follow a schedule. As a result, most women will complain of fatigue and physical exhaustion, and will experience unease concerning changes in their postpartum bodies (Russell, 1974). Thus, postpartum women should be assisted in relaxation, diet instruction, and progressive exercises. Postpartum exercises that strengthen the pelvic and abdominal muscles particularly need to be emphasized (Hung, 2007a). Our study indicated that women's mean scores for postpartum stress and for its three dimensions—concerns about maternal role attainment, negative body changes, and lack of social support—were low despite the women's different postpartum residences. Moreover, the levels of postpartum stress, the three components of postpartum stress, and their health status did not differ significantly among the four postpartum locations. Our findings are congruent with the established literature, which suggests that the still-observed Taiwanese custom of doing the month has a direct bearing on women's familial relationships and well-being (Pillsbury, 1978, 1982). We found that postpartum women perceived receiving a high level of social support regardless of postpartum location. It is consistent with the prior results of Hung (2007a) that Taiwanese postpartum women perceive a high level of social support and their greatest amount of support is from family members. We found that women who stayed with their own parents or in their own home had higher levels of social support and family support than women who stayed with their parents-in-law. A woman's mother, rather than her mother-in-law or postpartum nursing center staff, is usually the person who offers the most effective family support—including higher levels of care—during the ritual of doing the month. In this study, participants were those married woman who had a singleton birth, could read Chinese and speak Mandarin, agreed to receive an interview via telephone during her postpartum period, and stayed in only one place—her own home where neither parents nor parents-in-law also resided, her parents-in-law's home, her parents' home, or a postpartum nursing center during the postpartum ritual period. Thus, our study's results cannot be generalized to postpartum women who do not meet the inclusion criteria of this study. 6. Conclusion In Taiwan today, doing the month is a postpartum ritual practiced in a variety of places; it plays a role in supporting postpartum women, reducing postpartum stress, and improving maternal health. The postpartum nursing centers are home-like health care facilities. Their security, staff qualifications, food and nutrition supplies, hygiene, nurse–bed ratio, and record-keeping should be regulated and brought under an accreditation process. The postpartum has been recognized in the ethnographic literature as a highly ritualized period of risk commonly mediated by seclusion as well as sexual and food taboos for the mother (Sargent, 2004). The results of this study can provide a framework for future longitudinal studies of immediate childbirth to 1 year postpartum in order to compare possible fluctuations in postpartum stress, social support, and maternal health for women who stay in their permanent residence or some other place during the postpartum period. Further research should also compare women's transition to motherhood and differences in their childcare competence based on the different types of postpartum residence in Taiwan and elsewhere. Acknowledgments Funding for this study was supported in part by a grant from the National Science Council, Taiwan (NSC 95-2314-B-037-085).
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