Europe PMC Funders Group

Author Manuscript
Birth. Author manuscript; available in PMC 2016 September 01.
Published in final edited form as:
Birth. 2016 September ; 43(3): 247–254. doi:10.1111/birt.12233.
Europe PMC Funders Author Manuscripts

A Comparison of Practices During the Confinement Period

among Chinese, Malay, and Indian Mothers in Singapore
Doris Fok, FILCA [Assistant Manager],
Department of Obstetrics & Gynaecology, Yong Loo Lin School of Medicine, National University of
Singapore, National University Health System, Singapore

Izzuddin M. Aris, PhD [Research Fellow],

Singapore Institute for Clinical Sciences (SICS), Agency for Science, Technology and Research
(A*STAR), Singapore

Jiahui Ho, BSSc [Senior Executive],

Department of Obstetrics & Gynaecology, Yong Loo Lin School of Medicine, National University of
Singapore

Sok Bee Lim, MBBS [Head & Senior Consultant],

Department of Child Development, KK Women’s & Children’s Hospital (KKH), Singapore

Mei Chien Chua, MBBS [Consultant Neonatologist],

Department of Neonatology, KK Women’s and Children’s Hospital (KKH)

Wei Wei Pang, PhD [Research Fellow],

Department of Obstetrics & Gynaecology, Yong Loo Lin School of Medicine, National University of
Europe PMC Funders Author Manuscripts

Singapore

Seang-Mei Saw, PhD [Professor],

Saw Swee Hock School of Public Health, Tahir Foundation Building, National University of
Singapore and Head, Myopia Unit, Singapore Eye Research Institute, Singapore

Kenneth Kwek, FRCOG [Chief Executive Officer],

Department of Maternal Fetal Medicine, KK Women’s and Children’s Hospital (KKH)

Keith M. Godfrey, PhD [Professor],

Medical Research Council Lifecourse Epidemiology Unit, Southampton and Director at NIHR
Southampton Biomedical Research Centre, University of Southampton and University Hospital
Southampton NHS Foundation Trust, Southampton, UK

Michael S. Kramer, MD [Professor], and

Department of Obstetrics & Gynaecology, Yong Loo Lin School of Medicine, National University of
Singapore, and Professor at the Department of Epidemiology, Biostatistics and Occupational
Health, Faculty of Medicine, McGill University, Canada

Yap Seng Chong, MD [Executive Director]

Address correspondence to Yap Seng Chong, MD, Singapore Institute for Clinical Sciences, Brenner Centre for Molecular Medicine,
30 Medical Drive, S117609, Singapore; [email protected].
Members of the GUSTO Study Group are listed in the Appendix
 Fok et al. Page 2

Singapore Institute for Clinical Sciences (SICS), Agency for Science, Technology and Research
(A*STAR) and Senior Consultant and Associate Professor at the Department of Obstetrics &
Gynaecology, Yong Loo Lin School of Medicine, National University of Singapore

on behalf of the GUSTO Study Group

Abstract
Europe PMC Funders Author Manuscripts

Background—Confinement (restrictions placed on diet and practices during the month right
after delivery) represents a key feature of Asian populations. Few studies however, have focused
specifically on ethnic differences in confinement practices. This study assesses the confinement
practices of three ethnic groups in a multi-ethnic Asian population.

Methods—Participants were part of a prospective birth cohort study that recruited 1247 pregnant
women (57.2% Chinese, 25.5% Malay, 17.3% Indian) during their first trimester. 1220 participants
were followed up 3-weeks postpartum at home when questionnaires were administered to
ascertain the frequency of adherence to the following confinement practices: showering;
confinement-specific meals; going out with or without the baby; choice of caregiver assistance;
and the use of massage therapy.

Results—Most participants reported that they followed confinement practices during the first
three weeks post-partum (Chinese: 96.4%, Malay: 92.4%, Indian: 85.6%). Chinese and Indian
mothers tended to eat more special confinement diets than Malay mothers (p<0.001), and Chinese
mothers showered less and were more likely to depend on confinement nannies during this period
than mothers from the two other ethnic groups (p<0.001 for all). Malay mothers tended to make
greater use of massage therapy (p<0.001), whilst Indian mothers tended to have their mothers or
mothers-in-law as assistant caregivers (p<0.001).

Conclusion—Most Singapore mothers follow confinement practices, but the three Asian ethnic
Europe PMC Funders Author Manuscripts

groups differed in specific confinement practices. Future studies should examine whether ethnic
differences persist in later child-rearing practices.

Keywords
Confinement practices; Asian population; Birth-cohort; Post-partum

Introduction
Becoming a parent is a life-transforming event, and the postpartum period is a vulnerable
time of adjustment. In many cultures, the pregnancy period is considered a state of ‘hotness’
while the postpartum period is conceived as a cold and vulnerable state (1). During this
postpartum period, mothers often undergo ‘confinement’, a set of practices to assist them in
recovery from pregnancy and childbirth. Some of these practices may include prolonged rest
(2), a special diet (3, 4) and actions to heighten personal hygiene (2)”.Confinement practices
have been linked to later maternal health conditions such as postpartum depression (5) (6).

In Western populations, postpartum practices have been studied in the context of postpartum
visits (7) or home visits (8). Traditional postpartum practices of immigrants in Western
countries have also been examined in an effort to understand how immigrant mothers adapt

Birth. Author manuscript; available in PMC 2016 September 01.

 Fok et al. Page 3

to local Western culture (9, 10). The postpartum period is often given less focus in Western
cultures (2), than in Asian cultures (11–13). Postpartum support structures and practices also
tend to differ, with ethnokinship more prevalent and emphasized in countries such as Japan
and Korea (14). Furthermore, while western medicine has focused mainly on maternal and
infant health, social support rituals are a more crucial focus of postpartum practices in Asian
cultures (2).
Europe PMC Funders Author Manuscripts

Postpartum diets and practices differ among mothers from different Asian populations, even
within the same country. While several studies have examined post-partum practices and
diets across different Asian populations, such as Laos (3), Myanmar (15), India (4), Japan
(16), Taiwan (17), and Malaysia (18), few have focused specifically on confinement
practices A recent study in Malaysia (18) reported that postpartum and confinement
practices of mothers have certain similarities across different ethnicities. Earlier studies from
the “Growing Up in Singapore Towards healthy Outcomes” (GUSTO) cohort (13) have
looked into the dietary practices across three ethnicities during pregnancy and postpartum
periods (13). In this paper however, we sought to describe the general differences in the
confinement practices of the three ethnic groups.

Methods
Study population
The Growing Up in Singapore Towards healthy Outcomes (GUSTO) study is a prospective
cohort study, the details of which have been published previously (19). Briefly, pregnant
women aged 18 years and above were approached during their first trimester antenatal
ultrasound dating scan at Singapore’s two major public maternity units, namely the National
University Hospital and KK Women’s and Children’s Hospital , between June 2009 and
September 2010. Eligibility criteria included women who were Singapore citizens or
Europe PMC Funders Author Manuscripts

permanent residents of Chinese, Malay or Indian ethnicity with homogeneous parental

ethnic background, and who had the intention of delivering in the National University
Hospital or KK Women’s and Children’s Hospital and residing in Singapore for the next 5
years. The potential participants were approached at the clinic when they were at least 12
weeks pregnant. Questions were then asked to assess their eligibility for this study. Of 3751
screened women, 2034 individuals met these criteria and 1247 women were recruited
(response rate: 61.3%). Informed consent was obtained from each participant on the day of
recruitment. During the recruitment visit (< 14 weeks gestation) and at the first clinic visit
(26-28 weeks gestation), questionnaires were administered to the pregnant women to
ascertain demographic, socio-economic and lifestyle factors, as well as maternal well-being
and obstetric and medical history data.

Confinement practices questionnaires

Women were followed up at home 3 weeks after delivery by trained interviewers who had
successfully completed the GUSTO competency assessments. This includes observing and
subsequently conducting three supervised home visits respectively as well as the final
competency test. Only after the staff is assessed by the trainers to be competent to conduct
the interviews, were the ground staff able to conduct the questionnaires independently.

Birth. Author manuscript; available in PMC 2016 September 01.

 Fok et al. Page 4

Questionnaires administered during this visit captured the mother’s diet and infant feeding.
Mothers were asked to compare their present confinement diet with their usual diets, and to
indicate whether they increased, decreased or retained the consumption of a particular food
type during the confinement period. The frequency of adherence to confinement practices
was derived from questions on the five following confinement practices: showering, the
proportion of meals that were confinement-specific, going out with or without the baby,
Europe PMC Funders Author Manuscripts

choice of caregiver assistance and the use of massage therapy. These confinement questions
were formulated based on the description of confinement practices by Goh (20). The
questionnaires were pilot-tested for clarity and understanding, and revisions were made after
feedback from women and study staff.

Statistical analysis
Descriptive statistics are reported as means and standard deviations (SDs) for continuous
variables and percentages for categorical variables. Differences in confinement practices
across ethnicities were analysed using chi-square tests. Associations between ethnicity (as
the independent variable) and confinement practices (as the dependent variable) were
analysed using multivariable regression analyses adjusting for maternal age, education level,
household income, housing type (government or private) and parity. For dichotomous
outcomes (i.e. undergoing confinement, use of massage therapy), analyses were performed
using binary logistic regression models. For categorical outcomes (i.e. showering, proportion
of meals that were confinement-specific, going out with or without the baby, and choice of
caregiver assistance), analyses were performed using multinomial logistic regression
models. All analyses were performed using SPSS version 20.0 (IBM, SPSS Statistics,
Armonk, NY).

Results
Europe PMC Funders Author Manuscripts

Socio demographic characteristics of mothers in the three ethnic groups are compared in
Table 1. Most of the study participants were married. Significant differences in
socioeconomic status were observed between Chinese and Indian women on the one hand,
and Malay women on the other, with 68.7% and 69.6% of Chinese and Indian women,
respectively, attaining at least an advanced-level education ( Equivalent to pre-university
education), compared to 28.8% of Malay women (p<0.001). A significantly higher
proportion of Chinese and Indian women (18.6% and 12.0% respectively) lived in private
housing accommodations, compared to 6.3% of Malay women (p<0.001), while 41.3 and
23.8% of Chinese and Indian women respectively, reported a monthly household income
above $6000, compared to 6.1% of Malay women (p<0.001). We observed significant
differences in parity, with Indian women most likely to be multiparous (p = 0.001). There
were also significant differences observed in citizenship status amongst ethnic groups, with a
higher proportion of Chinese and Indian women having Permanent Resident (rather than
citizenship) status (32.8% and 46.5%, respectively), than Malay women (3.1%) (p<0.001).

Chinese women were more likely (96.4%) to engage in at least some confinement practices
while Malays [92.4%] and Indians [85.6%] were less likely to. (Table 2). Chinese women
were also more likely to hire confinement assistants (31.0%), while Malay [13.5%] and

Birth. Author manuscript; available in PMC 2016 September 01.

 Fok et al. Page 5

Indian women [9.4%] were less likely to hire confinement help. Chinese women were also
more likely to have all of their meals prepared specifically for confinement (45.9%) as than
Malay women (21.3%). Massage was particularly common among Malay women (85.9%),
and least frequent among Chinese (37.8 %). A significantly higher percentage of Chinese
women observed a ‘no bathing’ restriction during their confinement, whereas most Malay
[96.8%] and Indian women [88.8%] showered daily. True confinement (remaining at home)
Europe PMC Funders Author Manuscripts

was practiced among all 3 ethnic groups, with most mothers (63.7% of Chinese, 51.4%
Malay and 60.6% of Indian) staying at home during the confinement period. Similarly, other
family members avoided taking the infant out during confinement; 83.7% of Chinese, 66.1%
of Malays and 79.9% of Indian infants stayed at home during the confinement period. Malay
women however, were more likely to leave their house, with their baby (24.2%), at least
once a week during the confinement period.

After adjusting for socio-demographic covariates (i.e., maternal age, education level,
housing type, income level and parity), we noted similar observed ethnic differences in
relation to confinement practices, with Malay women being less likely to hire other
confinement assistants and have all of their meals prepared specifically for confinement,
whilst being more likely to undergo massage, shower daily and leave their house with their
baby during the confinement period (Table 3). Furthermore, we noted that most of the socio-
demographic variables were not significantly associated with the various confinement
practices, with the exception of household income significantly affecting massage practice,
and household income, maternal education level and parity significantly affecting daily
showering habits (tabular data not shown).

Discussion
While most Singaporean mothers engage in the confinement practices described, we
Europe PMC Funders Author Manuscripts

observed substantial differences in these practices depending on the mother’s ethnic

background. Although confinement practices have been known to be prevalent in East-,
South- and Southeast-Asian populations (3, 4, 11, 12, 18), these practices have rarely been
compared among Asian ethnic groups within a single country.

Undergoing confinement means restricting one’s movements in leaving the home and
avoiding certain behaviors, with the goal of accelerating the recovery process. The
confinement period is usually practised for 30–45 days (21). Whilst this designated rest
period is practiced across many Asian cultures (16, 22, 23), it is also practiced in non-Asian
cultures as well, including South African (24), Mexican (25) and Amish (26) women.
Confinement practices are influenced by assimilation (27), and disagreement between
traditions and modern beliefs may arise, owing to increasing influence from sources such as
the media and health professionals (28).

Within-culture differences in confinement practices have also been reported in major urban
centers, where younger women are less likely to participate in them (29). The act of staying
indoors during confinement may seem rather restrictive to the active modern mother. In a
study of Malaysian Chinese mothers, the traditional confinement practices amongst the
Chinese was adapted according to mothers’ perception of practicality (30).

Birth. Author manuscript; available in PMC 2016 September 01.

 Fok et al. Page 6

In our study, abstinence from bathing during confinement was mostly adhered to by Chinese
women. Bathing restrictions during the confinement period exist in many Asian cultures,
most of which are related to the “hot” and “cold” beliefs during confinement. While Chinese
mothers in our study mostly tended to avoid showers as a whole, cold showers in particular
are often prohibited in the belief that they may lead to blood clots and sore joints (9, 10). In
non-Asian cultures such as Guatemala, it is believed that bathing in cold water decreases
Europe PMC Funders Author Manuscripts

milk supply, and that bathing too soon causes stomach pains or prolapsed uterus(31). In
Mexico, bathing is restricted to protect the mother from cold or ‘evil air’(25). Warm baths
and showers are often acceptable confinement practices in Asian cultures, however,
particularly among mothers in Thailand (32), Malaysia (33) and India (4). A quick, warm
shower without hair washing (34), appears to be the practice adopted by Malay and Indian
mothers here in Singapore. Mothers may find it uncomfortable and unhygienic not to bathe
during the postpartum period, especially in a tropical climate such as Singapore. Hence
mothers who observe traditional confinement practices need to negotiate with their caregiver
assistants on alternative solutions, which may include the use of medical herbs added to hot
water for their daily baths, a practice that has been adopted in countries such as Laos (35)
and China (17). This may serve as a potential compromise for mothers to observe traditional
confinement practices while maintaining their general personal hygiene at the same time.

We observed a higher prevalence of massage use by Malay mothers during the confinement
period than by mothers from the two other ethnic groups. The practice of massage (Jamu
therapy) is a predominantly Malay/Indonesian practice (36, 37), but it was also practiced
amongst Chinese and Indian women in our study population. Such confinement practices
adopted across different groups are indicative of the cross-ethnic influence of confinement
practices. Naser et al. (38) found that Singaporean women adopted traditional practices that
they perceived as beneficial from other cultures. The practice of massage therapy amongst
mothers in the three ethnic groups illustrates how confinement practices are influenced by
Europe PMC Funders Author Manuscripts

the different cultures in Singapore.

Diet has been shown to be an important component of confinement practices. Consumption

of certain foods is believed to promote or restore health, while other foods are avoided as
they are thought to cause illness either immediately or in the future. We observed that
Chinese women were more likely to have all of their meals specially prepared for the
confinement period. As previously reported by Fok (39), Chinese women are influenced by
the concept of the yin and yang in balancing their foods during confinement. According to
traditional Chinese beliefs, the body of a woman is believed to be in a state of ‘cold’ during
the postpartum period and thus ‘hot’ foods (12), such as ginger and wine are generally
recommended (28). Although such beliefs are common in China and other East Asian
countries, they are found in many non-Asian cultures as well, including parts of Latin
America and Africa (1). Some similarities in confinement diets are apparent across the three
ethnic groups in Singapore. A turmeric drink, known as Jamu, is particularly important in
the Malay confinement diet, as it is believed that using correct supplements are important in
aiding mothers to regain the energy spent during labour (11). Some women in Nepal have
also been known to consume a herbal tonic containing turmeric, in an attempt to promote
milk production during the postpartum period (40). Among Guatemalan women, herbal teas
containing artemesia, pimipinela, oregano and white honey are taken for pain relief (41).

Birth. Author manuscript; available in PMC 2016 September 01.

 Fok et al. Page 7

Caregiver assistance during confinement includes provision of practical assistance to the

mother (e.g. doing household chores, cooking, providing care for the mother and her infant),
and is often provided by close relatives or respected elders within the community (2). In our
study, most women engaged close relatives as caregivers during confinement (grandmothers,
mothers-in-law, mothers, aunts and sisters), a practice that is universally adopted across
many other countries (2). Chinese women often engaged domestic helpers or confinement
Europe PMC Funders Author Manuscripts

nannies during the confinement period. The employment of confinement nannies specifically
for confinement purposes is unique to the Southeast Asian context. During the confinement
period, Chinese mothers may hire traditional confinement nannies, (known as peiyue) to
take care of them and their baby (30). This prevalence of caregiver assistance increasesthe
mother’s access to both practical and emotional support during the confinement period.
While we did not specifically ask the mothers for the reason they chose to hire confinement
help, the combined role of family support and hired confinement help in general is important
in assisting mothers in matters of physical recovery and to care for her baby,

Strengths of our study include its prospective design, high follow-up rate, and comparison
across different Asian ethnic groups. We are aware of no previous studies that have
examined ethnic differences in confinement practices in a multi-ethnic population. There are
however, some limitations to consider. We did not use focus group discussions with the
study participants. Such discussions would help mothers’ verbalize their thoughts (42) about
confinement practices and allow us to better understand the reasons Singaporean mothers
did or did not engage in the confinement practices we studied. Nor are we able to
disentangle the potential influences of personal choice and assimilation on the observed
ethnic differences in confinement practices. Future studies would also benefit from
examining the various reasons mothers choose to practice confinement practices or reasons
why mothers are selective in the practices they adhere to.
Europe PMC Funders Author Manuscripts

Conclusions
Despite modernizing trends, most Singaporean mothers engage in traditional confinement
practices. There are also substantial differences in those practices depending on the mother’s
ethnic background. These findings may help health care professionals to better understand
the dynamic and ethnic-specific nature of confinement practices, thus allowing them to
provide greater support and tailor ethnic-specific postpartum care for mothers. .

References
1. Kim-Godwin YS. Postpartum Beliefs and Practices Among Non-Western Cultures. MCN, The
American Journal of Maternal/Child Nursing. 2003; 28(2):74–8.
2. Dennis C-L, Fung K, Grigoriadis S, Robinson GE, Romans S, Ross L. Traditional postpartum
practices and rituals: a qualitative systematic review. Women's health (London, England). 2007;
3(4):487–502.
3. Barennes H, Simmala C, Odermatt P, Thaybouavone T, Vallee J, Martinez-Aussel B, et al.
Postpartum traditions and nutrition practices among urban Lao women and their infants in
Vientiane, Lao PDR. European journal of clinical nutrition. 2009; 63(3):323–31. [PubMed:
18000519]
4. Choudhry UK. Traditional Practices of Women From India: Pregnancy, Childbirth, and Newborn
Care. Journal of Obstetric, Gynecologic, & Neonatal Nursing. 1997; 26(5):533–9.

Birth. Author manuscript; available in PMC 2016 September 01.

 Fok et al. Page 8

5. Grigoriadis S, Erlick Robinson G, Fung K, Ross LE, Chee CYI, Dennis C-L, et al. Traditional
postpartum practices and rituals: clinical implications. Canadian journal of psychiatry Revue
canadienne de psychiatrie. 2009; 54(12):834. [PubMed: 20047722]
6. Bao W, Ma A, Mao L, Lai J, Xiao M, Sun G, et al. Diet and lifestyle interventions in postpartum
women in China: study design and rationale of a multicenter randomized controlled trial. BMC
public health. 2010; 10(1):103. [PubMed: 20187965]
7. Piejko E. The postpartum visit - Why wait 6 weeks?: 1. Australian Family Physician. 2006; 35(9):
Europe PMC Funders Author Manuscripts

674. [PubMed: 16969434]

8. Biro MA, Yelland JS, Sutherland GA, Brown SJ. Women's experience of domiciliary postnatal care
in Victoria and South Australia: A population-based survey. Australian Health Review. 2012; 36(4):
448–56. [PubMed: 23116571]
9. Davis RE. The postpartum experience for southeast Asian women in the United States. MCNThe
American journal of maternal child nursing. 2001; 26(4):208–13. [PubMed: 11452666]
10. Rice PL. Nyo dua hli– 30 days confinement: traditions and changed childbearing beliefs and
practices among Hmong women in Australia. Midwifery. 2000; 16(1):22–34. [PubMed:
11139859]
11. Haron H, Hamiz M. An Ontological Model for Indigenous Knowledge of Malay Confinement
Dietary. Journal of Software. 2014; 9(5):1302.
12. Pillsbury BL. “Doing the month”: confinement and convalescence of Chinese women after
childbirth. Social Science & Medicine Part B: Medical Anthropology. 1978; 12:11–22.
13. Chen L-W, Low YL, Fok D, Han WM, Chong YS, Gluckman P, et al. Dietary changes during
pregnancy and the postpartum period in Singaporean Chinese, Malay and Indian women: the
GUSTO birth cohort study. Public health nutrition. 2014; 17(09):1930–8. [PubMed: 23806144]
14. Posmontier B, Horowitz JA. Postpartum Practices and Depression Prevalences: Technocentric and
Ethnokinship Cultural Perspectives. Journal of Transcultural Nursing. 2004; 15(1):34–43.
[PubMed: 14768414]
15. Sein KK. Beliefs and practices surrounding postpartum period among Myanmar women.
Midwifery. 2013; 29(11):1257. [PubMed: 23415368]
16. Yoshida K, Yamashita H, Ueda M, Tashiro N. Postnatal depression in Japanese mothers and the
reconsideration of ‘Satogaeri bunben’. Pediatrics International. 2001; 43(2):189–93. [PubMed:
11285079]
17. Li R, Li S, Long C, Liu Y, Liu F, Lee S, et al. Herbs for medicinal baths among the traditional Yao
Europe PMC Funders Author Manuscripts

communities of China. Journal of Ethnopharmacology. 2006; 108(1):59–67. [PubMed: 16735101]

18. Fadzil F, Shamsuddin K, Wan Puteh SE. Traditional Postpartum Practices Among Malaysian
Mothers: A Review. Journal of alternative and complementary medicine (New York, NY). 2015 Jul
13. Epub 2015/07/15. Eng. [PubMed: 26167656]
19. Soh S-E, Tint MT, Gluckman PD, Godfrey KM, Rifkin-Graboi A, Chan YH, et al. Cohort profile:
Growing Up in Singapore Towards healthy Outcomes (GUSTO) birth cohort study. International
journal of epidemiology. 2014; 43(5):1401–9. [PubMed: 23912809]
20. Goh, E. Research and Information Dept., Singapore Council of Social Service; 1990. Research on
crisis and depression of motherhood: an exploratory study of the support needed by mother with
young babies.
21. Koon PB, Peng WY, Karim NA. Postpartum dietary intakes and food taboos among Chinese
women attending maternal and child health clinics and maternity hospital, Kuala Lumpur. Malays
J Nutr. 2005; 11:1–21.
22. Park E-HM, Dimigen G. A cross-cultural comparison: Postnatal depression in Korean and Scottish
mothers. Psychologia: An International Journal of Psychology in the Orient. 1995
23. Liamputtong P. Yu Duan Practices as Embodying Tradition, Modernity and Social Change in
Chiang Mai, Northern Thailand. Women & Health. 2004; 40(1):79. [PubMed: 15778133]
24. Selepe HL, Thomas DJ. The Beliefs and Practices of Traditional Birth Attendants in the Manxili
Area of KwaZulu, South Africa: A Qualitative Study. Journal of Transcultural Nursing. 2000;
11(2):96–101. [PubMed: 11982050]
25. Niska K, Snyder M, Lia-Hoagberg B. Family ritual facilitates adaptation to parenthood. Public
health nursing (Boston, Mass). 1998; 15(5):329–37.

Birth. Author manuscript; available in PMC 2016 September 01.

 Fok et al. Page 9

26. Finn J. Leininger's Model for Discoveries at the Farm and Midwifery Services to the Amish.
Journal of Transcultural Nursing. 1995; 7(1):28–35. [PubMed: 8716103]
27. Chee CYI, Lee DTS, Chong YS, Tan LK, Ng TP, Fones CSL. Confinement and other psychosocial
factors in perinatal depression: A transcultural study in Singapore. Journal of Affective Disorders.
2005 Dec; 89(1–3):157–66. [PubMed: 16257451]
28. Raven JH, Chen Q, Tolhurst RJ, Garner P. Traditional beliefs and practices in the postpartum
period in Fujian Province, China: a qualitative study. BMC Pregnancy and Childbirth. 2007; 7(1):
Europe PMC Funders Author Manuscripts

8. [PubMed: 17584930]
29. Hundt GL, Beckerleg S, Kassem F, Jafar AMA, Belmaker I, Saad KA, et al. Women's health
custom made: Building on the 40 days postpartum for Arab women. Health care for women
international. 2000; 21(6):529–42. [PubMed: 11235284]
30. Chin YM, Jaganathan M, Hasmiza AM, Wu MC. Zuo yuezi practice among Malaysian Chinese
women: tradition vs modernity. British Journal of Midwifery. 2010; 18(3):170–5.
31. Lang JB, Elkin ED. A study of the beliefs and birthing practices traditional midwives in rural
Guatemala. Journal of Nurse-Midwifery. 1997; 42(1):25–31. [PubMed: 9037932]
32. Kaewsarn P, Moyle W, Creedy D. Traditional postpartum practices among Thai women. Journal of
Advanced Nursing. 2003; 41(4):358–66. [PubMed: 12581101]
33. Laderman C. Destructive heat and cooling prayer: Malay humoralism in pregnancy, childbirth and
the postpartum period. Social Science & Medicine. 1987; 25(4):357–65. [PubMed: 3686085]
34. Nahas V, Amasheh N. Culture Care Meanings and Experiences of Postpartum Depression among
Jordanian Australian Women: A Transcultural Study. Journal of Transcultural Nursing. 1999;
10(1):37–45. [PubMed: 10476151]
35. de Boer HJ, Lamxay V, Björk L, Institutionen för o, Uppsala u, Biologiska s. et al. Steam sauna
and mother roasting in Lao PDR: practices and chemical constituents of essential oils of plant
species used in postpartum recovery. BMC complementary and alternative medicine. 2011; 11(1):
128. [PubMed: 22171719]
36. Chuthaputti, A. Traditional Medicine in REPUBLIC OF INDONESIA2010. Available from: http://
www.searo.who.int/entity/medicines/topics/traditional_medicines_in_republic_of_indonesia.pdf
37. Beers, S-J. Jamu: the ancient Indonesian art of herbal healing. Periplus Editions (HK) Limited;
2001.
38. Naser E, Mackey S, Arthur D, Klainin-Yobas P, Chen H, Creedy DK. An exploratory study of
traditional birthing practices of Chinese, Malay and Indian women in Singapore. Midwifery. 2012;
Europe PMC Funders Author Manuscripts

28(6):e865–e71. [PubMed: 22079015]

39. Fok D. Cross cultural practice and its influence on breastfeeding-the Chinese culture. Breastfeed
Rev. 1996; 4:13–8.
40. Reissland N, Burghart R. Active patients: The integration of modern and traditional obstetric
practices in Nepal. Social Science & Medicine. 1989; 29(1):43–52. [PubMed: 2740927]
41. Callister LC, Vega R. Giving birth: Guatemalan women's voices. Journal of obstetric, gynecologic,
and neonatal nursing : JOGNN / NAACOG. 1998; 27(3):289–95.
42. DiMatteo MR, Kahn KL, Berry SH. Narratives of birth and the postpartum: analysis of the focus
group responses of new mothers. Birth (Berkeley, Calif). 1993; 20(4):204–11.

Birth. Author manuscript; available in PMC 2016 September 01.

 Fok et al. Page 10

Table 1
Demographic and clinical characteristics in study of confinement practices of
Singaporean women, 2009-2010
Europe PMC Funders Author Manuscripts

Mothers Chinese Malay Indian P value+

N = 684 N = 319 N = 217

Age (yr)Mean+-SD 31.6 ± 4.9 28.9 ± 5.5* 30.0 ± 4.9 <0.001

Marital Status (%) 0.327

Married 96.5 95.0 98.1
Single 3.4 5.0 1.9
Divorced 0.1 0.0 0.0
Highest Education attained (%) <0.001
Below ""A" levels / diploma 31.3 71.2 30.4
“A” levels / diploma or higher 68.7 28.8* 69.6

Type of housing (%) <0.001

Government 81.4 93.7 88.0
Private 18.6 6.3* 12.0

Household Income (%) <0.001

Below SGD $6000 58.7 93.9 76.2
Above SGD $6000 41.3 6.1* 23.8

Parity (%) 0.001

Nulliparous 50.5 40.4 38.1
Multiparous 49.5 59.6 61.9*
Europe PMC Funders Author Manuscripts

+
P values across 3 ethnic groups were determined with the use of a chi-square analysis (categorical) or 1-factor ANOVA (continuous)
*
p<0.05 when compared with Chinese

Birth. Author manuscript; available in PMC 2016 September 01.

 Fok et al. Page 11

Table 2
Confinement practices of Singaporean mothers from the three ethnic groups
Europe PMC Funders Author Manuscripts

Chinese Malay Indian P value+

Undergo confinement < 0.001

No 22 (3.6) 19 (7.6) 26 (14.4)
Yes 584 (96.4) 230 (92.4) 154 (85.6)
Caregiver < 0.001
Mother/Mother-in-law 333 (59.4) 138 (71.5) 115 (83.3)
Other relatives 54 (9.6) 29 (15.0) 10 (7.2)

Other confinement people+ 174 (31.0) 26 (13.5) 13 (9.4)

Proportion of meals prepared for confinement < 0.001

None 20 (3.4) 39 (17.0) 28 (18.2)
Less than half 23 (3.9) 25 (10.9) 13 (8.4)
Half 58 (9.9) 81 (35.2) 21 (13.6)
Most 215 (36.8) 36 (15.7) 27 (17.5)
All 268 (45.9) 49 (21.3) 65 (42.2)
Massage during confinement < 0.001
No 377 (62.2) 35 (14.1) 90 (50.0)
Yes 229 (37.8) 214 (85.9) 90 (50.0)
Shower during confinement (%) < 0.001
None/once a week 156 (26.0) 5 (2.0) 7 (3.9)
2-6 times a week 147 (24.5) 3 (1.2) 13 (7.3)
Everyday 296 (49.4) 239 (96.8) 159 (88.8)
Europe PMC Funders Author Manuscripts

Go out during confinement (%) 0.014

None 383 (63.7) 128 (51.4) 109 (60.6)
Once a week 137 (22.8) 74 (29.7) 49 (27.2)
≥ 2 times a week 81 (13.5) 47 (18.9) 22 (12.2)
Baby goes out during confinement (%) <0.001
None 504 (83.7) 164 (66.1) 143 (79.9)
Once a week 73 (12.1) 60 (24.2) 28 (15.6)
≥ 2 times a week 25 (4.2) 24 (9.7) 8 (4.5)

+
P values across 3 ethnic groups were determined with the use of a chi-square analysis (categorical) or 1-factor ANOVA (continuous)
+
Other confinement people refers to people hired specifically to help out during the confinement period, such as Confinement Nannies

Birth. Author manuscript; available in PMC 2016 September 01.

 Fok et al. Page 12

Table 3
Associations between ethnicity and confinement practices of Singaporean women,
2009-2010
Europe PMC Funders Author Manuscripts

OR (95% CI)

Chinese Malay Indian

Undergoes confinementa ref 0.45 (0.21-0.93) 0.22 (0.12-0.42)

Caregiverb
Other relatives ref 0.92 (0.53-1.62) 0.59 (0.28-1.21)
Other confinement people ref 0.50 (0.30-0.83) 0.25 (0.13-0.47)

Meals prepared for confinementb

less than half ref 0.63 (0.26-1.54) 0.42 (0.16-1.07)
half ref 0.83 (0.40-1.70) 0.24 (0.11-0.55)
most ref 0.11 (0.06-0.24) 0.11 (0.05-0.23)
all ref 0.11 (0.05-0.22) 0.21 (0.11-0.41)

Undergoes massagea ref 18.07 (11.38-28.69) 2.05 (1.41-2.99)

Showerb
2 to 6 times a week ref 0.28 (0.03-2.47) 1.98 (0.74-5.32)
everyday ref 39.50 (15.44-101.04) 12.98 (5.83-28.89)

Mother goes out during confinement periodb

once a week ref 1.53 (1.03-2.28) 1.22 (0.80-1.85)
≥ 2 times a week ref 2.21 (1.36-3.57) 1.01 (0.59-1.74)

Baby goes out during confinement periodb

Europe PMC Funders Author Manuscripts

once a week ref 2.41 (1.53-3.79) 1.30 (0.79-2.15)

≥ 2 times a week ref 4.39 (2.15-8.99) 1.35 (0.57-3.23)

a
Analyses conducted using binary logistic regression, with ethnicity as independent variable and adjusted for the following covariates: maternal
age, education, accommodation, income level and parity
b
Analyses conducted using multinomial logistic regression, with ethnicity as independent variable and adjusted for the following covariates:
maternal age, education, accommodation, income level and parity

Birth. Author manuscript; available in PMC 2016 September 01.