Therapeutic Effects of the Traditional “Doing the Month” Practices on Postpartum Depression in China
A 33-year-old primiparous woman was admitted on her 14th day postpartum to the psychiatric clinic of the Shanghai Mental Health Center, Shanghai, China. The patient had a healthy pregnancy, followed by an uneventful vaginal delivery and slow recovery from childbirth, but during the first 2 weeks after birth, she developed signs of somatic discomfort and emotional instability, leading her to seek professional help.
On admission, she reported having difficulties in controlling emotions, feeling sad, crying, and worrying constantly throughout the day. She felt tired and hopeless and was losing interest in daily activities such as feeding the baby and cooking. She had lost her appetite and was eating irregularly. Her sleep was also impaired; she could not sleep even when the baby was asleep. These symptoms had a gradual onset within the first week after delivery. Although she did not have suicidal ideation, she did express feelings of guilt.
The patient had no significant past medical history, and she did not report any history of misuse of alcohol, medication, or illicit drugs. There was no relevant personal or family history of mental illness.
Results of a clinical assessment, including physical examination, laboratory studies (total blood count, thyroid function tests), and cerebral CT scan, were normal. The patient scored 21/30 on the Chinese version of the Edinburgh Postnatal Depression Scale (EPDS), a depression screening tool that has satisfactory sensitivity and specificity in identifying depression in the early postpartum period in Chinese populations (1–4). The patient was diagnosed as having postpartum depression and was offered treatment with a combination of psychotherapy and antidepressant or anxiolytic medication. The patient and her family were concerned about the safety of the medications for the mother and baby and declined pharmacotherapy but agreed to proceed with psychotherapy.
They believed that help, support, and reassurance from family or friends would lead the patient to recovery. For the following 4 weeks, the patient practiced the traditional Chinese postpartum ritual of “doing the month.” According to traditional practices, a new mother is in a yin state (depletion of vitality) and needs to recover her health by resting in bed, eating certain foods, and taking tonics. During the first postnatal month, while her body recovers from childbirth, she is spared from all household chores and is attended by a female relative, usually the mother or mother-in-law. This social support in the early postpartum period is an integral part of the zuoyuezi, which translates to “doing the month.” The intimacy and enriched emotional and material support made possible through these indigenous practices and rituals strengthen a mother’s self-esteem, provide emotional support, and buffer the stress experienced by women in early motherhood.
Within the first week of adhering to the custom, the patient had prolonged sleep, waking up only to eat. From the second week, a notable improvement was observed, with complaints of sadness and anxiety gradually subsiding. The patient resumed nursing her baby in the fourth week. On her 6-week postnatal checkup (42nd day postpartum), she scored 8/30 on the EPDS. Her signs and symptoms of depression gradually subsided, and after 4 weeks of practicing the ritual, she was symptom free and her social and family reintegration was complete.
In most cases of mild to moderate depression with little disability, supportive psychotherapy and education may be used as the major treatment. In our case, the patient opted for behavioral and interpersonal therapy, as offered by family and friends, by practicing the traditional Chinese custom of “doing the month.” In modern medicine, childbirth is a physiologic process that, for the most part, does not require additional health care, whereas in traditional Chinese medicine, childbirth is associated with a dramatic transformation of female energy and body. According to the cosmic dual principle (8), the first month after childbirth is crucial to bring yin and yang, unbalanced by the pregnancy and delivery, back to a balanced state and to resume normality. Consequently, during this time new mothers are confined to their homes, where they follow specific rules to control their emotions, diet, and physical activity while family members care for the needs of the new mother, her baby, and the household. Many generations of Chinese women have been brought up to believe that adherence to this ritual is physiologically and psychologically beneficial and that its absence is harmful and may have short- and long-term adverse health effects. Thus, it is not surprising that modern Chinese women, as in our case example, continue to follow the traditional practices, regardless of their educational attainment or where they live. Despite the dramatic changes in social environment and the rapid advancements in modern medicine, many new mothers still adhere to traditional medicine and cultural societal norms.
China is lagging behind countries in Europe and North America in the recognition and treatment of perinatal psychiatric disorders. Poor education among women, fear related to seeing a psychotherapist, and reluctance to take psychotropic medication are the most common barriers that hinder proper identification and management of postpartum depression in Chinese women. Furthermore, most clinical sites in China still lack the screening tools and management options to address women’s mental health in the postpartum period. There is an unmet need for qualified staff who are knowledgeable about the illness and its management and are able to provide adequate and targeted treatment options to patients after weighing the risks and benefits.
A commonly cited anthropological study has suggested that the prevalence of postpartum depression is low in China because of the enriched postpartum social network provided by the family members (9). The intimacy and enriched emotional and material support made possible through these indigenous practices and rituals may strengthen a mother’s self-esteem and provide emotional support, acting as a buffer against the stress and hardship encountered by women in early motherhood (10).
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