a qualitative study of the postpartum experience of chinese women living in england
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A qualitative study of the postpartumexperience of Chinese women living inEnglandErica Lam a , Anja Wittkowski c & John R.E. Fox ba University of Sheffield , Sheffield , UKb University of Manchester , Manchester , UKc University of Manchester, Department of Clinical Psychology ,Manchester , UKPublished online: 28 Feb 2012.
To cite this article: Erica Lam , Anja Wittkowski & John R.E. Fox (2012) A qualitative study of thepostpartum experience of Chinese women living in England, Journal of Reproductive and InfantPsychology, 30:1, 105-119, DOI: 10.1080/02646838.2011.649472
To link to this article: http://dx.doi.org/10.1080/02646838.2011.649472
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A qualitative study of the postpartum experience of Chinesewomen living in England
Erica Lama, Anja Wittkowskic* and John R.E. Foxb
aUniversity of Sheffield, Sheffield, UK; bUniversity of Manchester, Manchester, UK;cUniversity of Manchester, Department of Clinical Psychology, Manchester, UK
(Received 8 August 2010; final version received 24 November 2011)
Objective: to explore the postnatal experiences of Chinese women living inManchester, including the factors that contributed to their thoughts and feelings.Background: Chinese culture embraces some unique postnatal traditions, whichcan create conflict but also increase support for Chinese mothers. This study isthe first to investigate Chinese women’s postnatal experiences in the UK. Meth-ods: In this qualitative study eight mothers were interviewed. They spoke eitherboth Chinese and English or Chinese only. Grounded theory was used to ana-lyse the interview transcripts. Results: Two main themes of distress were identi-fied: isolation and conflict. The women’s preferred spoken language and culturalnorms determined the extent and nature of their distress. All mothers felt somedegree of isolation during their early motherhood, especially when they feltunsupported by local services and family members. Chinese-speaking mothersfelt more isolated, whereas bilingual mothers described more conflict, whichthey attributed to cultural differences with peers, as well as the role of theirmother-in-law and that of traditional cultural practices. In addition, the absenceof a strong parenting model seemed to be a mediating factor. Conclusions:These findings could promote understanding and provide insight into the poten-tial expression of postnatal depression in Chinese women.
Keywords: postnatal experience; postnatal depression; Chinese community sam-ple; qualitative study; grounded theory; women
Introduction
Over recent years, the cultural diversity of the UK has grown, with 9% of the totalpopulation of England being from ethnic minorities, with the Chinese communitymaking up 0.4% (Office for National Statistics, 2001). These figures reveal the poten-tial importance of statutory services understanding the mental health needs of the dif-fering communities. While greater mental health difficulties in minority populationshave been highlighted, few studies have explored postnatal experiences and postnataldepression (PND) in ethnic groups. However, studies conducted in the UK noted thatbeing a mother from an ethnic minority background (especially Asian) or originatingfrom a non-English-speaking country significantly increased their risk of developingPND (Hearn et al., 1998; Onozawa, Kumar, Adams, Doré, & Glover, 2003). Race/ethnicity was also a significant predictor of depressed mood in non-UK-based studies
*Corresponding author. Email: [email protected]
Journal of Reproductive and Infant PsychologyVol. 30, No. 1, February 2012, 105–119
ISSN 0264-6838 print/ISSN 1469-672X online� 2012 Society for Reproductive and Infant Psychologyhttp://dx.doi.org/10.1080/02646838.2011.649472http://www.tandfonline.com
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(Ghubash & Abou-Saleh, 1997; Inandi, Elic, Ozturk & Egri, 2002; Segre, Losch &O’Hara, 2006).
Only one study had directly examined at Chinese mothers’ experiences of PND.Chan, Levy, Chung and Lee (2002) looked qualitatively at the experience of 35Chinese mothers living in Hong Kong. They identified several themes, namely feel-ing ‘trapped’ in the situation; ambivalence towards the baby; and uncaring, butcontrolling and powerful, husbands and in-laws. The latter two themes were seen asmajor factors contributing to PND. However, their study lacked sufficientreflectivity and transparency in the data analysis.
No study to date has explored the postnatal experience of Chinese mothers inthe non-clinical population; the role of cultural beliefs in their postpartum adjust-ment is under-researched, and yet there are many specific traditions that come intoplay when a child is born. Chinese culture embraces some unique traditions thatgreatly influence the postnatal period, such as Zuo Yue,1 which is directly translatedas ‘doing the month’. These practices are believed to benefit the new mother’srecovery and prevent future health problems (e.g. rheumatism, headaches). Pei Yuerefers to a female relative (usually the mother or mother-in-law) taking care of thenew mother and her baby during the first postnatal month. These traditional prac-tices and family support play a major role in protecting the new mother’s healthand well-being against any stress and difficulties during early motherhood (Cheeet al., 2005; Chien, Tai, Ko, Huang, & Sheu, 2006; Holroyd, Twinn, & Yim, 2004;Cheung, 2002; Huang & Mathers, 2001). However, some mothers follow these tra-ditional practices and the advice of elders merely out of respect (Raven, Chen &Tolhurst, 2007). In addition, a recent study shows that the younger generation ofTaiwanese women enjoyed increased autonomy during the period of Zuo Yue onlyif they were separated from their mothers-in-law (Chen, 2010).
According to Chunxia and Chao (2005), an absence of family support practicesamong Chinese migrants in Western societies can have negative health implications.For example, conflicts were more likely to emerge among mothers who wererestricted by environmental constraints and struggled to follow traditional practices,indicating that Zuo Yue was not necessarily protective and supportive of the newmother, but led to conflict when trying to adapt traditional practices to fit modernlife (Leung, Arthur, & Martinson, 2005). A systemic review indicated that specificcomponents of confinement practices might reduce psychological distress in Chi-nese mothers of newborns. However, confinement cannot be presumed to be avail-able to, welcomed by or effective for all Chinese women (Wong & Fisher, 2009).
To date, no study has explored the interface between Chinese culture/traditions,and the experience of being a Chinese mother living in the UK. Therefore, the aimsof this study were to investigate the postnatal experience of Chinese mothers livingin the UK, with a specific aim to investigate factors that contributed to their feelingsand experiences.
Method
This study employed constructivist grounded theory methodology (Charmaz, 2000,2006). This method emphasises the inductive construction of theory directly fromdata, using the ‘constant comparison’ method. Allowing concept and theorygeneration becomes progressively more abstract at each level of comparison, i.e.comparison of data with data, data with category, category with category and
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category with concept (Charmaz, 2006). Analysing and collecting data simulta-neously is a key element of grounded theory, as analysis of initial data explicitlyshapes the direction of further sampling, which allows concepts to be explored indepth, and can enhance novel theory generation (Dey, 1999; Glaser & Strauss,1967).
Reflexivity, reliability and validity
The first researcher was a 27-year-old, middle-class, unmarried ‘Chinese–British’female without children. She grew up in a traditional Chinese family in HongKong and was educated in Chinese until her teens, before moving to England toreceive a British education. She is fluent in Chinese. She has adopted westernisedcultural values, although she embraces her Chinese values. Thus the researcherhad good insight into both cultures, including social norms and particular culturalpractices. The researcher received regular supervision to ensure reliability andvalidity. Supervision focused on overcoming implied cultural assumptions anddeveloping shared common knowledge between research and participant. Theresearch supervisors are specialists in perinatal psychology and grounded theory,respectively.
Participants and recruitment process
This study was presented at the Wai Yin Women’s Society centre, which is a widelyused charitable organisation for women in the Chinese community in Manchester.Three mothers from a postnatal group run at the centre expressed interest in takingpart and an additional five mothers from the community were recruited with thehelp of a recruitment poster. All eight mothers had given birth within the last 12months and were therefore eligible. The Wai Yin Women’s Society regularly runsprenatal and postnatal groups supported by the National Childbirth Trust (NCT).Hence, recruitment through this centre has enabled easier access to potential partici-pants, but these groups tended to attract mostly first-time mothers. Eight participantswere enough to achieve ‘theoretical sufficiency’, where categories have sufficienttheoretical power to account for the data collected (Dey, 1999, p. 117).
Data collection and analysis
The Edinburgh Postnatal Depression Scale (EPDS) (Cox, Holden & Sagovsky,1987) and its Chinese version (Lee et al., 1998) were used as a descriptor for thesample (see Table 1). Participants could choose which version to complete. Scoresof 10 or over are considered indicative of PND (Cox et al., 1987) in communitysamples. However, as a screening tool, the EPDS was used in this study to providean additional way of describing the sample’s well-being and postpartum mood.
An initial interview schedule was piloted and formulated with broad, open-ended questions that aimed to guide discussion of the mothers’ postnatal experi-ence, including their feelings and contributory factors, and their support networksince the birth. The initial two pilot interviews generated sufficient data, hence theywere included in the final analysis. As a result of data collection and analysis theinterview schedule was refined on two occasions and new probes were added toexplore participants’ experiences in more detail.
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Although interviews were mostly undertaken in English, participants wereencouraged to use their own language to express feelings and thoughts whenEnglish could not capture the full meaning. For mothers who were not fluent inEnglish, interviews were undertaken in Chinese and the data translated into Englishby the researcher. A proportion of these data (25%) was translated back to Chineseand cross-referenced with the original data to check for validity and reliability.Credibility checks (25% of the data) were carried out by an independent researcher.Additionally, Chinese to English transcriptions were checked with a professionalinterpreter. General agreement was found in all checks.
The process of data analysis in grounded theory is to unfold sequences of thedata under study and develop theories to understand them (Charmaz, 2000, 2006).The following process was adopted: (1) interview data were transcribed verbatim(by EL); (2) the transcripts were coded line-by-line; (3) the collected data and codeswere then used to inform and alter the interview schedule in order to continue todiscover and develop the theory as it emerged. Revising the interview scheduleallowed emerging theories to be developed through continual discovery; (4) initialinterview data established preliminary themes and ideas requiring clarification andexploration; (5) findings from the second phase of data collection provided rich datain cultural conflict, leading the researcher to investigate mothers who speak little orno English: three further participants were interviewed; (6) after the initial stage ofcoding, data were further reduced through reassembling and grouping the codes intoconcepts, known as core categories.
Results
Mothers in this study were organised into English-speaking and Chinese-speakinggroups according to the language used during interviews. Two of the English-speaking mothers were second-generation British–Chinese: they and their families
Table 1. Participant information.
No.EPDSscore
Ethnicorigin
Age ofmother
Countryof birth
Yearsin UK
Languagesspoken
Age ofchild
Otherchildren
1 2 Chinese 28 HongKong
8 Cantonese,English
Boy – 7months
None
2 10 BritishChinese
32 NorthernIreland
32 English,Cantonese
Boy – 8weeks
None
3 11⁄ Chinese 27 China 10 Mandarin,Cantonese,English
Boy – 9months
None
4 2 Chinese 24 China 5 Mandarin,English,Spanish
Boy – 7months
None
5 11⁄ BritishChinese
27 HongKong
20 English,Cantonese
Girl – 5weeks
None
6 17⁄ Chinese 27 China <1 Cantonese,Mandarin
Girl – 7months
None
7 9 Chinese 34 China 1 Cantonese,Mandarin
Girl – 5months
9-year-old boy
8 8 Chinese 29 China <1 Cantonese,Mandarin
Girl – 1month
None
⁄Suggestive of PND.
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were permanently residing in the UK. Their English was as good as their Chineseand they had integrated into the local community with an adopted westernisedlifestyle. The other three English-speaking mothers represented the ‘younger gen-eration’ who came to England to study in their teens, remaining in close contactwith their family back in China or Hong Kong. They considered themselves as‘Chinese living in England’ and very much embraced their Chinese values, butwere open to mixing with other cultures. Chinese was their first language but theywere fluent and comfortable to be interviewed in English. Mothers from the Eng-lish-speaking group were educated up to degree or postgraduate degree and allbut one held a professional career. They were all first-time mothers.
The three Chinese-speaking mothers had been in the UK for a year or less anddue to special circumstances arrived in the hope of a better lifestyle. Their livingstatus was indeterminate and under some immigration restrictions. They spoke verylittle English or none at all and were unable to be interviewed in English. Their tra-ditional Chinese cultural values were still very strong, especially those mothersfrom mainland China. Due to their strong Chinese values and language barriers,they remained close to the Chinese community and showed little signs of integra-tion. They relied heavily on Chinese services like the Wai Yin Women’s Centre andinterpreters for translation. Two of these three mothers were first-time mothers.
The eight mothers who took part in this study had different experiences accord-ing to their background and circumstances; however, common themes were found.Stress relating to child caring (Miller, Pallant, & Negri, 2006) and emotionaldistress (Matthey, 2009) were commonly observed during the postpartum period. Inaddition, Chinese mothers also dealt with some culturally specific conflicts and fam-ily values. The mothers’ reported difficulty was clustered around two main themes:isolation and conflict. Each theme is composed of a number of subcategories,presented in Figure 1.
Due to their diverse circumstances, some mothers were going through the post-partum phase on their own, while others were supported by close families andfriends. Hence the factors contributing to the development of isolation and conflictin Chinese-speaking and bilingual mothers were very different, resulting from dif-ferences in cultural norms and spoken language. Together they played an importantmediating factor accounting for the relationship between isolation and conflict.Overall, those who expressed feeling isolated and who faced many difficulties inthe postnatal phase tended to avoid talking about their emotions or avoidedacknowledging their struggles, hinting at holding a strong cultural belief about notwanting to be a burden (see Emotional Avoidance for more detail).
Language and cultural norms
Bilingual mothers were more likely to experience conflict and brief isolation,whereas Chinese-speaking mothers experienced isolation and not being understoodby others, which resulted in conflict.
P6: Things that trouble us after giving birth like translation, communication barrierand confusion with medical care … Mainly related to shortage of information.
The cultural norms (i.e. the western emphasis on attachment or Chinese beliefsabout routines and disciplines) that the mothers embraced appeared to play a crucial
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role in causing conflicts, determining a mother’s support network, coping strategiesand how she perceived her situations.
P2: … you get so many different opinions … So it makes you a bit confused and youfeel a bit annoyed with them sometimes … [I] got trouble feeding him, and they went,‘… you should set him into a routine.’ … And then the midwives tell you it shouldbe supply and demand. And for the first week I was going ‘oh, so who do I listento?’ You know Chinese people tell you he should be in a routine, if he cries just lethim cry. And then Westerners are saying if he cries he just needs to be hugged andheld and kissed (pause). So you get the two opinions …
Isolation
Traditionally, new Chinese mothers receive much attention and support during theperiod of Zuo Yue. However, some of the mothers in this study reportedly feltrestricted by these traditional practices and isolated from their social network andoutsider support. This was often more profound for bilingual mothers because thetraditional practice of Zuo Yue required them to stay inside the house for a monthand away from friends and other social events, restricting their contact to immediatefamily only.
P5: After the 2nd week you started to feel a bit um … irritated being at home all thetime. You want to go out and get some fresh air but obvious is the tradition you arenot allowed. My mother in law was here then so she kept an eye on me [laugh]
Chinese-speaking mothers experienced a different form of isolation resulting fromthe lack of support, caused by family absence and communication/language
Figure 1. Chinese mothers’ postnatal experience.
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problems. As the result of isolation, mothers were forced to rely on their ownresources including advice from friends and family or the internet.
P6: I called back home, asked friends and relatives, to find out what to do because Ihave no other way to learn … I called everyday …
Overall, the contributing factor of isolation can be understood as (a) adjustment and(b) lack of support.
Adjustment
All mothers mentioned feeling some degree of low mood, confusion or loss duringtheir early postnatal period. They were overwhelmed with new responsibilities, hav-ing to make sacrifices and feeling unsure about their new role. This period ofadjustment was not exclusive to Chinese mothers, but they experienced it as anadditional strain as the result of the traditional Chinese practice of Zuo Yue. Duringthe period of Zuo Yue mothers were not permitted to leave the house for the firstmonth and had to adhere to special dietary restrictions. Some mothers felt trappedand restricted by these practices, especially those who did not believe in its functionbut were made to comply by their mother-in-law.
P5: … at the end of the day is not such a big deal, you will be allowed out in amonth’s time. So … yeah is kind of … persistent and niggling … if I am frustrated Iwould take it out on my husband [laugh]
Two Chinese-speaking mothers in this study were relatively new immigrants tothe UK. Due to their special life circumstances some were forced to leave theircountry of origin: they had to cope with potentially traumatic travelling experiences,then adjusting to their new life, language and culture in the UK, in addition to theirnew role of being a mother. Feelings of isolation and frustration were noticeablethroughout their interviews.
P6: [It’s] not like we can speak English as soon as we arrived in the UK, being hereonly a year … people can’t expect me to adjust into everything ….
Lack of support
Support plays a main role in aiding maternal adjustment to parenthood and the bar-riers for lack of support identified were language barriers and communication diffi-culties, great geographical distances to family and the mother’s residential status.Not surprisingly, Chinese-speaking mothers suffered more from a lack of support.
Two bilingual mothers said that the reasons that stop them from accessing ser-vices were mainly due to differences in cultural values and a perceived lack of effi-ciency in postnatal services.
P1: I ask[ed] them I want to take my baby to some classes [but] they were not reallysure about it … They said ‘I think blah blah blah but not sure … this is the number,you go and check’. In that case. I would rather go direct to them. Why [do] I haveyou here? I don’t need you.
However, according to some Chinese-speaking mothers, it was the lack ofinvolvement from services, resulting mainly from communication difficulties, whichaffected the quality of support received.
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P6: When the midwife visits, I can only speak the sentences about requesting a trans-lator … They said that this kind of service is limited … that is what is difficult beingChinese – language barrier. [It] disables us to express ourselves … is a big threat …it’s very scary, bringing up a child is already hard.
Communication difficulties and their lack of confidence in integrating into theEnglish culture have stopped many mothers accessing English-speaking services,forcing them to rely on their own resources. When asked what stopped her going tobaby massage, P7 replied:
Mainly due to the language barrier, I really wanted to take her to that baby massagebut when I get there I couldn’t express what I want so I stopped going.
Great geographical distance to family
Chinese-speaking mothers, without family visits, relied on phone communicationand felt more isolated because they felt unsupported and were ‘left to cope bythemselves’. Their responses suggested that their assumption of given birth meantbeing looked after were challenged and left feeling their needs were unmet.
P8: Sometimes I felt really bad, why I have to deal with everything by myself. Thelife here is not like back home … being pregnant … treated like a queen. Everythingwould have been done for me … But the life here is lonely …
Although bilingual mothers seemed to have the advantage of family support dur-ing their early postnatal period, they were prone to exhibit sudden anxiety whenthis support terminated and they needed to re-adjust their role again.
P3: When they left, I was a little bit … I won’t say down but quite worrying at thetime, obviously the home felt empty and my husband had to work … really a testingtime for me to be a real mum just myself.
Status
Another crucial factor contributing to the lack of perceived support was themother’s residential status. Bilingual mothers had gained permanent living status;thus their family could visit relatively easily. Chinese-speaking mothers wererestricted by immigration laws and a visa for family visits was often improbable,which meant that they often lacked the support from their mother or mother-in-law(see Pei Yue).
Development of conflict
Based on the collected data, conflict only developed when mediating factors werepresent, such as different value systems and integration attempts, or if the motherhad no strong model of parenting.
The bilingual mothers were able to receive support from their overseas family,including parents and/or parents-in-law, who travelled to the UK and stayed for acertain period of time. They were provided with intensive, albeit one-off, support,help with household tasks, assisted with baby care and most importantly assistancewith the new mother’s special diet.
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P3: My mum and husband were both in the labour room, so is good to have familywith me … my dad came over [too], obviously he helped us to look after the babyand myself … my mum slept next [room] to me so anything I need, I shout for her ...So I got supported 24 hours, didn’t have to worry, someone was always with me.
In addition to aiding the mother’s adjustment, having the family around duringthe postnatal period also served as a family reunion.
Role of mother-in-law
Mothers regarded the help from their own mother as positive guidance andemotional support, whereas the mother-in-law was regarded as providing ‘merelypractical help’. Conflict arose due to various hidden confrontations between themother and the mother-in-law in relation to food customs and the practice oftraditions. Parents-in-law usually prepare a special diet for the new mother and takea strong role in ensuring that traditional cultural practices are followed.
P3: The first 2 days in hospital … I was eating separately because my husband wouldbring food from Liverpool that his parents made … so my mum said ‘okay, we willrespect what they want’ … According to them, I can’t [pause] I had a lot of ginger,which is fine. But to not have vegetables is ridiculous. They gave me all meat and Icouldn’t eat … I had to eat, obviously I was hungry …
Diets that contain only meat and ginger are believed to enhance maternalstrength and remove excess ‘wind’. However, conflict occurred when this causedinconvenience to the mother’s life and she felt forced to follow the diet in order toshow respect to her parents-in-law and maintain family harmony. Furthermore, thetraditional Chinese practices enforced by the mother-in-law caused a lot offrustration and conflict in the new mothers’ life.
P5: … because my mother-in-law is quite traditional Chinese woman, is not veryscientific … It was a struggle … we wanted to go out and she was like ‘no … no …no … you are not allowed to because 追風, 不太好 [catching the ‘wind’ is not good]’things like that.
Some of the conflicts in relation to the mother-in-law were due to culturalattitudes: having to respect the elderly and dutifully maintaining family harmony.
P5: … Just keep quiet. You don’t want to cause too much conflict between familymembers. Obviously she is here to help me really isn’t she. So I can’t really say much[laugh] ‘Oh well … I don’t believe that so I don’t want to follow it’. Because shewants me to follow it. So I have to force myself to follow that sort of rules, becauseshe wants me to. I don’t like things like that … is quite upsetting sometimes.
Thus, mothers felt that they could not ignore the important influence of theirmother-in-law’s role and the traditional Chinese practices imposed on them. Conflictand frustration built up when the mother felt she had to obey her mother-in-lawagainst her own better judgement.
Getting support
A mother’s fluency in both languages meant she could access and seek supportfrom various channels. It was apparent that mothers who adopted a more Western
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attitude relied more on services and found them more useful in general. The Inter-net was a popular resource for seeking support and there was a cultural differencebetween preferences. Mothers who only spoke Chinese accessed websites based inChina, whereas bilingual mothers chose their internet resources based on their cul-tural values. Regardless of language preferences, all mothers favoured parent forumswhere ‘real mums’ shared their experiences and questions could be posted andanswered, which suggests that mothers favoured peer support and enjoyed sharingtheir experiences, regardless of cultural background.
P2: Very useful. Because a lot of real life mums put their opinions … just Googlesearch and you find lots of forums that you just look at people’s opinions. What theyhave written about their babies. And sometimes not just the UK can be somewhere inthe States and you know what Americans are like, they write everything down …
No specific model for child parenting
Differences in child rearing commonly vary within cultures (Small, Lumley &Yelland, 2003), mothers who had no specific model of child parenting struggled tointegrate advice into both of their divergent cultures. However, it is possible thatsome difficulties arose because these participants were mostly first-time motherswho not yet developed a clear set of cultural reference points.
P2: … you get so many different opinions, what to do and what not to do. So itmakes you a bit confused and you feel a bit annoyed with them sometimes … Youknow Chinese people tell you he should be in a routine, if he cries just let him cry.And then Westerners are saying if he cries he just needs to be hugged and held andkissed [pause]. So you get the two opinions …
Different value systems
Mothers who had a clear idea of their own cultural values and followed a par-ticular set of child-rearing practices (for example, by embracing dominantChinese values) were more likely to seek advice only from sources that sharedtheir cultural ideas. Interestingly, mothers who reported to appreciate the differ-ence between Chinese and Western culture generally perceived it as both a‘curse and a blessing’; however, they are more likely to struggle with the gener-ation barrier.
P2: … you know like Chinese people, you respect your elders, even if they’re notyour in-laws you still respect them and try not to be too mouthy to them ...
Chinese-only speaking mothers were unenthusiastic about mixing with othersand showed no interest in integrating into the UK culture. When they were askedabout factors that stopped them from going to English-based services, the firstreason given was the language barrier and communication. However, furtherquestioning revealed that being the minority in a group posed a barrier too.
P7: I would suggest them having some Chinese mother there too, just one moreperhaps. So I can talk to … I really wanted to go. It’s really boring at home, is goodto go out and do things. But they have no translator or things like that … so Icouldn’t be asked.
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Emotional avoidance
As a result of postnatal distress mothers avoided talking about their emotion andexperience. P8 provided a prime example of how emotional avoidance waspresented, especially when she suffered isolation and low mood.
P8: … I was feeling so … why is it so hard … But is in the past now.
I: Sound like you had a very hard time.
P8: It’s passed now, let’s leave it.
Emotional avoidance was very noticeable in this study, especially in bilingualmothers who tended to use semantic emotion and denied their negative feelings bymoving away from the current topic.
P2: You’re just numb with all the feeding and the attention you have to give him andgetting yourself sorted. You have pain afterwards ... you didn’t have time to feel foryourself because you were just busy getting yourself changed, washed, getting himdone.
Discussion
The experiences described in this study were similar to the Baby Blues or indeedPND (Hopkins, Marcus & Campbell, 1984). While a number of researchers haveidentified cross-cultural similarity in maternal postnatal experiences (e.g. Hirst &Hewison, 2001), Small and colleagues (2002, 2003) noted that immigrant womenwere much less likely to experience care that gave them what they wanted. Whilethe findings from this current study identified some similarities in maternal postpar-tum experiences, there were important additional factors that are culturally specific,such as the Chinese cultural practices of Zuo Yue. Similarly to the study of Temple-ton and colleagues (2003) in which mothers from Black and minority backgroundsreported language barriers and associated negative experiences, the culturally deter-mined beliefs of not asking for help were also observed in these Chinese mothers,who do not want to become a burden. However, these Chinese mothers also had todeal with the additional restrictions of Zuo Yue and the cultural practice of respect-ing the mother-in-law’s role by conforming to her wishes.
One very interesting aspects of this study came from investigating the culturaldifferences between the two groups of Chinese mothers. Chinese-speaking mothersexperienced more severe isolation due to language/communication difficulties andtheir restricted residential status, which affected whether or not they received anysupport. However, whether their lack of support was primarily due to immigrationstatus or financial means (not able to afford air fares) needs additional investigationin a future study. In contrast, bilingual mothers expressed more conflict due to thevarious social norms to which they were exposed and the pressure from theirmother-in-law. Interestingly, three mothers in this study scored over 10 on theEPDS, which may indicate PND in community samples (Cox et al., 1987). Ofthese, two mothers were bilingual and they predominately reported being frustratedwith the culturally insensitive information from services and pressure to follow cer-tain customs from their mother-in-law. It is possible that their moods could haveinfluenced their views more negatively and different themes could have emerged if
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depressed mothers had not been interviewed. The exact nature of PND as experi-enced by Chinese women in England is worthy of further investigation in order todetermine if their views differ from those presented here.
Limitations
With regard to limitations, the researcher’s own views and perspectives can alwaysbe a possible threat to any qualitative study, in particular concerning cultural issues.However, close supervision and detailed footnotes were used to address terminologyand assumptions that might have been imposed on the mothers grounded the analy-sis to the data. In this instance, the researcher’s background and insight into bothcultures actually proved beneficial for this study.
Through recruitment and interviews, it became apparent that Chinese motherswere more comfortable discussing their cultural beliefs with someone from a similarcultural background. Additionally, mothers in this study assumed the researcher tohave a certain cultural awareness and understanding of Chinese family values. Thiswas especially true when they were talking about their relationship with theirmother-in-law, because it is considered to be disrespectful to imply negativity in afamily member. Thus, mothers were very diplomatic about this topic, but expectedthe researcher to correctly interpret the hidden annoyance in their relationship withtheir mother-in-law. This was evident by the mother’s change of tone, nervouslaughter and body language.
Clinical implications
This study confirmed some of the reasons that prevented ethnic minority groupsfrom accessing services in the UK. Lack of fluency in English and not being partof a social group (‘the only Chinese’ in the group) contributed to isolation and feel-ing unsupported. It is also evident that an interpretation service is crucial whenworking with service users who do not speak English. Advantageously, bilingualChinese mothers were very keen to access services for their child. Nevertheless,they were more likely to be restricted by the influence of their mother-in-law, espe-cially in the period of Zuo Yue. Hence, it is important for professionals who workin early postnatal care to be aware of this cultural custom and ensure open and flex-ible invitations for these mothers, in a way that they are welcome to join after thepostpartum period. It is also important to bear in mind that they may not be able tofollow some of the guidance given by services.
Overall, healthcare with an emphasis on individual needs play a crucial rolewhen working with people from ethnic background. Mothers should be encouragedto feel confident about their own model of parenting in order to avoid conflictcaused by mothers trying to integrate different sets of cultural values. In particular,for Chinese mothers who hold multiple cultural practices and beliefs (Wu & Chao,2005) often struggle to conform to a particular set of practices.
Professional working with ethnic minority group
Professionals who feel ‘culturally competent’ in their approach to caring (Bhui,Warfa, Edonya, McKenzie & Bhugra, 2007) and who provide individualised carethat is respectful of people’s background, social circumstances and individual needsinfluence how people experience that care (Suhonen, Välimäki, & Leino-Kilpi,
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2005; Suhonenab, Välimäkib, Katajistoc, & Leino-Kilpibd, 2007). Additionally, it isimportant to ask follow-up questions when working with this group of mothersbecause of their tendency of emotional avoidance.
As some professionals may not feel equipped to meet the culturally specificneeds for minority groups (Edge, 2010), ethnically sensitive community servicessuch as the Wai Yin Women’s Centre are very important for new immigrants andthose who treasure Chinese cultural values. Although the Chinese-speaking mothersin this study experienced limited or restricted support from their family, they werecomforted and supported by staff at the Wai Yin Centre. This may be part of thereason why these mothers were less active in accessing English perinatalcommunity support.
AcknowledgementsThe authors would like to thank the Wai Yin Women’s Centre and the National ChildbirthTrust worker for their support of this study and the eight women who shared their viewsand feelings with us. Thank you to Kerry Chan for her help with the translations and VaniaRanjbar for her help with the credibility checks.
Note1. It is associated with a variety of traditions including dietary, behavioural and hygiene
precautions, as well as practices associated with infant feeding.
References
Bhui, K., Warfa, N., Edonya, P., McKenzie, K., & Bhugra, D. (2007). Cultural competencein mental health care: a review of model evaluations. BMC Health Services Research, 7(15).
Chan, S.W., Levy, V., Chung, T.K.H., & Lee, D. (2002). A qualitative study of the experi-ences of a group of Hong Kong Chinese women diagnosed with postnatal depression.Journal of Advanced Nursing, 39(6), 571.
Charmaz, K. (2000). Objectivist and constructivist grounded theory. In N.K. Denzin & Y.Lincoln (Eds.), Handbook of qualitative research (2nd ed). Thousand Oaks, CA: Sage.
Charmaz, K. (2006). Constructing grounded theory: A practical guide through qualitativeanalysis. London: Sage.
Chee, C.Y., Lee, D.T., Chong, Y.S., Tan, L.K., Ng, T.P., & Fones, C.S.L. (2005).Confinement and other psychological factors in perinatal depression: A transculturalstudy in Singapore. Journal of Affective Disorders, 89, 157–166.
Chen, S.S. (2010). Zuo Yue Zi sitting the month in Taiwan: Implications for intergenera-tional relations. Doctor of Philosophy, Case Western Reserve Unviersity, Ohio.
Cheung, N.F. (2002). The cultural and social meanings of childbearing for Chinese andScottish women in Scotland. Midwifery, 18, 279–295.
Chien, L.-Y., Tai, C.-J., Ko, Y.-L., Huang, C.-H., & Sheu, S.-J. (2006). Adherence to‘Doing-the-month’ practices is associated with fewer physical and depressive symptomsamong postpartum women in Taiwan. Research in Nursing & Health, 29(5), 374–383.doi: 10.1002/nur.20154.
Chunxia, W., & Chao, R.K. (2005). Intergenerational cultural conflicts in norms of parentalwarmth among Chinese American immigrants. International Journal of BehaviouralDevelopment, 29(6), 516.
Cox, J.L., Holden, J.M., & Sagovsky, R. (1987). Detection of postnatal depression. Develop-ment of the 10-item Edinburgh Postnatal Depression Scale. British Journal of Psychiatry,150, 782–786.
Dey, I. (1999). Grounding grounded theory: Guidelines for qualitative inquiry. San Diego,CA: Academic Press.
Journal of Reproductive and Infant Psychology 117
Dow
nloa
ded
by [
Mia
mi U
nive
rsity
Lib
rari
es]
at 0
3:50
03
Oct
ober
201
4
Edge, D. (2010). Falling through the net – Black and minority ethnic women and perinatalmental healthcare: Health professionals’ views. General Hospital Psychiatry, 32, 17–25.
Ghubash, R., & Abou-Saleh, M. (1997). Postpartum psychiatric illness in Arab culture:Prevalence and psychosocial correlates. The British Journal of Psychiatry, 171, 65–68.
Glaser, B.G., & Strauss, A.L. (1967). The discovery of grounded theory: Strategies forqualitative research. New York, USA: Aldine Transaction.
Hearn, G., Iliff, A., Jones, I., Kirby, A., Ormiston, P., Parr, P., et al. (1998). Postnatal depres-sion in the community. The British journal of General Practice, 48(428), 1064–1066.
Hirst, J., & Hewison, J. (2001). Pakistani and indigenous ‘white’ women’s views and theDonabedian-Maxwell grid: A consumer-focused template for assessing the quality ofmaternity care. International Journal of Health Care Quality Assurance, 14, 308–316.
Holroyd, E., Twinn, S., & Yim, I.W. (2004). Exploring Chinese women’s cultural beliefsand behaviours regarding the practice of ‘doing the month’. Women Health, 40(3),109–123.
Hopkins, J., Marcus, M., & Campbell, S.B. (1984). Postpartum depression: A critical review.Psychological Bulletin, 95(3), 498–515.
Huang, Y., & Mathers, N. (2001). Postnatal depression – Biological or cultural? A compara-tive study of postnatal women in the UK and Taiwan. Maternity and Infant Care Journalof Advanced Nursing, 33(3), 279–287.
Inandi, T., Elic, O.C., Ozturk, A., & Egri, M. (2002). Risk factors for depression in postnatalfirst year, in eastern Turkey. International Journal of Epidemiology, 31, 1201–1207.
Lee, D.T., Yip, S.K., Chiu, H.F., Leung, T.Y., Chan, K.P., Chau, I.O., et al. (1998). Detect-ing postnatal depression in Chinese women. Validation of the Chinese version of theEdinburgh Postnatal Depression Scale. British Journal of Psychiatry, 172, 433–437.
Leung, S., Arthur, D., & Martinson, I. (2005). Perceived stress and support of the Chinesepostpartum ritual ‘doing the month’. Health Care Women International, 26, 212–224.
Matthey, S. (2009). Women’s perceptions of the causes of their postnatal distress: Develop-ment of the reasons for postnatal distress checklist. Depression and Anxiety, 26(10),938–948. doi: 10.1002/da.20485.
Miller, R., Pallant, J., & Negri, L. (2006). Anxiety and stress in the postpartum: Is theremore to postnatal distress than depression. BMC Psychiatry, 6(12).
Office for National Statistics. (2005). Census 2001: General report for England and Wales.London: ONS.
Onozawa, K., Kumar, R., Adams, D., Dore, C., & Glover, V. (2003). High EPDS scoresin women from ethnic minorities living in London. Archives of Women’s Mental Health,6(2), S51–S55.
Raven, J., Chen, Q., Tolhurst, R., & Garner, P. (2007). Traditional beliefs and practices inthe postpartum period in Fujian Province, China: A qualitative study. BMC PregnancyChildbirth, 21, 7–8.
Segre, L.S., Losch, M.E., & O’Hara, M.W. (2006). Race/ethnicity and perinatal depressedmood. Journal of Reproductive and Infant Psychology, 24, 99–106.
Small, R., Yelland, J., Lumley, J., Brown, S., & Liamputtong, P. (2002). Immigrant women’sviews about care during labor and birth: An Australian study of Vietnamese, Turkish,and Filipino women. Birth, 29, 266–277.
Small, R., Lumley, J., & Yelland, J. (2003). Cross-cultural experiences of maternal depres-sion: Associations and contributing factors for Vietnamese, Turkish and Filipinoimmigrant women in Victoria, Australia. Ethnicity & Health, 8(3), 189–206.
Suhonen, R., Välimäki, M., & Leino-Kilpi, H. (2005). Individualized care, quality of lifeand satisfaction with nursing care. Journal of Advanced Nursing, 50(3), 283–292.
Suhonenab, R., Välimäkib, M., Katajistoc, J., & Leino-Kilpibd, H. (2007). Provision ofindividualised care improves hospital patient outcomes: An explanatory model usingLISREL. International Journal of Nursing Studies, 44(2), 197–207.
Templeton, L., Velleman, R., Persaud, A., & Milner, P. (2003). The experiences of postnataldepression in women from black and minority ethnic communities in Wiltshire, UK.Ethnicity & Health, 8, 207–221.
Wong, J., & Fisher, J. (2009). The role of traditional confinement practices in determiningpostpartum depression in women in Chinese cultures: A systematic review of the Englishlanguage evidence. Journal of Affective Disorders, 116, 161–169.
118 E. Lam et al.
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Wu, C., & Chao, R.K. (2005). Intergenerational cultural conflicts in norms of parentalwarmth among Chinese American immigrants. International Journal of BehaviouralDevelopment, 29, 516–523.
Appendix – Final interview questions
1. Can you tell me about your pregnancy?Probes: Father’s role in supporting the process of birth? (Clarify the father’s rolesin the process of birth, attending the labour room?)
2. How would you describe the time after you gave birth to your child?3. How has it been for you since the birth of your child?4. What factors do you think led to how you were feeling?5. What is it like having the culture of ‘pui jung’ (house bound for a month) in UK?6. Now that you have had your baby, can you tell me about a particular time when
you felt particularly happy or upset/sad since the birth of your baby?7. What exactly did you feel or think then?8. What it is that made you feel like that at that moment you just described?9. Now that you have given birth to your baby, who is supporting you in your role
as mother?Probes: What is the role of your mother/mother-in-law, can you describe yourrelationship with them?What role does your husband take on? What was your expectation?How do youdeal with the different way of receiving advice? (When there is different advicefrom Chinese and English.)
10. Do you experience any cultural conflict living in UK?Probes: The traditional role of mother and the family system.How did you manage the challenge of these transition/cultural restrain?
11. Anything you think I should know about your postnatal experience?12. Any questions regarding the questions I have ask?
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