Breastfeeding is the cornerstone of infant nutrition and the dangers of not breastfeeding are well recognised(1). The early initiation of breastfeeding after birth and subsequent early post-partum establishment of breastfeeding are important for successful breastfeeding(2). Close and continuous proximity of mother and baby 24 hours a dayis also important to the establishment of breastfeeding (3).In some traditional cultural post-partum practices,restrictions to contact between mother and baby may occur. These may affect mother-infant interaction and breastfeedingpractice.
Malaysia has a multi-ethnic societyandeach ethnic group hasits own traditional postnatal practice.Chinese ethnicity is one of the 3 major groups and despite modernisation, most Chinese women adhere strictly to a 30-day traditional post-partum period, known locally as the “confinement period” or “zuoyuezi’(4-7).
These practices are based on the traditional Chinese belief system about the maintenanceof Yin and Yang in the mother after childbirth so that her health is restored. Many believe that non-adherence to these practices will result in potentially long-term adverse effects on the quality of life to the mother. Influences of relatives, in particular the new mother’s mother, her mother-in-law and her grandmother, are factors that ensured that these practices are carried out and passed down from generation to generation(4, 7).
During the confinement period, the mother would be assisted fully at her home by someone (or sometimes more than one person) – ensuring that she gets enough rest, providing the appropriate diet, caring for the newborn baby and ensuring she abides by confinement practices such askeeping warm(8). This usually means the motheravoids draughtsor taking showers for the whole month(4, 7, 9). This person was traditionally a close female relative (6)but practices have evolved to hiring a professional ‘confinement lady’ (yueso) who is considered an expert in the necessary diet and practices(9, 10). The confinement lady would be employed to stay in the new mother’s home after delivery for at least 4 weeks(10).
Over the last decade, a new method of providing this care emerged and is increasingly replacing the role of confinement ladies or female relatives at home. Confinement centres(CCs)provide a place for post-partum Chinese motherstostay during their confinement period and observe traditional post-partum practices under the care of theCCstaff(10). A typical CC is often a converted house with several rooms for mothers and a room designed as a nursery where the babies are all placed. Mothers may share rooms and typically all the babies would be in a single ‘nursery’. This centre would be staffed by women who have experience with newborns and are familiar with the Chinese cultural confinement requirements, a cook to prepare the required confinement diet for mothers and occasionally qualified nurses to look after the well-being of mothers and babies(10).Although care of the infant is in no way neglected, but because the focus of these CCsis mainly towardsproviding traditional care for the mother, compromises in mother-infant bonding and breastfeeding may occur. This has led to concerns that breastfeeding may not be adequately supported in CCsand therefore,further compromisingbreastfeeding rates for the Chinese population which is currently the lowest among the major ethnic groups in Malaysia(11, 12) despite evidence that a high proportion of them intend to breastfeed(11).
The aim of the study is to describe the breastfeeding experience of Chinese mothers who stayed in CCs and compare the breastfeeding outcomes at 1 and 6 months with Chinese mothers who stayed at home to determine if the place of confinement had any effect on breastfeeding.
What this study will add:
There is currently no published data about breastfeeding practices in confinement centres and these centres are a growing phenomenon across Asia and beyond. This study describes current practices at confinement centres and identifies areas for potential improvement in breastfeeding support in confinement centres.
This was a prospective cohort study. Participants were recruited from the postnatal wards of six hospitals in Penang, Malaysiabetween August 2017 to October 2017.Written consentwas obtained from the participants prior to the commencement of study.
Participants were Malaysian of Chinese ethnicity, married and aged above 21 years, who delivered a healthy full-term infant within the previous 48 hours and had the intention to breastfeed. Recruitment was done by the infant’s attending doctor, who apart from this was not otherwise involved in the study. For every recruited participant who chose to go to a confinement centre, a control (i.e. a mother who chose to stay at home) was recruited for the purpose of comparing breastfeeding outcomes.
After consent was obtained, maternal and infant baseline characteristics were collected before discharge. These included maternal age, educational level, occupation, parity, previous breastfeeding experience, place of intended confinement; infant’s date of birth, hospital of birth, gender, gestational age at birth, mode of delivery and birth weight. After discharge, there was no contact between the research team and the participant until after her30-day confinement period.
A telephone interviewwith the participant was conducted at 1-month post-partum (the end of the confinement period). The focus of this telephone interview was to seek the breastfeeding experiences of participants who stayed at CCs and compare it with those at home.The questions included infant’s feeding practices, opportunity to room-in and/or spend time with their infants, problems encountered during breastfeeding (such as engorgement, mastitis, insufficient milk), sources of help for these problems and any perceived barriers to breastfeeding.There were also free field options for participants to make comments on their experiences. The second telephone interview to collect data on breastfeeding practices was conducted when the infant was 6 months old. All questions used had been tested in a separate group of breastfeeding mothers not involved in the study. Both telephone interviews were conducted by 3 trained research staff and the responses were directly entered into a specially designed interview form.
Sample size calculation
Based on the data on exclusive breastfeeding rates at 0 to 2 months for Malaysian Chinese mothers obtained from the National Health and Morbidity Survey 2016: Maternal and Child Health findings(13) and our hypothesis that there is a 50% reduction in breastfeeding rates in mothers who spend their confinement period in a confinement centre, we calculated the sample size using the Openepi software (14). The calculated sample size was 94 in each group,considering a 20% drop out rate.
We defined exclusive breastfeeding according to the World Health Organisation’s definition which means no other food or drink, not even water, except breast milk (including milk expressed or from a donor) for the first 6 months of life.Any breastfeeding was defined as breast milk (including milk expressed or milk from a donor) for 6 months of life, and any other food or liquid including non-human milk and formula(15).
We tabulated thebaseline demographics of the mothers according to place of confinement. Continuous data was presented as mean with standard deviation (SD) and categorical data presented as frequency with percentage (%).Chi-square analysis was used to compare the baseline characteristics between participants staying in confinement centres (CCs) and those staying at home.Comments from free fill options were tabulated and categorized into groups. Some of these free field responses were quoted as illustrations.Simple logistic regression was used to determine whether CCs affected breastfeeding rates (any breastfeeding and exclusive breastfeeding) at 1 month and 6 months post-partumand presentedas crude odds ratio (OR) with 95% confidence interval (CI).Wemodeled the likelihood of exclusive breastfeeding or any breastfeeding as a function of CCs after adjusting for others clinically importantvariables. The results were presented as adjusted odds ratio (aOR) with95% CI. We considered a p-value of <0.05 as significant.