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Experiences of Chinese immigrant women following zuo yue zi in the lower mainland of British Columbia Chang, Sylvia Hsi-Ching 2016

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EXPERIENCES OF CHINESE IMMIGRANT WOMENFOLLOWING ZUO YUE ZI IN THE LOWER MAINLAND OF BRITISHCOLUMBIAbySYLVIA HSI-CHING CHANGA THESIS SUBMITTED IN PARTIAL FULFILLMENT OFTHE REQUIREMENTS FOR THE DEGREE OFMASTER OF SCIENCE IN NURSINGinTHE FACULTY OF GRADUATE and POSTDOCTORAL STUDIES(Nursing)THE UNIVERSITY OF BRITISH COLUMBIA(Vancouver)February 2016© Sylvia Hsi-Ching Chang, 2016iiAbstractThere are increasing numbers of women emigrating from China and Taiwan who chose tofollow Chinese traditional post-partum practices which refers to “zuo yue zi”in the lowermainland of British Columbia. However, there are insufficient Canadian studies and a paucityof qualitative studies explicitly exploring women’s experiences with zuo yue zi. I used aqualitative description design to obtain narrative data on the perspectives of experiences withzuo yue zi from 13 mothers residing in the Greater Vancouver region. The development of thecore theme, Chinese women’s novel encounters with zuo yue zi, incorporated women’sexpectations of zuo yue zi, their struggles with the practices, and the modifications of theirexpectations. The Chinese women followed some traditional practices and modified othersdepending on their level of comfort with potential health effects and support from family andpaid helpers. They needed to consider their own and their infants’ wellbeing, considerationsfor family members, their previous experiences, and structural limitations in their newenvironments. Based on the study findings, I suggest nursing implications for clinicalpractice, education and research starting in the prenatal period and into the postnatal period. Ialso make recommendations in terms of supporting new immigrant mothers who wish tofollow traditional practices and addressing regulatory guidelines to protect their newbornsfrom unregulated paid care providers in their new adopted homeland.iiiPrefaceEthics approval for this study was granted by the University of British Columbia,Behavioural Research Ethics Board, UBC BREB Number H14-02416.I recruited all participants for the study and conducted interviews with all thirteenparticipants. Data collection and analyses were undertaken concurrently. My thesis projectsupervisor, Dr. Hall and I undertook ongoing analysis and write up of the findings anddiscussion chapters. The other two thesis committee members, Dr. Campbell and Lily Lee,contributed their feedback for the research proposal and the thesis chapters.ivTable of ContentsAbstract ............................................................................................................................... iiPreface ................................................................................................................................ iiiTable of Contents................................................................................................................ ivList of Tables ..................................................................................................................... viiGlossary............................................................................................................................ viiiAcknowledgements............................................................................................................. ixChapter 1: Introduction...................................................................................................... 11.1 Background to the Problem ......................................................................................... 11.2 Significance................................................................................................................. 31.3 Problem Statement ...................................................................................................... 51.4 Purpose ....................................................................................................................... 61.5 Research Questions ..................................................................................................... 61.6 Chapter Summary........................................................................................................ 7Chapter 2: Review of Literature......................................................................................... 82.1 Cultural Shock Theories and Adaptive Models ............................................................ 82.2 The Accessibility of Health Care System ..................................................................... 92.3 Awareness of Cultural Differences ............................................................................. 102.4 Experiences and Barriers in Immigrant Women’s Encounters with Health Care ......... 122.5 Chapter Summary...................................................................................................... 14Chapter 3: Research Method............................................................................................ 163.1 Research Design........................................................................................................ 163.2 Ethical Considerations ............................................................................................... 173.3 Inclusion & Exclusion criteria ................................................................................... 203.3.1 Inclusion criteria. ................................................................................................ 203.3.2 Exclusion criteria. ............................................................................................... 20v3.4 Sampling ................................................................................................................... 203.5 Data Collection.......................................................................................................... 213.6 Data Analysis ............................................................................................................ 223.7 Rigor ......................................................................................................................... 243.8 Chapter Summary...................................................................................................... 25Chapter 4: Presentation of Findings................................................................................. 334.1 Description of Sample ............................................................................................... 334.2 Chinese Immigrant Women’s Novel Encounters with Zuo yue zi................................ 364.3 Expectations of zuo yue zi.......................................................................................... 394.3.1 Reinforcement to follow guidelines of zuo yue zi. ............................................... 404.3.2 Perceived effects of zuo yue zi............................................................................. 404.3.3 Organizing zuo yue zi.......................................................................................... 444.4 Struggles with Reality as Opposed to Expectations .................................................... 504.4.1 Relationships with others. ................................................................................... 524.4.2 Disagreement with elder family members. .......................................................... 594.5 Modifications of Expectations ................................................................................... 614.5.1 Accommodating climate and living conditions. ................................................... 634.5.2 Modifications to original plans............................................................................ 644.5.3 Evaluating principles of zuo yue zi in modifications. ........................................... 674.5.4 Considerations for family members..................................................................... 684.5.5 The influences of previous experiences. .............................................................. 694.6 Chapter Summary...................................................................................................... 70Chapter 5: Findings Summary, Discussion, Implications for Nursing and Conclusion . 715.1 Summary of the Findings........................................................................................... 715.2 Discussion of Findings .............................................................................................. 725.3 Strengths of the Study................................................................................................ 795.4 Limitations of the Study ............................................................................................ 805.5 Implications for Nursing............................................................................................ 815.5.1 Implications for nursing practice. ........................................................................ 81vi5.5.2 Implications for nursing education. ..................................................................... 835.5.3 Implications for nursing research. ....................................................................... 855.6 Conclusions............................................................................................................... 86References.......................................................................................................................... 87Appendix A: Participant Letter........................................................................................ 96Appendix B: Participant Consent Form .......................................................................... 98Appendix C: Demographic Data .................................................................................... 101Appendix D: Semi-Structured Interview Questions ...................................................... 104Appendix E: Translated Appendices .............................................................................. 105viiList of TablesTable 4.1 Summary of participants’ demographic characteristics………………………35Table 4.2 Themes and subthemes of Chinese Immigrant Women’s Early Post-PartumExperiences………………………………………………………………….. 38viiiGlossaryZuo yue zi: The Chinese traditional post-partum practice known as zuo yue zi (tso-yueh-tzu),translated as “doing the month” or “lying in”. Zuo yue zi” refers to Chinese postpartumtraditions that include a number of practices such as requiring a woman to stay at home,eating a stricter and healthier diet, refraining from performing housework and touching coldwater.Traditional Chinese Medicine (TCM): Traditional Chinese Medicine which originated inChina and has evolved over thousands of years. TCM applies a holistic system to diagnoseproblems and includes various forms of herbal medicine, acupuncture, and massage to easeand/or cure the illnesses.Post-partum Doula: also known as yue sao is employed as a maid for a few hours a day oras a live-in assistant with the host families. They assist Chinese women following zuo yue ziwith food preparation and newborn care.Post-Partum Centre: A location that provides room and food following principles of zuoyue zi. The range of post-partum services generally can be extended according to the pay forservices.Chinese Breast Massage Therapist: also known as Tong Nai Shi or Cui Nai Shi iscommonly required to massage breasts as initiating breastfeeding or when new mothersexperience breast engorgement.ixAcknowledgementsI would like to thank the thirteen mothers who participated in the study for their time andwillingness to share their experiences. I feel honoured and privileged to obtain a glimpse oftheir journey in their newly adopted homeland.I feel sincerely fortunate to have had Dr. Wendy Hall as my thesis supervisor who hassupported me throughout my thesis with her patience and knowledge from the inception ofthe research study questions to the completion of the thesis. Her commitment to supportingmy work went above and beyond expectations. Without her encouragement, guidance andsupport, this thesis would not have been completed.I would like to thank the members of my graduate committee, Dr. Suzanne Campbell andLily Lee for their valuable insightful comments and clear suggestions. I really appreciate yourtime, wisdom and expertise for guiding my thesis study.My deepest gratitude goes to my parents Shu-Lin, Lan-Mei and sister, Hsi-Lien and my mostsupportive friends, Zim, Wanda and Clara. Thanks for being great listeners, your words ofencouragement, understanding, support were greatly appreciated.Lastly, I would like to have special thanks to my husband, Bing Zhou, for seeing me throughthe good times and the bad times and supporting me in every possible way throughout mygraduate study.1Chapter 1: IntroductionIn this chapter, I present the background describing Chinese immigrant women’straditional post-partum practices. Furthermore, I describe the significance of exploringimmigrant Chinese women’s experiences of traditional post-partum practices and a problemstatement that supports the exploration of that experience. Finally, I outline the study purposeand research questions.1.1 Background to the ProblemChinese culture has been in existence for more than 5,000 years. As a result, there aresome customs and practices that are, at times, regarded as necessary prescriptions in areas ofChinese society. The Chinese traditional post-partum practice known as zuo yue zi (tso-yueh-tzu), translated as “doing the month” or “lying in” requires a woman to stay at home, eat astricter and healthier diet, refrain from performing housework and touching cold water. It isseen as a time to strengthen the health and well-being of the post-partum woman (Brathwaite& Williams, 2004; Cheung, 1997). In the Chinese tradition, women are considered to be in aweak and vulnerable condition after giving birth and are required to have four to six weeks’rest in order to regain their strength and to restore their bodies to balanced states (Cheng &Pickler, 2009; Chu, 2005; Dennis et al., 2007; Holroyd, Twinn & Yim, 2004). According tothe Chinese philosophy of yin and yang or hot and cold, zuo yue zi is believed to be atraditional practice which represents a “golden opportunity”. It is a time to recognize awoman’s reproductive contribution, while facilitating her physical recovery and protectinghealth. Part of the practice includes the belief that by adhering to prescribed actions, thewoman can avoid developing chronic illness and strengthen her intra-family relationships(Cheung, 1997; Chu, 2005).2As stated in a report by Holroyd and colleagues (2004), during the early post-partumperiod, some middle class women in China delegated the care of their newborn children totheir mothers or in-laws. In addition to receiving support from their immediate familymembers, these women also employed a maid or post-partum doula to assist them with foodpreparation and newborn care. In contrast, some Chinese women in Taiwan prefer to stay inpost-partum maternity care centres for at least one month after birth (Chen, Tsai, Tseng, &Wang 1994).Dennis and associates (2007) emphasized the importance of culturally appropriate post-partum care because if women do not follow prescriptions, “in some cultures, women feelthey need to have another pregnancy and post-partum care in order to correct their healthstatus” (p. 495). The literature suggests that Chinese women, who adhere to particular beliefsystems, have to follow traditional post-partum care to be healthy; if they are unhealthy in thepost-partum period or later in their life, it is because they did not follow the practice of zuoyue zi. The way to rectify their state of health would be to follow the prescribed practices in afuture pregnancy.Chinese women, with certain traditional post-partum beliefs, practice rituals during thefirst four to six weeks of the post-partum period that include eating traditional dishes that arebelieved to benefit the health of a woman (Brathwaite & Williams, 2004; Cheung, 1997;Dennis et al., 2007). Ginger root is one of the recommended post-partum dietary supplementsbecause it benefits the immune system and is believed to reduce the possibility of catching acold (Chan, Nelson, Leung & Cheung, 2000; Holroyd et al., 2004). As a result, ginger-friedrice and ginger-based soups are some of the most popular post-partum dishes. Anotherexample of a suggested post-partum dish, which was included in Dennis et al.’s (2007)systematic review of traditional post-partum practices and rituals, is pork feet stew with3soybeans or peanuts. This is widely believed to increase the production of breast milk inwomen during the post-partum period.Post-partum rituals that some women ardently follow include avoiding hot and coldfood, wind and water, and adhering to specific food prescriptions and prohibitions (Holroydet al., 2004). The main principles of “zuo yue zi” for a post-partum woman are to: a) avoidwashing herself or her hair [for four to six weeks]; b) avoid going outside for the month; c)avoid eating raw or “cold” (yin) foods; d) avoid eating chicken or “hot”(yang) foods; e) avoidthe wind; f) avoid walking or moving a great deal; g) refrain from visiting others; h) avoidgetting sick during the month; i) stop reading and; j) avoid crying (Pillsbury,1978, p.12-14).There is insufficient information regarding whether or how Chinese immigrant womenengage in and manage their traditional post-partum practices in new settings followingmigration, and their perceptions about effects of not following or being unable to follow thesepractices in their adopted countries. In addition, based on this researcher’s observations andanecdotal information, there are four popular approaches that Chinese immigrant women inVancouver use to support their traditional post-partum care practices: a) maternity post-partum care centres, b) post-partum home meal delivery services, c) post-partum doula homeservices, and d) maternal care providers (often close relatives). Despite this anecdotalinformation, there is a lack of empirical data that captures the types of acceptable post-partumservices that Chinese immigrants use in Vancouver.1.2 SignificanceAccording to Statistics Canada (2006), Chinese people are the largest visible minoritygroup in British Columbia (BC). In 2006, there were 432,435 Chinese people in BC, whichmade up 10.6% of the total population. Statistics from the BC Perinatal Data Registry (2008)4indicate there have been 40,000 births per year in BC since 2000. During this time period, theestimated annual delivery rate among Chinese immigrants in Vancouver, Richmond, andSurrey was around 2,641 (Tse, 2010) which is 6.6% of the total births per year in BC.Researchers have examined Chinese women’s post-partum practices in otherjurisdictions. Ninety percent of Chinese women in Hong Kong practice “zuo yue zi”, with66% of these women living with their in-laws or parents (Lee et al., 1998). Kit, Janet, andJegasothy (1997) also reported that 85.7% of their sample of Chinese, Malay and Indianmothers in Malaysia adhered to a special diet after giving birth, and 78.8% of Chinesewomen had relatives or friends who provided care and support for them during the post-partum period. In a study conducted in Sydney, Australia, researchers concluded that 90.2%of 102 participants of Chinese descent followed traditional Chinese cultural practices aftergiving birth (Matthey, Panasetic, & Barnett, 2002).In Vancouver, Canada, we have not studied the nature of Chinese immigrant women’spractices in the post-partum period or the potential effects of their experiences if they areunable to follow traditional practices. The increase in the Chinese population in BritishColumbia and the frequent use of traditional practices in other countries supports theimportance of health care providers’ understanding of Chinese traditional post-partumpractices. Such understanding can afford providers the means to better advocate for patientsto find the necessary resources to support their traditions and ensure that appropriate post-partum care is offered (Grigoriadis, Robinson, Fung, Ross, Chee, Dennis & Romans, 2009;Hyman & Dussault, 2000).Lopez and Willis (2004) argued that, “it is important for nurse scholars to developknowledge that is culturally relevant and respectful of the realities of those living within thesituation” (p. 726). Adherence to Chinese traditional post-partum care relies on external5support, understanding of the importance of the tradition, health beliefs, and linking Chineseimmigrant women to community resources. As such, awareness of the different aspects ofChinese traditional post-partum care can assist nurses to tailor their care to promote thewellbeing of Chinese immigrant women. Immigrant women, who are separated from theirextended families, represent a vulnerable group that is disadvantaged with regards to theexperience of childbirth (Gagnon et al., 2006). For example, many new immigrant mothersmust cope with multiple family responsibilities, such as performing household chores orcaring for other children while experiencing loneliness and isolation (Krueger, Sword &Watt, 1999; Shin & Shin, 2006).In addition to social isolation, immigrant women may encounter: limited transportationoptions to access community resources, a lack of community support for infant feeding, andlanguage barriers which expose “immigrants to a greater risk for poorer health than theirnative-born counterparts” (Sword et al., 2006, p.717). Lack of knowledge of culturaldifferences and insensitivity about appropriate cultural care cannot be separated from factorsthat influence women’s health. A qualitative research study of women’s experiences of “zuoyue zi” has the potential to illuminate problems that could be used to inform policies requiredto integrate new immigrants and to demonstrate respect for immigrant communities.1.3 Problem StatementAs stated previously, 10.6% of the BC population comprises individuals self-identifyingas Chinese. Immigrant women from mainland China, Hong Kong, and Taiwan give birth to asignificant proportion of babies in British Columbia. Furthermore, traditional post-partumcustoms and practices are embedded in Chinese culture, consisting of a common tradition,with slight variations by country, known as zuo yue zi. Although the existing evidence6suggests that immigrant women’s process of childbearing can include significant physical,financial, and emotional challenges, there is minimal understanding about how Chinesewomen practice their traditional post-partum customs in Canada. Two studies about Chineseimmigrant women who have given birth in Canada describe zuo yue zi including Yin-Yangfood regimes, beliefs about personal hygiene, rituals of post-partum care, and post-partumdepression (Grigoriadis et al., 2009; Strand, Perry, Guo, Zhao & Janes, 2007). While there isstrong evidence that traditional post-partum practices are followed by Chinese women in theirown countries, limited published research studies have examined Chinese immigrantwomen’s approaches to zuo yue zi or other elements of their post-partum experiences in theirnew countries. Increased understanding about the postpartum care obtained and experiencedby Chinese immigrant women during their first four to six weeks post-partum in Vancouverin British Columbia, Canada is required to better understand the health care needs of thispopulation.1.4 PurposeThe aim of this study is to explore the experiences of Chinese women emigrating frommainland China, Hong Kong, and Taiwan in regards to how they approach their first four tosix weeks of post-partum practice in their new home city of Vancouver, BC.1.5 Research QuestionsTo avoid simple and under-developed answers, Sadala and Adorno (2003) suggestedresearchers should structure and word questions for qualitative studies to obtain in-depth dataabout experiences. Therefore, open-ended research questions are as follows:7 What are Chinese immigrant women’s experiences of post-partum practices(potentially zuo yue zi) during the first four to six weeks post birth? What resources are utilized by Chinese immigrant women during the first four to sixweeks post birth?1.6 Chapter SummaryIn the first chapter, I described the background and significance of the study aboutcertain traditional post-partum beliefs and practice rituals and provided research questions forexploring Chinese new immigrant women’s post-partum experiences. I also describedChinese women’s decisions to approach their first four to six weeks of post-partum practicein their newly adopted homeland. In chapter 2, I will synthesize the literature and describemajor risk factors for immigrant Chinese women. The concepts of cultural shock, culturalshock experiences, and awareness of cultural differences are incorporated in the review. Inchapter 3, I will provide an overview of my research method including study design,sampling plan, data collection procedures and plan for data analysis. I will also include inchapter 3 some ethical considerations, and possible challenges and limitations associated withthe study. In chapter 4, I will present my findings. Finally, in chapter 5, I will discuss thefindings and their implications for practice, education, administration and research.8Chapter 2: Review of LiteratureImmigrants are exposed to various challenges while they are establishing their lives in anewly adopted homeland. In this chapter, I present my literature review guided by culturalshock theory (Oberg, 1960) to illustrate how immigrant women can encounter challenges andbarriers during the process of adapting to a new culture. I highlight challenges in accessibilityof the health care system, awareness of cultural differences in traditional Chinese traditions,and provide specific examples of immigrant women’s experiences with the health caresystem.2.1 Cultural Shock Theories and Adaptive ModelsWhen considering the practice of zuo yue zi, which is a practice unique to the Chineseculture, it is likely that the practice involves adapting specific ideals to remain true to thebeliefs in a new culture. Migrating from one culture to another is usually accompanied by adegree of cultural shock, a concept first introduced by Oberg (1960). Winkelman (1994) alsoemphasized that “cultural shock reactions may provoke psychological crises or socialdysfunction when reactions to cultural differences impede performance” (p. 121). Austin(2005) illustrated the symptoms of cultural shock which include confusion, disorientation anddisheartenment as well as the following:Psychological and emotional strain due to work required to adapt to new cultures resultin: a sense of loss; feelings of deprivation due to having given up a certain status, wealth, andprivilege in another culture; feelings of rejection by, or rejecting members of the new culture;confusion regarding roles; reduced self-identity; increased anxiety and indignation afterbecoming aware of differences between the home culture and the adopted culture; andfeelings of powerlessness and diminished locus of control (p.134).9Cultural shock theories generally consist of two broad themes, “cultural-learning” and“stress-coping” (Austin 2005). The first theme emphasizes the significance of learning a newculture which requires extensive time and effort to adjust to new customs and conventions.The stress-coping theme views cultural shock as a specific life stressor that requiresindividual strategies to adapt and adjust to new realities.Oberg (1960) emphasized the four-stage adaptive model. There are elements of learningand stress and coping at the different stages. In stage 1, the honeymoon, there is an initial andsuperficial fascinating impression with the new culture. Stage 2 is the crisis stage, recognitionof differences between the new and previous culture, which involves some negative feelingssuch as confusion, frustration, impairment, and anger. Stage 3 is the stage of recovery whichsuggests resolving the crisis through knowledge of the new culture, with improved verbal andnon-verbal communication skills. Stage 4 is the adjustment stage in which immigrantsbecome comfortable; they enjoy life and are able to blend with the mainstream of society.As with many theories there are limitations in their generalizability and a lack ofspecificity for populations. Nonetheless, evidence has shown that these themes have beenapplicable to many cultures. Therefore understanding cultural shock theories and culturalshock experiences can inform our study of how immigrants adapt to new cultures physicallyand psychologically.2.2 The Accessibility of Health Care SystemAnother important concept to examine for immigrants is the accessibility of the healthcare system. Basic health care accessibility is often a concern for individuals regardless oftheir background. Researchers have linked several factors to immigrant women’s abilities toaccess the health care systems in their newly adopted homelands. These factors revolve10around issues of settlement including: language and cultural barriers, low socioeconomicstatus, unemployment, under-employment, limited social support, difficulty understandingand navigating health care information, and the experience of racism and/or discrimination(Balneaves, Bhagat & Grewal, 2008; Bollini, Kupelnick, Pampallona & Wanner 2009;Gagnon et al., 2010; Newbold, 2005). Furthermore, these factors have significant impact onimmigrant women’s maternity health care needs because of difficult access to the health caresystem and lack of healthcare services that are responsive to diversity there is the potential toineffectively address the needs of immigrant women and increase health risks associated withinadequate care and treatment (Gustafson & Reitmanova, 2008). In addition to the stress ofadjusting to a new culture and country, an absence of access to acceptable health care maysignificantly affect a woman’s hormonal and immune responses which can increase someimmigrant women’s vulnerability to unfavorable childbearing outcomes, such as pre-termlabour and low birth weight (Gustafson & Reitmanova, 2008). Therefore, it is important tosensitize the researcher to potential factors affecting Chinese immigrant women’s adaptationwhen giving birth in a new cultural setting, while maintaining their traditional culturalpractices.2.3 Awareness of Cultural DifferencesAn individual’s beliefs and culture affect how she or he views health and the delivery ofhealth care services because each individual has been influenced by that background. Actonand Walker de Felix state, “I may speak many languages, but there remains one in which Ilive” (1986, p.20). Each person is unique, and it is important to not only be aware of aperson’s cultural identity but also his or her relationship with other individuals of a newculture and their current environments. Chinese women who believe in traditional post-11partum practice may take up ‘doing the month’ in different ways. Two Chinese women fromthe same geographic area may present different post-partum beliefs depending on theirexposure to other cultures and experiences before immigrating to Canada. In other words,particular Chinese women may have developed cultural post-partum beliefs that vary fromthose of others. Jenni and O’Connor (2005) emphasized that culture is not monolithic because“all cultures are partial, in the sense that they select for certain human preferences andpossibilities and omit (or never even imagine) others” (p. 205). Therefore, awareness of inter-individual cultural differences is foundational to the everyday practice of health careproviders.While enacting cultural practices, health care providers need to be aware of their owncultures, values, and beliefs and how these affect their views of other cultures. Health careproviders should be reminded that putting a patient into a stereotypical cultural group ratherthan viewing the person as an individual may lead to the use of generalization, which is aninability to consider or acknowledge each individual’s unique characteristics (Ridley et al.,1994). This could be relevant to “zuo yue zi”. Using stereotypical approaches furthercompounds one’s ability to understand others, and also creates obstacles for health careproviders to establish understanding and provide holistic care for an individual. As Leininger(1988) emphasized, care and culture are linked together and cannot be separated.Awareness of cultural differences involves the recognition that clients do not represent amonolithic culture and that they participate in cultural elements in their own unique andcreative ways. A person’s culture represents a personal belief system that is important andmeaningful to his or her own personal well-being (Jenni & O’Connor, 2005). It is importantto acknowledge that Chinese women from China, Hong Kong and Taiwan, who willparticipate in this research study, may have different experiences of zuo yue zi that are12influenced by geographical, political and other factors and to be sensitive to how thoseelements might operate.2.4 Experiences and Barriers in Immigrant Women’s Encounters with Health CareThere is often limited assistance for new immigrants adapting to a new country(Newbold, 2005); lack of assistance can enhance negative impacts of the immigrationexperience and limit immigrants to lower skilled employment and constrained economicopportunities. Newbold also indicated that female immigrants with low incomes are at greaterrisk of experiencing poor health when compared to Canadian-born females. She suggestedthat poor housing and nutrition and unhealthy lifestyles are risk factors associated with lowsocioeconomic status.In some research studies, immigrant women have reported they received insufficienthealthcare information about pregnancy issues, such as physical and mental changes, diet,and exercise (Gustafson & Reitmanova, 2008). Women’s perceptions of receivinginsufficient information have resulted from problems of language barriers which haveaffected women’s awareness about what information they have received and what they need.For example, in a stratified random sample of 6421 women in Canada, 16.8% of recentimmigrant women (i.e., those who have lived in Canada for five years or less) reported thatthey could not speak English well enough to conduct conversations with health careprofessionals throughout their pregnancy, delivery, and post-partum periods (Kingston et al.,2011).As a result of limited language skills and poor access to health services, immigrantwomen start prenatal care later and attend care less regularly than their native counterparts(Kingston et al., 2011). New immigrant women are less likely to take folic acid before13conception or during pregnancy, which may increase the risk of neural-tube defects(Reynolds, 2006). Kingston and colleagues also reported that immigrant women who havearrived recently tended to place their infants to sleep on their stomachs which may exposeinfants to Sudden Infant Death Syndrome (SIDS).Researchers have also indicated that women migrating from areas of low economicstatus, domestic wars, human rights abuses, and countries prone to natural disasters are morelikely to have gestational diabetes because of disruption of normal dietary habits; they arealso more likely to experience postpartum depression due to lack of support in the postpartumperiod (Kingston et al., 2011; Oldroyd, Renzaho & Skouteris, 2010). In addition to languageand communication difficulties, immigrant women find accessing health services challengingbecause family responsibilities, jobs, lack of transportation, and gaps in child care interferewith their mobility and time availability (Newbold, 2005; Renzaho et al., 2010). It isimportant to explore the postnatal practices of Chinese women who have immigrated toCanada to understand how engaging with zuo yue zi might affect their access to health careand health information.Some studies have demonstrated immigrant women’s dissatisfaction with their hospitalcare (Small et al., 2002). Their dissatisfaction is often attributed to “cultural differences inwomen’s expectations of hospital care in their newly adopted homeland, and to thedifficulties of hospital staff acknowledging and accommodating women’s traditional culturalpractices” (Small et al., 2002, p. 275). Some researchers have suggested that women’sexposure to different cultural practices, through contact with health care professionals, suchas washing and exercising which are contrary to “zuo yue zi”, may put Chinese women at riskfor attributing physical problems later in life to their failure to follow traditional practices(Barnett, Matthey & Panasetic, 2002). Without understanding how Chinese women approach14and manage the postpartum period, particularly with regards to zuo yue zi, it is difficult forhealth care providers to offer culturally sensitive care.Low socioeconomic status, limited access to health information, separation fromprevious social support, and language and cultural barriers are all disadvantages thatimmigrant women face that may reduce maternal health and well-being (Gustafson &Reitmanova, 2008). Such disadvantages affect not only immigrant families and their childrenin the immediate transitional immigration period but also have consequences for long termhealth. This is particularly the case for zuo yue zi because some Chinese women attributepoor longer term health outcomes to failure to follow traditional practices. Thus, it isimportant for health care providers to understand Chinese immigrant women’s expectationsabout adequate post-partum care and their views about potential problems arising from unmetexpectations.2.5 Chapter SummaryThe challenges that immigrants experience while establishing their lives in a new cultureand the tremendous difficulties that immigrant women encounter with the health care systemduring the childbearing period are described in numerous studies (Gagnon et al., 2006;Krueger, Sword & Watt, 1999; Shin & Shin, 2006).Nonetheless, empirical literature that specifically examines the postnatal experiences ofimmigrant Chinese women in British Columbia could not be located. There is also a paucityof studies about Chinese immigrant mothers’ efforts to manage their postnatal periodsthrough the practice of zuo yue zi. There is little known about the expectations of Chineseimmigrant women who prefer to follow traditional Chinese post-partum practices. In theabsence of such support, we do not understand resulting challenges that affect Chinese15immigrant women and their newborns. Because many unaddressed questions remain, thisresearch study will endeavor to provide more understanding about Chinese immigrantwomen’s experiences in Vancouver during the first four to six weeks of the post-partumperiod, in particular, the practice of zuo yue zi. This research study also aims to sensitizeproviders about appropriate interactions with regards to the awareness of cultural differences,and also aims to promote the overall well-being of Chinese immigrant women in the post-partum period.16Chapter 3: Research MethodThis research study explores the experiences of zuo yue zi in the post-partum periodamong Chinese immigrant women who are currently living in Vancouver. This chapterdescribes research methods including study design, ethical considerations, sampling plan,data collection, data analytic plan and rigor.3.1 Research DesignBecause the study aimed to develop in-depth understanding of the postnatal practices ofChinese immigrant women, in particular zuo yue zi, I used a qualitative design. “Descriptivequalitative studies enhance researchers’ understanding of not only the natural phenomena butalso the why of their occurrence” (Polit & Beck, 2012, p. 131). Qualitative methods wereparticularly appropriate for describing Chinese immigrant women’s experiences of their firstfour to six weeks of post-partum care in their newly adopted country because they involvereflection and require inquiry “based on the realities and viewpoints of participants’ realities -viewpoints that are not known at the outset” (Polit & Beck, 2012, p.487). A qualitativeapproach helps to enhance the nursing profession’s understanding and perceptions ofpatients’ concerns, problems, situations, experiences, and/or potential solutions to problems(Polit & Beck, 2012). Moreover, qualitative research methods are ideal “when an explorationof meanings of phenomena as experienced by individuals themselves is undertaken” (Ek,Idvall & Wahlin, 2006, p. 371). The meaning of phenomena is important because meaning isconveyed by using a literary structure to report findings, which consists of situating therichness of participant commentary in a qualitative approach (Carpenter & Streubert, 2011).In other words, the subject gets to tell their stories through qualitative data.17The qualitative method used for this study was an inductive descriptive design, which isa specific approach to inquiry. Sandelowski (2000) indicated that qualitative descriptivestudies offer a comprehensive and valued “summary of an event in the everyday terms ofthose events” (p. 335). The researcher conducting a qualitative descriptive study is requiredto stay close to the words and events described by participants. Sandelowski providedquestions that reflect this qualitative descriptive approach such as: what are people’s concernsand responses including thoughts, feelings and attitudes toward an event?  Who uses aservice or procedure and when? What factors operate as advantages or disadvantages in anevent?By using a qualitative inductive descriptive method, I endeavored to capture thevariation within Chinese immigrant women’s experiences of zuo yue zi and to present a richdescription about their perceptions of their first four to six weeks of traditional post-partumpractices. Utilizing this methodology also highlighted perceived advantages anddisadvantages of post-partum services used by Chinese immigrant women in Vancouver, inrelation to zuo yue zi, and obstacles and difficulties these immigrant women encountered intheir pursuit of traditional practices.3.2 Ethical ConsiderationsI obtained ethics approval for the study from the University of British ColumbiaBehavioural Research Ethics Board. Ethics approval was based on the Tri-Council PolicyStatement Guidelines. Before proceeding with this study, prior approvals were also obtainedfrom three physicians working in obstetrical clinics in Vancouver. This approach permittedme to achieve maximum variation sampling (Polit & Beck, 2012). Maximum variation18sampling means that women from a variety of settings had opportunities to volunteer for thestudy.The recruitment posters and pamphlets displayed in various settings contained theresearcher’s contact information, which included a mobile phone number and email address.After contacting the researcher, potential participants were informed about the purpose of thestudy through the participant letter by email (Appendix A), and were asked if they wantedmore in-depth information about the study. If the potential research participants indicated aninterest in the study, the researcher explained the study in more detail and answered theirquestions. Following contact with me, potential research participants were given a minimumof 24 hours to consider whether they wished to participate in the study. A consent form(Appendix B) in both English and Mandarin that outlined the study in greater detail wasprovided for participants to sign at the time of the interview. Women were offered a choice toconduct the interview in Mandarin or in English.Informed written consent was obtained from each of the Chinese immigrant women whoagreed to participate in this study. There were no known risks associated with this researchfor participants. If a participant became emotionally distressed when discussing theirexperiences in their new country, the interviewer would stop the recording and provide timefor them to recover. The interviewer also prepared a list of potential community resources forwomen if they seemed to be experiencing significant distress. Of the thirteen participants inthis study, none of the women indicated that they experienced any emotional distress whensharing their post-partum experiences in Vancouver.To ensure the confidentiality of the participants, any identifiers were removed from theirtranscripts. I kept the list of participants and their contact information separately from thetranscripts in an encrypted file. All audio recordings and transcripts were stored securely in a19filing cabinet inside a locked office. All study data will be kept in a locked office at UBCfollowing completion of the study and will be destroyed five years after completion of thestudy. I kept reflective journals throughout the research study process for auditing purposeswhich I shredded following completion of the study.No form of coercion to gain a participants’ cooperation in this study was used. Therewere no penalties or significant rewards associated with withdrawing from or participating inthis study. A small baby towel as a thank-you gift was offered to participants. The womenmay have benefited from opportunities to describe their early post-partum experiences, inparticular, zuo yue zi and to share their feelings about the experience. The participants wereadvised that they could choose not to answer any questions. If other family members werepresent in the home or the clinics, the researcher checked the interviewee’s comfort levelwith interviewing in terms of privacy and confidentiality. The researcher requested someparticipants’ family members or post-partum doulas leave the area where interviewingoccurred or selected an alternate location for the interviews.During the interview process, the participants could elect to discontinue participation inthe study. In these circumstances, interviews would be stopped immediately and participants’interview data would be omitted from the study. Thirteen participants engaged in face-to-faceinterviews, while nine of the 13 participants had telephone follow-up interviews in order toclarify and validate interview content. I translated all of the ethics materials into Mandarin,including the consent forms, and conducted the interviews in Mandarin. All the participantsfelt comfortable expressing their feelings about and experiences of their post-partum periodduring either face-to-face or telephone interviews.203.3 Inclusion & Exclusion criteria3.3.1 Inclusion criteria.Participant inclusion criteria for this study were: BC residents who are ethnic Chinese(from mainland China, Hong Kong, and Taiwan), are aged 19 or older, were born and/orlived in mainland China, Hong Kong, or Taiwan, and have immigrated to and lived in Canadawithin the last five years. The participants primarily spoke Mandarin (Mandarin is the officiallanguage in mainland China) with English as their second language, and had given birthwithin the last six weeks. The participants could be either a primipara (have only had theirfirst child) or parous (have had more than one child), who had given birth to a term singletonby natural or assisted delivery including vacuum, forceps delivery, and caesarean sectionwithin the last six weeks.3.3.2 Exclusion criteria.Participant exclusion criteria for this study were women who: gave birth to multiples,reported pregnancy complications, delivered premature infants or infants with any kind ofanomaly, or developed infections or other illnesses that required hospitalization or significantpost-partum complications such as sepsis, eclampsia or psychosis.3.4 SamplingOriginally, the participants for this study were to be recruited purposively from threecommunity obstetrical clinics in Vancouver. Posters and pamphlets used for recruitment werewritten in both English and Mandarin. The posters were displayed in the waiting areas ofobstetricians’ offices, and pamphlets were placed on the front desk so that the officeassistants had an opportunity to inform potential participants about the study. Unfortunately,21one obstetrician only scheduled appointments for post-partum patients after eight weeks.Therefore, the post-partum patients from this particular clinic did not meet the inclusioncriteria for this study. Snowball (network) sampling was used as a recruitment method tomaximize the purposive selection process (Polit & Beck, 2012). The researcher applied thesnowball technique by asking participants who initially participated in the study to refer otherChinese women who met the inclusion criteria. Snowball sampling reaches a broadersegment of the population and community and helps researchers to build trustingrelationships with new participants (Polit & Beck, 2012).3.5 Data CollectionI recruited 13 Chinese immigrant mothers in order to provide an adequate sample toreach data saturation for this qualitative descriptive study. Saturation refers to the repetitionand confirmation of elements in the previously collected data (Carpenter & Streubert, 2011).In other words, when data saturation is achieved, the researcher will be able to recognize therepetition of themes from the interviewed Chinese immigrant women and determine that nofurther novel information has surfaced. Because it was necessary to obtain more detaileddescriptions from 12 participants they were contacted for a second interview; however, fourparticipants indicated they were not available. The second interviews were conducted withinthree months post-partum. Eight participants were asked for a second interview to providemore detailed descriptions based on the data from their first interviews. Data collectioncontinued until there were no longer new themes emerging from the additional data providedby participants.Participants were also given a choice of an interview location that offered them thegreatest comfort. Five interviews were conducted in a spare room in the obstetrician’s clinics.22The researcher visited other mothers to conduct interviews in their homes. Descriptive datawere collected from participants through a demographic tool (Appendix C), and thequalitative data were collected through semi-structured interviews (Appendix D), with aspecific set of questions. The researcher also observed participants during the interviewprocess. The second interviews were telephone interviews. The researcher had developedsome rapport with participants during the face-to-face interviews and perceived that mothersfelt more relaxed with telephone interviews as a second round of data collection. Theparticipants’ responses were recorded with digital recorders.All interviews were conducted in Mandarin. The researcher translated all of theinterviews to English. That process took, on average, 15 hours per interview. The firstinterviews averaged about 20-30 minutes and the second interviews were approximately 40-50 minutes long. The interviews were completed over five months.3.6 Data AnalysisMy data analysis was undertaken concurrently with data collection. Pope and colleagues(2000) emphasized that the “analytical process begins during data collection as the dataalready gathered are analyzed and shape the ongoing data collection” (p.114). The transcriptsof the face-to-face interviews were carefully reviewed by the researcher and compared withthe audio recordings. My analytic process required continuous reflection about thephenomena of interest. The translated interview transcripts were also reviewed by the thesissupervisor.The steps of data analysis were undertaken based on Elo and Kyngas’ (2007) descriptionof their study methods. The raw text was translated word by word or line-by-line carefullyfrom Mandarin to English. It was important for me to immerse myself in the data to capture23how Chinese immigrant women approached their first post-partum month and how theyfollowed or modified the traditional practices of zuo yue zi in their new home city.The open codes, which are the notes and headings from the content of the data, were createdby examining the similarities and differences among women’s experiences within andbetween interviews. Both I and my supervisor generated open codes from the translated data.As concurrent data collection and analysis continued, I sorted and grouped similar codeswhich generated the categories (Elos & Kyngas, 2007). Each category was bounded by adefinition unique to that category and exclusive from other categories (Elos & Kyngas,2007). My supervisor assisted with generating categories. Sub-categories were groupedtogether to create higher level categories. In turn I clustered the higher level categories toformulate the themes that described the essence of the context of the research phenomenon.The purpose of developing categories for this study was to increase understanding andgenerate knowledge about the nature of Chinese women’s post-partum experiences and howthey followed and/or modified traditional post-partum practices, specifically zuo yue zi, intheir newly adopted homeland.For example, in the analysis of my data, I developed the following codes. The codes:existence of heating systems indoors, favorable climate and availability of transportation toindoor parking formulated the category of change in climate and improved living conditions.The codes: followed the science and discarded traditional post-partum practice, followedsome of the early tenets but changed beyond the first two weeks, and believed not followingzuo yue zi did not lead to illnesses, supported the category of incorporating some principles ofzuo yue zi in modifications. Then, I clustered these categories into the theme of modificationsof expectations.243.7 RigorAlthough there are no set guidelines for interpretation in a qualitative study, “the goal ofrigor in qualitative research is to accurately represent study participants’ experiences”(Carpenter & Streubert, 2011, p. 48). The researcher applied Guba and Lincoln’s (1994)framework to support the trustworthiness or rigor of this qualitative research study; theirframework includes four criteria: credibility, dependability, confirmability and transferability.According to Carpenter and Streubert’s (2011) explanation of the four criteria, credibilityindicates the probability of credible findings. In other words, credibility refers to “confidencein the truth of the data and interpretation of them” (Polit & Beck, 2012, p.585). Dependabilityis a criterion that is similar to the validity or reliability in quantitative research and is builtupon the credibility. In other words, the explanation of the women’s experience seems valid.Confirmability indicates a process that clearly illustrates evidence leading to the conclusionsor data supporting the findings in ways other individuals can follow. Lastly, transferabilityindicates the applicability and probability that the findings have meaning to other groups orothers in similar situations (Carpenter & Streubert, 2011). In other words, the researcherneeds to provide adequate descriptions for future researchers to possibly transfer data toexamine conclusions reached in other contexts.I planned to provide an opportunity for each participant to review the contents of theirinterviews to confirm the statements are accurately transcribed. Twelve participants werecontacted for clarification in follow-up interviews to enhance the credibility, dependability,and transferability of the study. I also shared my transcripts and coding with my supervisorwho reviewed all of the transcripts, the coding, and the higher level categories. Mysupervisor’s participation supported the credibility, dependability and confirmability of theresearch findings.25Awareness of potential researcher bias was essential for this particular research study inorder to respect the life experiences of the Chinese immigrant women who practicedtraditional post-partum customs. I had particular perspectives on ‘zuo yue zi or doing themonth’ arising from my practice experiences and being a prenatal educator and intended tosustain openness and sensitivity towards participants’ perspectives. Therefore, throughoutthis research study, I took notes myself to reflect and understand Chinese immigrant women’spost-partum experiences, specifically zuo yue zi, in their newly adopted homeland to enhancethe research process. Polit and Beck (2012) emphasized that to achieve confirmability“findings must reflect the participants’ voice and the conditions of the inquiry, not theresearcher’s biases, motivations, or perspectives” (p.585). I believed that I achieved theconfirmability toward the end of this research project.3.8 Chapter SummaryThis chapter presented a description of the study design. An inductive qualitativedescriptive approach was utilized. Ethical considerations were described. Purposefulmaximum variation and snowball (network) sampling were presented as the samplingmethods used. Data collection involved some demographic data and recorded interviews. Thechapter also included a description of data analysis and how rigor was addressed.33Chapter 4: Presentation of FindingsIn this chapter, I present the findings of the study. The central theme is Chineseimmigrant women’s novel encounters with zuo yue zi. I begin by describing participants’characteristics. This is followed by sub-themes developed from women’s perspectivesincluding: the importance of zuo yue zi, factors reinforcing women’s efforts to practice zuoyue zi and affecting the experience of zuo yue zi, implementation of zuo yue zi, factors thatenhance zuo yue zi, modifications of zuo yue zi practice, and the rationale for some not tofollow zuo yue zi. This chapter begins with a description of the study sample.4.1 Description of SampleThirteen mothers, who followed various degrees of zuo yue zi, participated in the study.Five mothers from an obstetrician’s clinic responded to my study after being contacted by thereceptionist regarding the poster advertisement (see Table 4.1). Eight of the participantslearned about the study through word of mouth, either from a social network group or contactwith another mother.All mothers in the study met the inclusion criteria. Eleven participants ranged in agefrom 25 years to 35 years. Two participants were over 35 years of age. All of the participantswere married and lived with their partners. Only one participant lived in the same householdwith her mother. Five participants had extended family, such as a mother-in-law, that stayedwith them temporarily for a few weeks before and after delivery.As for the geographical background of the participants, they were from Mainland China,and Taiwan. The self-reported areas of origin for participants were in Northern China (8%),and Southern China (4%). One participant was from Taiwan. One mother indicated she hadlived in Japan for seven years before coming to Canada.34The occupations of the participants varied. One mother stated that she was a housewifein China. Five mothers reported that they were students before immigrating to Canada. Therest of the participants’ previous occupations before immigration were nurse, salesrepresentative, accountant, manager, software engineer, teacher and hospital publicrelationship. Of all the participants, four mothers held a job in Canada and the otherparticipants defined themselves as housewives.All the infants ranged from 4 to 6 weeks of age at the time of the first interviews. Theywere all healthy at birth and full term gestation (thirty-seven completed weeks or more). Nineinfants in the study were first-born children in the family. Four families had more than onechild at home. Four mothers delivered their babies by caesarean section and the rest hadspontaneous vaginal deliveries.All the participants indicated they were new immigrants because they had been inCanada for less than six years. None of the participants identified themselves as havingexcellent English language skills. Eight participants indicated they were fluent in English.Five participants had poor English language skills. All the participants reported having atleast post-secondary education. Five participants indicated they had achieved graduatedegrees.Family income was reported by three participants as more than CAD $60,000 annually.Three participants reported that their family incomes were between $41,000 and $60,000 perannum. Four participants reported their family incomes were between $20,000 and $40,000.Three participants reported their family incomes were less than $20,000.The mothers expressed a variety of views about their knowledge of zuo yue zi customs.Fifty-four percent of mothers indicated that they were familiar with traditional Chinese post-partum practices while 5% expressed some familiarity. One participant indicated that she was35not familiar with these customs at all. All of the mothers indicated that they were practicingzuo yue zi customs to the best of their knowledge.In terms of accessing support services, none of the participants chose maternal post-partum care centres for their most recent zuo yue zi. Two participants chose post-partumhome meal delivery. Six mothers hired post-partum doulas, of which three were live-in andthe other three were half-day doulas. Five participants had their mothers or mothers-in-law asthe main caregiver during zuo yue zi. Two participants received help from mother and/ormother-in-law in addition to arranging paid post-partum services.Table 4.1: Participants’ demographic characteristicsMaternal age Number Percentage25-29 4 30.8%30-34 7 53.8%>34 2 15.4%Shared home with extended familyYes 5 38.5%No 7 53.8%Not answered 1 7.7%Geographical background:Mainland China 12 92.3%Taiwan 1 7.7%Time in Canada:1 – 3 years 6 46,2%4 – 6 years 7 53.8%Fluency in English:Poor 5 38.5%Maternal age Number PercentageGood 8 61.5%Highest level of education: Number PercentageSome postsecondary courses 4 30.8%Undergraduate degree 4 30.8%Graduate degree/PHD 5 38.4%36Current family annual income:< CAD $20000 3 23.1%CAD $20000 - $40000 4 30.7%CAD $41000 - $60000 3 23.1%> CAD $60000 3 23.1%Number of children:1 9 69.2%2 4 30.8%Type of delivery:Vaginal delivery 9 69.2%Caesarean section 4 30.8%Maternal age Number PercentageFamiliarity with traditional practices:Yes 7 53.8%No 1 7.7%Not sure 5 38.5%Sought Post-partum services:Post-partum home meal delivery 1 7.7%Post-partum home meal delivery 1 7.7%Live-in Post-partum doula 3 23.1%Live-in Post-partum doula 1 7.7%Part-time Post-partum doula 3 23.1%Maternal care providers 4 30.7%4.2 Chinese Immigrant Women’s Novel Encounters with Zuo yue ziThe core theme of my study was participants’ novel encounters with zuo yue zi in a newcountry. The encounters were novel because the women were bringing expectations fromtheir countries of origin about zuo yue zi, which arose, in some cases, from prior experiencesof giving birth, but were also transmitted by family members and friends continuing to residein their countries of origin. Although expectations were communicated by others, as a result37of their migration, the participants were not immersed in cultures where everyone wasfollowing the principles of zuo yue zi.The participants’ encounters with zuo yue zi were also novel because the resourcesavailable in their new country were not equivalent to what was available in their countries oforigin. The women had to make adjustments to their relationships with paid assistants andfamilies. The women were participating in zuo yue zi in circumstances where health careprofessionals and others they encountered were not as familiar with zuo yue zi as in theircountries of origin. One participant shared:Because I had a Caesarean section, the air conditioning in the hospital was relativelystronger and colder and the room is relatively small so the conditions do not look sogood, so it’s not necessarily appropriate for mothers to bathe in there. Not only was herfacial expression, her tone of voice was quite obvious to make me feel veryuncomfortable. She really cannot understand! (P8)As elements of novel encounters with zuo yue zi, I created three themes. The first themeinvolved the mothers’ expectations about practicing zuo yue zi in Greater Vancouver. Thesecond theme captured their struggles with reality as opposed to mothers’ expectations. Thethird theme captured mothers’ modifications of their expectations in Greater Vancouver inresponse to the facilitators and challenges they encountered.38Table 4.2 Women’s novel encounters with zuo yue ziSub-Themes Supporting CategoriesExpectations about zuo yue zi  Reinforcement to follow guidelines of zuoyue zi Perceived effects of zuo yue zi Organizing zuo yue ziStruggles with Reality as Opposed toExpectations Relationships with others Disagreement with eldersModifications of Expectations inResponse to Facilitators and Challenges Accommodating climate and livingconditions Modifications to original plans Evaluating principles of zuo yue zi inmodifications Considerations for family members Influences of previous experiencesAll study participants described being aware of the guidelines for zuo yue zi and itspotential positive and negative effects. They indicated their awareness was rooted in Chineseculture and reinforced by TCM (TCM; Traditional Chinese Medicine which originated inChina and has evolved over thousands of years. TCM applies a holistic system to diagnoseproblems and includes various forms of herbal medicine, acupuncture, and massage to easeand/or cure the illnesses). The women’s awareness was also transmitted through theirChinese contacts. Most of the participants indicated they expected to practice at least someelements of zuo yue zi as they stressed its contributions to recovery in the post-partum period.In their new country and changed circumstances they also described struggling with a new39reality where family members were not always available and mothers were uncertain aboutthe quality of services provided. These new mothers indicated they faced challenges whichthey ascribed to being in a ‘vulnerable state’. In situations where family members werevisiting and resources differed from their home countries the women described relationshipswith hired external helpers and surrounding family members were not meeting expectations.Participants described disagreements regarding the expectations surrounding zuo yue ziand newborn care between generations. All mothers described making modifications to theiroriginal plans. They developed rationale to support their practices of zuo yue zi; for example,stopping the intake of prescribed Chinese herbal medicine, hiring 24-hour post-partum doulasafter they recognized their additional needs for care, and going outdoors before thecompletion of zuo yue zi. Central to the participants’ early post-partum experiences of zuoyue zi was what they described as their needs for support that was provided in ways differentfrom their countries of origin.4.3 Expectations of zuo yue ziThe participants’ decisions to follow traditional post-partum practices began with theirunderstanding of what they regarded as the effects of zuo yue zi. They made their decisionsduring the antenatal period. As the participants prepared for zuo yue zi, they researchedinformation to add to their knowledge of the practice. In part, they were relying oninformation transmitted to them through family and friends. The women intended to followthe guidelines and recommendations. They anticipated that they would recuperate withadequate rest as well as sufficient help with newborn care via post-partum doulas, post-partum meal delivery, post-partum centres and family members. Their expectations arosefrom their belief in TCM and the principles of zuo yue zi.404.3.1 Reinforcement to follow guidelines of zuo yue zi.The women’s efforts to engage in zuo yue zi were reinforced by multiple factors: theinfluence of the older generation, friends’ shared experiences, online information from China,and information from books. Participants also described the availability and the accessibilityof some resources enabling them to accomplish zuo yue zi in Vancouver as a factor indeciding to follow the practice.Most participants regarded information from their mothers and grandmothers to be credible.They also indicated that their cultural beliefs were deeply embedded.One participant particularly emphasized this point.For women giving birth to babies, zuo yue zi is essential after giving birth. Despitereceiving education in the West these years, I still feel that I am Asian; on the physicaland other levels, I still have the traditional concepts. (P5)4.3.2 Perceived effects of zuo yue zi.Most of the participants believed that, without zuo yue zi, they would experience longterm health problems. They believed it was critical during zuo yue zi to have others look afterthem and their babies. Mothers believed that without rest, they would not overcomeweaknesses and would experience bodily discomfort.Almost all the participants discussed their understanding of the effects of avoiding zuo yue zi.The experiences of friends also contributed to the reinforcement of zuo yue zi.I have a classmate. She really has joint pains. She is the same age as me and a verygood friend of mine. She did not listen to the elderly, so the last time I heard she saidthat her joints are painful…but her character is such that she does not believe what theelderly say. (P4)41The women believed that outcomes included lower back pain, joint soreness, headaches,teeth or gum sensitivity, and impaired vision. Most of the participants described theirunderstanding as being influenced by TCM, which explained effects of zuo yue zi or notpracticing zuo yue zi.After women give birth, their bone sutures are open. After the sutures are open, it iseasy for cold air to enter. If the cold air enters, you will get joint pains, and afterwardsother diseases may remain because of this. It must have been from the oldergeneration because all Chinese medicine has this theory. (P10)In response to potential effects the participants described being advised to limit theircontact with cold water and cold wind. One participant talked about her sore wrist from aprevious zuo yue zi because she touched cold water: “it was a very painful wrist! …I guess itwas during the last zuo yue zi, I was exposed to cold water” (P10). Another participant said,“my mom told me that she was in a strong cold wind when she did zuo yue zi before so sheoften gets headaches” (P12).During zuo yue zi, the women indicated that TCM links wind and cold entering into thebody to taking showers and/or baths. If taking a shower or bath could not be avoided, it waspreferable to add ginger water and higher concentration wine to the basin used for a spongebath. “You have to add ginger, Asian mugwort, Kaoliang wine to take a bath and wash yourhair” (P9).So in case you were exposed to the wind, adding ginger and wine to the bath waterwill enable you to release it from your body …do not touch cold water. You can takeshower but the water that is used for showering needs to be brought to a boil thencooled down before using. (P9)In addition, one participant described discomfort of her left arm resulting from a42previous exposure to the cold during zuo yue zi.It’s because my left arm was exposed to the cold. When I compared my two arms, itwas obvious which arm felt uncomfortable …As soon as the temperature lowersslightly, my left arm would feel cold…so every time you would feel the need to takesomething to cover your left arm. Also, it’s obvious that your left arm does not havethe strength so your mood will not be good. … It’s because our bodies are weaker.(P12)Most participants described zuo yue zi as a crucial time for the weak body to recuperate.The women portrayed effects on body parts including arms, eyes, and joints. They outlinedprecautions required to ensure that the body was not overly exhausted such as: “lying downas much as possible, not walking, [and] do not hold the baby.” (P9). One participant saidwhen she was a baby, “my mom … [was] holding me night after night, so heavy lifting isvery difficult, even painful, for my mom now; the pain comes when it is cloudy or rainy too!”(P5). Several mothers were warned to avoid watching TV and using cell phones. Oneparticipant emphasized that she wore sunglasses to protect her eyes: “When I went out, Icovered myself, including the eyes. If the sunlight directly shines into my eyes or if my eyesare exposed to cold wind, they would become teary. Therefore, I wore sunglasses and a hat”(P7).Another participant stressed that she struggled to follow prescriptions about not cryingduring zuo yue zi because the postpartum period was demanding and she was exhausted.You are totally unprepared. At that time you experience great physiological changesand need to be restored. The body is very weak, and you cannot get a good night’ssleep, which is really very grueling…Your mental state would be particularly poor …Iwould guess that there isn’t any mother who did not cry during zuo yue zi. The elderly43would say, “Do not cry! It’s not good for your eyes if you cry.” (P5)A few participants shared others’ experiences of suffering from gum sensitivity, due toeating hard and cold foods during their zuo yue zi. One participant stated “during her zuo yuezi, my grandmother particularly wanted to eat pear, and at that time my grandfather could notresist so he gave her to eat a small piece. Now just by eating pears, her teeth will ache” (P5).During zuo yue zi, a mother felt that her gums had required extra protection, which she didnot follow. She attributed her ongoing sensitive gums to her failure to follow traditionalpractices.My mother told me not to brush my teeth during zuo yue zi, but I couldn’t stand not tobrush my teeth so I still did. I didn’t change to a soft-bristled toothbrush and ended upwith bleeding. Even now while brushing my teeth, it is easy to get bleeding. At thattime my body was very weak, so the gum of the teeth was also fragile. Once it’s hurt,it’s hard to recover. (P12)Most participants also stressed that illnesses contracted before or during zuo yue zi couldbe healed during a new period of zuo yue zi. In other words, a new experience with followingzuo yue zi, would enhance the condition of their bodies.As the traditional saying goes, the illness in zuo yue zi can only be cured during zuoyue zi. This means that if you were in the cold wind in the yard and caught illnessessuch as rheumatism, the next time you zuo yue zi, if you do it well, you have a chanceto recover from it. (P8)One mother was pleased that her current zuo yue zi has strengthened her lower back.My lower back used to feel especially cold, the kind of cold that makes youuncomfortable. I had to use hot pads at home …I'm getting better and betterphysically and also being restored to a good condition. (P12)44Another example from one participant; “[my left wrist] was not painful during my zuoyue zi this time …this time it was fine. I did not do much work this time … [or] touch coldwater to wash things either” (P10).A few participants emphasized that the timing of zuo yue zi was critical in terms of theextent of their post-partum recovery. After three months of zuo yue zi, some participants feltthat they had attained only 50% of their previous state. Two participants indicated that theywould have extended their period of zuo yue zi if they had been more aware of the demandsfor physical recovery and newborn care.Following traditional prescriptions appeared to be a mixed experience for some of thewomen. A few participants described experiences of negative effects after completing theirzuo yue zi. When mothers followed prescriptions to stay inside and rest they found theydeveloped physical weaknesses that restricted their daily activities such as walking and takinga shower after zuo yue zi was completed.I will feel a little out of breath that I must walk slowly. After all, within this monthafter giving birth, you have only been moving around indoors, have not contactedfresh air, and have had little physical activity, you really need a period of time toadjust ... I felt that I can finally take a bath, so I adjusted the water temperature to veryhigh. But even with the high water temperature, I still felt a cool breeze fromsomewhere as I was bathing, and then after showering I felt particularly weak. (P5)4.3.3 Organizing zuo yue zi.All participants acknowledged the importance of organizing their zuo yue zi. Planningfor zuo yue zi enhanced the comfort and support associated with their post-partumexperiences. One mother emphasized, “good preparation at the earlier stage can make the45later stage more comfortable” (P11). Almost all the participants had their family memberspresent in their newly adopted homeland, mainly their mothers. They requested motherscome to share the household chores, take care of older children, help with cooking; and helpwith newborn care. One participant ordered one month of post-partum home meal delivery inaddition to relying on the presence of family members. She affirmed her decision prior to herbirth by visiting the central kitchen of the post-partum meal provider.Because I have gone to the home of the people who make these post-partum meals tosample the food and it was also recommended by a friend, so their sanitary conditionis good. Every container they use is made of glass and the kitchen is pretty clean. I’veeaten them [the meals] so I felt they’re quite good. If they were not good then I wouldnot have ordered their post-partum meals. I would have ordered from another place.(P4)One mother described taking the post-partum doula training in China in order to preparefor her own zuo yue zi in Vancouver; “The training lasted one week from morning to evening.The obstetricians and pediatricians were the ones giving us some professional knowledge.There were also lessons about how to make post-partum meals and how to look afternewborns” (P11).The participants’ ability to access the internet for support is a new concept in the worldof the traditional zuo yue zi practice. Mothers in this study indicated it enhanced their abilityto practice zuo yue zi here in Canada. Using the internet, they shared their concerns andlearned from each other. In China, because the majority of the population may have practicedzuo yue zi women could observe what other mothers are doing. In Canada where there aremany different cultures and practices the women recognized that zuo yue zi practice is notmainstream. They used social media such as Wechat groups to prepare for their zuo yue zi46experiences. One mother indicated “Wechat group is very important! We have such aconvenient technology for the benefits of the public (P5)”.One participant described preparing questions from online research prior to interviewinga post-partum doula to attend to her following her birth. Because the doula was not known tothe mother and she was aware that doulas were not regulated in Canada she wanted to ensurehonesty and professionalism.You will have a sense about this person when you meet her face-to-face. You couldprobably tell whether this person was honest and professional during theconversation …I wanted to know whether she knew what she would be doing. Isearched online beforehand to find out how to test a post-partum doula’s professionalknowledge. There are some fundamental questions available online. (P12)All of the participants raised serious concerns regarding the qualification and liability ofthe private paid post-partum services in Greater Vancouver as they were preparing for theirzuo yue zi. Mothers expressed concerns because of the absence of a government licensingbody to ensure the quality of services delivered by postpartum doulas. They wereuncomfortable with their inability to access a police authority to request criminal recordchecks of these service providers to protect families and babies. Because the differences intheir expectations of zuo yue zi had to be modified from their home countries; they had to payattention to more details.I will not hire, will not dare to hire her, because there is no guarantee for the post-partum doula’s health. Without a license, you cannot be sure whether they have anyinfectious disease, mental illness, or violent tendencies…In China, yes. She will showproof of her state of health and a training diploma. There is formal support by her47company so if there is a problem you can go to her company. If a post-partum doulawithout a license says she will help you take care of the baby, who would dare let her?(P1)Most of the participants who hired helpers prior to their births sought recommendationsfrom their friends. A participant expressed many reasons for her hesitancy to hire a paidhelper including the requirements to pay prior to the work, a lack of company support forcontracts, and postpartum doulas’ lack of worry about poor reputations.Actually, I would worry! [The post-partum doula] has been paid in cash already, andshe does not have a license or belong to a post-partum organization, so it iscompletely non-binding. And we cannot do ten zuo yue zis in a lifetime, unlike goingto restaurants, whether you would go eat there tomorrow affects the restaurant greatly.To Chinese people, zuo yue zi is done once or twice at most three times, so post-partum doulas do not mind whether they have recurring customers. I don’t think thereputation among post-partum doulas and post-partum meals in Vancouver is thatimportant! You have heard a lot of bad reports After all, in this market the supply isless than the demand, that is, there are more mothers seeking post-partum doulas andthere are less post-partum doulas. (P8)One participant and her mother-in-law tried each dish from a post-partum recipe bookbefore giving birth.So I bought a lot of recipe books, constantly studying them, including the parentingbooks. I kept reading them and we even practiced making the meals in the recipebooks, taking note of which ones we can cook, which ones taste better, and how tomake improvements; we studied that for a long time. (P5)In addition to the physical practices associated with zuo yue zi, a few mothers stressed the48importance of their 'state of mind' in terms of mental preparation for zuo yue zi so they wouldmaintain mental wellbeing. “Another importance of the preparation for zuo yue zi is thepreparation of the mind. If the mind is not prepared, you may experience some depression ormood swings” (P11). Two participants shared how they modified their expectations prior totheir zuo yue zi: “I don’t think my standard was very high. I did not expect to do nothingduring zuo yue zi, or that I must have Taiwanese post-partum meals. Overall, I'm stillsatisfied with this zuo yue zi” (P8).Another mother described adjusting and preparing her expectations of zuo yue zi andfeeling less pressure because she resided in Vancouver where zuo yue zi is not followed bythe majority of the society.Although zuo yue zi is very important... being here, I feel it can be done to about 70-80 percent so that it does not affect you; this is enough. In China, you can do zuo yuezi as well as it can be done but here if you do it according to the best measures, it’sactually fine! (P4)One participant indicated that by reading more books, she felt that she was betterprepared to empower herself about her zuo yue zi: “I bought many books during pregnancy,since as a book editor myself, I believe that you can find all the relevant knowledge you wantfrom books. They can equip you to face many challenges and give you confidence” (P5).A participant with health care training was confident about detecting any problems specific toherself and her newborn’s care during zuo yue zi, which made her preparation of zuo yue zieasier....because I was a nurse in China…many people do not understand, they are notaware of it due to a lack of experience. They don’t know that they need to follow up onthese things. (P1)49All participants emphasized the financial constraints operating during their preparationfor zuo yue zi. Their modifications to zuo yue zi and decisions about the type of services theyrequired to perform zuo yue zi primarily depended on their financial situations. Financialsupport from their families made organizing zuo yue zi easier. Some participants stated that,without their family’s support, they would not have been able to afford the post-partum homemeal delivery in Vancouver.For me [the home meal delivery] was a little expensive! The problem with newimmigrants is that over here, they cannot do the work that they previously did, so mysalary is not very high. Therefore, I feel that $3500 is a little expensive! Actually myparents gave me a sum of money, like a red envelope, money for zuo yue zi or forchildren. Nevertheless I still feel the cost is quite burdensome. (P13)The “One-Child” policy was attributed by some participants to receiving familyfinancial support. The women indicated that after financial concerns were eliminated bysupportive families, they could choose the services of zuo yue zi according to theirpreferences.For most Chinese people, when they have their first child, it is the parents whosupport them financially. For some… the parents will give them money and they willgo to post-partum centres. We are all the only child [in the family]; we never hadyounger siblings so we don’t know how to take care of children. If the family is well-off, [and] her parents do not want to worry about this or be burdened with this, theywill give you money to go to the post-partum centre or to hire someone. Therefore,even if both [parents] are international students with no income, even if it’s with awork permit, she will go to the post-partum centre, because she has other sources ofmoney to support her. (P1)50Lack of substantial family income and access to money from parents elsewhereeliminated the choice of post-partum centres to support practicing zuo yue zi in Vancouver.If my annual income is $100,000 Canadian or more, I would definitely go to the post-partum centre. There is hardly anyone with such income here so no one goes to post-partum centres …In China, you can hire one with $500 Canadian …If the two of usearn 100,000 Canadian annually in China, then I spend 3,000 Canadian dollars to hirea post-partum doula, I would not be worried. If it’s around one third of our combinedincome, I do not worry. If our financial situation is not good, I would not hire a post-partum doula. (P1)Because adhering to zuo yue zi was regarded as important, almost all participantsasserted that their family would try their best to accomplish the expectations of zuo yue zi inVancouver. One participant emphasized “zuo yue zi is [such] a major event... people will nottry to save money in this area” (P6).4.4 Struggles with Reality as Opposed to ExpectationsThe study participants indicated that their experiences of zuo yue zi were not typicallysmooth. All participants described encountering some challenges along the way. Althoughmost of the mothers had family members present to assist them, pre-ordered meal delivery,and/or hired part-time or full-time post-partum doulas, their physical conditions during zuoyue zi did not meet their expectations. Most of the mothers described their experiences asmore difficult than they expected because they felt more physically tired. They contrastedtheir experience in their new country with believing that they would have had more supportin their previous settings. Even those participants who were able to purchase resources inCanada felt that they would have had more options if they had not immigrated to Canada, and51their adherence to TCM would have been easier. They also trusted the resources more in theirprevious locations where postpartum doulas were regulated because in Canada that was notthe case. On the other hand, they also indicated they would have been under more pressure toconform in a location where all mothers were doing zuo yue zi.One participant ordered prepackaged TCM because she expected it would enhance theprocess of recuperation. Unfortunately, the standard prepackaged prescribed medicinal herbsdid not meet her needs; instead, she attributed taking them to developing constipation andhemorrhoids during zuo yue zi because they were not customized Chinese herbal medicine.I only did zuo yue zi for one month. I had planned to have six weeks but I could notcarry on. …The post-partum meals made my body really heated and I couldn’t takeit. …The food contained a lot of ginger which made me hard to have bowelmovements. I also suffered from the hemorrhoids. Therefore, as soon as it reached theone month, I stopped zuo yue zi. …the hemorrhoids are still there. I really don’t knowwhat to do about it. (P6)Some participants linked their exhaustion from labour and delivery to limited mobilityand needs to adjust their home settings in the first four to six weeks. The support available tothem was not adequate for their recovery during zuo yue zi.I didn’t think it would require so much energy and manpower to practice zuo yue zi. Ijust thought it would be sufficient to take care of the baby by myself and hiring apost-partum doula. I didn’t think I would not be able to go downstairs for meals. I hadto ask my husband to buy a table and place it upstairs for dining or else the bed wastoo low for eating. (P12)524.4.1 Relationships with others.As part of struggling with the reality of doing zuo yue zi in Canada the participantsdescribed challenges managing their relationships. Although none of the participants feltforced to practice zuo yue zi their relationships with post-partum doulas, professional healthcare providers, and other family members contributed challenges to their experiences of zuoyue zi.The participants described difficulties adjusting Chinese practice in a Western culturewhile encountering differences in expectations from person to person. Not only did theparticipants have varying expectations of acceptable practices but also their paid doulas andfamily members did not always share participants’ expectations about appropriate food andchild care.Mothers had to search for paid helpers that understood their customs and fit with theirexpectations. For example one mother stressed that the hiring of a doula was difficult if shedid things differently from her understanding of appropriate practices for zuo yue zi.From the first week to the fourth week, I hired a 24-hour post-partum doula but Ididn’t agree with her way of caring for the baby so I switched to another post-partumdoula from Guangdong. She was good at cooking, stewing soup and she loved babies.(P12)Because mothers were practicing zuo yue zi in a new country with less establishedregulations for registering postpartum doulas trust relationships between families and theirpost-partum doulas were challenging. One participant described a relationship with her post-partum doula that was not beneficial. She indicated that her experience of zuo yue zi wasruined by this individual’s personality and lack of professionalism. She felt a lack of harmonywith a doula is particularly difficult when mothers are feeling unwell during the postpartum53period.My problem was that the food that I was eating was totally opposite from my usualeating habit. During the zuo yue zi, my post-partum doula cooked fish and meat whichwere considered greasy food. I have heard that if you eat relatively greasy food, yourrelease of breast milk is poor from older people from Northern part ofChina …Because of the food I wasn’t supposed to eat, I still feel a bit weak, and havecold sweat if I walk a bit more at the present 6th week …We didn’t feel comfortable ofletting her look after our baby because he cried when he heard her voice. I didn’t thinkshe was professional …Not sure if it was because I didn’t not have a good zuo yue zior because of the cesarean section that caused my “qi” to be destroyed. I also neededto spend some time to restore the health of my uterine. My friends told me that it willtake half a year. (P7)One participant reported that her family was disappointed with her post-partum doulawho could not manage all her daily assigned duties. Her lack of efficiency gave the familythe sense that the doula was frantic and rushed.Because if you give too much work to one person, she may not be able to complete allthe tasks, this post-partum doula may feel overly exhausted at the end of the day.Perhaps a more professional and better post-partum doula may not be in such a franticrush or confusion. (P6)Another participant expressed that during her previous zuo yue zi, she felt depressed andcontemplated suicide and felt that she was beyond help and understanding. Her post-partumdoula was so focused on completing her defined list of services that she did not have time tolisten to the mother’s feelings of depression. Some participants suggested that post-partumdoulas could make you feel like you were nagging them for attention and your concerns were54not valid.[The post-partum doula] can only help you take care of the baby. But you still have tochat more with others, talk about positive things, contact more of the outside world,and watch TV or surf the Internet. If you try to talk to the post-partum doula, whenshe tells you she feels that you keep nagging her, your pressure will increase.” (P1)In another example, one participant shared that during each zuo yue zi mothers andfamilies need to adjust to what paid post-partum doulas are prepared to do rather thanexpecting them to follow family guidelines. By respecting post-partum professionals, it madeher experiences in the early post-partum period smoother. “What [the post-partum doula]cooked was totally different from the recipes I looked at. Because each post-partum doula hasher own set of operating procedures, it varies from doula to doula” (P5). Because the familytrusted their post-partum doula’s professionalism and adapted to what she advised this motherdescribed her post-partum experience as being enhanced by the positive relationship with herdoula.I think it’s very helpful if you could find a favorable post-partum doula …Don’t beanxious; don’t panic. It will be fine if you find a post-partum doula beforehand. Youreally need to have the professionals to come do things professionally. Post-partumdoulas will deal with matters more sensibly because they are experienced. (P5)All of the participants appreciated the municipal health care services such as post-partum home visits provided by the public health nurses because they offered good advice onbreastfeeding, newborn care and were available for further support according to each family’sneeds. Also, the visits did not require mothers to leave their homes so they could follow zuoyue zi. Mothers agreed that Canadian community health nurses were patient and professionalin terms of breastfeeding establishment and close observation of newborn growth.55The community nurses here visits about one hour each time. They would recommenda better place to breastfeed, which posture is better, and they would check if the babyis feeding correctly. She would help you like a post-partum doula. The second timethey will call first to ask if you need anything. If there is a need, she will come again.(P1)Many participants stated that they gradually accepted and understood how communityhealth nurses here made their assessments according to maternal and newborn needs, andbelieved in nurses’ professionalism and experiences throughout their interactions with nurses.At first I would feel that whatever I asked, [the nurse] would say that this is normal.Why is it like that? Later, I asked myself, she has seen countless babies, she musthave seen a lot of similar cases, and that the babies were all fine proves that mine willbe fine. (P5)Two mothers expressed that they trusted the community health nurse because of herconnection with Chinese culture. One participant felt comfortable having her nurse becausethe nurse was Asian from Hong-Kong. In addition to the enhanced comfort of interactingwith a community health nurse of Chinese descent, all mothers agreed that because thecommunity nurses in general in Vancouver have had more exposure to Chinese culture, theyare more open, accepting and less judgmental to different cultures.Now that they have had more contact with Asians, they have some understanding ofChinese post-partum practices. She will only say, “Pay attention to the ventilation andair circulation.” She will not force you or say that you must do something a certainway. She will just remind you that it should not be too hot inside the house so thebaby does not have hyperthermia. (P1)Only one participant described feeling pressured about refusing to take a shower in the56hospital due to the nurse’s lack of cultural awareness when she received post-partum care.[The nurse said]…"Why do you not take a shower?" I felt I was being judged andthought of as “How come you’re so dirty?” Not only was her facial expression clear,her tone of voice was quite obvious to make me feel very uncomfortable. (P8)Most of the participants’ obstetricians were Chinese. The mothers indicated that theyappreciated their doctors of Chinese descent because they had more understanding about zuoyue zi and tended to respect the principles of zuo yue zi. For example, a mother reported thather decision to stay at home for the first four to six weeks and have other family membersaccompany the baby for the first few regular newborn appointments was an understandableoccurrence for her Chinese physician.My husband and my mother-in-law went with the baby. The doctor even asked whythe mother didn’t go because he wants to do a check-up on the mother. My husbandreplied that I am in zuo yue zi. My family doctor is Chinese too, can speak Chinese, soit was understandable. (P5)In addition to participants’ relationships with hired post-partum doulas and health careprofessionals, the mothers indicated that interactions and relationships with family memberswere also crucial during zuo yue zi. A few participants agreed that the process of post-partumrecovery could be helped by family members, especially their partners. They felt that coupleswho tried to understand each other and were committed to their marriage, relationships, andwell-being would see lasting benefits from zuo yue zi.On one hand, the psychological level, the zuo yue zi period may be a test for acouple’s relationship. If during zuo yue zi, couples are able to work together to surviveand to take care of the baby, this may solidify the couple for the future. In the earlystage of becoming parents, if two people are truly able to understand each other, this57may be a help to their future, because the wife may not understand her husband’sexpression of love, but she can experience the process of re-shaping the family values.(P5)All of the mothers indicated that a challenge that new fathers encountered was, duringzuo yue zi, they were designated to purchase ingredients for cooking and other necessities.They felt it created a gap for fathers to engage with fatherhood because they were focused onproviding physically and financially for the family rather than on bonding with their children.In addition, mothers regarded elder family members as taking the role of experienced parentsand authorities for how to provide care during zuo yue zi. They noted that elders werereluctant to allow mothers and fathers to care for their newborns at such an early stagewithout receiving their input.Because both grandmothers are there, plus the help of the post-partum doula, onlyrecently did the two of us really have a chance to hold the baby and play withhim, …now the elders are willing to let you hold the baby …During zuo yue zi, thefather is usually left at the back; the role of the father during zuo yue zi is the shopper.So he would be slower in entering the role of the father in taking care of the baby.[The father] may watch the baby from afar and desire to hold him, but one reason [notto] is that the elders may not feel assured in the father’s capabilities and another is thatthe father himself might also be somewhat timid. This [bonding] may really require aprocess. (P5)Participants practicing zuo yue zi indicated that extra help from extended familymembers and paid post-partum doulas reduced their access to the baby which added to thetime necessary for them to adjust to their new roles. This was one struggle that was notnecessarily envisioned by participants when having the added support during zuo yue zi. One58mother stated, referring to her husband, “he was slower in entering [his role], but he still hasthis heart to help. If the elders were not there and I only had the post-partum meals, it wouldbe more perfect!” (P4).In terms of developing relationships with others, mothers indicated that they requiredtime for themselves (apart from newborns) to socialize and interact with other adults. Theybelieved that contact helped prevent feelings of depression and encouraged them to avoidstaying in bed or in isolation. All participants believed that isolating mothers to perform zuoyue zi could contribute to depression. They felt they needed to interact with the outside world.Furthermore, a few participants emphasized the importance of building relationships withothers to avoid feeling trapped with repeated chores such as feeding the baby and changingdiapers. They believed that being in a culture with access to people and technology, such asonline social media, contributed to a faster recovery in the post-partum period.It can get a bit boring because I feel like I’m doing the same thing every day. A friendof mine came to see the baby just last Sunday; she came over to our house to eat andchat. I felt I wasn’t in a bad mood that day at all, but the visit made things better! Ifeel that there is some variation to my life that day! (P13)You still have to chat more with others, talk about positive things, contact more of theoutside world, and watch TV or surf the Internet… After about three months in China,you can feed baby solid food after 100 days, you can have one to two hours of time toyourself and you can go out to chat with people, meet up with friends, so I felt better.(P1)One participant compared her previous experience of zuo yue zi to her novel experiencein Canada and felt that she had reduced feelings of depression as she gained familiarity withthis country: “I’m much more familiar with the environment this time, so my post-partum59depression was better this time” (P10).Another mother also compared her previous and current zuo yue zi experiences. Shedescribed differences in friends’ and family members’ support; she suggested higher levels ofsupport could help prevent mothers from feeling depressed not only by providing physicalcare but by distracting and diverting mothers’ attention from common stresses after having ababy. This mother was caring for her newborn and first child but she felt this improved herexperience of zuo yue zi.My mindset is not the same [as with my previous zuo yue zi]. Plus, I have my [older]daughter to take care of; she divides my attention and she would talk to me every day.And you can go out every day here; there are not so many restrictions. I watch TVevery day and I can use my phone to surf the Internet. Also, it is very good that thereare several classmates abroad who have babies around the same time as me so we canchat with one another so it’s been a lot better. (P1)4.4.2 Disagreement with elder family members.All participants described conflicts with their elder family members around theirexpectations of zuo yue zi and implementation of newborn care. The mothers indicated thattheir conflicts were unforeseen, challenging, and interrupted their experiences of zuo yue zi.I told my mom, “do not give the baby water to drink”. Although my mother alsoagreed…but then at the mothers’ party she would ask other moms, “do you give waterto your baby?” The inherent concepts in people are very very persistent…if shesuspected me, she would not say it directly, but she would go and ask someone else.(P.8)The participants indicated that being with elder family members involved additional60patience and understanding. The women wanted time to learn to understand otherperspectives because: “despite having lived with my in-laws for ten years, neither of us everneeded care from one another so desperately. There are still some different habits in dailyliving” (P11).Because their mothers and mother-in-law had differences in interpretation of zuo yue zi,a few participants felt anxious about refusing to practice what their mothers expected them tofollow. The women described struggling with satisfying their own wishes in addition to theirelder family members’ expectations.Overall, I'm still satisfied with this zuo yue zi but my mother is not very satisfied withit, because she feels that I toiled more compared to what she had expected, like onlysleeping [and nothing else] aside from breast-feeding. Because I took care of my babymyself, my mom thinks that it’s more difficult for me. My case was unlike otherpeople who pump their milk and then let the family or the post-partum doula feed thebaby; my mother would probably be a little more satisfied if this was the case. She[was] distressed and said, "Oh! You didn’t zuo yue zi well; you didn’t rest well” (P5).Another participant shared her feelings of being pressured by elders to follow hermother’s expectations of zuo yue zi or ending up with feeling unwell.When it comes to the psychological aspect, I would say it is the pressure from mymother’s side. The older generation will keep nagging, saying, “You must do zuo yuezi well. Our circumstances were not good back then.” My mom is telling me this assomeone who has experienced this so if I do not do according to her words, then Iwould feel bad. So you are afraid of doing zuo yue zi poorly and of becoming likewhat she described. (P4)By virtue of doing zuo yue zi participants relied on elder family members to provide61support and care which created difficulties when the women and elders were in conflictduring zuo yue zi. Participants believed some mothers or mothers-in-law were “quite stronglyopinionated… [and] adhered to the parenting concepts in China such as feeding the babywater…” (P10). Such adherence to Chinese concepts made mothers’ experiences moredifficult.For small families, usually there are two people. When influenced by traditional ideasof zuo yue zi, her mother or her mother-in-law will come to help. You’re prone to getinto small conflicts with the elderly; under awful conditions it’s easy to seriouslyupset your emotions. This is basically a major reason that affects the mood, especiallywhen the concepts of nursing the baby differ between the two generations, there areprone to be conflicts. (P8)One mother explained that her next zuo yue zi would involve requesting her parents stayat home because, “the grandparents’ love and care sometimes is a hindrance, it would causemore trouble”. She provided an example of her friend who hired a post-partum doula in aforeign country during zuo yue zi; “everything went very smoothly!” (P5).4.5 Modifications of ExpectationsSeveral participants described making modifications from usual principles of zuo yue zibecause of the different weather and living conditions, as well as personal preferences andfamily needs. They described contributing factors to them feeling less pressured during theirfirst four to six weeks post-partum in their adopted country. Firstly, mothers felt less culturalpressures because they were away from their home country where the practice was commonbut in Vancouver where it was not: “Because we are not in China, we will not zuo yue zi onehundred percent according to the zuo yue zi methods in China. It’s fine as long as I feel okay62about it in my heart” (P4).Secondly, some participants described feeling more comfortable with their mothershelping them during zuo yue zi, as opposed to their mothers-in-laws. They felt their motherscould make more allowances for their temperament. The women indicated that, with mothers-in-law, they could not easily modify the way they chose to practice zuo yue zi becausecommunication and negotiation with their in-laws was more difficult.I am the type of person that if I do not eat something, I just do not eat it no matterwhat, and my mom understands my temper. If it were the post-partum doula or mymother-in-law they do not understand me so well. I might feel pressured. For instance,some mother-in-law would say you need to eat pork hocks to help promote lactation.But if you are a person like me who does not eat pig hocks, then there may be somepressure there! (P8).There were factors that supported zuo yue zi in terms of modification by making zuo yuezi last longer. Several participants indicated if their financial support allowed: “it’s better tohave zuo yue zi for at least four weeks. However, if the financial situation is good, doing it fortwo months would be the best” (P2). In addition to their preference of extending the practiceof zuo yue zi, they would have asked their family members to extend their stays inVancouver.I didn’t think it would require so much energy and man power to zuo yue zi. I justthought it would be sufficient to take care of the baby by myself and to hire a post-partum doula. …I would be prepared with more support in terms of man power. If myfamily is around, I would not let them leave in such a short time. Instead, I would askmy mother-in-law to stay for at least three months. I will not tell her to go after onlyone month of zuo yue zi. (P12)63Two participants actually continued to have part-time post-partum doulas to help duringthe daytime after the month of zuo yue zi to reduce their feelings of fatigue, particularly forhusbands.Since the post-partum doula only comes during the day … [my husband] has to get upat six or seven in the morning and when he gets home from work around five or six inthe evening, he has to help me take care of the baby so he is already quite exhausted.If there is no one to help us, it will truly be tiring and not good for our health. (P12)A few participants continued healthier eating habits after zuo yue zi; they ate lighter, notso greasy foods. “Especially since eating lighter recently, my body actually feels verycomfortable. But rather, after zuo yue zi, when I returned to eating more salty foods, I actuallyfelt unaccustomed to it!” (P8). One participant continued to cook soup daily after the 30-daypost-partum home meal delivery ended. She believed cooking and eating the homemade soupconferred benefits for her baby. “The nutrients in my milk are adequate [for the baby]because the soup is cooked really well. So I still continue to stew a pot of soup each daybecause I am still feeding my baby all breast milk” (P4).4.5.1 Accommodating climate and living conditions.The women commented on differences in climate and heating methods between theirhome countries and Canada. A warmer climate and central heating required mothers tomake adjustments for themselves and children. During zuo yue zi the participants expressedtheir appreciation for the moderate indoor temperatures.Of course I have to adjust! Because I live in an apartment so I have an electric heater;I can have all the temperatures adjusted to 25 degrees. The temperature of the house64has been 24 or 25 degrees, very warm, so I only wear a single layer of clothes athome. Also, my mother told me that when I was little, I would often cry at night; shedid not think much of it then but later she realized it may be that it was too cold in thenorth. So why do babies like the mother to hold them to sleep? It’s because it was toocold. Now, it’s not the same. Our baby only wears a sleeper, the single-layer kind.When he goes to sleep, we give him a thin layer of cloth as a cover. He would sweateven with that while sleeping so I turn the heater down a bit. So these are thedifferences. It’s much more convenient nowadays so those problems do not existanymore. (P5)Some participants commented that they did not need to dress as warmly in their newcountry compared with wearing sweaters and knitted hats indoors in Northern China duringzuo yue zi.I didn’t wear socks, and my heels were not sore as long as you didn’t catch thecold. …it would be better to have zuo yue zi in Vancouver than in Northern part ofChina because it’s cold during this season in China. The body should be no problembecause the weather is nice here. (P7)4.5.2 Modifications to original plans.The participants indicated that medical practices in Vancouver were not alwaysfavorable to their intention to follow traditional Chinese post-partum practices. Almost all theparticipants felt that they were pressured to modify their practice of zuo yue zi due toscheduled routine check-ups for newborns. As a result some mothers did not feel respected65concerning their beliefs of zuo yue zi. Rather than following the principles of zuo yue ziwhere mothers would stay indoors for a full month to restore their energy as much aspossible, the participants described taking newborns for doctors’ appointments in Vancouver;“I went with the baby [to see the doctor]! Normally speaking, you don’t go out for a month,but there’s no way for that here” (P9).Mothers indicated that they appreciated their opportunities to stay at home when themidwives/nurses could provide care in the clients’ homes.My midwife will come to my house, so I do not need to go out. In the ten days aftergiving birth, I did not need to take the baby to the post-partum clinic. I know thatsome new mothers have to take the baby to see a pediatrician after five days. Mymidwife… felt that I was relatively weak due to having a Caesarean, so in the tendays after giving birth, she came to my home three times, that’s why I did not need togo out to see the pediatrician on my own. (P8)One participant’s practice of zuo yue zi had to be postponed because of her newborn’srequired admission to emergency. The mother recalled that she was constantly in an anxiousstate about her baby’s condition for the first week of zuo yue zi; “therefore, relativelyspeaking, I [actually] started zuo yue zi from the third week” (P5). Thus, despite the womenregarding zuo yue zi as an important practice, unexpected occurrences affected their abilitiesto start or continue the practice.A few participants also described having to leave home to see their doctors for follow-upand blood tests as well as for infections in the perineum or cesarean incisions. When motherswere having difficulty with recovery, they looked to TCM and followed their prescriptions.One mother applied specific TCM beliefs and modified her original plan of zuo yue zi inresponse to her feeling of weakness and her low mood.66I felt very weak and it was the third week already …I was a little afraid, so I asked myTCM friend to take a look …because my sleep and rest were not good, I felt kind ofdepressed every day… I felt very unhappy every day and then felt fatigued every day.Because I have always trusted TCM, I asked my doctor friends in China then theywanted to look at the tongue coating, so I take pictures to show them. He said, “Yourtongue coating is really bad,” he said “then you must quickly nurse your health.” Ifound my TCM friend and sure enough he said that I had too much accumulated in thebody, we must discharge it. We cut out the Chinese herbs from my diet and my TCMfriend helped me do acupuncture …there was a great improvement. (P5)I think I should find a way that is more suitable for my body …They use thisTaiwanese-style TCM package for all kinds of physique …I drank less and less of thesoups later on because I found that I had excessive internal heat when I drank them,and I did not want to make my body more heated. I did not want to be over-nourished,so I drank less towards the end. (P6)A few participants described modifying their expectations based on the limitations oftheir doulas. The post-partum services for Chinese immigrant mothers to access in GreaterVancouver are not supervised or overseen by authorized organizations, which caused thewomen to question their quality and doulas’ liability. The women felt that the lack ofregulation led to potentially corrupt services being offered for financial gain of the providerwhich were not truly supportive of these mothers and their health in the post-partum period.674.5.3 Evaluating principles of zuo yue zi in modifications.Some mothers indicated they discarded traditional beliefs because they evaluated themas being irrelevant. As a result, in their novel circumstances, they attributed any mood andphysical changes to recovering from birth rather than not doing zuo yue zi.In the first few months, there are a lot of changes; your mood and spirits will beaffected. So they think that having headaches and back pains is due to not havingdone zuo yue zi well. This is mainly related to the psychological impact; the problemis their traditional concepts and beliefs. Maybe she caught a cold in the wind one timethen she thinks it’s because zuo yue zi was not done well. (P1)Some participants clearly stated that not following zuo yue zi did not lead to illnesses.I think the importance of this month to me is not as important as to my mother and mygrandmother, so I did not especially focus on finding information… because I do notcare that much about this matter of zuo yue zi. (P13)The study participants described modifying zuo yue zi by following some of the earlytenets but then doing what was comfortable for them beyond the first two weeks. They usedevidence about physiological effects of bedrest from readings to challenge the beliefs andvalues of zuo yue zi that they did not want to followI’ve read a report before about lying in bed and not getting out of bed… [which] willcause your waist and legs to be sore. If you lie in bed and not get out of it… then yourwaist and legs deteriorate from disuse. No exercise at all would cause calcium lossbecause you don’t use it. (P1)One participant not only drew from science for her reasons to resist part of zuo yue zi butalso maintained her personal preference for her food ingredients.Zuo yue zi in Taiwan has become a zuo yue zi industry. They will tell me why I have68to eat certain foods! [Making] it sound more scientific. For example, eating sesame oilchicken is for such and such reason; eating red bean soup is for discharging dampness[But] because I personally do not eat intestines, those sesame oil pork liver andsesame oil pork kidney, those more mainstream Taiwan post-partum meals, I did noteat… because I do not eat pork liver and kidney these kinds of intestine things myself,so I did not particularly eat them just for zuo yue zi (P8).Although traditional Chinese practice avoids taking a shower for thirty days to preventthe cold from entering the body, most participants shortened that period and/or reduced theirfrequency of showers to once a week.My post-partum doula said…nowadays most of the girls born in the 80’s can’t persistfor so long. She said among all the families she has done zuo yue zi with, only a totalof three mothers [did] not take a bath or washing the hair for an entire month. (P5)4.5.4 Considerations for family members.Some participants’ mothers came to Canada specifically to help for the period beforeand during zuo yue zi. The women were aware that their mothers’ involvement required a lotof work and could be tiring. Thus, the women described the need to entertain their motherswhile they were in Canada to demonstrate their appreciation. For example, some participantsindicated they accompanied their mothers to go out to shopping malls; sometimes feeling theneed to do this before the end of their zuo yue zi.In the third week, I accompanied my mother to go out, that is, going out once ortwice …In fact, the reason I went out was because my mother came to stay with me asI do zuo yue zi. It’s her first time to come here, and her stay was only a short time,so…my mom did not really go out and then she has to return… I asked my mom to go69out together. I …convinced my mother to go out and walk around. (P4)One participant said that she did not rest as much as her mother requested because shewanted to spare her mother from too much effort. She stated: “I don’t want my mother tobecome overly exhausted” (P8). This particular participant modified her practice of zuo yue zifor fear that her mother would be overwhelmed by housework.When having their second babies the mothers practicing zuo yue zi indicated that theyhad to modify some principles of zuo yue zi. One participant described needing to take care ofher first child so that going out was inevitable.In fact, I hardly followed the regimes of zuo yue zi. This year my older daughter hasto go to kindergarten. Starting from about the tenth day after I gave birth to the secondbaby, I took my daughter to school every day. I waited for one hour and brought herhome after classes finished. I had to go out every day and touch the cold air. It isconsidered that I had no zuo yue zi. (P1)4.5.5 The influences of previous experiences.After adjusting and modifying their current practice some mothers often reflected ontheir previous experiences of zuo yue zi. They used their past experiences as a basis for howthey conducted zuo yue zi their next time. They were aware that they could not manage twochildren very easily and follow the practices of zuo yue zi so they hired help. One participantsaid:I hired a part-time post-partum doula after I gave birth to the second baby. The post-partum doula came to my house four hours a day. She helped me do householdchores, prepare food for my family and myself, and took care of my first son …I waslooking after my first child by myself, and it was harder. I’m not able to take care of70two children at the same time, so I hired a post-partum doula this time. (P2)One experienced mother shared her intention to exclusively breastfeed with her first childduring zuo yue zi. She described feeling depressed during the postpartum period followingher first birth because she was not able to produce enough milk. She indicated it was differentwith this child because she was willing to use a mix of breastfeeding and formula so shecould persevere and she did not feel depressed: “because I had to take care of the first childand I was busy and exhausted, I chose mix feeding for the second baby” (P1). She wassatisfied with her decision.4.6 Chapter SummaryIn this chapter, I presented the findings of my study by describing the characteristics ofmy sample. I presented the major theme of my study: Chinese immigrant women’s novelencounters with zuo yue zi. The subthemes I presented included women’s expectations of zuoyue zi in their new circumstances, their struggles with their new reality as opposed to theirexpectations, and their modifications of expectations in response to facilitators andchallenges. In the next chapter, I will discuss my study findings and provide suggestions fornursing implications as they relate to clinical practice, education and research.71Chapter 5: Findings Summary, Discussion, Implications for Nursing and ConclusionIn this chapter I present a brief summary of my study findings and a discussion of thefindings, and the strengths and limitations of my study. Based on the study findings, I providesuggestions and recommendations for clinical nursing practice, education and research.5.1 Summary of the FindingsThirteen immigrant Chinese mothers participated in this qualitative study. Their initialinterviews were commenced during the period of their first 4 to 6 weeks post-partum. Mydata collection and analysis began in October 2014 and was completed in June 2015. In thisstudy, the core theme of novel encounters with zuo yue zi was represented by four subthemeswith supporting categories. These subthemes included: expectations of zuo yue zi, struggleswith realities as opposed to new Chinese immigrant women’s visions of zuo yue zi,modifications of expectations, and the challenges encountered during zuo yue zi in GreaterVancouver.The beliefs of zuo yue zi are deeply implanted in Chinese culture. Most of the womendescribed continuously practicing the customs of zuo yue zi, albeit in novel ways, in theirnewly adopted homeland. The importance of recuperation during early post-partum isemphasized during zuo yue zi according to the principles of TCM. Equally important ishaving the accessibility of resources to practice these customs. The importance of rest duringthis period and the need to have support at home, combined with the understanding that thepractice of zuo yue zi can be complex all supported the development of the core theme of thisstudy: Chinese immigrant Women’s novel encounters with early post-partum experiences ofzuo yue zi.725.2 Discussion of FindingsThe core theme of Chinese immigrant women’s novel encounters with zuo yue zi adds tothe limited literature describing Chinese immigrant women’s experiences in adoptedcountries. It is the first study to describe their experiences in Canada. No Canadian studieshave captured the types of post-partum services available to Chinese immigrants who wish topractice zuo yue zi.A number of qualitative studies have explored the integrated set of traditional post-partum practices for Chinese mothers not only in China and Taiwan but also in foreigncountries, such as Australia, Scotland and the United States (Cheung, 1997; Chu, 2007; Kit,Janet & Jegasothy, 1997). For example, Cheung (1997) refers to facilitating the physicalrecovery of mothers to prevent chronic illness and also to strengthen their intra-familyrelationships. She has some detail about strengthening the intra-family ties, especiallybetween the woman and their own mothers or mothers-in-law and short and long-term effectson the psychological well-being of Chinese women postnatally and in their future life. Cheng& Pickler (2009) refer to how culturally relevant care may help new mothers manage theirdepressive symptoms and promote post-partum maternal health. Chu (2005) identifiesreasons for increased risk of post-partum stress because of unmet cultural post-partum needsin the adopted country Australia. Holroyd et al. (2011) point out the younger Chinesemothers, although encountering enforcement of traditional practices by family members,found highly individualized ways of negotiating traditional practices. However, none of thesestudies have documented how Chinese immigrant women approach traditional post-partumcare, the obstacles they encountered, and modifications they were forced to make in theirnewly adopted homelands. The important contributions of my study findings are aboutconflicts between elder family members and women, the need for women to plan ahead to73effectively manage zuo yue zi, the challenges of managing financially to cover assistance,Chinese fathers being burdened with shopping and unable to engage fully with their neonates,and the difficulties with the lack of regulation of services the mothers needed to access.Zuo yue zi, which is influenced by the principles of TCM, remains popular among theChinese community. Indeed, regardless of the geographic or socioeconomic differences,many Chinese women still choose to practice traditional rituals of zuo yue zi during theirearly post-partum experiences. Most of the mothers in this study felt they were compelled tofollow certain traditional post-partum rituals. This study finding is consistent with those ofother studies (Chen, 2011; Strand et al., 2007) where some concepts of zuo yue zi, such asbeing weak after giving birth, avoiding cold temperatures and confinement indoors during thefirst few weeks post-partum, also strongly influence women’s practice of their post-partumcare.Participants in my study were pleased that most of the Chinese herbal medicine andingredients required for post-partum meals were accessible for purchase locally inVancouver. This enabled them to meet their expectations and practice zuo yue zi. However,the availability of Chinese herbal medicine and ingredients required during sitting in themonth are not documented in any studies of Chinese immigrant women’s zuo yue zi in otherforeign countries.From my study results, participants’ experiences of zuo yue zi were influenced byphysiological experiences, relationships with others, adaptations to the changed relationshipwith spouse, confidence in newborn care and connections with the outside world. A Fewresearch studies focused on relationships between mothers and/or mothers-in-law duringsitting in the month (Chen, 2011; Holroyd, Lopez & Chan, 2011; Strand et al., 2007).Several mothers in the study described challenges to their relationships with their74spouses during zuo yue zi. My study findings reflected the understanding that the relationshipbetween wives and husbands during zuo yue zi could put more strain on their marriages dueto lack of direct help in their newly adopted homeland. This challenge of marriage was alsohighlighted and addressed in Chen’s (2011) research study about sitting the month in Taiwan.Her findings indicated women’s autonomy and authority of obtaining their own way of zuoyue zi did not depend on their education, employment and income. Instead, the relationshipswith their husbands and mothers-in-law were the most important factors that influenced theirdecision making. Therefore, “sitting in the month” is the first important circumstance thatyoung couples encounter after the marriage. However, my study adds information aboutpositive impact toward the relationships between spouses during zuo yue zi. A fewparticipants in my study indicated that zuo yue zi strengthened their relationships byconsidering each other’s needs, making decisions together, and overcoming obstacles toaccomplish the wives’ expectations of zuo yue zi during the period of “sitting in the month”.Most of the participants in this study described an experience of less cultural pressureduring zuo yue zi because of the absence of mothers-in-law in their newly adopted homeland,e.g., eating certain foods or ingredients recommended by recipe books for zuo yue zi. Thisstudy result adds to Holroyd et al.’s (2011) report that younger women decided to draw onpost-partum knowledge from their mothers as opposed to their mother-in-law. Their studyalso indicates “a shift from the past, where the kinship obligations of daughters drew on aConfucian-informed mother-in-law relationship” (p.51) in this modern era.As evidenced in my study findings, participants emphasized that their preparation forzuo yue zi was influenced by family members, particularly their mothers, in-laws, andgrandmothers, as well as through their friends and on-line information.The concepts of 'sitting the month' have been fundamental to the Chinese culture, and75these expectant mothers received further reinforcement about the beliefs of zuo yue zi duringtheir perinatal period by their family members, friends and on-line information. Theparticipants prepared for zuo yue zi by requesting their mothers to come to Vancouver fromChina to share house chores, help with cooking, and provide newborn care. One motherchose to take formal post-partum doula training prior to immigrating to Canada. Almost allthe participants had to access the internet for support in terms of zuo yue zi practice giventheir newly adopted homeland and the lack of typical resources they would have had in theircountries of origin. This finding highlights the importance about using the internet to connectwith other mothers and to do research about effects of some of the practices.My finding is consistent with other studies that reported elders, especially mothers-inlaw, in the family dynamics, possess the primary authority to decide for their daughters ordaughters-in-law the intensity and adherence to which they practice zuo yue zi (Chen, 2011;Holroyd, Lopez & Chan, 2011; Strand et al., 2007).Several mothers in the study described challenges to their relationships with theirspouses during zuo yue zi. My study findings reflected the understanding that the relationshipbetween wives and husbands during zuo yue zi could put more strain on their marriages dueto lack of direct help in their newly adopted homeland. This challenge of marriage was alsohighlighted and addressed in Chen’s (2011) research study about sitting the month in Taiwan.Her findings indicated women’s autonomy and authority of obtaining their own way of zuoyue zi did not depend on their education, employment and income. Instead, the relationshipswith their husbands and mothers-in-law were the most important factors that influenced theirdecision making. Therefore, “sitting in the month” is the first important circumstance thatyoung couples encounter after the marriage. However, my study adds information aboutpositive impacts toward the relationships between spouses during zuo yue zi. A few76participants in my study indicated that zuo yue zi strengthened their relationships byconsidering each other’s needs, making decisions together, and overcoming obstacles toaccomplish the wives’ expectations of zuo yue zi during the period of “sitting in the month”.Most of the participants in this study described an experience of less cultural pressureduring zuo yue zi because of the absence of mothers-in-law in their newly adopted homeland,e.g., eating certain foods or ingredients recommended by recipe books for zuo yue zi. Thisstudy result adds to Holroyd et al.’s (2011) report that younger women decided to draw onpost-partum knowledge from their mothers as opposed to their mother-in-law. Their studyalso indicates “a shift from the past, where the kinship obligations of daughters drew on aConfucian-informed mother-in-law relationship” (p.51) in this modern era.Some participants mentioned their dilemmas during early post-partum of not meetingtheir mothers’ expectations of getting enough rest or appropriate care for their newbornsduring zuo yue zi and experiencing conflicts between paid doulas and their mothers. My studyresults were similar to those of Grigoriadis et al. (2009) and Strand et al. (2007) about effectsof lack of positive support from mothers-in-law or a poor relationship with mothers, in termsof Chinese mothers resisting zuo yue zi, with the beneficial effects being depleted.Chinese immigrant mothers in this study not only experienced some unforeseensituations with their family members who interrupted their experiences of zuo yue zi, but alsosuffered from unfulfilled expectations of zuo yue zi because of their disappointment with theirpaid post-partum services. Although the participants were aware that postpartum doulas werenot regulated or trained in Canada they were unprepared for postpartum doulas’ low levels ofcompetence and accountability. My results contribute to the literature because no otherstudies have examined women’s expectations about available care in their adopted countriesand their reactions to sub-optimal care.77In order to better assist Chinese immigrant mothers’ ability to practice their beliefs oftraditional post-partum care in their newly adopted homeland, some participants arrangedpaid assistance in addition to the help provided by their family members during zuo yue zi.Most of the mothers in the study took verbal referrals about the available services fromfriends because hiring outside helpers for post-partum services was difficult given noauthorized regulatory bodies in Canada. These findings illustrated structural featuresaffecting new Chinese immigrant women’s expectations of zuo yue zi in Canada. Theseparticipants’ negative experiences and concerns have not been reported in any other studies.Compared to other immigrant groups, the participants in my study had access to many moreresources from family members here and overseas. The women in my study describedfinancial aid from extended family members and direct support.The participants in my study indicated that they designated their husbands to purchaseingredients for cooking and other necessities during zuo yue zi in addition to their daily workactivities. The men made daily trips for specific supplies, and fresh medicines and foodsduring zuo yue zi. The women indicated that their partners’ response to the increasedworkload impressed them because they received so much support from their spouses; thatsupport reinforced their confidence in their marriages and relationships. Unfortunately, theparticipants also described a delay in their husbands’ transition into fatherhood, as a result ofextra demands and the presence of elders or post-partum assistants. To my knowledge, thisfinding has not been reported in any other studies.Experienced mothers in my study juggled the complexity of caring for their firstchildren by adjusting and adapting their expectations of zuo yue zi. No other studies werelocated that described the modifications made by multiparous women to zuo yue zi. Myfindings also indicated that women felt weaker when mobilizing again and feeling depressed78is an unintended consequence of doing the month that women feel more isolated in thecontext of adherence of certain traditional post-partum practices and thus experience moredepression. Similarly to the findings in my study, Liu and her colleagues (2014) argue thattraditional practices such as activity restriction during zuo yue zi has negative effects onwomen’s aerobic endurance and increases their postpartum depression. My findings also addto Holroyd and her team’s (2011) research result as they were examining the postnatalpractices of two generations of Chinese women. Their findings also indicated that youngChinese women felt pressured to adhere to certain practices from family expectations ratherthan their personal preferences (Holroyd, Lopez & Chan, 2011).Almost all the participants in this study indicated the importance of connecting to theoutside world which enhanced their experiences of zuo yue zi. Mothers accessed the internetand social network such as “Wechat”. The participants in my study felt strongly supportedand helped by the shared experiences of the mothers in the Wechat groups. Some participantsfound so much support through the internet that they argued it could not have been replacedby visits from relatives and friends or return to country of origin. This is the first study toreport Chinese women’s efforts to connect on the internet with other mothers having similarexperiences during zuo yue zi. The findings of my study add to claims that social networkingenhances the feelings of connection to the world outside new mothers’ homes and mayimprove new mothers’ well-being (McDaniel, Coyne & Holmes, 2012). Hall and Irvine(2008) explored mothers using E-communication among mothers of infants and toddlers in acommunity cohort in British Columbia. Their findings indicated that mothers exchangedstrategies, provided knowledge and information, shared mothering experiences, facilitatedlearning and expressed feelings by using the electronic communication to build a localcommunity. Their research study also suggested that the cohort-based electronic79communication is particularly important for parents when travel is restricted and access toprofessional support is limited.Specific modifications of expectations to zuo yue zi were demonstrated by participantsthroughout the study. Participants attributed some modifications to the accommodatingclimate and living conditions in Vancouver, for example in-home heating systems. Forexample, they felt comfortable shopping in shopping centers before they completed theirthirty days of zuo yue zi. Some participants indicated that because their mothers wereprepared to accept modifications to zuo yue zi, they washed their hair and took showers muchearlier than principles recommended through the TCM. This finding is also consistent withthe research results illustrated by Strand and his team (2007) and Holroyd et al. (2011) aboutchanges in forced agreement to traditional customs, with individual variation. These studyfindings add depth of understanding to specifically explain the Chinese immigrant woman’sexperience of zuo yue zi in the Greater Vancouver district of B.C.5.3 Strengths of the StudyThis study is the first of its kind, a qualitative study undertaken in Canada that focuseson new immigrant Chinese women. Individuals of Chinese ethnicity represent the largestvisible minority group in British Columbia. I used Mandarin to advertise this study,capitalized on my working relationships with Chinese obstetricians, and conducted interviewsin Mandarin which likely gave me unprecedented access to Chinese women practicing zuoyue zi. Furthermore, my Chinese background and use of Mandarin enhanced recruitment,trust and rapport with participants which permitted detection of subtle nuances in women’sexperiences.The research design I used developed rich information to contribute to the body of80literature regarding Chinese new immigrant women’s experiences of recuperation duringtheir post-partum period with the influence of traditional Chinese post-partum practice.5.4 Limitations of the StudyThere were some study limitations. First, important information may have been lostduring the translation of interviews from Mandarin to English. Words used by the participantsto describe their experiences often did not have an English equivalent. As indicated by otherauthors when interviews are translated into English, “the terminology and subtitles ofdifferent Chinese languages and dialects are very difficult for an English speaker tocontextualize” (Cheung, 1997, p.58). For example, one participant in my study described herfeeling by using two Chinese words: Yu Jie which means feeling of some unhappiness, somedegree of depression, and some feeling of being not able to move forward both emotionallyand physically. In addition, there were probably some linguistic differences between thetranslator and the participants. As Majumdar, Keystone and Cuttress (1999) indicated,different socio-economic and educational status can affect how the translator interprets andtranslates the information even where there is a shared language and/or shared culturalbackground. The researcher’s use of the Mandarin language, although the official language inmainland China and Taiwan, could have created differences in the use of the Mandarinlanguage between Chinese people from mainland China and Taiwan which could createchallenges around translation and interpretation.Another limitation was the subtle differences in the beliefs and lifestyles of Chinesepeople from different geographical areas. Mainland China, Hong Kong and Taiwan are threeareas that have had different historical influences through civil wars and politics; culturaldifferences are very real and should be acknowledged and respected by the researcher. The81small sample size required for a qualitative descriptive study created challenges in describingany nuances arising from countries of origin in women’s post-partum practices.Unfortunately, there were no participants from Hong Kong and only one participantfrom Taiwan who met the inclusion criteria. Because immigrants from Hong Kong andTaiwan have been established in Canada longer than immigrants from Mainland China, theywould be less likely to follow Chinese traditional post-partum practices. Nonetheless, someof the women from Mainland China described adopting Taiwanese practices because it wassimpler for them to do so in their current setting. None of the participants chose post-partumcentres to practice their zuo yue zi, which could have affected the findings.Another limitation was the potential to access a small group of homogeneous friends,through snowball sampling. My background as a maternity nurse and childbirth educatorcould have influenced the findings through nonverbal facial reactions or body language.5.5 Implications for NursingThe implications for nursing including nursing practice, nursing education and nursingresearch derived from this research study will be presented in the following sections.5.5.1 Implications for nursing practice.My study findings provided valuable insights for nursing practice. In order to promotequality post-partum nursing care for new Chinese immigrant women, nursing care in terms ofrespecting Chinese immigrant women’s expectations for the post-partum period should bedeveloped during the prenatal period. Nurses can initiate discussions with Chinese immigrantwomen about the practices they would prefer during their postnatal periods. Nurses can beinformed by the study findings to develop an assessment tool to distinguish each new82immigrant woman’s needs to provide suitable professional care. Group discussions aboutpreparation for post-partum care, specifically zuo yue zi, for new Chinese immigrant womencan be facilitated by nurses on a regular basis so that the resources available for health care inthe community and the Canadian health care system can be introduced. Nurses could alsolead group forums to gather and reflect concerns and questions regarding post-partumservices in recommending to provincial governments the regulation of postpartum doulas.Therefore, nurses could bridge and facilitate communications between new immigrantmothers and regulatory bodies. Because new Chinese immigrants are likely unaware ofavailable prenatal education provided by professional registered nurses, nurses could institutecommunication strategies specifically targeted with new Chinese immigrants in mind.Because expectant parents who are practicing zuo yue zi will likely engage with elder familymembers, nurses could provide evidence-informed information in an appropriate format to beshared with elder family members. The information could include the important support rolethat family members play as well as implications of differences in views about adequatefeeding and newborn care. As Svensson, Barclay and Cooke (2006) suggested expectant andnew parents need opportunities to discuss and learn from peers and professionals.Because of the limited language skills and access to resources, nurses could createwritten documents in Mandarin which include advertisements, posters, pamphlets orbrochures. They could approach physicians who see Chinese immigrant women or groupssuch as SUCCESS to locate the information.Because study participants explained regarding their preferences for professionals who areChinese or of Chinese descent practicing nurses could approach agencies to offer prenatalclasses taught by Chinese nurses.Most of the participants expressed concerns about the lack of respect from health care83providers about their choices to follow zuo yue zi. They felt forced to leave their homes fortheir newborns’ regular check- ups. Having health care providers in the form of midwives orpublic health nurses who would visit women and their newborns on several occasions toassess their wellbeing would permit women to regard their traditional practices as beingrespected. Nurses could develop an outreach home visit program for new immigrant motherswho choose to follow Chinese traditional post-partum customs. Nurses could also offerweekly postnatal drop-in parent-infant discussion groups in Mandarin to assist the newparents to learn from professionals about self and newborn care and to extend their socialnetworks.For new immigrant Chinese women, current home visit practices by community healthnurses could be modified. Rather than one home visit during the first five days after dischargefrom the hospital, the same nurse could arrange visits every seven to ten days until the periodof zuo yue zi was complete. The implications for nursing are consistent with Tarkka,Paunonen, and Laippala’s (1999) recommendation that mothers expect nurses to providethem advice on child’s growth and development. The affirmation and encouragement fromthe public health nurses are crucial for new mothers as they learn to recognize and respond tothe needs of their children through development of coping skills and confidence.Providing the ‘Nurse Line’ with a direct dedicated number for a nurse who spoke Mandarincould provide assistance for new Chinese immigrant mothers who lack access to resourcesand have limited communication skills.5.5.2 Implications for nursing education.My study provided clear direction for not only nursing education but alsointerprofessional development to provide skills to meet new Chinese immigrant mothers’84needs because nurses alone in the interdisciplinary team would not be able to provideadequate perinatal care with cultural sensitivity.In addition to learning about providing cultural care, it also requires interprofessionalperinatal services team members including hospital, public health, clinic professionals tolearn about the importance of social support to avoid exposing immigrant women tosignificant additional stress (Cheng & Pickler, 2009; Hyman & Dussault, 2000). As stated bysome authors, “globalization may negate any culturally existent relations” (Grigoriadis, et al.,2009, p.839). First of all, to avoid distancing some immigrant women who adhere to theirtraditional cultural rituals, all health care professionals require communication skills andknowledge that permits them to be open to women expressing their concerns when they areconfronted by individuals with culturally insensitive practices (Grigoriadis, et al., 2009).Secondly, all health care providers should be taught communication skills to engage indiscussion, clarify individual needs and build a non-judgmental environment between theprofessional care providers and the new immigrant expectant mothers. Therefore,interprofessional team members can recognize the potential for stereotyping individuals andtheir contributions to the team. Lastly, Majumdar, Keystone and Cuttress (1999) reinforcedthe importance of cultural sensitivity while communicating and establishing professionalrelationships with clients. Majumdar and his team described the cultural sensitivity trainingfor health care providers by using simulated patients and providing videos as teaching aids tointroduce new teaching and learning principles. In conclusion, it is crucial to include theliterature reviews about cultural awareness and cultural care in the curricula ofinterprofessional education and to provide opportunities to apply those concepts to practicesettings.855.5.3 Implications for nursing research.This is the only Canadian study about early post-partum experiences of Chineseimmigrant women. Further qualitative studies would enhance understanding of Chinese newimmigrant mothers’ circumstances and their satisfaction regarding their early stage of post-partum care. Future Canadian studies would contribute to the evidence-based literature aboutthe knowledge of the needs that are urgently requested by new Chinese immigrant women.Further studies could utilize the qualitative findings of my study to reach more new Chineseimmigrant mothers to obtain broader perspectives about their decision-making processes withexpectations of first four to six weeks post-partum practices.All of the participants raised the same concern about the qualifications and liability oftheir paid services including Chinese post-partum doulas. Due to the variations inqualifications, lack of preparations and licensure of post-partum doulas, the quality ofwomen’s experiences in zuo yue zi can be greatly affected. The findings of my study wouldsuggest that there is a need to understand the perspectives of post-partum doulas in providingservices to women experiencing zuo yue zi. A study among post-partum doulas can helpclarify perceptions of their role in meal preparation, baby care, mother care or providingmedical care for women in zuo yue zi. Such studies can inform policy makers to discuss anddevelop legislation about the scope of practice and regulation of standard requirements forpaid post-partum doulas. In addition, more studies need to be conducted on post-partumservices in Greater Vancouver, including home meal deliveries and post-partum centres todetermine the availability of these services for women who choose to practice zuo yue ziIn addition to the paid resources of post-partum services, research examining practices usedby paid breast massage therapists could highlight practices that require attention fromrelevant authorized organizations such as BCLCA (British Columbia Lactation Consultant86Association). A thorough questionnaire about paid breast massage therapists and theirservices could be developed and distributed to mothers postnatally to have a detailedunderstanding about what breast massage therapy involves and the use of breast massagetherapy among Chinese immigrant mothers.Most of the participants in my study had their family members, mainly their mothers ormothers-in-law, helping during their post-partum period, and many of the participantsdescribed their post-partum experiences as being significantly influenced by these familymembers. It would be beneficial to gather data about the needs of new immigrant extendedfamily members using an open-ended questionnaire.5.6 ConclusionsThe beliefs of Chinese zuo yue zi are still embraced by many Chinese women whomigrate to Canada. This study bridges the limited research about their experiences andidentifies the need for more support to better understand Chinese traditional post-partumpractices. These study findings add to the literature regarding the current popular approachesto post-partum care including post-partum home meal deliveries, post-partum doulas andpost-partum centres used by Chinese immigrant women in Vancouver to support theirtraditional practices. This study also provides an important perspective on Chinese immigrantwomen’s early post-partum experiences, in particular their modifications to traditionalpractices and encounters with extended family members and paid help. Furthermore, thisstudy highlights the need for professional health care providers to support immigrant Chinesewomen who wish to follow traditional practices and to address regulatory guidelines toprotect mothers and their newborns from unregulated paid care providers in their newadopted homeland.87ReferencesAustin, Z. (2005). Mentorship and mitigation of culture shock: Foreign-trained pharmacists inCanada. 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Journal of Counseling &Development, 73(2), 121-126. doi: 10.1002/j.1556-6676.1994.tb01723.x96Appendix A: Participant LetterResearch Project: First four to six weeks Post-Partum Experiences of Chinese ImmigrantWomen in Vancouver, CanadaPrincipal Investigator: Dr. Wendy HallCo-Investigator: Sylvia ChangDear Participant,You are invited to participate in a research study in which you will be asked about your firstfour to six weeks of post-partum experiences in Canada.I am a registered nurse and a graduate student completing the Master of Science in NursingDegree at the University of British Columbia. My master’s thesis aims to understand Chineseimmigrant women’s post-partum experiences during the first four to six weeks period in theadopted country for women who were emigrated from mainland China, Hong Kong andTaiwan.Inclusion Criteria are BC residents who are ethnic Chinese (mainland China, Hong Kong, andTaiwan); are aged 19 and above; were have lived in mainland China, Hong Kong, or Taiwan;and have immigrated and lived in Canada within the last five years. The participants willprimarily speak Mandarin (Mandarin is the official language on mainland China) withEnglish as their second language; and have given birth within the last six weeks. Theparticipants can be either having their first child or having more than one child and havegiven birth to their baby by vaginal delivery or caesarean section within the last six weeks.The exclusion criteria are: aged younger than 19, multiple infants, pregnancy complications,premature infants or infants with any kind of anomaly or mother/baby have developedillnesses that were required to be hospitalized and significant post-partum complications such97as sepsis, eclampsia or psychosis.Participants in the study will be involved in an approximately one-hour interview at a timethat is convenient for you.  The interviews will be conducted in Mandarin at your choice ofinterview location. You will be asked to respond to questions about your post-partumexperiences in the first four to six weeks after your birth. Your responses will be recordedwith the use of digital recorders and translated verbatim to English. No personally identifiableinformation will be shared.Your participation is entirely voluntary. You may refuse to answer any questions, and youmay also withdraw data and/or participation in the study at any time without any negativeconsequences to your medical care or other services.There will be no direct benefit or compensation from participation in this study. However, itis hoped that the results from this study will increase our understanding of the first four to sixweeks of post-partum experiences of Chinese immigrant women in Vancouver as well asidentifying implications for future nursing practice, education, administration and research. Asummary of the results will be shared with you.I appreciate your consideration for involvement in this study, and participants will receivebaby face cloth as an incentive gift. If you would like to have more information about thisresearch project, please call me.Sincerely,Sylvia Chang, RN, BScN98Appendix B: Participant Consent FormResearch Project: First four to six weeks Post-Partum Experiences of Chinese ImmigrantWomen in Vancouver, CanadaPrincipal Investigator: Dr. Wendy HallCo-Investigator: Sylvia ChangCompletion of this consent form indicates your willingness to participate in a research studywhere you will be asked to describe your post-partum experiences in Vancouver.Purpose:The objective of this study is to explore the experiences of Chinese women who haveemigrated from mainland China, Hong Kong and Taiwan in regards to their post-partumexperience in first four to six weeks after giving birth in Vancouver, BC.Procedure:Participants in the study will be involved in an approximately one-hour interview session at atime that is convenient for you.  The interviews will be conducted in Mandarin at yourchoice of interview location. You will be asked to respond to questions about your first fourto six weeks post-partum experiences. Your responses will be recorded with the use of digitalrecorders and translated verbatim to English.Risks:There are no anticipated risks to you and no risk of physical injuries with your involvement.You may choose to stop or end the interview at any time if expressing some of yourexperiences makes you uncomfortable. If you become emotionally distressed whendiscussing your experiences in the new country, the interviewer will stop the recording andprovide time for you to recover. The interviewer will also have a list of potential communityresources for you.99Benefits:There is no direct benefit or compensation from participating in this study, except a baby facecloth as an incentive gift to participate. It is anticipated to take a few months to analyze theresults. A summary of the results will be shared with you. The results from this researchproject will increase our understanding of the first four to six weeks of post-partumexperiences of Chinese immigrant women in Vancouver as well as suggesting implicationsfor future nursing practice.Confidentiality:All information will be kept strictly confidential. Personal information that could potentiallyidentify you will not appear in written reports of the completed study. The study informationwill be kept and stored in a secured place. Only the master’s student and the thesis supervisorwill have access to your interview data. All audio recordings and transcripts will be storedsecurely in a locked filing cabinet inside a locked office, and the list of participants will bekept in a separate location. All study data will be kept in a locked office for five years afterthe study is completed and then destroyed. Reflective journals written by me and keptthroughout the research study process for auditing purposes will be destroyed after 5 years.Participation:Participants will receive a small baby face cloth as an incentive gift for participation, andthere will be no penalties for withdrawing from this study. You will be advised that you canchoose not to answer any questions. During the interview process, you can also change yourmind and elect to not participate in the study. In this circumstance, the interview will bestopped immediately and your answers will be omitted from the study.Questions or Concerns:If there are questions or concerns regarding this study and participation, you may contact100Sylvia Chang (Mandarin and English speaking) or Dr. Wendy Hall (English speaking only). Ifyou have any concerns/complaints regarding your rights as a research subject and/or yourexperiences while participating in this study, you may contact the Research SubjectInformation Line at the UBC Office of Research Services.Consent:Your signature below indicates that you have (1) received a copy of this consent form foryour own records; (2) understand the content of this consent form and; (3) consent toparticipate in this study.I have read and received a copy of this informed consent form, I understand andconsent to participate in this study.__________________________________________Participant’s Name (Please Print Clearly)_______________________________________ ___________________________Signature of Participant Date Signed101Appendix C: Demographic DataPlease answer or circle your response1. Age __________2. Marital statusa. Marriedb. Separated/ divorcedc. Common Lawd. Single3. Religious beliefsa. Buddhistb. Christianc. Catholicd. Other4. Does your partner live in your home?a. Yesb. No5. Do you share your home with extended family, e.g. mother or mother-in-law?a. Yesb. No6. If yes, what is the category of the member of your extended family?______________________7. Previous city of residence ________________8. How long have you been in Canada (months/years) _____________9. How would you indicate your fluency in the English languagea. Noneb. Poor102c. Goodd. Excellent10. Highest level of educationa. Some high schoolb. High school diplomac. Some postsecondary coursesd. Undergraduate degreee. Some graduate coursesf. Graduate degree/PhD11. Current family annual incomea. < CAN $20000b. CAN $20000-$40000c. CAN $41000-60000d. > CAN $6000012. Current occupation ___________________13. Previous occupation before immigration14. Number of children (including recent birth) ___________List age of any other children ___________Birth date of current child ___________15. Type of deliverya. Vaginal deliveryb. Caesarean section16. Are you familiar with the traditional Chinese post-partum practicesa. Yesb. Noc. Not Sure17. If you sought any post-partum services, which one(s) did you use?a. Maternity post-partum care center103b. Post-Partum home meal deliveryc. Post-partum doula home cared. Maternal care providers (may be close relatives)104Appendix D: Semi-Structured Interview Questions1.  What were your experiences in general during the first four to six weeks after your birth?2.  What is the meaning of “zuo yue zi” to you? Do you value “zuo yue zi”?3.  If “zuo yue zi” is relevant to you, what were your experiences with respect to it duringthe first four to six weeks post birth?4. What are your perceptions of possible effects of not following or being unable to followthese rituals or practices?5. If you used any post-partum services were they in relation to your expectations of “zuoyue zi”?  If so, did they meet your expectations of “zuo yue zi”?Why or why not?6. Are there any questions that I should have asked you about with respect to your first fourto six weeks post-partum?  Are there any other points you would like to raise regardingyour experiences and/or your impression of the practice of “zuo yue zi” in Vancouver?105Appendix E: Translated AppendicesDr. WENDY HALLSYLVIA CHANG經產婦倂產後精神異常者106。Sylvia Chang 敬啟107好讓您的情緒得以平復,並會提供您相關的社區協助資源108SYLVIA CHANGWENDY HALLUBC109110111D12345 ?6E/的…..:a.b. 19c.d. 週multigravidae.SYLVIA CHANGDr. WENDY HALL

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