Effects of Postpartum Dietary Restrictions on Maternal Nutritional Status

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Effects of Postpartum Dietary Restrictions on Maternal Nutritional Status

Meredith Jackson

October 18, 2000

Text: 10 pages

Biblography: 2 pages

Tables and Graphs: in scanner
Introduction

In indigenous populations around the world, anthropologists have recorded various taboos and avoidances associated with puerperium and lactation. Food avoidances are one of the more common associations with these conditions. Reasons dictating these taboos are numerous and diverse. Townsend (1980) found that among the New Guinea Sago Gatherers a lactating woman will begin to observe food taboos at the first signs of illness in her infant. The food items to be avoided might could include wild pig, several common fish species, several snake species, cassoway, and Polynesian chestnuts. In this society, the mother runs the risk of upsetting spirits if she doesn’t obey. The diet is restricted for women in Tamilnad, India during the postpartum period. This is considered to be a pollution period that lasts 40-41 days. The restrictions in this case are usually of Ayurvedic origin, but can vary from mother to mother (Ferro-Luzzi, 1980). Many other cultures worldwide practice food avoidances during lactation, including some populations in Vietnam, Philippines, Malaysia and other countries of southeast Asia (Hart et al., 1965).

The purpose of this paper is to examine the possible effects of the absence of certain foods from the maternal diet in several Malaysian populations during the postpartum period and lactation. Anthropological literature offers a plethora of information regarding the effects of maternal diet on lactation and milk composition, however, information on the effects of maternal diet on maternal nutritional status is lacking (Adair, 1992; Mackey et al., 1998). Although not yet plentiful, the amount of information available on maternal nutritional status has increased over the past decade. By examining data from several studies involving populations in Malaysia, I aim to determine if Malaysian mothers observing the food taboos of the 40 day puerperium, or the number of days as determined by the mother (Laderman, 1981; 1983), place themselves at risk of acquiring poor nutritional status and low energy intake.

Maternal Nutritional Status

The National Academy of Sciences Committee on Nutritional Status Subcommittee on Lactation issued a report in 1991 advising that data are lacking to use in the identification of lactating women who are at risk of exhausting their nutrient stores. Adequate maternal nutritional status cannot be determined by evaluating data on infant growth and development because the maternal nutritional stores can be depleted to maintain sufficient nutrient content in the breastmilk (National Academy of Sciences, 1991). Adair (1992) points out that most studies in the past have focused on postpartum anthropometric changes in lactating women, but have not compared the results with those of nonlactating women.

By the 1990's, researchers had begun using new techniques and tools for assessing maternal nutritional status. One of these tools is the Body Mass Index (BMI) chart (see Figure 1) that includes both metric and English units. Body Mass Index is determined by charting weight and height measurements. Guidelines divide BMI’s into groups of low, normal, high and obese (Olson, 1994). Adair and Popkin (1992) provide an example of the application of BMI analysis in studies of postpartum women, specifically in assessing postpartum weight loss. This study showed that women with a low BMI had mean net weight losses comparable to women with higher body mass index, indicating that women with low BMI will have higher nutritional stress since their energy intakes will be smaller.

Other important factors to consider when looking at maternal nutrition are daily energy intake and expenditure, and daily dietary intake. Adair (1992) speculates that lactation is more likely to affect nutritional status of women in developing countries than in places with higher incomes because women of low income may not be able to meet the energy and nutrient demands of lactation by increasing dietary intake. Instead, the body will use its own fat stores, as is shown by Adair and Popkin (1992) in their findings that lactation has a strong negative effect on weight loss in Cebu women in the Philippines. To estimate energy requirements for lactating women, the estimated expenditures of milk synthesis are added to the energy requirements of a nonpregnant, nonlactating woman. In the United States, the recommendations are for an additional 500 kcal/day for a total daily allowance of 2700 kcal/day (Doran and Evers, 1997). Several recent studies that have calculated maternal energy intake have found that the mean maternal energy intake for their population is less that the Recommended Daily Allowance (RDA), but without a negative effect on lactation. This indicates that the current RDA may be too high (Adair and Popkin, 1992; Butte et al., 1984; Doran and Evers, 1997; Mackey et al., 1998). In addition to this, maternal energy intake has been shown to decrease significantly for at least the first four months of lactation (Butte et al., 1984).

Food Avoidances during Puerperium and Lactation in Malaysia

Many countries of southeast Asia practice food taboos or avoidances during puerperium, which, for much of the region, is a 40 day postpartum period (Hart et al., 1965; Laderman, 1981; 1983). As early as the beginning of this century, information about Malay postpartum food restrictions was being documented as part of the popular religion (Skeat, 1972 [1900]). Wilson has studied Malaysian dietary practices during pregnancy and lactation and reports that dietary intake does not meet the Malaysian RDA for lactating women. All kinds of food restrictions are referred to as pantang in Malay. These can best be described as guideposts for behavior, leaving the possibility for cautious experimentation. Pantang have no ruling force behind them, no punishment or vengeance will fall upon the woman if she doesn't observe the restrictions (Laderman, 1981; 1983). When a woman has a baby, her body enters into a state of “coolness”, therefore, she should only eat “hot” foods to help restore balance. The postpartum diet cannot include any “cool” foods or foods that have “cooling” properties as derived from the Greek humoral system. This marked category of foods eliminates a large number of items from the diet temporarily as shown in Table 2 (Wilson, 1980). Skeat (1972[1900]) listed items restricted after childbirth: things that have a lowering effect on the constitution, such as fruits and vegetables; things that have a heating effect on the blood; things that have an irritating effect on the skin; things that are supposed to cause faintness, such as gourds and cucumbers; sugar, chilies, and coconuts. “In effect she was eating rice, fish roasted over coals, and black pepper, and drinking coffee,” reports Wilson (1980:68) of a postpartum, lactating mother. Malay diet is centered around rice. Their ethnic categorizations of food reflect their reliance upon rice as a mainstay. There are two main recognized categories of food: rice and fish. Vegetable are thought of as merely additives for improving rice, usually in the form of relishes, and fruits are merely pleasant treats (Laderman, 1981; 1983).

Laderman

As social scientists have worked feverishly over the past two centuries to document and record cultural practices from every part of the world, our understanding of traditional lifestyles and beliefs has deepened in such a way that modern anthropologists take great measures to maintain an unbiased level of objectivity in our research. Laderman (1981; 1983) found the behavior surrounding the food taboos to be quite different than had been recorded by earlier anthropologists. An important factor in this discrepancy lies between the ideologies as put forth by previous researchers and the Malays themselves, and the actual behavior of the subjects. Although fruits had been classified as an unimportant component of the diet, Laderman (1981; 1983) found that in Merchang, the place of her research, fruits are a substantial part of a meal during peak seasons. Vegetables are considered the basis for relishes, but nonetheless, are still consumed in rather large quantities: 40-230 grams per meal. Compare this with the average weight of one day’s intake in an American adult diet: 69.4grams of green beans or 81 grams of peas and it appears that vegetables are consumed in quantities equal to or greater than the average American adult. Even though Malays do not consider vegetables an important facet of the diet, Laderman (1981; 1983) found in her household surveys that 63.5 percent of all households ate a green or yellow vegetable at least once a day, and 35 percent twice a day. Laderman (1983) also documented a total of 127 kinds of edible plants eaten in Merchang. Different ecological zones in Malaysia account for differences in actual diet. Each ecological setting needs to be analyzed and described in order to produce accurate data on the actual behavioral dietary habits of Malays (Laderman, 1983). Laderman comprised a detailed list of specific “hot”, “cold”, and “sederhana”, or neutral, foods listed in Fig. 2.

The Humoral System

Malays use a humoral system to categorize foods, diseases, illness, and treatments. These can all be classified according to intrinsic qualities which give it “heating” or “cooling” properties. Temperature does not affect the humoral qualities of food in Malaysia. The humoral system came to Malaysia first through trading with China and India and later with the coming of Arabic medicine and Islam. Malayan aborigines already had beliefs about childbirth that resemble the new “hot” and “cold” system and probably helped in the spread of its acceptance (Laderman, 1981). The practice of “roasting” a new mother over a fire is a common tradition throughout southeast Asia (Hart et al., 1965; Laderman, 1981; 1983). The heat from the fire treats the “cold” state the mother entered after giving birth, helping to restore balance.

Although Laderman (1981; 1983) found a great deal of agreement on the humoral classification of foods, ultimately the decision was made by the individual either according to their own empirical experience, or by the advice of someone else who could better perceive the qualities intrinsic to a certain food item. Consequently, there exists a great deal of variation within a single community in the categorization of specific foods (Laderman, 1981; 1983). “Humoral systems are dynamic rather than taxonomic. They not only admit the possibility of variation, they incorporate it into the model,” (Laderman, 1981:470). This is characteristic of Malay beliefs about all aspects of life. Everything can be interpreted differently or can be individually altered because of the acknowledgment and belief that not only do individuals differ from one another physically and temperamentally, but that the stages of life, the seasons of the year, even the hours of the day can have different effects on each individual (Laderman, 1981; 1983). The Malay humoral system also specifies marked and unmarked features. Items that are “hot” and “cold” are marked items, that is they have been singled out. Food items that fall into the “sederhana” category are unmarked, they haven’t been specified (Laderman, 1981; 1983).

The concept of Bisa

Magical power, whether used for evil or good, is considered bisa by Malays. The most common association made with the concept of bisa is in connection with foods and food avoidances. The system of food avoidance is not a result of the Malay humoral system, instead all foods to be avoided are considered bisa foods. However, the humoral characteristics of "hot" and "cold" could be used to classify a food as bisa. Bisa foods are thought of a "intensifiers of disharmonies" already present in the body (Laderman, 1981; 1983). In the past, the dynamic list of bisa foods has been interpreted by social scientists as lacking in structure and being primarily symbolic, but Laderman (1981; 1983) found that Malays practice the avoidance of bisa foods as a practical health measure. These proscriptions are firmly grounded in empirical knowledge gained through experience. Some of these foods categorized as bisa are common knowledge for most people, but other foods may be bisa for an individual person due to allergies or a past illness. Symbolism is a factor in the classification of some foods as bisa. For example, a sick Malay would want to avoid eating cucumbers and watermelon since they are grown close to the ground and have to be manured. Generally, bisa food avoidances are observed when a person has entered a state of imbalance, or an "extreme expression of a marked feature" (Laderman, 1981; 1983).

The most misinterpreted bisa food in the Malay diet is fish. During the postpartum period, Landerman (1981) found that 54 species of fish fall into the bisa category. This seemingly large group of fish species has alarmed social scientists in regards to maternal nutrition. Wilson (1980) writes, "the restriction of diets of newly parturient, traditional Malay village women to what they consider safe levels would not appear to be physiologically and nutritionally prudent." Taking this even further, Wilson (1980) postulates that the lowering of the nutritional status following childbirth may be a contributing factor in infant mortality. McKay (1980) also feels that beliefs such as the concept of bisa can often result in a restricted dietary intake of protein, vitamins, or minerals during times of particular physiological need.

Contrary to the assumption of restriction of protein intake as a result of bisa fish avoidances, Laderman (1981; 1983) found that although there are a large number of fish on the bisa list (54 agreed upon species), they represent only a small portion of the local fish population. Most of these fish fall into specific categories that may be harmful anyway, as seen in Table 3. Laderman (1981; 1983) was able to identify 6 species of fish that everyone agreed upon as being safe to eat during puerperium, with many people adding 13 others. None of these fish is scombroid or suspected of toxicity, none are top carnivores, and all are rather small. The bisa list represents the rarist species while the "safe" list represents the more abundant species. The "safe" fish can be found at the market on a daily basis, whereas, the bisa fish only occasionally can be purchased there. Laderman (1981; 1983) concludes that even though the list of bisa fish is considerably longer, no nutritional sacrifice accompanies the absence of these fish from the diet, even for extended periods of time.

Evaluation of the Maternal Diet

Laderman (1981;1983) points out the discrepancies in the literature regarding Malaysian maternal dietary intake. She attributes these discrepancies to differences in stated ideology and observed behavior. Previous researchers have recorded the Malaysian diet as consisting of rice and fish with a little vegetable relish on the side and an occasional fruit as a snack (Laderman 1981;1983; Wilson, 1980; McKay, 1980). However, as previously stated, Laderman (1983) found that although Malaysians do consider vegetables as additives not absolutely essential for survival and strength, they have a comparatively adequate portion of vegetables in their daily diet (40-230 g). During the monsoon season, people bring home large quantities of leafy greens, daun kayu, on a daily basis which form a significant part of the diet during the season (Laderman, 1983). In Merchang, Laderman (1983) counted 72 varieties of wild plants being consumed, in addition to 55 varieties of cultivated fruits and vegetables.

Wilson (1980) conducted a study in which 50 married women between the ages of 16 years and approximately 54 years were randomly selected from the village of RuMuda. A subsample of 6 women were asked to do a dietary recall and a hypothetical diet was devised from foods "generally accepted as permissible during confinement." The nutritional makeup of hypothetical diet as compared with the Malaysian RDA's are shown in Table 4. Two women were chosen to have their dietary intake observed for one day. The results show a large number of inadequacies when the vitamin and mineral composition is compared with the Malay RDA's, as shown in Table 5. Wilson (1980) does concede, however, that the woman in Table 4 did not consume any vegetables on that day, which was an abnormal practice for her.

The hypothetical diet as formulated by Wilson (1980) reveals that a banana is the only fruit or vegetable consumed in the maternal diet during puerperium. Wilson reported that all fruits with the exception of cooked bananas and durian are considered "cold" and therefore, eliminated from the postpartum diet. These findings differ from those of Laderman (1981;1983) who found that 8 percent of her subjects said all fruits are cold and none believed that all wild plants could be categorized en masse. All of her informants agreed that most bananas are sederhana, but that some are definitely "cold". These "cold" bananas apparently fall under the description of "slimy". The list of "cold" foods as presented by Laderman (1981;1983) is defined by only "marked" foods. That is, foods that have been singled out and identified as being "cold". This list is not exhaustive of all of the wild plants in the region, therefore, implying that all of the fruits and vegetables that do not fit into the marked categories can be considered safe. The cause for differing results obtained from asking the same essential questions can be found in the questions themselves. Wilson's questions (1980) appear to be thorough enough (see Table 6), but as Laderman (1983) found through informal field observation, more specific questions friendly to the underlying criteria Malays use for classification were needed to fully account for all of the dietary restrictions. In light of Laderman's (1981;1983) findings that Malaysian maternal diet is comprised of sufficient amounts of protein and fruits and vegetables, there appears to be no negative effect on maternal nutritional status as a result of postpartum dietary restrictions.