Postpartum practices differ widely across cultural contexts
[1]. In many Western societies, postpartum recovery often lacks structured traditions, with new mothers typically resuming household and caregiving responsibilities soon after childbirth
[2]. In contrast, regions such as Asia, the Middle East, Latin America, and Africa maintain culturally embedded traditions of postpartum “confinement” or “doing the month”
[3-5]—a designated recovery period involving rest and various dietary, hygienic, and behavioral prescriptions aimed at restoring maternal health and preventing long-term illness
[6].
In China, this practice—known as “Zuo Yuezi”—is nearly universal, yet highly variable in its implementation
[2, 7-8]. It includes taboos such as avoiding physical exertion, limiting personal hygiene, and consuming specific foods
[6]. Notably, this period coincides with the critical window for postpartum depression (PPD), a common but often underdiagnosed mental health condition
[9-10]. While health-promoting elements of “Zuo Yuezi”—such as rest, family support, and nutritional care—may buffer against PPD, restrictive, inflexible, or poorly supported implementations may conversely increase psychological distress
[2, 11-12].
Previous researches have produced conflicting conclusions regarding the mental health impact of “Zuo Yuezi”
[4, 13], often due to treating the practice as a binary variable (i.e., practiced or not), without accounting for its heterogeneous nature or contextual conditions
[12, 14-15]. In reality, “Zuo Yuezi” encompasses a complex array of behaviors and norms related to diet, activity, warmth, hygiene, and more
[16-18]. Compliance to these practices—and the extent to which they are followed—varies significantly among individuals
[1, 19], meaning that “different women experience ‘Zuo Yuezi’ differently”. This heterogeneity has often been overlooked, leading to potential misinterpretations of the relationship between “Zuo Yuezi” and maternal mental health. Furthermore, beyond the content of the practices themselves, women’s engagement with “Zuo Yuezi” is also influenced by personal beliefs, caregiving arrangements, and the broader family and cultural environment
[20]. However, such factors have not been comprehensively examined in the literature
[13].
To address these gaps, the present study investigates the heterogeneity of “Zuo Yuezi” practices among Chinese postpartum women, using latent profile analysis to identify distinct patterns of compliance across domains such as behavior, diet, hygiene, and warmth. We also explore the relationship between these profiles and postpartum depressive symptoms, to provide a nuanced perspective on how tradition, family support, and maternal agency intersect to shape mental health outcomes. This work aims to inform culturally sensitive and contextually grounded approaches to postpartum care.
1 Subjects and methods
1.1 Ethical statement
1.2 Subjects
A cross-sectional study was conducted at 42-day postpartum clinics in 2 Maternal and Child Healthcare Hospitals (Hunan and Xiamen) and one general hospital (Chongqing Fuling Central Hospital) between January and February 2016. Women within 30-60-day postpartum were recruited through convenience sampling. Trained researchers provided informed consent procedures and facilitated completion of an online questionnaire via the Questionnaire Star platform.
1.3 Measurement instruments
1.3.1 Socio-demographic information
Data were collected on participants’ age, education level, employment status, monthly household income, prior depression history, parity, pregnancy intention, mode of delivery, infant gender, alignment with gender expectations, and current infant health.
1.3.2 Related information on “Zuo Yuezi”
The study comprehensively explored women’s experiences with “Zuo Yuezi” through the following domains. Domains A to D were measured using a questionnaire designed specifically for this research purpose, while domain E was developed based on the “Postpartum Confinement Behavioral Compliance Scale”
[19] and modified through a pilot study among local postpartum women. Domain A (Willingness): Self-reported willingness to observe the practice, both prenatally and retrospectively. Domain B (Attitudes): Views on whether the tradition should be preserved and its perceived health relevance. Domain C (Practice characteristics): Details on decision-makers, caregivers, recovery location, and duration. Domain D (Emotional experience): Subjective mood and emotional state during the “Zuo Yuezi” period. Domain E (Compliance): Based on a culturally adapted version of the Behavior Compliance Scale by Chien, et al.
[19], with a reliability (Cronbach’s α) of 0.825, 29 items were assessed retrospectively across 4 subdomains: 1) Hygiene (e.g., not washing hair, not bathing, not brushing teeth); 2) Behavior (e.g., avoiding sunlight, staying in bed, limiting speech); 3) Warmth (e.g., avoiding cold exposure, wearing a hat except in summer); 4) Diet (e.g., eating warm and protein-rich foods, avoiding raw/spicy/hard foods). Participants retrospectively self-assessed their actual practices. According to the instructions provided in the questionnaire, compliance levels were defined as follows: “Fully complied” referred to strict adherence throughout the entire “Zuo Yuezi” period (scored as 2 points); “partially complied” referred to adherence for only part of the time or in a modified manner (scored as 1 point); and “did not comply” referred to a complete lack of adherence (scored as 0 points). The total item scores for the 4 subdomains (e.g., hygiene, behavior, keeping warm, and diet) were calculated separately and used in subsequent latent profile analysis (LPA) to identify distinct compliance patterns.
1.3.3 Postpartum depression
Postpartum depression (PPD) was assessed using the Chinese version of the Edinburgh Postnatal Depression Scale (EPDS)
[21]. The 10-item scale yields scores from 0 to 30, with a Cronbach’s α reliability coefficient of 0.868 in this study. A cutoff of >9.5 was used to indicate risk of PPD
[22].
1.4 Statistical analysis
LPA was conducted using Mplus, while all other statistical analyses were performed using SPSS 27.0. Descriptive statistics (frequency and percentage) were used to summarize participant characteristics. Chi-square and Fisher’s exact tests were conducted for univariate associations between variables and PPD. LPA was employed to identify latent compliance profiles based on domain scores. Logistic regression was used to examine associations between “Zuo Yuezi” compliance and PPD, adjusting for sociodemographic and “Zuo Yuezi”-related variables. Statistical significance was set at P<0.05.
2 Results
2.1 General socio-demographic information
A total of 542 women who met the study criteria were recruited for participation. The majority of the participants were ≤35 years old (90.8%), 71.2% had a bachelor’s degree or higher, and nearly 70% were employed. Regarding pregnancy-related characteristics, more than half of the participants were primiparous (68.1%), had planned pregnancies (63.1%), and delivered vaginally (63.7%) (Supplementary
Table 1,
https://doi.org/10.57760/sciencedb.xbyxb.00194).
2.2 General compliance with “Zuo Yuezi”
According to the findings, 98% (531/542) of women reported having undergone “Zuo Yuezi”. Among them, the majority (86.4%, 459/531) indicated that their decision to undergo “Zuo Yuezi” was based on personal preference prior to delivery, and 86.6%
(460/531) expressed willingness to participate in “Zuo Yuezi” again if given the opportunity. However, 11 women who had initially planned to do “Zuo Yuezi” were unable to do so due to reasons such as lack of caregiving support (n=3), work-related conflicts (n=1), or other factors (n=7). Among these 11 women, 3 stated they would not choose to undergo “Zuo Yuezi” again. Furthermore, over 90% (498/542) of participants believed that “Zuo Yuezi” had positive effects on their future health, with approximately 75% (402/542) of women suggesting it could help prevent age-related diseases. Nevertheless, fewer than 65%
(349/542) of women felt that this traditional practice should be preserved. A comparison between women who experienced “Zuo Yuezi” and those who did not revealed that women with ≤35 years old, higher education levels, better health of their children, and those who perceived “Zuo Yuezi” as beneficial to their future health were more likely to comply with the practice. Conversely, women who did not engage in “Zuo Yuezi” were more likely to report symptoms of depression (Supplementary
Table 1,
https://doi.org/10. 57760/sciencedb.xbyxb.00194).
2.3 Characteristics and heterogeneity of “Zuo Yuezi” practices
Among the women who experienced “Zuo Yuezi”, the majority based their “Zuo Yuezi” practices either on traditional customs (41.2%) or the advice of their parents (29.5%). The primary caregivers during this period were mostly their parents-in-law (40.8%), their own parents (29.4%), or professional staff (21.9%). The “Zuo Yuezi” period typically took place in the woman’s own home (44.7%) or in her parents-in-law’s home (39.6%). Approximately 95% of participants adhered to a “Zuo Yuezi” duration of 30 days or more, with nearly half of them following the 30-day period (
Table 1).
Supplementary
Table 2 (
https://doi.org/10. 57760/sciencedb.xbyxb.00194) shows the content of and degree of compliance with the “Zuo Yuezi” practices. The 5 most rigorously followed practices were: Not have sexual intercourse (98.7%), not eat spicy food (89.1%), not participate in religious activities such as worshipping Buddha (79.5%), avoid carrying heavy objects (77.8%), and avoid eating hard foods (73.4%). In contrast, the 5 elements with the highest rates of full non-compliance included: Not brushing teeth (53.3%), avoiding talking too much (52.2%), keeping wearing a hat (51.6%), keeping supine (44.5%), and avoiding going out of bed (34.7%) .
A comparison of women’s compliance across the 4 subdomains of “Zuo Yuezi” practices revealed that the highest compliance was observed in the Behavior, followed by the Diet, while the lowest compliance was in the Hygiene. To further explore the heterogeneity in compliance with “Zuo Yuezi” practices, LPA was conducted based on the 4 subdomains. The 4-class model demonstrated superior performance on information criteria [Akaike Information Criterion (AIC), Bayesian Information Criterion (BIC), and adjusted Bayesian Information Criterion (aBIC)], achieving a favorable balance between model fit and parsimony, and showed acceptable classification quality (entropy=0.717) with reasonable class sizes; therefore, it was selected as the optimal solution.The results revealed 4 distinct compliance profiles: Low compliance across all domains, moderate-low compliance across all domains, moderate compliance across all domains, and high compliance across all domains (
Figure 1 and Supplementary
Table 3,
https://doi.org/10.57760/sciencedb. xbyxb.00194).
Further analysis of the factors influencing women’s overall compliance showed that compliance was generally higher among those who believed “Zuo Yuezi” helped prevent age-related diseases, those who chose to undergo “Zuo Yuezi” at home, and those who had a longer “Zuo Yuezi” duration (
Table 1).
2.4 Relationship between the “Zuo Yuezi” practices and PPD
Univariate analysis revealed that women who were unemployed, had a history of depression, had an inconsistency between the gender of the newborn and expectations, chose to undergo “Zuo Yuezi” at their in-laws’ home, experienced distress or dissatisfaction during the “Zuo Yuezi” period, and had lower compliance with “Zuo Yuezi” practices were more likely to experience PPD (
Table 2). After controlling for potential confounders, including age, education level, employment status, monthly family income, history of depression, and other relevant factors, a history of depression and mood during the “Zuo Yuezi” period remained significantly associated with PPD. Specifically, women with a history of depression had a higher risk of PPD [adjusted odds ratio (
aOR)=11.93, 95% confidence interval (
CI) 2.38 to 59.88], whereas women reporting an average or happy mood during “Zuo Yuezi” had a lower risk of PPD compared with those reporting an unhappy mood (average mood:
aOR=0.23, 95%
CI 0.13 to 0.40. Happy mood:
aOR=0.05, 95%
CI 0.02 to 0.09). Regarding the “Zuo Yuezi” practices, the association with PPD was attenuated after adjustment. Compared with the reference group (e.g., the group with low consistency across all domains), neither the group with moderate-low compliance across all domains (
aOR=0.507, 95%
CI 0.200 to 1.284) nor the group with moderate compliance across all domains (
aOR=0.955, 95%
CI 0.372 to 2.456), nor the group with high compliance across all domains (
aOR=0.408, 95%
CI 0.117 to 1.423) showed a statistically significant association with PPD (
Table 3).
3 Discussion
This study offers a nuanced examination of “Zuo Yuezi” among Chinese women, emphasizing its heterogeneity and association with PPD. Rather than treating “Zuo Yuezi” as a binary exposure, we identified 4 distinct compliance profiles using latent profile analysis. Compliance was highest in behavioral and dietary domains, and lower in hygiene-related taboos—reflecting differences in perceived relevance and acceptability of specific practices.
This study reveals a complex landscape of postpartum “Zuo Yuezi”, characterized by significant heterogeneity in how traditional prescriptions are followed. While dietary modifications and behavioral restrictions remain deeply entrenched, hygiene-related taboos (such as avoiding bathing or hair washing) are increasingly being contested or abandoned. This selective adherence suggests that modern Chinese women are not passive recipients of tradition; instead, they act as active negotiators, weighing cultural legitimacy against contemporary health literacy.
The identification of 4 distinct compliance profiles via LPA further dismantles the monolithic view of “Zuo Yuezi”. Our findings indicate that these practices are less about individual whim and more a reflection of the socio-familial ecosystem. Notably, women residing with in-laws or undergoing extended “Zuo Yuezi” periods exhibited paradoxically lower overall compliance. This trend likely points to a tension between maternal autonomy and family power dynamics. In patrilocal settings, where traditional authority may clash with a mother’s own recovery goals, “Zuo Yuezi” can shift from a supportive ritual to a source of psychological strain or a site of quiet resistance.
Crucially, the risk of PPD appears tethered to these specific patterns of adherence rather than the mere act of “Zuo Yuezi”. We found that lower compliance—particularly in behavioral and hygiene domains—correlates with a higher likelihood of depressive symptoms. This association may be driven by an “expectation-reality gap”—low compliance may not merely reflect individual resistance to tradition, but rather structural or familial barriers that prevent engagement. When women are unable to sustain their desired level of practice due to insufficient support or interpersonal conflict, the resulting loss of control may exacerbate emotional vulnerability. This interpretation is supported by our prior focus group research among Chinese mothers in Rochester
[23], where women who were unable to practice “Zuo Yuezi” as desired, often due to living apart from family or lacking help at home, reported the highest levels of depressive symptoms. These experiences suggest that low compliance may serve as a proxy indicator for insufficient family support—a known risk factor for PPD
[24]. Additionally, rather than viewing “Zuo Yuezi” as inherently protective or harmful, these results suggest its impact is contingent on the degree of agency the woman maintains and the quality of the caregiving environment. Consequently, clinical interventions should move beyond a binary assessment of tradition and focus on identifying high-risk compliance profiles to provide more tailored, culturally sensitive mental health support.
Thus, “Zuo Yuezi” should be understood not only as a cultural or physical health practice, but also as a psychosocial experience shaped by caregiving dynamics, maternal expectations, and access to supportive environments. When implemented in a supportive, flexible, and culturally congruent way, it may serve as a protective factor for maternal mental health by providing structured rest, social validation, and familial care. Conversely, rigid, isolating, or conflict-ridden “Zuo Yuezi” experiences may increase emotional distress.
These findings carry several implications for perinatal care. First, healthcare providers should move beyond binary assessments of “Zuo Yuezi” and explore the lived experience, support systems, and emotional context surrounding the practice. Second, interventions should aim to preserve the beneficial components—such as rest, nourishment, and emotional support—while modifying or eliminating elements that conflict with women’s autonomy or modern health standards. Finally, public health programs should empower women and families to adapt “Zuo Yuezi” practices to align with both cultural traditions and individual needs.
It should be noted that the cross-sectional data of this study were collected in 2016. Given the slow evolution of cultural practices, the heterogeneity in practices and its association with postpartum depression revealed in this study may still hold reference value today, yet the extrapolation of the findings should be made with caution. In sum, postpartum “Zuo Yuezi” is a complex and heterogeneous experience. It functions not only as a recovery protocol but also as a reflection of maternal agency, caregiving structure, and sociocultural identity. Future research should continue to investigate how these dynamics shape maternal well-being and how traditional practices can be constructively integrated into modern postpartum care models.
In conclusion, this study highlights the importance of moving beyond a binary understanding of postpartum “Zuo Yuezi” to recognize its diverse forms and implications for maternal mental health. By identifying distinct compliance patterns and linking them to PPD risk, we demonstrate that the psychosocial context and level of family support are central to how traditional practices affect well-being. These findings underscore the need for culturally attuned postpartum care that validates tradition while promoting maternal autonomy and mental health. Future research should explore the mechanisms through which caregiving dynamics, unmet expectations, and cultural identity shape the psychological impact of “Zuo Yuezi”, both within and beyond Chinese contexts.
the National Natural Science Foundation(82273643)
the National Natural Science Foundation(81973059)
the Hunan Provincial Natural Science Foundation(2023JJ30712)
the Youth Science Foundation of Hunan Provincial Natural Science Foundation Committee Class A Project(2025JJ20095)
the Nutrition and Care of Maternal & Child Research Fund Project of Biostime Institute of Nutrition & Care(2018BINCMCF31)
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