Food Habits and Practices During the Postpartum Period Among Saudi Women Vs American Women

Home , Dermatoses of pregnancy, Infant nutrition, Melasma, Multiple birth, Postpartum infections, Postpartum period

FOOD HABITS AND PRACTICES DURING THE POSTPARTUM PERIOD AMONG SAUDI WOMEN VS AMERICAN WOMEN

A thesis submitted to the Kent State University College of Education, Health, and Human Services in partial fulfillment of the requirements for the degree of Master of Science

Najlaa Y. Osailan

December 2014

©Copyright, 2014 by Najlaa Y. Osailan

A thesis written by

Najlaa Osailan

B.S., College of Education for Preparing Female Teachers, 2006

M.S., Kent State University, 2014

Approved by

______, Director, Master’s Thesis Committee Karen Lowry Gordon

______, Member, Master’s Thesis Committee Natalie Caine-Bish

______, Member, Master’s Thesis Committee Tanya Falcone

Accepted by

______, Director, School of Health Sciences Lynne Rowan

______, Dean, College of Education, Health and Human Services Daniel F. Mahony

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OSAILAN, NAJLAA Y., M. S. December, 2014 Education, Health and Human Services

FOOD HABITS AND PRACTICES DURING THE POSTPARTUM PERIOD AMONG SAUDI WOMEN VS AMERICAN WOMEN (97 pp.)

Director of Thesis: Karen Lowry Gordon, Ph.D.

The purpose of this study was to examine the difference between Saudi women and American women living in United States, concerning their maternal dietary restrictions and practices during the postpartum period. A survey was distributed electronically to Saudi and American females who delivered a live birth during 2014 and live in United States. There were 28 participants in this study. Statistical analysis included descriptive, frequency, and comparative statistics. A Chi- Square (Ӽ2) test was used to compare Saudi postpartum women versus American postpartum women. This research study found that there was no significant association between groups with regard to maternal dietary restrictions and traditional practices. These finding suggested that both groups tended not to restrict or use special diet after the child birth, as well as not to restrict their physical activity. However, this study also found that Ӽ2 analysis showed a significant association among American postpartum women versus Saudi postpartum women (P=0.049) with respect to attempting to lose weight during this period. This indicates that some women might use some dietary restriction to enhance weight loss in the postpartum period. Identifying the restrictions associated with traditional postpartum practices is critical to develop better understanding to the cultural values and targeting health education programs to increase healthcare providers’ cultural awareness and their possibilities to provide culturally congruent care.

ACKNOWLEDGEMENTS

First and foremost, I would like to express my special appreciation and thanks to my advisor Dr. Karen Lowry Gordon, you have been a tremendous mentor for me. I would like to thank you for encouraging my research and for allowing me to grow as a research scientist. Your advice on my thesis have been priceless. I would also like to thank my committee members, Dr. Natalie Caine- Bish, and Mrs. Tanya Falcone for serving as my committee members. Your support and expert input and comments were very helpful and appreciated.

A special thanks to my family. Words cannot express how grateful I am to my mother, and father for all of the sacrifices that you’ve made on my behalf. Your prayer for me was what sustained me thus far. Next, I would like to thank my daughters:

Shahad, Joud, and Layan for their endless love, patience, and support. I would also like to thank all of my friends who supported me in writing, and incented me to strive towards my goal. At the end I would like to express appreciation to my beloved husband Khalid

Alshami who spent sleepless nights with, and was always my support in the moments when there was no one to answer my queries.

TABLE OF CONTENTS

ACKNOWLEDGEMENTS ...... iv

LIST OF TABLES ...... vii

CHAPTER Page

I INTRODUCTION ...... 1 Statement of the Problem ...... 2 The Purpose of the Study ...... 3 Research Hypotheses ...... 3 Operational Definitions ...... 3

II REVIEW OF LITERATURE ...... 6 Defining the Postpartum Period ...... 6 Maternal Nutrition ...... 7 Energy Intake ...... 7 Protein and Calcium ...... 8 Iron ...... 8 Fluid Intake ...... 8 Alcohol and Caffeine ...... 9 Fish Consumption ...... 9 Vitamins ...... 10 Physical Changes during Postpartum...... 12 Breastfeeding (Initiation of Milk Secretion) ...... 12 Weight Changes ...... 13 Bone Mineral Density (BMD) Changes ...... 13 Hormonal Changes ...... 14 Skin Changes ...... 15 Psychological Changes during Postpartum Period ...... 16 Emotional Changes ...... 18 Frequency and Nature of Health Problems during Postpartum ...... 19 Infections...... 19 Bladder Problems ...... 21 Backache ...... 22 Frequent Headaches ...... 23 Constipation ...... 23 Breast Problem ...... 24 Anemia ...... 25

TABLE OF CONTENTS (Continued)

Chapter Page

Hemorrhage...... 25 Effect of Poor Diet during Postpartum Period ...... 26 Effect on Mothers ...... 26 Effect on New Born ...... 26 Dietary Intake in American Postpartum Women ...... 27 Dietary Intake in Saudi Arabian Postpartum Women ...... 29 General Information about Saudi Arabia ...... 29 Health Custom during Postpartum among Saudi Women ...... 29 Postpartum Diet in Saudi Arabia ...... 30 Cultural Beliefs ...... 32 The Function of the Foods ...... 32

III METHODOLOGY ...... 39 Research Design...... 39 Study Population ...... 39 Data Collection Instruments ...... 40 Procedure ...... 41 Statistical Analysis ...... 42

IV JOURNAL ARTICLE ...... 44 Introduction ...... 44 Methods...... 46 Study Population ...... 46 Data Collection Instruments ...... 46 Procedure ...... 48 Statistical Analysis ...... 49 Results ...... 49 Discussion ...... 55 Application ...... 58 Limitations ...... 59 Conclusion ...... 60

APPENDICES ...... 62 APPENDIX A. SURVEY ...... 63 APPENDIX B. EMAIL INVITATION ...... 75 APPENDIX C. HANDOUT ...... 77 APPENDIX D. CONSENT FORM ...... 79

REFERENCES ...... 82 vi

LIST OF TABLES

Table Page

1 Practices and Beliefs during the Postpartum Period among Different Cultures ...... 4

2 Comparison between Dietary Intake in Adult Women and Lactation ...... 11

3 Timing of Onset, Symptom, and Incidence of Maternal Psychological Problems ...... 20

4 Recommendation for Postpartum Women in Saudi Arabia ...... 31

5 Demographic Data of Saudi and American Postpartum Women ...... 51

6 Significant Association of Food Restrictions and Practices during the Postpartum Period among Saudi vs American Women ...... 52

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CHAPTER I

INTRODUCTION

The Postpartum period is the state of physiological stress characterized by profound metabolic and hormonal changes. This period is the time of transition for women and their families (Geneva, 1984). Mothers during this time undergo a lot of pressure and concern about how they can get their health and shape back after childbirth, which in some situations may cause psychological problems or disorders. Therefore, women need to receive special health and social support during this time to prevent such problems. Inadequate care might result in complications for the mother and her child.

Nutrition plays an important role in the course of the postpartum period. It is well documented that dietary modification during this period has a profound effect on the nutritional status of both the mother and the newborn (Geneva, 1984).

During this period, culture plays a major role in the way a woman perceives and prepares for her birthing experience (Al-Kanhal & Bani, 1995). In fact, the notions of birth and postnatal care vary considerably with cultural beliefs and traditional practices.

Each culture has its own values, beliefs and practices related to pregnancy and birth.

According to recent studies, eating habits after delivery among American women are not very complex. Women simply continue to eat a good quality diet similar to the diet that they used to consume during pregnancy. In contrast, in the Saudi culture, a postpartum female is treated as a sick patient for the first six weeks after her childbirth. A long list of food restrictions and work limitations is typically enforced on her (Piperata, 2008). For

1 2 instance, a Saudi postpartum woman is not supposed to consume certain types of food such as cold foods and drinks. Also, new mothers are encouraged to consume more meat and hot soups, as well as dates and herbal supplementations (Hundt, Beckerleg, Kassem,

Abu Jafar, Belmaker, Abu Saad & Vardi, 2000).

Statement of the Problem

The Post-partum period is a very stressful period for women worldwide due to the changes that occur during this time, such as life, physical, and emotional changes as well as some of the common problems encountered during this period. Approximately, 1,400 women die every day during postnatal period from complications related to childbirth results in 500,000 death /year (Veneman AN, 2008). Therefore, the information on food habits and beliefs during the reproductive period helps in assessing the causes and the magnitude of those complications and in planning of the intervention programs.

Recently, Saudi families have come to the United States in large numbers to pursue academic studies. Saudi Arabia's oil wealth allows the government to sponsor these students financially. Consequently, the number of Saudi women who gave birth in the United States is increasing. Some of these women follow the same food restrictions that they used to follow in Saudi Arabia, while others follow the kind of restrictions that are common in the United States because they either do not have access to the types of foods that they used to eat during this time, or they do not have enough support to help with their needs as well as that they have eventful times that are filled with much studying and working. Therefore, the health care policy makers and health care providers need to be cognizant of food restrictions and practices among those population which

3 may be followed. So that these practices can be incorporated into care of the postpartum women.

This study intends to provide insightful information for health care providers about the postpartum food habit and practices that are used during postpartum period among Saudi women. Likewise, this study intends to investigate the food restrictions and practices among United States women and Saudi women during the postpartum period and living in the United States and make a comparison between the two. The study will attempt to identify the differences between the US and Saudi women and demonstrate how such differences can be used to support women and recover their health after delivery.

The Purpose of the Study

The purpose of this comparative study is to examine the difference between Saudi women and American women living in USA, concerning their maternal restrictions and practices during the first six weeks after childbirth. (Table 1).

Research Hypotheses

There will be a difference in the maternal restrictions and practices during the first stage of postpartum period (1-6 weeks) between Saudi and American women in USA.

Operational Definitions

 Food restrictions and practices: limitations/ or exclusion, and preference of some

types of food or food choices by women as well as exercises during the first six

week of postpartum period due to believes or traditional customs.

Table 1: Practices and Beliefs during the Postpartum Period among Different Cultures

Saudi women’s postpartum beliefs American women’s postpartum beliefs

 Restrictions: women are not  Restrictions: there are no restrictions but recommended to leave the house women avoid fad weight reduction diets. unless for emergency. They also avoid exposure to wind and cold, avoid performing hard work, and use a special diet.

 Exercise:  Exercise: women encourage to do o Women avoid doing exercise exercise not only for losing weight but during the first 20 days in this also for health recovery. period due to the belief that exercise could effects and harm here reproductive organs’ health. o In the other 20 days she can do some exercises.

 Diet: women use a special diet  Diet: (high protein, high fiber, and low o Eat a wide variety of foods with high CHO diet). nutrient density. o Eat the recommended servings from each food group using the Food Guide Pyramid as a guide for family meal selection and preparation. o Use foods and recipes that require little or no preparation (avoid high-fat fast foods). o Take in plenty of fluids such as water, juice, and soups.

 Food taboos: women avoid  Food taboos: women avoid harmful certain types of food such as: substances (such as alcohol, tobacco and • Food that have a strong smell. drugs), and excessive intake of fat, salt, • Foods that have sticky textures caffeine, sugar, and artificial sweeteners. (okra). • Food high in citrus (lemon). • Cold food or drinks. (Hundt, Beckerleg, Kassem, Abu Jafar, Belmaker, Abu Saad & Vardi, 2000; Choose My Plate, 2014)

 First stage postpartum: Is the period of time that begin immediately after the birth

of a child and the delivery of the placenta, and it extend for six weeks (Geneva,

1984).

 Saudi women who live in USA: defined as a group of women who are citizens of

Saudi Arabia (nation in the Persian Gulf region), and currently residing in USA to

peruse their academic studies. Must be currently a parent, and the child must be

between newborn to six months old.

 American women who live in USA: Those women who are mothers for a live

infants and residing in USA. Must be having a child that is newborn to six months

old.

CHAPTER II

REVIEW OF LITERATURE

Defining the Postpartum Period

Postpartum period “also called puerperium” start shortly after the birth of placenta and extending for about six weeks (Geneva, 1984) .The characteristics of this period are the start of lactation and return of the reproductive organs to their approximate, pre-pregnancy position (Lawrence, 1989). The post-partum period has been termed the fourth stage of labor and has three distinct but continuous phases (Romano, Cacciatore,

Giordano & Rosa, 2010). Phase one is the initial or acute period and involves the first

6-12 hours postpartum. This is a time of rapid change with a potential for immediate crises such as postpartum hemorrhage, uterine inversion, amniotic fluid embolism, and eclampsia (Abdullah & Ali, 2007). The second phase is the sub-acute postpartum period, which lasts 2 –6 weeks. During this phase, the body is go through major changes in terms of hemodynamics, genitourinary recovery, metabolism, and emotional status.

Nonetheless, the changes are less rapid than in the acute postpartum phase and the patient is generally capable of self-identifying problems. The third phase is the delayed postpartum period, which can last up to 6 months (Romano, Cacciatore, Giordano &

Rosa, 2010). Changes during this phase are extremely gradual, and pathology is rare.

This is the time of restoration of muscle tone and connective tissue to the pre-pregnant state. Although change is subtle during this phase, a woman’s body is nonetheless not fully restored to pre-pregnant physiology until about 6 months post-delivery (Cosen,

2004. 6 7

Maternal Nutrition

The role of good nutrition in improved neonatal and maternal survival extends beyond the time a woman is pregnant. Promoting adequate nutrition and counseling women to gain enough weight during pregnancy is just the first step. Proper diet is important after delivery to help the mother recover, and to provide enough food energy and nutrients for a woman if she breastfeed her child (Picciano, 2003). The Dietary

Guidelines published by the US Department of Agriculture and endorsed by the

American Dietetic Association form the basis for nutrition counseling for postpartum women (USDA, 2010). For postpartum women who are not breast-feeding, the nutrient and calorie needs are the same as they were before pregnancy. On the other hand, breastfeeding, having anemic or recovering from a cesarean delivery, require a special nutritional management (USDA, 2010).

Energy Intake

During breastfeeding women need to eat extra calories, protein and nutrients to provide for the growth of the new baby and maintain health. The DRIs for normal weight lactating women assume that the energy spent for milk production is Five hundred calories per day in the first 6 months and four hundred calories afterword (Food and

Nutrition Board, Institute of Medicine, 2002). Therefore, an additional 500 Kcal/day is recommended for women who breastfeed and even higher intake may be recommended for lactating women who are underweight, exercise vigorously, or breastfeeding more than one infant (USDA, 2010). However, because breastfeeding burns calories, weight

loss still occurs with good healthy eating habits and moderate physical activity (Picciano,

2003).

Protein and Calcium

Women should eat two to three servings from the protein group every day during

this period. Also, The safe levels recommended by WHO are 16–17 g/day for 0–6

months of lactation, 12.3 g/day for 6–12 months of lactation, and 11.3 g/day for 12–24

months of lactation (WHO, 1990). In addition, mothers need to get at least three servings

from the milk group for the calcium requirements. Adequate protein and calcium in the

diet will help postpartum women to maintain body stores as well as providing what a

baby needs in the breast milk (Brown, 2011).

Iron

Dietary requirements for iron return to pre-pregnancy levels in the postpartum

period. The recommended iron intake for women of reproductive age is 18 mg/d. (USDA,

2010). Recommended iron intakes for non-reproducing women were estimated based on

basal losses and menstrual losses. For lactating women, estimations were based on basal

losses, with the assumption that menstruation resumes at 6 months, plus the quantity

secreted in milk. Postpartum iron supplementation may be indicated when blood loss is

higher than usual. In the presence of a low hemoglobin oral supplementation of 60 to 120

mg of iron can be recommended (Lawrence, 1999).

Fluid Intake

For the fluid intake, adequate fluid intake is an important element of good

nutrition. Women, especially those who are lactating, should be encouraged to drink

9 enough to satisfy thirst and prevent constipation. Eight to ten glasses a day is very important (Lawrence, 1999).

Alcohol and Caffeine

The excessive maternal consumption of caffeine may adversely affect the infant who is breastfeeding. Newborns cannot completely break down caffeine, and some research suggests that they can become irritable with large amounts of caffeine. Caffeine has been known to inhibit the letdown reflex. According to guidelines of the Institute of

Medicine (IOM), they considers that moderate consumption of caffeine (e.g., a morning cup of coffee) to be acceptable during breastfeeding. Also, other lesser sources of caffeine, such as tea, cocoa, soda and chocolate should be alleviated (Food and Nutrition

Board, Institute of Medicine, 2002). Women also should be cautioned that consuming large amounts of alcohol during postpartum period may interfere with their ability to breastfeed effectively and may adversely affect their infant. Alcohol consumption may also impair a mother’s ability to nurture and care for her infant. Excessive alcohol intake has been shown to affect the let-down reflex and may cause poor growth and development in the newborn (Fowles & Walker, 2006).

Fish Consumption

As part of a balanced diet, fish should be included weekly to provide Omega-3 fatty acids. Omega 3 fatty acids have many health benefits for moms and it is the building blocks of breast milk. At the same time, women of reproductive age are particularly vulnerable to the industrial pollutants mercury and polychlorinated biphenyls (PCBs) that accumulate in fish flesh (Grandjean, Weihe, White, Debes, Sorensen, Yokoyama,

Jorgensen, 1997). Several studies have documented prenatal exposure to mercury and its effects on fetal development, and breastfeeding mothers are advised to minimize fish consumption because mercury passes through breast milk (Steuerwald, Weihe, Jorgensen,

Bjerve, Brock, Heinzow, Budtz- Jorgensen, Grandjean, 2000). To avoid possible mercury contamination, the guidelines for all adults are no more than 12 ounces per week (two servings) e.g., cod, haddock, Pollock, shrimp, tilapia, chunk light tuna, mackerel, tilefish, shark or swordfish (Papathakis, Rollins, Chantry, Bennish, & Brown, 2007).

Vitamins

Vitamins are simple and inexpensive measure that could prevent birth defects in future pregnancies. In a study by O'Rourke et al. only 66% of 329 mothers took postpartum multivitamins. Multivitamin consumption declined by 29% for each postpartum week. The majority of 247 women with multivitamin counsel (59%) were told to finish prenatal vitamins or to continue use it while breastfeeding. A provider recommendation highly motivates early postpartum women to consume multivitamins

(2006).

From the subcommittee on nutrition during lactation, they did not propose a food guide for postpartum women because they recognized that diverse ways are available to meet nutrient need during this time, but they did offer particular recommendation

(Lawrence, 1999). Avoiding diets and medications that promise rapid weight loss, eating a wide variety of food that are rich with vitamins, taking three or more serving of milk products daily, and lowering caffeine and alcohol intake are some general guideline for

11 postpartum women (Lawrence, 1999; USDA, 2010). The institute of medicine dietary guideline for lactating women vs. adult women are shown in Table 2 (1997).

Table 2: Comparison between Dietary Intake in Adult Women and Lactation

Dietary Reference Intakes (DRI)

Nutrient Adult Lactation Women Energy, 2 kcal 19–50 y 1500 kcal/d 0–6 mo. 1400 kcal/d 7–9 mo. Protein, 3 g 46 71 Vitamin C, 3 mg 75 120 Thiamin, 3 mg 1.1 1.4 Riboflavin, 3 mg 1.1 1.6 Niacin, 3 mg NE 14 17 Vitamin B-6, 3 mg 1.3 2 Folate, 3 g DFE 400 500 Vitamin B-12, 3 g 2.4 2.8 Pantothenic acid, 4 mg 5 7 Biotin, 4 g 30 35 Choline, 4 mg 425 550 Vitamin A, 3 g RE 700 1300 Vitamin D, 4 g 5 5 Vitamin E, 3 mg –TE 15 19 Vitamin K, 4 g 90 90 Calcium, 4 mg 1000 1000 Phosphorus, 4 mg 700 700 Magnesium, 3 mg 310 310 Iron, 3 mg 18 9 Zinc, 3 mg 8 12 Iodine, 3 g 150 290 Selenium, 3 g 55 70 Fluoride, 4 mg 3 3 *Values are from the Institute of Medicine, 1997.

Physical Changes during Postpartum

Breastfeeding (Initiation of Milk Secretion)

During pregnancy and the first few days postpartum milk supply is hormonally driven, this is called the endocrine control system (Cox, Kent, Casey, Owens &

Hartmann, 1999). Essentially, the mother will start making colostrum about 12 weeks before delivery, but high levels of progesterone inhibit milk secretion and keep the composition of prepartum secretion fairly constant until delivery, this is called

(lactogenesis stage I). The composition of colostrum is heralded by significant increases in lactose, total proteins and immunoglobulin and by decreases in sodium and chloride, and the gathering of substrate for milk production (Lawrence, 1999). Around two to three days after birth the mother milk is increase in volume in the second stage of lactogenesis

(Cox, Kent, Casey, Owens & Hartmann, 1999). At birth, the delivery of the placenta results in a sudden drop in plasma progesterone, estrogen, and human placental lactogen

(HPL) levels while prolactin levels remain high. This abrupt withdrawal of progesterone in the presence of high prolactin levels cues lactogenesis II which leads to copious milk production (Lawrence, 1999). Other hormones like insulin, thyroxin, and cortisol are also involved, but their roles are not yet well understood (Cosen, 2004). Although biochemical markers indicate that lactogenesis II commences approximately 30-40 hours after birth, mothers do not typically begin feeling increased breast fullness until 50-73 hours (2-3 days) after birth (Cregan, Mitoulas & Hartmann, 2002).

Weight Changes

Women loss about 10-12 lbs. immediately after delivery. The loss is from the weight of the infant, placenta, and amniotic fluid. Women who have an average amount of weight gain during pregnancy will retain about 1 kg (2.2 lb.) after the birth of each child. This amount is above the 0.45 kg (1 lb.) per year normally gained with age

(Greene, Smiciklas, Schott & Karp, 1988). Studies have confirmed that women are heavier after pregnancy than before pregnancy (Chou, Chan & Moyer-Mileur, 1998). At least one woman in ten retain excessive weight, i.e. ≥ 6.6 kg (15 lb.). Women who were underweight prior to pregnancy retain minimal weight. Women who are of normal weight or overweight prior to pregnancy and gained 9.1 kg (20 lb.) or more in pregnancy were found to be 2.6 kg (5.7 lb.) to 4.6 kg (10.2 lb.) heavier at this period ( Gould Rothberg,

Magriples, Kershaw, Rising & Ickovics, 2011). 6-8 weeks after delivery women return to normal pre pregnant weight if an average of 25-30 lbs. is gained during pregnancy.

Bone Mineral Density (BMD) Changes

During pregnancy and breastfeeding, major changes occur in the maternal calcium homeostasis and bone metabolism in order to fulfill the demand of calcium to the fetus and the newborn child (Lotinun, Limlomwongse & Krishnamra, 1997). In a controlled cohort study, bone mineral density (BMD) was measured in 153 women pre-pregnancy; during pregnancy; and 0.5, 4, 9, and 19 months postpartum. Results showed that both pregnancy and breastfeeding cause a reversible bone loss (Mosekilde,

Rejnmark, Streym & Møller, 2011). Compared to pre-pregnancy, BMD decreased significantly during pregnancy. Postpartum, BMD decreased further with an effect of

14 breastfeeding duration (Lawrence, 1989). Breastfeeding for more than 4 months leads to a lower BMD at 9 months postpartum at the whole body, lumbar spine, and hip.

Breastfeeding for less than 4 months leads to a lower BMD than pre-pregnancy. At

19 months postpartum, BMD returned to pre-pregnancy level independently of breastfeeding length (Mosekilde, Rejnmark, Streym & Møller, 2011).

Hormonal Changes

Levels of estrogens and progesterone rise gradually during pregnancy, in large part as a result of placental production of these hormones (Speroff L, Glass RH, Kase

NG, 1983). With removal of the placenta at delivery, estrogen and progesterone levels drop sharply, reaching pre-pregnancy levels by the ﬁfth postpartum day (Hendrick,

Altshuler, & Suri, 1998). Estradiol and estriol are biologically active forms of estrogen that are produced by the placenta. The levels of these active hormones rise during pregnancy and decrease sharply after delivery (Lawrence, 1999). High estrogen levels during pregnancy stimulate production of thyroid hormone binding globulin, leading to a rise in levels of bound triiodothyronine and thyroxin and a simultaneous drop in levels of free triiodothyronine (T3) and thyroxin(T4). Thyroid stimulating hormone (TSH) increases to compensate for the low free thyroid hormones, and free T3 and T4 thus remain within the normal range. With the drop in thyroid binding globulin following delivery, levels of total T3 and T4 drop, whereas free T3 and T4 remain relatively constant(Brown, 2011). Prolactin levels rise throughout pregnancy, peak at delivery and, in non-lactating women, return to pregravid levels within 3 weeks postpartum. By inducing the release of oxytocin, a hormone that stimulates pituitary lacto trophic cells,

15 breast feeding keeps prolactin levels high. However, prolactin levels eventually return to prepregnancy levels even in breast feeding women (Learoyd, Fung &, McGregor, 1992).

Cortisol levels peak in late pregnancy as a result of placental production of corticotrophin releasing hormone, and fall abruptly at delivery. Levels of beta-endorphin and human chorionic gonadotropin also rise through pregnancy, and decline at delivery (Lawrence,

1999).

Skin Changes

The increase of hormones during pregnancy cause changes in the skin pigmentation. Hyperpigmentation is very common during pregnancy and may occur in up to 90% of women. It is usually mild and generalized, with accentuation of normally hyperpigmented regions such as the areolae of the breasts, axillae, perineal skin, genitalia, anal region, and inner thighs (Winton, Lewis, 1982; Wade, Wade, Jones, 1978).

In general, hyperpigmentation begins early in pregnancy, progresses until delivery, and frequently decreases in postpartum and return to the previous color (Kar, Krishnan &

Shivkumar, 2012; Muallem, Rubeiz, 2006).

Melasma also known as chloasma is recognized by blotchy, irregular but sharply marginated, or non-elevated light to dark-brown hyperpigmentation of the face, is common during pregnancy. The most frequently involved sites are the cheeks, nose, and chin. It has been reported in 50% to 75% of pregnant women, with an onset usually during the second half of pregnancy (Winton, Lewis, 1982; Wade, Wade, Jones, 1978). It is more common in dark haired, dark complexioned individuals. It also occurs in up to

16 one third of none pregnant women taking birth control pills. Melasma usually completely disappears within a year of delivery (Kar, Krishnan & Shivkumar, 2012).

Striae distensae are seen in most pregnant women during the sixth and seventh months; there seems to be a familial tendency (Demis, Dobson, McGuire, 1975). They are uncommon in black and Asian women. These irregular, linear, pink to violaceous atrophic and finely wrinkled stripes develop opposite to the skin tension lines on the abdomen initially, then on the breasts, upper arms, lower portion of the back, buttocks, thighs, and inguinal areas. The striae gradually fade and become less noticeable after delivery, although they may never disappear entirely (Chang, Agredano, Kimball, 2004).

Psychological Changes during Postpartum Period

The weeks following childbirth are a time of vulnerability to depressive symptomatology in women (Lawrence, 1999). Many psychological changes occur during this time as a result of several factors such as physical, emotional, and social factors

(Cosen, 2004). Adjustment to all the new changes, and the roll the family will play, may cause many different emotions. Also, the physical pain and tiredness that women feel after a long labor process affect mother’s mood and behavior (Cosen, 2004; De

Choudhury, Counts, Horvitz, 2013). Research has shown that women usually go through three stages after the birth of a baby. First stage is the taking in phase which is the time immediately after birth and last for 24 to 48 hours, during which the mother needs sleep, depends on other to meet her needs, and relives the events surrounding the birth process.

This phase is characterized by dependent behavior. Mothers often assume a very passive role in meeting their own basic needs for food, fluid, and rest, and they facing difficulties

17 making decisions for themselves. During this phase the women spend time recounting their labor experience. Such action help mothers integrate the birth experience into reality

(Martha Rider, 2003) .The second stage of maternal adaption is the taking hold phase.

This stage is characterized by dependent and independent behavior and start in the second to third day postpartum and may continue for several weeks. During this phase women regain control over their bodily functions, and they start worrying about their health and their infants’ condition (Ricci & Kyle, 2009). Mothers express a strong interest in caring for their infants by themselves during this time (Martha Rider, 2003). Third is the letting go phase. Women reestablish relationships with other people and adapt to parenthood through their new roles as mothers. They establish a lifestyle that include their infants in this phase (Ricci & Kyle, 2009). These stages also are known as Rubin’s maternal role and they can be used to monitor the woman progress while she try to adjust to her new role as a mother. Absence of these progresses or inability to progresses through the phases satisfactory may lead to serious mood disorders (Rubin, 1984).

Essentially, the abrupt and dramatic changes occurring in hormone levels after delivery is the chief cause of mood and psychological disorders during this period

(O'Hara, Schlechte, Lewis & Varner, 1991). In an animal study, they have demonstrated that estradiol enhances neurotransmitter function through increased synthesis and reduced breakdown of serotonin which affect the mother’s mood. The abrupt decrease in estradiol levels following delivery may thus theoretically contribute to postpartum depression

(Hendrick, Altshuler, & Suri, 1998). The sharp decline in progesterone levels following childbirth has also been implicated in postpartum mood changes (Hendrick, Altshuler, &

Suri, 1998). Two recent studies have reported that estrogen supplementation signiﬁcantly reduced postpartum depressive symptoms (Sichel, Cohen, Robertson et al. 1995). A study of 147 mothers at 6 to 8 weeks postpartum found that the depressed breast feeding women had lower levels of salivary progesterone than the euthymic breast-feeding women (Lawrence, 1999). Oxytocin and vasopressin are two posterior pituitary hormones that undergo changes in production levels in the postpartum, but they have not been assessed for their relationship to postpartum depression. Oxytocin, which rises sharply at delivery and with breast-feeding, stimulates uterine muscle contraction at labor and promotes release of breast milk. However, in animal studies, oxytocin also appears to stimulate maternal behavior and mood changes (Hendrick, Altshuler, & Suri, 1998).

Emotional Changes

Postpartum hormonal fluctuations can result in clinical states of many different emotional illnesses (Lawrence, 1999). Not all women experience these health issues.

From pregnancy to pregnancy and delivery to delivery a woman’s biochemical responses can differ (Geneva, 1984). Psychological and emotional disturbances continue or begin to manifest themselves in a substantial proportion of women postnatally. In most cases, these disturbances occur as mild depression ("the blues") of rapid onset (3-10 days postpartum) and short duration. Postpartum blues is the most common, with a prevalence of 40% to 80%. In others, the depression may be atypically severe (postpartum psychosis). In such cases, onset usually occurs within three months of delivery (Bledin, &

Brice, 1983). A very small minority with a rate of 0.1% to 0.2% of patients suffer from major psychiatric disorders in the puerperium (Lawrence, 1999; O’Hara, Schlechte,

Lewis, Wright, 1991). According to the CDC, between 12 and 20 percent of new mothers report postpartum depression (CDC,2013; O’Hara & Swain, 1996), a form of depression that typically begins in the first month after giving birth and is characterized by symptoms including sadness, guilt, exhaustion, and anxiety. Early identification of depression can reduce the rate of morbidity and mortality and can improve overall outcomes for the mother and her baby. The differences between each psychological disorder are shown in Table 3 (Lawrence, 1999).

Frequency and Nature of Health Problems during Postpartum

Infections

Postpartum infection is more common than has often been indicated. One in four women are suffering some infectious problem in the postpartum period, with mostly mild problems (Ahnfeltd-Mollerup, Petersen, Kragstrup, Christensen & Sorensen, 2012). The diagnostic criteria require that the woman has a temperature over 38.6◦C during the ﬁrst

24 hours after delivery or over 38◦C on any other day of the ﬁrst 10 postpartum days

(Yokoe, Christiansen, Johnson, Sands, Livingston, Shtatland et al, 2001). In a five years cohort study the incidence of postpartum infection has been estimated to be 1–4% after vaginal delivery and 10–20% after cesarean section, depending on deﬁnition (Leth,

Møller, Thomsen, Uldbjerg, Nørgaard, 2009). The most common etiology for postpartum infection is the local spread of colonized bacteria following vaginal delivery. Wound infection is more common with cesarean delivery (Tajnert, Tie, J O'Neill & Plavsic,

2013).

Table 3: Timing of Onset, Symptom, and Incidence of Maternal Psychological Problems

problem Onset Duration Symptom Incidence The “blues” 3-5days A few days Labiality of mood; 30%- 84%; mean (baby blues) postpartum tearfulness; cognitive incidence across typically confusion; studies 55.75% forgetfulness; headache; depersonalization; negative feeling toward baby; restlessness; irritability; nightmares.

Postpartum Within first At least Tearfulness; 27% had depressive depression postpartum two weeks, despondency; feeling symptoms at 3-5 year but usually inadequacy; numbness; months postpartum longer suicidal ideation; sadness; reduced 20% mild and 8% apatite and interest; severe depression at insomnia; 6 weeks postpartum; oversensitivity; feeling 40% mild and 17% of helplessness and severe depression at hopelessness; excessive 12 months dependency; anxiety postpartum and despair; irrational 12% major and fears about infant or minor depression mother’s health. combined at 9 weeks postpartum 10%- 40% experienced a depression of clinical severity at 3 days postpartum 6.1% with major depression at 8 weeks postpartum Postpartum Typically Depends Heightened or reduced 1-2 per 1000 psychosis within 2-4 on motor activity; postpartum women weeks or as diagnoses hallucinations; marked late as 8 and deviation in mood; weeks treatment severe depression, postpartum prescribed mania, or both; confusion; delirium

Modified from Kendall- Tackett KA, Kantor GK: Postpartum depression, sage series in clinical nursing research, Newbury Park, Calif, 1993, sage.

Endometritis is also a common infection in the postpartum period (Cosen, 2004).

It is an inﬂammation of the endometrial lining of the uterus without systemic signs, which is associated with chronic postpartum infection of the uterus with pathogenic bacteria, primarily Arcanobacterium pyogenes (Bondurant, 1999). One more postpartum infections is post-surgical or post caesarean wound infections. In a prospective descriptive study in a district hospital in central Kenya, they found that overall post- caesarean wound infection rate is quite high. Prolonged pre-operative duration of labor, prolonged Rupture of membranes and long duration of operation are associated with significantly higher incidence of wound infection. (Koigi-Kamau, Kabare &

Wanyoike-Gichuhi, 2005). Another postpartum infection is perineal cellulitis which is originating from an episiotomy incision resulted in 20% of the maternal mortality in King

County, Washington, between 1969 and 1977 (Shy, Eschenbach, 1979). Another relatively common postpartum infection is mastitis, a breast infection, 1 in 20 nursing mothers are suffering from mastitis. Other postpartum infection include: respiratory complications from anesthesia, retained products of conception, urinary tract infections, and septic pelvic phlebitis (Tajnert, Tie, JO'Neill & Plavsic, 2013).

Bladder Problems

Postpartum urinary incontinence is a serious problem in many developing countries, it is caused by vesico vaginal fistulae (Geneva, 1984). In hospital studies in

Nigeria less than 1% of all deliveries were complicated by fistula, but it is likely that in the general population the condition is much more prevalent (Liang, Chang, Chang,

Chen, Chueh & Cheng, 2007). Researchers from the University Medical Centre in

Utrecht, Netherlands, studied 344 women, during 12 and 36 weeks pregnant and three and 12 months after delivery. They found that just over 50% of first-time mothers’ experienced overactive bladder (OAB) symptoms. These included 3.5% who had the added problem of incontinence when they needed to empty their bladder urgently (Van der Vaart, De Leeuw, Roovers & Heintz, 2002). Goodwin and Scardino collected information about vesico-vaginal fistulas that were treated at University of California at

Los Angeles (UCLA) and its’ affiliated hospitals. They found only 43 cases of vesico-vaginal fistulas over 20 years (1980). Lawson found 166 cases of vesico-vaginal fistulas over an 18-year period in Newcastle-upon-Tyne, United Kingdom. Compare these with the report of 377 cases in Ibadan, Nigeria, over a 16-year period (1989).

Postpartum urinary retention (PUR) is a common phenomenon in patients who had a cesarean delivery, and there have been multiple studies that found morphine-related postoperative analgesia was the main contributing factor to PUR (2011). Also, stress incontinence, starting as a new symptom within three months of delivery, is associated with long second-stage labors and big babies, and in some instances with forceps delivery

(Geneva, 1984)

Backache

Fertilization lead to the release of estrogen, progesterone and relaxin, which are hormones essential to the growth and development of the fetus. These hormones that are essential to the pregnancy cause relaxation to the ligaments and muscles in the pregnant woman (Russell, Dundas & Reynolds, 1996). A conglomerate of functional changes are created by the laxity in muscles and ligaments, which compromises the stability of the

23 spine. Spinal stabilizers, such as the abdominal muscles, lose their effectiveness and ability to counteract the increasing lordotic curve. The zygapophyseal joint, the pelvis and ligaments and muscles that surrounding the spinal column, lose their ability to stabilize the spine during pregnancy (Dimarco, 2005). During the transition of post-partum, hormones begin to reset. This event is the prerequisite to re-hardening of muscles and ligaments. This can exposes the mother to be at risk of increasing the probability of back injury. Adaptations in posture, during pregnancy causes a posterior shift in the center gravity. Stabilization of the spine relies more heavily on the posterior joints. Asymmetric movement and altered biomechanics caused by hypermobility in the joint may result in adhesions about the zygapophyseal joints where re-attempts to stabilize the region becomes preemptive to spinal osteoarthritis (Geneva, 1984).

Frequent Headaches

Headache is a frequent complexity following childbirth (Geneva, 1984).

Postpartum headache is described as a complaint of headache and neck or shoulder pain in the ﬁrst 6 weeks after delivery. It is one of the most common symptoms with up to

39% of postpartum women experiencing headache in the ﬁrst postpartum week.

Postpartum headache can result from ﬂuctuating hormone and hydration levels, caffeine withdrawal as well as various life changes associated with motherhood (Sabharwal &

Stocks, 2011).

Constipation

Constipation is common during pregnancy and the postpartum period.

Contributing factors include relaxed muscle tone following delivery, inadequate fluid

24 intake, a diet low in fiber, iron or calcium supplementation, painful hemorrhoids, or fear of damaging perineal repair during a bowel movement (Lawrence, 1999; Cosen, 2004).

Researchers Suggestions for preventing constipation include eating foods high in fiber, drinking eight to ten large glasses of liquid daily (water, juice including prune juice or milk), and getting regular exercise. The use of ice packs or seats baths can be encouraged to alleviate persistent hemorrhoidal or perineal pain that interferes with bowel movements (who, 1990).

Breast Problems

During the first weeks after delivery women may experience some breast problems. These problems may affect breastfeeding status. About 80% of breast feeding mothers have sore nipples (Newton, Lansdowne, 1952). In a study by Livingstone et al.,

49% of subjects were asymptomatic and 51% complained of sore nipples ranging from mild tenderness with latching to severe nipple pain with latching and suckling (1996).

Some women have flat or inverted nipples which do not extend very far in the infant’s mouth and may impact the breastfeeding (Brown, 2011). Plugged duct is one of breast problem. It is a localized blockage of milk resulting from milk stasis “milk remaining in the duct” (Lawrence, 1999). In a retrospective case series of 25 breast feeding mothers, eight women experienced recurrent plugged ducts (Lavignea, & Gleberzon, 2012).

Mastitis is an inflammation of the breast most commonly found in breastfeeding women.

It can be infective or not. It occurs in about 3-20% of breast feeding women (Brown,

2011). According to recent studies, most of these problems can be easily treated or solved.

Anemia

Women are often iron depleted postpartum. Even for women in the United States who were enrolled in the Women, Infants, and Children (WIC) program, postpartum anemia occurred in 27%overall and in 48%of non-Hispanic blacks (Bodnar, Scanlon,

Freedman, Siega-Riz, Cogswell, 2001). The risk of postpartum anemia was greatest in those who were anemic in pregnancy. 49% of women who were anemic in trimester 3 developed anemia postpartum compared with 21% who were non-anemic (Meyer,

Eichorn Karl-Heinz, Vetter, Christen, Schleusner, Klos, Huch, 1995). Studies show that mothers with postpartum anemia have more symptoms of “postnatal blues” and are at increased risk for postpartum depression compared to non-anemic mothers (Corwin,

Murray-Kolb, Beard, 2003).

Hemorrhage

Hemorrhage is the most important single cause of maternal death in the world

(WHO, 1990; Kwast, 1991; Li et al, 1996). The majority of these deaths (88%) occur within 4 hours of delivery (Kane et al 1992), indicating that they are a consequence of events in the third stage of labor. Postpartum hemorrhage is a complication which occurs at the transition between labor and the postpartum period which lead to a loss of more than 500 mL of blood after delivery (WHO, 1996). The causes of hemorrhage is that after delivery, the uterus normally continues to contract (tightening of uterine muscles) and expels the placenta. After the placenta is delivered, these contractions help compress the bleeding vessels in the area where the placenta was attached. If the uterus does not contract strongly enough, called uterine atony, these blood vessels bleed freely and

26 hemorrhage occurs (WHO, 1996). This is the most common cause of postpartum hemorrhage. If small pieces of the placenta remain attached, bleeding is also likely

(Kwast, 1991).

Effect of Poor Diet during Postpartum Period

Effect on Mothers

Poor nutrition during postnatal period can cause depression. Women’s bodies must have enough iron and vitamin B3 (niacin) to convert tryptophan into a compound known as 5-hydroxy-L-tryptophan (5-HTP) and enough other B vitamins plus the mineral magnesium to convert vitamin B6 to pyridoxyl-5-phosphate (P5P). Without enough 5-

HTP and P5P available in the brain, serotonin cannot be made at adequate levels, which in result can lead to postpartum depression (Astrachan-Fletcher, Veldhuis, Lively,

Fowler, & Marcks, 2008). Therefore, women need to have adequate nutritional precursors available to avoid this problem. Also, research has shown that women with poor diets have six times the expected rate of perinatal mortality (Brinch, Isager,

Tolstrup, 1988).

Effect on New Born

Maternal micronutrient deficiencies during lactation can cause a major reduction in the concentration in some of these nutrients in breast milk, with subsequent infant depletion (Allen & Graham, 2003). Based on a categorization of the relation between maternal status or intake of each nutrient and its effect on the nutrient concentration in breast milk, “priority” nutrients for lactating women include thiamin, riboflavin, vitamins

B-6 and B-12, vitamin A, and iodine (Allen, 1994). This is based on the fact that low

27 maternal intake or stores reduces the amount of these nutrients in breast milk, and maternal supplementation can reverse this problem. (Astrachan-Fletcher, Veldhuis,

Lively, Fowler, & Marcks, 2008). In terms of the impact of these issues on actual weight of the newborn, research has shown that infants of malnourished mothers weigh less than those of non- malnourished mothers at the age of 1. In some cases, this weight difference is extreme; for instance, Russell et al. found that 9 of 14 children had suffered food deficiency that impacted their weight-for-age and height-for-age measurements. More specifically, six of these children had weight-for-age measurements and eight had height-for-age measurements below the 10th percentile (1998). In another study, 28% of children of mothers with eating disorders had eating or weight problems, and 17% met criteria for failure to thrive in the first year of life. (Brinch, Isager & Tolstrup, 1988).

Despite these findings, some case studies suggest that malnourished mothers with eating disorders may be less concerned about their children having abnormally low weight

(Astrachan-Fletcher, Veldhuis, Lively, Fowler, & Marcks, 2008). Research has shown that eating disturbance at age 5 has been predicted by events in the infant’s first month of life (Stice, Agras & Hammer, 1999). More specifically, poor maternal nutrition, body dissatisfaction, and hunger in the first month of an infant’s life predict secretive eating, whereas maternal restraint and drive for thinness predict overeating at the age of 5

(Astrachan-Fletcher, Veldhuis, Lively, Fowler, & Marcks, 2008).

Dietary Intake in American Postpartum Women

American postpartum women’s diet should replace nutrients lost during pregnancy and include nutrients needed to maintain their body (Women's Health, 2010).

The Dietary Guidelines published by the US Department of Agriculture form the basis for nutrition counseling for postpartum women (US, 2010) An additional 500 Kcal/day is recommended for women who breastfeed (e.g., 2,300–2,500 Kcal/day versus 1,800–

2,000 for a moderately active non-pregnant, non-lactating women) (Institute of Medicine,

1992). Even higher intake may be recommended for breastfeeding women who are underweight, women who exercise vigorously, or women who are breastfeeding more than one infant (Association of Reproductive Health Professionals, 2013). Whether breastfeeding or not, the new mothers in United States are encouraged to take good care of themselves. They also encouraged to eat a healthy diet. For example, American women are recommended to eat a wide variety of foods with high nutrient density (US,

2010). The recommended servings from each food group is provided from the Food

Guide Pyramid which is used as a guide for family meal selection and preparation. The number of servings from each of the food groups recommended for a postpartum woman may differ slightly depending on the postpartum woman’s needs. The number of servings will depend on the woman’s: age, body size, activity level, weight before pregnancy, weight gained during pregnancy, and breastfeeding status (Food Guide Pyramid, 2014).

American postpartum women’s also recommended to use foods and recipes that require little or no preparation as well as taking in plenty of fluids such as water, juice, and soups

(Choose My Plate, 2014). In addition, American postpartum women are advised to avoid fad weight reduction diets during this period. Also, avoid harmful substances (such as alcohol, tobacco and drugs), and excessive intake of fat, salt, caffeine, sugar, and artificial sweeteners (Association of Reproductive Health Professionals, 2013)

Dietary Intake in Saudi Arabian Postpartum Women

General Information about Saudi Arabia

Since the mid -20th century, Saudi Arabia, with its oil riches, has been in a sociodemographic, culture and economic transformation. In the last four decades, the population has increased from four million (5% urban, 70% literate) to 28 million (80% urban, 81% literate) with over 50% of the population in Saudi Arabia now less than 25 years of age. This fast transformation raised many new concepts. Young women became more reluctant to marry at an earlier age, choosing to pursue a higher education and a career, and less accepting of having their roles restricted to motherhood. The consequences of these changes would have substantial effects on the mother, her child and the family (AL-Sabaie, 2011).

Health Custom during Postpartum among Saudi Women

Many societies observe a 40- day postpartum period of rest, seclusion, and ritual following childbirth. The first 40 days in postpartum period is characterized in Saudi

Arabia and generally in the Middle East by an observance of seclusion, congratulatory visiting, the reciprocal exchange of gifts and money, and a special diet (Abdulallah &

Ali, 2007). Women in Saudi Arabia usually return home after two nights in the hospital, and on the third day after delivery if there are no medical complications. Family and neighbors visit the new mother, and the men then contribute some money. According to the religion, on the seventh postpartum day the father should slaughter two sheep if the baby is a boy and one sheep if the baby is a girl; this ritual is called “Aqeeqah”

(Albukhari, 2006). The father gives half of the sheep to the people in need and cooks dinner from the other half for guests and visitors. During the first 40 days, the mother and infant do not leave the house unless it is necessary to go to the clinic. Also, during the first six weeks, women receive help with their daily work and catering for visitors who visit during this period. The amount and duration of work varies depending on whether their families are living nearby and if they have cordial reciprocal relationships with them. Most women seem to rest for at least two weeks, and some receive help for longer.

Most women receive congratulatory visits from relatives and neighbors. The visitors come in the morning and leave in the early afternoon. Gifts are given in the form of sweets, clothes, and money. The mother’s diet during this period is different than the diet she used to eat before delivery. It has a lot of restriction and taboos. In next section, there will be an explanation about what these restrictions are (Hundt et al., 2000).

Postpartum Diet in Saudi Arabia

The recommended dietary intake for Saudi women is provided by department of nutrition in ministry of health and shown in table 3 (Cosen, 2004). Women during this time are recommended to consume a high protein diet and a low carbohydrate diet. For example, the postnatal diet containing proteins might include meat, fish, cheese, eggs, and milk because it contains lime, as well as vitamins and minerals (liver and kidney), vegetables and fruits, which should be kept at room temperature (Musaiger, 2009). In

Saudi Arabia, women are encouraged to eat multiple meals in a day (5-6 times) after birth. Woman should not starve herself or even overfeed herself (Abdulallah & Ali,

2007). Breastfeeding women need to add (700 calories) and eat sufficient quantities of

31 nutrients such as protein, calcium, iron, vitamin A, niacin, riboflavin, vitamin B6, and

B12.

Table 4: Recommendation for Postpartum Women in Saudi Arabia

*Dietary Reference Intakes (DRI)

Nutrient Non- lactating Women Lactating Women

Energy, kcal 2000 kcal/d. 2500 kcal/d Protein, g 70 80 Carbohydrates, g 270 350 Vitamin C, mg 90 90 Thiamin, mcg 1.8 1.8 Riboflavin, mcg 1.8 1.8 Niacin, mg 20 20 Vitamin B-6, mg 2.5 2.5 Folate, g 400 500 Vitamin B-12, mcg 4 4 copper, mg 3 3 Selenium, mcg 65 75 Choline, mg 400 500 Vitamin A, mcg 1000 1300 Vitamin D, mcg 15 20 Vitamin K, mcg 54 55 Calcium, mg 1200-1500 1200-1500 Phosphorus, mg 1000 1000 Magnesium, mg 480 480 Iron, mg 8-25 13 Zinc, mg 15 19 Iodine, mcg 175 200 Selenium, g 55 70 Fluoride, mg 3 3 *(Cosen, 2004).

Cultural Beliefs

In Saudi Arabia, while a mother is in postpartum seclusion, they believe that if a woman wants to squeeze “dirty blood” out of the womb and increase her milk production, she needs to eat: honey with whole wheat bread, tea spiced with ginger, fenugreek, which is commonly used for treating stomach problems in women, and arugula (Musager, 2009). Also, women need to increase their milk supply. During the postnatal period, Saudi women believe that they can soothe their body by drinking green and chamomile tea and eating hot soup. In addition, to strengthen their bodies they eat much meat cooked with water and black pepper and eat dates (Kinsara, Farid, Wajid, &

Sadi, 2002).

Restricted foods are thought to make the woman get severe postpartum stomach contractions, prolonged bleeding, malodorous vaginal secretions, and blood retention in the uterus, or a womb filled with air (Abdulallah & Ali, 2007). These foods include: foods perceived as having a strong smell such as onion, garlic and spicy foods; foods that have sticky textures such as okra, green onion, cantaloupe, watermelon, and cucumber; food high in citrus such as lemons; and cold foods and drinks such as smoothies, ice- creams, ice, etc. (Kinsara, Farid, Wajid, & Sadi, 2002).

The Function of the Foods

Dates. Date consumption has been emphasized during pregnancy and after delivery in many Islamic traditions (Hadarmi et al., 1999). Date fruit has Calcium, serotonin, tannin, linoleic acid and Prochcidas anzime that are important for bleeding control. Date fruit also, has much glucose that is the most important source of production

33 of energy in body and also it is the best food for muscles of uterus. In addition Date fruit descends blood pressure in pregnant women for a little time so that causes women to have lesser bleeding in delivery. Also dates is laxative which is caused to facilitate delivery and prevent constipation (Musaiger, 2009). Dates strengthen uterine muscles and facilitating delivery as well as reduce postpartum hemorrhage (Abdulallah & Ali, 2007).

In connection with possible mechanism of date effect on bleeding, one can say that one important factor in preventing women from bleeding is Serotonin that there is in date.

Studies indicate that this substance is a stimulus of vessel and smooth muscle contraction

(Cosen, 2004). Tannin and its compounds are also significant factors which involve 1% of the weight of fresh dates (Hadarmi et al. 1999). Also tannin can be effective in controlling bleeding (Attalla & Harraz, 1996). Among other factors existing in date, we can consider Linoleic acid, Oleic and Starteic (Abdulallah & Ali, 2007). Linoleic acid can be changed into Arachidonate and then into Ichosanoids. Ichosanoids are 20-Carbon lipoacids that fall into three categories: Prostaglandins, thromboxane and locoterins

(Cosen, 2004). Prostaglandins play an important role in contraction of uterine muscles and bleeding control. Thromboxane cause platelet accumulation and vessel contraction.

Leucoterins are substances which affect vessel contraction. Peroxidase enzymes existing in date is a significant factor in bleeding control (Cosen, 2004). Date has some basic and significant minerals like iron and calcium. In countries with limited resources, where a majority of women have anemia at the onset of their pregnancies, the slightest deviation from normality during labor and/or delivery leading to excessive hemorrhage can put women's lives at risk (Nama, Karoshi & Kakumani, 2006). Calcium is an element quite

34 necessary for muscular contraction (Attalla, Harraz, 1996). There is usually 50 international units of Vitamin A, 0.09 mg Vitamin B1, 0.1 mg Vitamin B2 and 0.22 mg

Thiamin in each 100 gram of date (Abdulallah & Ali, 2007).

Fenugreek (Trigonella Foenum Graecum). Is one of many condiments known to mankind, and has been cultivated for a very long time. It has been popularly used as a food and as a medicine in the Mediterranean region, western Asia, northern India, and

Africa (Musager, 2009) In India, Fenugreek seeds are consumed with jaggery during the postpartum period, which is supposed to facilitate lactation. Also, its seed powder is considered an antiseptic and employed towards improving skin texture. The foliage of

Fenugreek is also a commonly consumed leafy vegetable in many parts of India. One hundred grams of Fenugreek seeds contain 26.2 g% protein, 5.8 g% fat, 44.1 g% carbohydrate, and provides 333 Kcal (Gopalan, Rama Sastri & Balasubramanian, 1989).

Women have used the spice fenugreek since ancient times in the Middle East, North

Africa, and India to stimulate milk flow. Research has shown that fenugreek can increase milk production as much as 90 percent, although no one knows exactly how. The oil contained in fenugreek seeds is believed to play a role in boosting milk supply

(Abdulallah & Ali, 2007).

Ginger (Zingiber Officinale). Ginger is primarily used for anorexia, nausea and vomiting, dyspepsia, cold, and motion sickness, as well as an expectorant. Studies conducted in vitro and in animal models have elicited physiological effects related to a number of the compounds found in the ginger rhizome. Among these are antiemetic, anti- inflammatory, antimicrobial, and anti-oxidative effects. The root of zingiber officinale

35 has also shown to have immune-system stimulating and platelet aggregation-inhibitory activity (Li, McGrath, Nammi, Heather & Roufogalis, 2012, p.238). The major component found in ginger, [6]-gingerol, was reported to have “significant reduction in

12-0-tetradecanoyl-phorbol-13 acetate (TPA)-induced ear inflammation” (Park et al.,

1998). Major postpartum pain is caused by uterus contractions. Similar to menstrual pain, uncomfortable cramping can be alleviated by dietary consumption of ginger. Studies had showed that ginger significantly minimized the intensity and shortened the duration of pain; and “it was as effective as mefenamic acid and ibuprofen in relieving menstrual pain” (Ozgoli, Goli, & Moattar, 2009; Rahnama, Montazeri, Huseini, Kianbakht, &

Naseri, 2012). Moreover, major component found in ginger, 6 shogaol, was assessed to have ability to significantly attenuate numerous neuroinflammatory responses (Shim et al., 2011).

Green Tea. This popular antioxidant has been touted to fight fatigue, help with stomach disorders, alleviate nausea, vomiting, diarrhea, and fevers, and prevent cancer

(Gruenwald, 2004). It also helps to reduce that stubborn postpartum fat that lingers on abdominal area, but the data in a study by Weia S.H. et al. suggest that persistent green tea consumption by mothers during pregnancy may be associated with an increased risk of pre-eclampsia, especially severe pre-eclampsia (Weia Xua, Xiongc, Luoa, Audiberta,

& Fraser, 2009).

Chamomile. The oil extracts of this plant have been utilized for various health conditions, such as dyspepsia, menstrual problems, and even nervousness. Despite these uses, no therapeutic use has undergone scientific study as of yet (Gruenwald, 2004).

Chamomile may be used as an antispasmodic or digestive aid (Spoerke, 1980). Kay

(1977) documented the use of chamomile tea in a Mexican-American barrio. During the last month of pregnancy, women took chamomile tea every night. When contractions commenced, the amount of tea consumed was increased believing that the tea would make the contractions stronger if the woman was truly in labor or cease the contractions if the labor was false. Chamomile contains a volatile oil which may irritate mucous membranes and act as a spasmolytic. Other sub-stances which are contained in chamomile may act as spasmolytic agents and exert anti-inflammatory and anti-bacterial properties; however, the substances are in such small concentrations that they do not exert much physiological activity (Spoerke, 1980). Large amounts of chamomile can produce vomiting. Chamomile can cause skin rashes or serious allergic reactions in individuals known to be sensitive to ragweed pollens (Spoerke, 1980; Lewis, 1978).

Arugula. Also known as watercress, it shows extraordinary potential in the realm of cancer prevention and management, as well as offering the culinary versatility of a delicious leafy green. The anticancer benefits of watercress may arise from its ability to increase the level of antioxidants in the blood and to protect DNA against damage (Gill,

Haldar, Boyd et al, 2007). In fact, growing evidence suggests that watercress may lower the risk of prostate, colon, and breast cancers, and may counteract certain processes by which cancers proliferate and spread (Pledgie-Tracy, Sobolewski, Davidson, 2007).

Watercress is an excellent source of the antioxidants vitamins A and C, as well as vitamin

K, an essential micronutrient for bone health. It is also a rich natural source of lutein and zeaxanthin, two carotenoid nutrients that are gaining attention for their ability to protect

37 vision and support cardiovascular health (Juge, Mithen, Traka, 2007). However, there is no scientific evidence that Arugula consumption during postpartum period can increase the mother’s breast milk production or help the mother recover quickly from the exertion of labour as females in Saudi Arabia believe.

Honey. It is a supersaturated sugar solution with approximately 17.1 percent water. Fructose is the predominant sugar at 38.5 percent, followed by glucose at 31 percent. Disac-charides, trisac-charides and oligosaccharides are present in much smaller quantities. Besides carbohydrates, honey contains small amounts of protein, enzymes, vitamins and minerals. Honey is known to be rich in both enzymatic and non-enzymatic antioxidants, including catalase, ascorbic acid, flavonoids and alkaloids. Although appearing only in trace amounts honey also contains about 18 different amino acids

(Crane, 1976). In Middle Eastern culture, honey has been used in new mother’s diet due to the belief that it has the ability to help in the uterine contractions which lead to its return to normal size. Also mothers in Middle East are using honey for wound healing

(Musager, 2009). Recent studies have shown that honey is a great remedy for wounds. It forms a wall defending the wound from outside infections and allows skin cells to grow without creating a scar. The sugars in honey extract grime and moisture, which helps prevent bacteria from growing (Thompson, 2010).

Hot vs. Cold. It is a common belief in many non-Western cultures. The necessity of maintaining a “hot-cold balance” within the body and with the environment after the birth of a baby is very important. Hot-cold concepts of healthcare also known as humoral theories. They are old theories in the traditional cultures of Latin America, Asia, Middle

East and Africa. In many non-Western cultures, blood is considered “hot.” Therefore, after giving birth, when the women have lost blood, they are considered to be in a cold state. Accordingly, postpartum care in these cultures is aimed at keeping the new mother warm; it is believed that this will restore her humoral balance (Kim-Godwin, Soo, 2003).

The hot-cold principle in medicine, has been persistent in history and currently is very widespread. In spite of variations in hot-cold theory and practice among members of different cultures and even within the same cultures, the dimensions by which particular hot-cold systems vary and the mechanisms by which they are perpetuated within particular cultures in spite of cultural variation have not been thoroughly studied

(Mizsser, 1981).

CHAPTER III

METHODOLOGY

The purpose of this comparative study was to examine the difference between

Saudi women and American women living in United States, concerning their maternal restrictions and practices during the first six week after childbirth. The research hypotheses is:

There was a difference in the maternal restrictions and practices during the first stage of postpartum period (1-6 weeks) between Saudi and American women in USA.

Research Design

The research design of this descriptive study was mixed method design, including qualitative non-experimental and quantitative data, of two groups. The two groups were

American women and Saudi women during the postpartum period. Both groups gave information about their dietary intake during the postpartum period and the reason why they were using it. Therefore, the dependent variables were the dietary restrictions and practices. The independent variable was the nationality of the participant.

Study Population

In this study, a convenience sampling was used. Twenty eight females aged from

20-40 living in United States (18 Saudi and the 10 American), who delivered a live birth during 2014, were participants in this study. Selection criteria included: 1) female gender who delivered a live birth during the year of 2014; 2) Living in United States;

3) Full-term or near-term birth (babies who were born between 37 weeks or later).

39 40

Exclusion criteria included male gender, females who did not have a baby during 2014, and females who had premature babies (babies that were born under 37 weeks of pregnancy).

Data Collection Instruments

Participant women were asked to respond to an online survey questionnaire. The questionnaire (Appendix A) was found on the WIC website and created by Kansas

Nutrition and WIC services (2013). The researcher added some updates on the questionnaires. The survey was available to participants through the Qualtrics website online. It was consist of two parts:

Twenty one questions were in part I of the questionnaire to gather demographic information about participants, including age, nationality, primer language, place of resident and duration of resident in United States, race and ethnicity, household size and number of children in a household, and household income. There was a section also asking whether the female had a baby who was born in 2014. If yes, then she was asked when was the baby born, and to qualify, women and their infants had to meet these criteria:

 Full-term or near-term birth (babies who were born between 37 weeks and 42 weeks

of pregnancy)

41 square comparison test and were asked about how many times mothers eat per day, weather if she restricted or used a special diet, tried to lose weight during this period or not, and avoidance or preference of any type of food or beverages that occur only during the postpartum period and why. There was also a question that asked if the mother received pressure to follow cultural and familial norms during this period or not.

Question eleven through seventeen were excluded from the study results because most of the participants did not responded to this part of the survey which were asked about the dietary intake. In this seven questions, participant were asked to choose which foods, or beverages they have consumed within postpartum period from the lists that provided in the survey, as well as the frequency of use (per day, week, or month) and how much per serving. Questions 18 through 32 were asked about physical activity, family support or judgment, breastfeeding status, source of information used, and medications or supplements used. This section also asked participants to provide some personal experiences during the postpartum period.

Procedure

This study was approved by the Institutional Review Board (IRB) at Kent State

University (KSU). An email was sent through the account of the Saudi Student

42 criteria. An email invitation (Appendix B) with a link to the survey was sent to Saudi females explaining the purpose of the electronic survey and requesting them to complete it. Permission was then granted from the Child Development Center at Kent State

University to hand out (Appendix C) the survey link to US females. Females were given a brief description of the survey then asked to fill out the questionnaire by typing the survey link. Upon typing/ clicking on the survey link, participants were first directed to an online consent form (Appendix D), and then onto the survey. The survey was sent out through Qualtrics.com (version 21.0), and was accessible for six weeks. Qualtrics.com is a website that allows users to easily create electronic surveys. Two reminder emails were sent out during the six weeks’ time frame to remind the participants to complete the survey. Data collection was completed on September 29, 2014 and data was then summarized using SPSS.

Statistical Analysis

Statistical analysis was completed using SPSS Version 21.0 (IBM, New York).

Descriptive statistics were used for anthropometric and demographic variables.

Frequencies was perform on questions# 2, 3, 10, 12, 13, 17, 19, 20, and 21 to determine the differences in the variables between two groups: Saudi and American postpartum women who lives in United States. Chi- square (Ӽ2 test) comparisons was used to analyze the association between groups in terms of dietary restrictions and practices. Statements measured by chi square were (3-11) in the postpartum questionnaire. P ≤ .05 was the level of statistical significance set a prior for test. Also, means were calculated for the

analysis of the sources of information used regarding dietary restrictions used during the postpartum period.

CHAPTER IV

JOURNAL ARTICLE

Introduction

Each culture has its own values, beliefs and practices related to pregnancy and birth.

44 45 food restrictions and work limitations is typically enforced on her (Piperata, 2008). For instance, a Saudi postpartum woman is not supposed to consume certain types of food such as cold foods and drinks. Also, new mothers are encouraged to consume more meat and hot soups, as well as dates and herbal supplementations (Hundt, Beckerleg, Kassem,

Abu Jafar, Belmaker, Abu Saad & Vardi, 2000). In spite of the obvious differences between the Saudi and US diets and practices during the postpartum period, there is a scarcity of research on the impact of these diets and practices on women’s health (Ngoc

Thu & Lundberg, 2011).

Approximately, 1,400 women die every day during postnatal period from complications related to childbirth results in 500,000 death/year (Veneman AN, 2008).

The information on food habits and beliefs during the reproductive period is very important to help in assessing the causes and the magnitude of those complications and in planning of the intervention programs (Stowart & Whiteford, 1987). Recently, Saudi families have come to the United States in large numbers to pursue academic studies.

Saudi Arabia's oil wealth allows the government to sponsor these students financially.

Therefore, the number of Saudi women who gave birth in United State is increasing.

Some of these women follow the same food restrictions that they used to follow in Saudi

Arabia, while others follow the kind of restrictions that are common in the United States because they either do not have access to the types of foods that they used to eat during this time, or they do not have enough support to help with their needs as well as that they have eventful times that are filled with much studying and working. Therefore, the health care policy makers and health care providers need to be cognizant of food restrictions and

46 practices among those population which may be followed, so that these practices can be incorporated into care of the postpartum women.

The purpose of this comparative study is to examine the difference between Saudi women and American women living in United States, concerning their maternal dietary intake and practices during the first six weeks after childbirth. The hypothesis of this study was that there will be a difference in the maternal dietary intake and practices during the first stage of postpartum period (1-6 weeks) between Saudi and American women living in United States of America.

Methods

Study Population

In this study a convenience sampling was used. Twenty eight females aged from

20-40 living in United States (18 Saudi and the 10 American), who delivered a live birth during 2014, were participants in this study. Selection criteria included: 1.) female gender who delivered a live birth during the year of 2014. 2.) Living in United States at time of birth. 3.) Full-term or near-term birth (babies who were born between 37 weeks or later).

Exclusion criteria included male gender, females who did not have a baby during 2014, and females who had premature babies (babies that were born under 37 weeks of pregnancy).

Data Collection Instruments

Participant women were asked to respond to an online survey questionnaire. The questionnaire (Appendix A) was found on the WIC website and created by Kansas

Nutrition and WIC services (2013). The researcher added some updates on the

47 questionnaires. The survey was available to participants through the Qualtrics website online. It was consist of two parts:

 Full-term or near-term birth (babies who were born between 37 weeks

and 42 weeks of pregnancy)

Part II of the survey consist of thirty two questions and asked about the postpartum diet which collect information from mothers about their food consumption and intake of nutrients from foods and dietary supplements as well as the practices that was used during this period. The first ten questions of this part were measured by chi square comparison test and were asked about how many times mothers eat per day, weather if she restricted or used a special diet, tried to lose weight during this period or not, and avoidance or preference of any type of food or beverages that occur only during the postpartum period and why. There was also a question that asked if the mother received pressure to follow cultural and familial norms during this period or not.

Question eleven through seventeen were excluded from the study results because most of the participants did not responded to this part of the survey which were asked about the

48 dietary intake. In this seven questions, participant were asked to choose which foods, or beverages they have consumed within postpartum period from the lists that provided in the survey, as well as the frequency of use (per day, week, or month) and how much per serving. Questions 18 through 32 were asked about physical activity, family support or judgment, breastfeeding status, source of information used, and medications or supplements used. This section also asked participants to provide some personal experiences during the postpartum period.

Procedure

This study was approved by the Institutional Review Board (IRB) at Kent State

University (KSU). An email was sent through the account of the Saudi Student

Association at Kent State University, Ohio and Saudi Student Association at USA, as well as social media to find the Saudi female participants who met the criteria and were willing to participate in this study. For the American population, permission was obtained from the Child Development Center (CDC) at Kent State University to see if there were participants who were willing to participate in the study and who met the selection criteria. An email invitation (Appendix B) with a link to the survey was sent to Saudi females explaining the purpose of the electronic survey and requesting them to complete it. Permission was then granted from the Child Development Center at Kent State

49 through Qualtrics.com (version 21.0), and was accessible for six weeks. Qualtrics.com is a website that allows users to easily create electronic surveys. Two reminder emails were sent out during the six weeks’ time frame to remind the participants to complete the survey. Data collection was completed on September 29, 2014 and data was then summarized using SPSS.

Statistical Analysis

Statistical analysis was completed using SPSS Version 21.0 (IBM, New York).

Descriptive statistics were used for anthropometric and demographic variables.

Results

Between Saudi females and American females, 300 individuals were invited to participate in this online study. Responses to the survey were collected during August and

September of 2014, for a total of 40 days. A total of 158 subjects consented to participate in the survey. However, only 78 participants completed the survey. Eighty subjects did not complete any questions of the survey which yielded a 62% return rate. Of the survey

50 participants, only 47 participants answered, “Yes” to the filter question (Are you currently a new mother of a baby born during 2014?) and were therefore eligible to answer the rest of the survey. However, there were 19 eligible females that did not answer any questions beyond the first one. This yield a 36% response with a total of 28 actual participants in the study. Of those participants, 18 were Saudi females and 10 were

American females. Most of the data obtained were in nominal form, which did not allow for sophisticated statistical analysis. Frequency distribution, percentage, mean and Chi

Square were the statistics used in the data analysis.

Table 5 represents the demographic data of the 28 participants. The majority of the population was Saudi female (64%, n=18), lived in United States for 2-5 years (40%, n=11), had single birth (89%, n=25), with no medical problems (96%, n= 27), and breastfed their babies (82%, n= 23).

Table 6 examines the differences between Saudi and American females regarding their maternal restrictions and practices during the postpartum period. Crosstabs were used to calculate a Chi-Square (Ӽ2 test), which tests the association between variables.

For trying to lose weight during the postpartum period, there was a significant association between American and Saudi women (P= 0.05). Fifty percent of Saudi participants indicates that they tried to lose weight while only eleven percent of American participants said yes to this statement.

Table 5: Demographic Data of Saudi and American Postpartum Women

Demographic n % Nationality Saudi 18 64 American 10 36 Primary Language Arabic 18 64 English 9 32 Other 1 4 Country of Residence (United States) Yes 28 100 No 0 0 Length of living in United States Less than 2 years 6 22 2-5 years 11 39 6-10 years 2 7 10-30 years 0 0 More than 30 years 2 7 All my life 7 25 Multiple Birth Yes 3 11 No 25 89 Medical Problems or Special Needs for Mothers Yes 1 4 No 27 96 Medical Problems or Special Needs for Babies Yes 1 4 No 27 96 Breastfeeding* Yes 23 82 No 5 18 Household Sizeb 8 (1S) 1 3 7 0 0 6 (1S) 1 4 5 (2S,1A) 3 11 4 (7S, 2A) 9 32 3 (2S, 5A) 7 25 2 (2S) 2 7 Number of Children 1 13 46 2 9 32 3 5 18 4 or more 1 4 Yearly Income Under $10,000 7 25 $10,000 - $19,999 2 6 $20,000 - $29,999 3 11 $30,000 - $39,999 3 11 $40,000 - $49,999 5 18 $50,000 - $74,999 0 0 $75,000 - $99,999 1 4 $100,000 - $150,000 1 4 Over $150,000 0 0 Would rather not say 6 21 *%= Percentage as defined by frequency. a 6 American and 17 Saudi women. b S= Saudi women, A= American women.

Table 6: Significant Association of Food Restrictions and Practices during the Postpartum Period among Saudi vs American Women. Saudi women American Statements women P n % n % 1. Did you try to lose Yes 9 50.0 1 11.1 weight during 0.049 No 9 50.0 8 88.9 postpartum period? 2. Did you use restricted Yes 3 16.7 1 11.1 0.702 diet? No 15 83.3 8 88.9 3. Were you on a special Yes 8 47.4 1 11.1 0.061 diet? No 10 52.6 8 88.9 4. Were there any Yes 9 50.0 2 22.2 pressured to follow 0.166 No 9 50.0 7 77.8 cultural/family norms? 5. Were there any food or beverages that you Yes 5 29.4 2 22.2 avoid or did not eat 0.694 No 12 70.6 7 77.8 during the postpartum period? 6. Were there any foods or beverages that you use Yes 7 38.9 1 12.5 only during the first six 0.178 No 11 61.1 7 87.5 weeks of the postpartum period? 7. Did you restrict your Yes 5 55.6 4 50.0 physical activity during 0.819 No 4 44.4 4 50.0 the postpartum period? 8. Did you get adequate Yes 8 88.9 5 62.5 0.200 family support? No 1 11.1 3 37.5 9. Were there anyone of your family who judge Yes 4 44.4 2 25.0 the way you eat or 0.402 No 5 55.6 6 75.0 drink during the postpartum period? P= statistical significance as defined by Chi Square

There was no significant association exists between use of restricted or special diet and nationality (P= 0.702 and P= 0.061 respectively), that is, both Saudi and

American women equally prefer not to restrict nor use a special diet during the postpartum period. However, the researcher found that 47% of the Saudi population used a special diet. 10% of these population said that the physician prescribed this diet for them, while 90% of them indicates that they prescribed it for themselves. Also, 50% of the Saudi participants, who did not used the restricted diet, indicates that they received a lot of pressure to follow family or cultural norms. Moreover, both American (25%) and

Saudi (44%) participants indicated that there were some of their relatives whom judge the way they eat or drink during this period. For restricting the physical activity, there was no significant association between the groups (P=0.819). However, 50% of the American population indicated that they restricted their physical activity, and 55% of Saudi population did.

As presented in Table 6 there were no significant association in the avoidance or usage of some foods or beverages during the postpartum period (P= 0.694, 0.178 respectively). The percentage of Saudi women who indicated that they avoided or used some foods or beverages only during the postpartum period were (29%, 39% respectively), whereas the percentage of American women were (22%, 12%). For the small percentages of participants whom indicates that they used or avoided some foods or beverages during the postpartum period, they were asked to list the foods and/or beverages that they used or avoided and provided the reasons why, which is summarized as following:

Avoided food and beverages were: Cold beverages, coffee, lentils, beans, gooey food, spicy foods, coffee, soda, ice-creams, rice, and fast food. The reasons were:

 Relief or regulation of labor pain (n=2)

 Cold beverages increases pain and bleeding (n=1)

 It is not good for the Uterus (n=1)

 Cold beverages freezes the blood in the uterus (n=1)

Used foods and beverages were: Drinking milk with prouder cinnamon and Fenugreek, herbal tea with honey, hot soup and beverages, a lot of meet, and dates. The reasons were:

 Relief or regulation of labor pain (n=2)

 Restore balance within the body (n=1)

 Liquid plus protein increases milk secretion and lactation for me (n=1)

 Control of bleeding (n=1)

 Weight loss (n=1)

 Relief of faintness after childbirth (n=1)

Respondents were also asked to indicate and rank the scores from which any information was obtained regarding use of the dietary intake and practices during the postpartum period. Educational sources listed in the questionnaire included professional care provider, herbalist, health food source, friends or relatives, books, magazines, newspapers, and/or television, and/or other sources which the respondent was asked to specify. Professional care provider was the highest ranked sources of information among both nationality with (Mean= 1.7), followed by health food sources and friends or

55 relatives (Mean= 2.3, 2.45 respectively). Herbalist, books, and magazines, newspapers, television, or websites were ranked lower.

Discussion

The purpose of this comparative study was to examine the difference between

Saudi women and American women living in the United States, concerning their maternal restrictions and practices during the postpartum period. This study is the first to compare dietary restrictions and practices of Saudi and American women. Overall, there were limited significant differences demonstrated between Saudi and American women in regards to their maternal restrictions and practices during the postpartum period. Thus, the hypothesis of the study was rejected.

There was a significant association in trying to lose weight during the postpartum period between Saudi and American women. 50% of the Saudi participants tried to lose weight while only 11% of the American population did. This finding is supportive with similar research study which showed that 61% of the new Saudi mothers tried to lose weight and assumed that losing their baby fat were easy (Musaiger, 2009). Other study did not promote weight loss after childbirth because it lead to inadequate caloric consumption which may increase postpartum fatigue and have a negative impact on mood, especially if the mother is breastfeeding. The study also indicated that post pregnancy dieting may be accompanied by a significant decrease in bone mineral density

(Oliveri, Parisi, Zeni, Mautalen, 2004). Also, in a study by Mary et al., 13 American women out of 23 had a significant weight loss during the first year postpartum (2003). In the study they found that women who completed the structured diet and physical activity

56 intervention successfully lose weight. The study also indicated that these 13 participants, who were attending a one hour educational session once a week for 12 weeks during the early postpartum period, had a high preferences to lose weight during the postpartum period (2003). These postpartum behaviors in this study, among Saudi population might cause a series health problems such as nutrients deficiencies and complications, and also could affect the growth of infants. Therefore it is important to increase women knowledge about the impact of postpartum dieting on both mother and infant’s health.

According to the demographics of the participants, most of the surveyed women

(78%) had been living in the United States for 2-5 years and more. This is might be the reason why there were no association between the groups. Saudi population might be influenced by the environment of United States and started to use the restrictions and norms that are used in United States during the postpartum period. Also, this study reveals that the restricted diet were not used among most of the participants (85%), but most of the Saudi participants (50%) indicated that they were under pressure to follow cultural and family norms that are used in their country. This present that it is also possible that some women did not really want to follow traditional practices, but had to yield to pressure from their mothers-in-law, mothers, other old relatives or neighbors.

Therefore, they did not use the traditional food habits or practices during their stay in

United States. In similar Chinese studies, they showed that the majority of participants did not want to follow cultural or family norms during this period but they enforced to do it by their old relatives (Holroyd et al., 1997; Leung et al., 2005).

The present study showed that professional care provider was most often consulted for information on dietary intake during postpartum period. According to Nuss et al. (2007), The most common source of nutrition information reported at one year postpartum by American women were books/magazines (40.0%) , followed by family

(32%) and friends (29%). Also the study found that 40% of the educated women used the

Internet as a source of nutrition information. Previous research in Saudi Arabia has shown that the majority of the women did not use nurses, physicians, or professional provider as their source of information (Mansour, & Hassan, 2009). Other study has shown that friends and relatives were the primary source of nutritional information

(Musaiger, 2009). This finding suggest that it is possible that Saudi women who live in

Saudi Arabia might be relying on family’ and old relative’ information, while Saudi population who live in United States do not have their friends or relatives to depend on and use their information; therefore, they used professional care providers as number one source of information. This indicate that expatriation to other countries must be influential, because there are several changes in nutritional behavior and believe in the food habits and restrictions in Saudi participants who live in United States. Thus, further investigation is needed to compare between Saudi women who live in United State and

Saudi women who live in Saudi Arabia and see if there is differences in their believe or not.

In this study, almost all of participants did not reported their dietary intake during this period because data were collected by means of retrospective self-report in a questionnaire. This inevitably relies on participants’ memory of dietary intake, which

58 results in missing most of the dietary intake data in this study. Therefore, Quantitative studies on dietary intake with bigger sample are needed to provide more information about the dietary habits of both Saudi and American women during the postpartum period. Also, there is a need to investigate Saudi women’s believe about the food habits, restrictions, or practices they used during this period and whether if it has any significant nutritional and healthful value.

Application

It is important for dietetic practitioners and other health care providers to be aware of postpartum’ food habits and practices among Saudi and other population so that these practices can be incorporated into planning maternal and obstetrical care. Many of the diet habits and practices are beneficial to the mothers’ and babies’ health and well-being, but some may be harmful. Therefore, nurse practitioners and health professionals are in a position to support safe practices and discourage unsafe practices.

The World Health Organization (1998) recommended that “postpartum care must be a collaboration between parents, families, caregivers, trained or traditional, health professionals, health planners, health care administrators”. Midwives and nurses should educate women about the benefits of contemporary care and provide strategies to help them deal with conflicts between their traditional believes and practices and those recommended in contemporary healthcare practice. Also, healthcare professionals need to give appropriate information and care to the women and their families while paying due attention to the cultural and traditional context. According to this study findings, there was a small percentage of Saudi participants who used a restricted diet (17%), and 47%

59 who used a special diet during this period. This indicates that there might be some of

Saudi population whom still use some cultural restrictions and traditional practices during the postpartum period. These demands make it imperative that appropriate knowledge about cultural values are included in the education of dietetic practitioners, nurses and other healthcare professionals to increase their cultural awareness and their possibilities to provide culturally congruent care. This is important not least in Western countries which have become multicultural. As most health professionals who look after American and Saudi women, they are often unaware of the cultural values that influence their clients’ care. However, if they combine both Western and Eastern values in their national health care system, improvements can be achieved in maternal and child health. It is also important for Saudi population to understand that dietary restrictions and practices might not needed because it does not have a fateful impact on mothers’ health. Thus, health professionals and nurses should educate Saudi women about the benefits of contemporary care and provide strategies to help them deal with conflicts between their practices and those recommended in contemporary healthcare practice.

Limitations

The small number of participants was a limitation of this study. In this study postpartum restrictions and practices were studied with a small sample of women who live in United States; therefore, the results might not be representative. In addition, of the

28 surveys, only ten surveyed participants were American women. These ten participants comprised 30% of the surveyed population and that might influenced the results of the study. Also, the restrictions used among American postpartum women is varies

60 depending on the region. Geographical location (northeast Ohio) may prevent data from being applicable to other postpartum women in the United States. Therefore, this data is not an accurate representative of Saudi and American population with regard to their maternal restrictions and practices during the postpartum period. The other limitation of this study was the lack of dietary intake information. Most of the participants did not answer the questions that related to the dietary intake. This could indicate that the participants did not understand the questions, or they did not remember the dietary intake that they were using during this period.

Conclusion

In conclusion, this study sheds light on some of the traditional beliefs, taboos and practices surrounding postpartum period among both Saudi and American women. The finding of this small research study clearly indicates the need for further research of the food habits and practices during the postpartum period. Few significant differences existed between groups. This may be attributed to the small sample size. The outcome of this research study was that there were no significant differences in the dietary restrictions and practices during the postpartum period among Saudi and American women. These finding suggested that both groups tended not to restricted or used special diet after the child birth, as well as not to restrict their physical activity. However, this study also found that Ӽ2 analysis showed a significant association among American postpartum women versus Saudi postpartum women with respect to attempting to lose weight during this period. This indicates that some women might use some dietary restriction to enhance weight loss in the postpartum period. In addition, this study showed

61 that there was a small percentage of Saudi participants who used a restricted diet (17%), along with using a special diet (47%) during the postpartum period. This indicates that traditional postpartum beliefs and practices are still prevalent among Saudi population who are living in United States. Thus, the restrictions associated with traditional postpartum practices is critical to develop better understanding to the cultural values and targeting health education programs to increase healthcare providers’ cultural awareness and their possibilities to provide culturally congruent care.

APPENDICES

APPENDIX A

SURVEY

Appendix A

Survey

The Demographic Questionnaire 1. What is your age? ______years 2. What is your nationality? 3. What is your primary o Saudi language? o Unites States o Arabic o Other ______o English o Other______4. Are you currently a new mother and your baby is 1 5. What is the baby’s to 6 months old? birthday? o Yes Month ____ o No ( if not please stop here and do not complete Day ____ the questionnaire) Year______6. How much did your baby weigh at birth? 7. Did you have twins/ Pound ______& Ounces ______triples or more than baby? o Yes, 2 or more o No 8. How much did you weight? (estimate if you are not 9. How tall are you? sure) ______Feet o Before you became pregnant? ______Inches Pound ______/or Kg ______cm o By the end of pregnancy? Pound ______/or Kg ______o After birth? Pound ______/or Kg ______10. Did you have any medical problems that prevented you from caring for your baby for more than a week? o No o Yes o Please Explain briefly ______11. Did your baby stay in an intensive care unit? o No o Yes, 3 days or less o Yes, more than 3 days

64 65

12. Did your baby have any special needs or medical problems that affected his or her feeding? o No o Yes o Please explain briefly ______13. Did you breastfed your baby? o Yes ○ No 14. If yes, how long did you breastfed your baby? o One week o One month o Two months o Three months o Four months or more______15. Did you have any special needs or medical problems? o No o Yes o Yes, Please explain briefly ______16. Are you living in USA? o Yes o No 17. If yes, how long have you been living here? 18. Where were you born? o Less than 2 years o Saudi Arabia o 2-5 years o United States o 6-10 years o Other o 10-30 years o More than 30 years o All my life 19. How many members in your household? 20. What is your current ______household income in U.S. dollars? o Under $10,000 o $10,000 - $19,999 o $20,000 - $29,999 o $30,000 - $39,999 o $40,000 - $49,999 o $50,000 - $74,999 o $75,000 - $99,999 o $100,000 - $150,000 o Over $150,000 o Would rather not say

21. How many children do you have? o None o 1 o 2 o 3 o 4 or more

The Postpartum Diet Questionnaire  Below is a list of questions that apply only to the postpartum period (six week period following delivery) of the infant born in 2014. Please check or write the response that most closely describes you. (please describe what you remember and estimate if you are not sure) 1. Birth date of infant______

2. How many time did you eat each day during the first six weeks after giving birth? o Meal _____ o Snack _____ 3. Did you try to lose weight during postpartum period? o Yes o No

4. Did you use restricted diet during this period? o Yes o No

5. Were you on a special diet during postpartum period? o No o Yes

If yes a) Please describe. b) For how long did you c) Who ______use this diet? prescribed ______this diet to ______o 1 month you? ______o 2 months o Physician ______o 3months o Your self o More than 6 months o Family o ______o Other

6. Were there any pressured to follow cultural/ family norms during this period? o Yes o No

7. Were there any foods or beverages that you avoid or did not eat during postpartum period? o No (if not go to#7) o Yes o Please list______

 Listed below are reasons why those food or beverages have been avoided during the six weeks after delivery. Beside each reason, list the food or beverages that were avoided. If you did not avoid any food or beverages for a particular reason, please write "none" under the column entitled “food or beverages avoided”. In the next column, please indicate if you felt that the avoidance were effective (yes) or were not effective (no). In the last column briefly state why you felt the avoidance food/ beverages were or were not effective. 8. What was the reason that Food/ Not you avoid this type of food? Beverages Effective Why? effective (Please list all that apply) avoided o Relief or regulation of labor pain o Childbirth aid o Control of bleeding o Relief of faintness after child birth o Promotion of lactation o Other reasons (please specify)______

9. Were there any foods or beverages that you eat or drink only during the first six weeks of postpartum period? o No o Yes o Please list ______

 Mother’s sometimes during the first six weeks of postpartum period consume certain fortified foods, foods of concern, and herbal and botanical preparations. Below is a list of reasons why those foods have been consumed during the six weeks after delivery. Beside each reason, list the food or beverages that were used. If you did not used any food or beverages for a particular reason in this period, please write "none" under the column entitled “food or beverages used”. In the next column, please indicate if you felt that the food that you used were effective (yes) or were not effective (no). In the last column briefly state why you felt the food/ beverages that you used were or were not effective. 10. What was the reason that Food/ Effect you used this type of food? Beverages Not effective Why? ive (Please list all that apply) used o Relief or regulation of labor pain o Childbirth aid o Control of bleeding o Relief of faintness after child birth o Promotion of lactation o Other reasons (please specify)______o 11. Were there any foods of which you think you did not eat enough? o No o Yes o Please list ______why? ______

Number of Times Drink 12. What did you drink As Was Used Per during postpartum H Room Cold Warm period? (Please check ot Temp all that apply) Day Week month o Water o Juice/ Juice Drinks o Gatorade/ Sports Drinks o Wine/ Beer/ Alcoholic Drinks o Coffee o Herbal Teas/ Tea o Hot chocolate o Soft Drinks o Milk o Other

How much Number of Times Milk 13. What type of milk do you usually drink? per Was Used Per serving? Day week Month

o Cow’s (Whole- Vitamin D)/ Reduced/ Low Fat (2%, 1%, Skim) o Lactose Free o Evaporated o Sweetened Condensed o Soy o Rice o Almond o Goat’s o Raw (cow’s or Goat’s) o Other ______How many times did you How much 14. Which fruits (not Juice) did you eat during eat fruits and vegetables per that time? (please check all that apply) during serving? Day Week Month o Bananas o Grapes o Apples o Oranges o Watermelon o Cantaloupe o Pears o Kiwi o Strawberries o Raspberries o Blueberries o Peaches o Others ______How many times did you 15. Which vegetables (not Juice) did you eat How much eat fruits and vegetables during that time? (please check all that per during apply) serving? Day Week Month o Beans o Beets o Broccoli o Carrots o Celery

o Corn o Cucumbers o Green/ red peppers o Lemons o Lettuce

o Okra o Peas o Spinach o Sweet potatoes o Tomatoes o Watercress o Other ______

How much How many times did you 16. Which protein foods did you eat? (Please per eat protein foods during chick all that apply? serving? Day Week Month o Beef/Buffalo o Chicken/Turkey o Fish/Seafood o Pork o Lamb o Hot Dogs/Lunch Meat o Meat Spreads/Pâté o Dried/Canned o Beans o Eggs o Tofu o Yogurt o Soft Cheese (Feta, Brie, Blue-Veined ….) o Hard Cheese (American, Cheddar, Swiss…) o Other______

17. Did you ever eat anything that is not food, How such as ashes, chalk, clay, dirt, large How many times? much? quantities of ice, or starch (laundry or cornstarch) during postpartum period? o No o Yes o Please list ______

18. Did you restrict your physical activity during postpartum period? o Yes o No

19. Did you get adequate family support (help with preparing food or caring for the baby) during this period? o Yes o No

20. Were there anyone of your family who judge the way you eat or drink during the postpartum period? o Yes o No

21. Did you receive any judgments by your friends/peers during postpartum period? o Yes o No

22. Did you have any medical/health/dental problems? o No o Yes o Please list ______

23. Was this problem diagnosed by a doctor / dentist? o No o Yes 24. Please check and describe all of the How many times per? Briefly explain following you were using during why you used it? postpartum period? Day Week Month o Over-the-counter drugs (laxatives, pain killers, etc.). If yes, please list: ______o Prescription medication. If yes, please list: ______o Vitamin and/or minerals supplements If yes, please list: ______

___ o Herbs/Herbal Supplements (Echinacea, ginger, etc.). If yes, please list: ______o Tobacco Street drugs (Marijuana, cocaine, methamphetamines, etc.). If yes, please list: ______o Other: ______

25. Please check any of the following that are true about your last Yes No pregnancy? o My baby was born more than 3 weeks early o My baby was born weighing less than 5 pounds 9 ounces o My baby was born weighing 9 pounds or more o My baby was born with a birth defect o My doctor told me I had gestational diabetes o My doctor told me I had pregnancy induced hypertension o I had a C-Section o I had more than one baby (twins, triplets, etc.) o I had no complications o Other, please list ______26. From the sources listed below, please indicate the areas from which you have learned anything about maternal dietary intake. Please rank the sources according to their usefulness, i.e., place a "1" by the most useful source, a "2" by the second most useful source, "3" by the least useful source, and "4" by the non-useful source. Rank only those sources which you utilized. ( ) Professional care provider ( ) Books ( ) Herbalist ( ) Magazines, newspapers, television, ( ) Health food source" or website ( ) Friends or relatives ( ) Other (please specify) ______27. Including this last time, how many times have you been pregnant? ______

28. Have you breastfed your baby at any time since the delivery o Yes, and still breastfeeding o Yes, but not now o No 29. Did you get supports in your choice on infant feeding? o Yes o No 30. From your experience what do you think the advantage and disadvantage of breastfeeding? Advantages of breastfeeding Disadvantages of breastfeeding 1. 1. ______2. 2. ______3. 3. ______4. 4. ______5. 5. ______6. 6. ______

31. Did you experiencing any of the following situations? (Check all that apply.) o Baby always seems to be hungry o Don’t have enough milk o Baby refuses breast, o Arches back o Sore nipples o Sore breasts o Engorged or full, hard breasts o Other ______. 32. Please tell us your stories and experiences during postpartum period (optional)? ______

APPENDIX B

EMAIL INVITATION

Appendix B

Email Invitation

Dear participants,

I am a graduate student at Kent State University. I would like to invite you to participate in my research study which is looking at the differences between Saudi women and American women living in USA, concerning their maternal dietary intake and practices during the postpartum period. You may be part of the study if you are female who delivered a live birth who born during 2014.

Ten participants will be drawn randomly to receive a $10 reward gift card.

Participants will be asked to complete a 20-30 minute questionnaire.

If you are interested in participating in this study/ know anyone who meet this criteria please click on/ send the following link (or copy and paste link): https://kent.qualtrics.com/SE/?SID=SV_doqZgxZ4cYeP15P

If you have any questions or comments about this study, please contact Najlaa Osailan, Researcher, via email at [email protected] or Karen Gordon, Ph.D, at [email protected]

Thank you for your interest and participation in this online survey. Your responses are valued and appreciated.

Sincerely,

Najlaa Osailan. Principal investigator Nutrition Master of Science School of Health sciences Kent State University

APPENDIX C

HANDOUT

Kent Females! Participate in a study to receive a $10 gift card! The KSU Nutrition department is looking for women (20 years & older) to participate in a research study. Why we need you: this study is looking at the maternal dietary intake and general practices during the first six weeks after childbirth among Saudi & American females to evaluate the differences between them. Who qualifies for participation?  20 years females and older  Saudi & American Females  Females who delivered a live birth during 2014. Participants will complete an anonymous, online survey examining the dietary intake and practices during the postpartum period. This study will take approximately 30 minutes. And upon completion, ten participants will be drawn randomly to receive a $10 gift card. To participate and receive your gift card, visit: https://kent.qualtrics.com/SE/?SID=SV_doqZgxZ4cYeP15P

For more information, contact: Najlaa Osailan [email protected]

Principal investigator Dr. Karen Gordon [email protected]

APPENDIX D

CONSENT FORM

Appendix D

Consent Form

Welcome to “Food Habits and Practices during the Postpartum Period among

Saudi Arabian women vs. American women”. Before taking part in this study, please read the consent form below and click on the “I agree” button at the bottom of the page if you understand the statements and freely consent to participate in the study.

This study involves a web-based questionnaire to examine the maternal dietary intake and general practices during the first six weeks after childbirth among Saudi versus American females at USA. The study is being conducted by Dr. Gordon and

Najlaa Osailan of Kent State University, and it has been approved by the Kent State

University Institutional Review Board. No deception is involved, and the study involves no more than minimal risk to participants (i.e., the level of risk encountered in daily life).

Participants in the study typically takes 15 to 20 minutes and is strictly anonymous. Data will be collected through a series of questions including questions regarding personal demographics such as age, nationality, primary language, race and

Hispanic ethnicity, marital status, household size and number of children in a household, education, employment status, occupation, and household income, as well as questions on food consumption of certain fortified foods, foods of concern during lactation, alcohol intake, and vitamin & herbal supplements during the postpartum period.

All responses are treated as confidential, and in no case will responses individual participants be identified. Rather, all data will be pooled and published in aggregate form only. Participants should be aware, however, that the survey is not being run from a 80 81

“secure” https server of the kind typically used to handle credit card transactions, so there is a small possibility that responses could be viewed by unauthorized third parties (e.g., computer hackers).

Taking part in this research study is entirely up to you. You may choose not to participate or you may withdraw from the study at any time without penalty or loss of benefits to which you are otherwise entitled.

Ten participants will be drawn randomly to receive a $10 reward gift card

If you have further questions or concern about this research, you may contact the principal investigator, Najlaa Osailan at [email protected] and at (330)389-3507 or Dr.

Gordon at [email protected] and at (330)672-2248. If you have any questions about your rights as a research participants or complaint about the research, you may reach the Kent

State University Institutional Review Board, at (330)672-2704.

If you are 20 years of age or older female who have a live birth, understand the statements above, and freely consent to participate in the study, click on the “I agree button to begin the survey.

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