Traditional Postpartum Rituals of India, North Africa, and the Middle East: Seclusion,  Henna, & 40 Day Homecare by Catherine Cartwright Jones 2002 Kent State University, Medical Anthropology Hennaing a woman after she gives birth is a traditional way to deter disease, depression, and poor bonding with her infant. The action of applying henna to a mother after childbirth, particularly to her feet, keeps her from getting up to resume housework.  A woman who has henna paste on her feet must let a friend or relative help her care for older children, tend the baby, cook and clean! This allows her to regain her strength and bond with her new baby. She is also comforted by having friends who care about her well-being, and is helped to feel pretty again. It’s a comfort to have feet beautified when you haven’t seen them for several months. The countries that have these traditions have very low rates of postpartum depression. Non-western societies have postpartum rituals within the popular expression of their religions that directly address the needs of a mother in the 8-week period after birth. These ritual actions serve to support her physically and emotionally after birth, and reintegrate her into the community after recovery.  Henna traditions within popular religion practices of Islam, Sephardic Judaism, Hinduism, and Coptic Christianity are part of the management system for postpartum depression in India, North Africa and the Middle East. Henna is becoming more widely available in western countries at present due to the popularization of henna body art in western pop culture (Maira S, 2000), and henna’s association with beautification and protection from evil are comforting. Henna’s requirement that a woman be still for several hours during and after application insures that a mother will rest and allow others to take care of her! During the weeks after ornate henna patterns are applied, a woman is culturally allowed to not do household tasks that would spoil the beauty of the stains. This increases the likelihood that she will rest properly to regain her strength after giving birth. A woman goes through a social status change when she becomes a mother, and her relationship with her husband, other family members, and social group is changed. Caring for and nursing a neonate requires much from woman’s physical and emotional resources. These stresses added to the precipitous fall in estrogen and progesterone levels following birth, coupled with the elevation of prolactin in the first week postpartum are believed to give rise to irritability, mood changes, tearfulness, guilt, anxiety, fatigue and feelings of inadequacy. In extreme cases, the symptoms of postpartum psychosis include agitation, confusion, hallucinations, fatigue, delirium and diminished thinking (Stern and Kruckman, 1983). Though women universally experience the biological processes of the postpartum adjustment, they conceive of these changes through their social and religious constructs (Kleinman, 1978; and Cosminsky, 1977). When rituals are performed to relieve the woman of the stresses of social reintegration, childcare and fatigue, theconceptualized demons of postpartum depression may be averted as the biological adjustments are buffered. Henna is frequently used within performance of rituals actions in North Africa, the Middle East and South Asia to deter the evil eye. Western neonatal practice screens for postpartum depression, recognizes that it exists in several degrees of severity, that it is a clinically recognizable affective disorder, and that there are statistically predisposing socio-economic factors. Traditional cultures recognize that a woman is in a fragile, stressed state after giving birth, and that timely assistance from ritual actions of popular religion helps the mother reintegrate into society. In contrast, western medicine conceptualizes postpartum depression as a psychobiological phenomenon to be addressed by medication rather than a socio-magical phenomenon to be addressed by ritual performance. Indian Traditions Postpartum practices in Rajasthan are typical of those throughout rural regions in India.  In rural Rajasthan, ritual actions surrounding childbirth include henna applications and rangoli during late pregnancy, well before birth (called a 'blessingway' in native american tradition). A woman in the eighth month of her first pregnancy has an Athawansa ceremony. She is rubbed with scented oils, bathed in perfumed water, and ornamented with henna, on her hands, feet, up to the wrist and ankle, in a manner similar to her wedding henna. She is dressed in new clothing and ornaments. She is seated on a cauki, ceremonial wooden seat. Women friends and family fill her lap (god) with sweets, fruit, and a coconut. This ritual is "The Filling of the Lap."Women ornament the floor with rangoli called “Athvansa-ko-cowk” (Saksena 1979:121). The patterns used are acknowledged to bring health, protection and luck to the new mother and her child by inviting the aid of supernatural forces. Primiparous women are statistically most at risk for postpartum depression, and prenatal screenings for depression are often carried out in western medicine at this period (Stern and Kruckman, 1983). The eighth month ritual may serve to establish the woman’s “social safety net” within her community, who will help her through birth and reintegrate her after childbirth. At birthing, the mother is ornamented with henna before being escorted out of the delivery room. After the woman has given birth, she must have all of her fingernails and toenails hennaed in a ceremony known as Jalva Pujani, as henna is considered a medium for purging the pollution incurred from the process of giving birth (Saksena 1978, 75). If she is not properly hennaed at this time, she is considered at risk of not recovering from birth. For the first 9 days after birth, the woman is secluded and attended to by female relatives. The Rajasthani enforced rest, physical and emotional support during the establishment of maternal bonding and lactation may be crucial in preventing or relieving postpartum depression, and are similar to those observed in Nepal which are also considered to manage postpartum stress (Upreti, 1979) ...In most of the tribal groups, women were hennaed, and ornamented with kohl (a traditional black makeup made of antimony) and swak, (a traditional dark lip stain made of walnut root) as if they were brides before they go into labor. These not only deterred malicious spirits, but also prepared the woman for the possibility of dying in childbirth. If a woman died in childbirth, she was believed to enter paradise as a bride, and should be appropriately adorned (Westermarck II, 1926, 383). A woman who died in childbirth was believed to have no punishment after death (Legey, 1926: 119). Women in western maternity clinics are well supported medically to prevent death in childbirth, but no attention is given to her potential entrance into afterlife. North African Traditions An Amazigh woman who gave birth to twins was regarded as full of baraka, or blessedness, and those who visited her after birth would kiss her hand and address her as lalla, “my lady”. If a woman gave birth to triplets she was regarded as holy. Even an ordinary birth was believed to have baraka (Westermarck I, 1926, 47). Though birth is regarded as a wonderful event, an immigrant woman in a western hospital maternity ward is unlikely to feel very special. If she gives birth to twins or triplets, they are swiftly removed to a neonatal intensive care unit for monitoring and health support, and treated as a medical emergency rather than being celebrated. Multiple births in the have a high statistical correlation with impaired maternal bonding and postpartum depression in western pediatrics (Stern and Kruckman 1983). The midwife attending the birth in North Africa took care to assure the woman that malicious supernatural spirits were dispelled. This was accomplished with henna, incense, amulets, and ritual actions. In Moroccan Jewish households, a magic circle was drawn in the air around the laboring woman with a large sword to deter evil spirits. At the moment of birth in Amazigh Morocco, the mother was kept covered, with only the midwife can attending her, so the “evil eye” could not catch sight of her genital organs and cause her harm (Legey, 1926: 124). A laboring woman was therefore in a secure and familiar place, undistracted, accompanied only by one trusted helper. Several strangers peering between her legs, bright lights, and machines surround a woman in a western obstetric ward. An Amazigh woman was repeatedly ornamented with henna during the seven days after birth, as well as having her eyes rimmed with kohl. She was kept secluded, and only the midwife was allowed to attend her behind her curtain. This was seen as a safeguarding the mother against malicious spirits and witchcraft that would cause her illness, depression and death (Westermarck II, 1926, 385). The effect of these ritual actions was to allow the mother to rest and be cared for by an experienced attendant during the 10 day period required for her estrogen, progesterone and prolactin levels to stabilize and for her to recover her strength (Stern and Kruckman 1983), as well as being comforted by ritual actions familiar from her wedding. Neither mother nor child were washed with water during this period, but were cleaned with oil and henna. At each application of henna, the woman would have to remain still for several hours, resting, and allowing others to take care of household tasks, ensuring that she would regain her strength quickly. On the seventh day after birth, the child was washed and named. In Andjra, the midwife again adorned the mother with henna, and dressed her in clean clothing. The child was also hennaed on the head, neck, navel, feet and fingernails, in its armpits and between the legs, all in an effort to avert malicious spirits. The mother was dressed with slippers on her feet, and her head was covered, leaving only eyes, nose and mouth uncovered, so that witchcraft or malicious spirits would not cause her mental or physical illness. The mother still abstained from work at this time, though she directed household tasks. Women in the house trilled a zgrit several times at the birth of a son, fewer at the birth of a daughter (Westermarck II, 1926: 386 – 94) to dispel evil spirits. At the seventh day and days following, the family put on as extensive celebration as could be afforded. Female relatives who visited during this period assisted household tasks so the mother could continue to rest. Music and feasting was arranged to celebrate the birth, and the mother was dressed in fine clothing, hennaed, harquuesed, her hair dressed in fragrant oil and rosewater as if she were a bride. She was given the heart and fat of the sacrificed animal to eat,  one of the few times that a woman was guaranteed abundant calories and protein. Again, elaborate henna ensured that the mother would rest for several hours during and after the application. She would be excused from household chores for the following weeks to keep her henna stains beautiful, so the henna encouraged continued rest and recovery. For forty days after giving birth, the woman was regarded as in a delicate state of transition. The phrase often spoken was that “her grave is open”. Marital intercourse was not resumed until forty days after birth in most of the communities, though a man could return to sleeping by his wife after the seventh day. For forty days, if not longer, the child was never left alone, lest malicious spirits come and steal it, exchanging it for their own (Westermarck II, 1929: 398-9). During this period, maternal bonding was not impaired by separation as is common in western medical obstetric practice. A woman suffering postpartum depression may assert, “The child is not my own, or I am afraid of my baby.” (Brockington et al, 2001: 136 - 8). The North African ritual actions managed the risk of postpartum psychosis by keeping mother and child together, supported and undistracted during the 40-day period when depression is most likely to appear. If a depression or psychosis did develop and woman felt that her child had been stolen and replaced by a supernaturally evil creature, (medical literature notes postpartum psychoses can take the form of the mother believing the child to be evil or malicious (Brockington et al, 2001)) rituals were be performed to retrieve the natural child so maternal bonding could be re-established. The infant believed to be a changeling, a mebeddel, had to be taken back to the jnun, supernatural spirits, and exchanged for the human child. The mother took the evil creature to a cemetery, looked for a demolished tomb, and put the changeling child there, with an offering of meat for the jnun. She withdrew, to avoid contact with the spirits as they came to collect the meat. As soon as the child cried, she reclaimed it, and washed it with holy water, and exclaimed, “I have taken my own child, not that of the Other People” (Legey, 1926: 154 – 5). Thus the postnatal ritual actions acted to buffer depression, and offered an option for reinstating maternal bonding in the instance of psychosis. Performance of postpartum rituals, particularly those which include henna, for South Asian, Middle Eastern and North African women during the forty days after birth may reduce their high levels of depression in their host countries to levels found in their indigenous countries. It is notable that these rituals are performed to provide physical and emotional assistance, and enable the woman to recuperate and bond with her infant through the period wherein the woman is most at risk for postpartum depression due to hormonal adjustment. In particular, the henna applications during this period require a woman to rest quietly for hours during the process, and abstain from household tasks that would spoil the patterns for three or four weeks following. This enforcement of inactivity ensures that a woman will rest during the period of hormonal stabilization and bond with her infant. If ritual performance can achieve similar reduction in depression to SSRIs, and does not directly interfere with medical practice, then religious pluralism may be practical medical policy. Women recently immigrated into western countries have up to 10 times the incidence of postpartum depression in comparison to their peers in their native non-western countries and in comparison to women acculturated to the west (Bashiri and Spielvogel, 1999). New mothers in non-western cultures display few symptoms of postpartum depression; some sociologists believe that the women may be so well supported by their postpartum rituals within their countries of origin this affective disorder is nearly eliminated (Stern and Kruckman, 1983). Other studies demonstrate that the physical and emotional stresses following childbirth are well identified and managed by ritual in the indigenous community, so that the experience of depression is minimized (Pillsbury, 1978). Immigrant women’s lack of access to their postpartum rituals in their host country has been proposed as a cause of this elevation in psychiatric morbidity (Lee et al, 1998; Moon Park and Dimigen 1995). In North Africa, women who feel they are suffering from postnatal illness seek help from a traditional healer rather than from a physician (Cox, 1983), and such preference is common in other countries. The women feel that their needs for postpartum reorientation and support are better met by popular religious ritual rather than formal religion or western medical practice. When they are immigrants into a western country, the formal religion may be available, but performance of appropriate popular religious rituals for childbirth may be impossible do to lack of knowledgeable practitioners and implements for performance. Western Medical and Popular Religious Ritual Approaches to Birth and Postpartum Depression Western doctors understand that their patients are religiously and ethnically diverse, but they are selective about which religious/medical actions they are willing to tolerate or perform. Western neonatal practice is willing to perform male circumcision, but not female circumcision. A priest may be admitted into a hospital setting to bless a child, but a large group of women loudly trilling a zgrit to bless a child (Westermarck 1926, II, 375) might be unwelcome. A woman may be able to order kosher or vegetarian food for her hospital stay, but not exotic foods required by popular religious ritual in her country of origin. Women in obstetric wards receive flowers from a florist, but are usually discouraged from decorating their bedposts with traditional textiles to deter evil spirits, as only sterilized bedding and autoclaved instruments are permitted. An obstetrical room will be cleansed with antibacterial spray, but anti-smoking regulations may be interpreted to prohibit cleansing incensing with gum-sandarach, which rural Moroccan women believe to excite fear in malevolent spirits (Westermarck 1926, II, 382). A woman going into surgery is required to remove all jewelry, even if that includes amulets and talismans that she feels are crucial to insure a safe delivery. Western physicians often mistake henna for skin disease, and may dismiss other traditional postnatal rituals as unhygienic or medically useless. If performance of postnatal rituals can be demonstrated to significantly reduce maternal psychiatric morbidity incidence in immigrant women, they are NOT medically useless! In addition, there is concern that selective seratonin reuptake inhibitors prescribed by physicians to depressed mothers are found in their breast milk. The long-term effect of antidepressants consumed by infants through breast milk has not been assessed for possible side effects, though it is noted to cause sleep disturbance (Schmidt, Olesen, Jensen, 2000). A mother may be asked to choose between breastfeeding and depression if a western doctor offers her only SSRIs to assist her postpartum depression. If performance of traditional postpartum rituals could reduce depression to levels achieved with medication, such a choice might be avoided. An immigrant woman may thus be unable to access the rituals she regards as necessary for purifying and reintegrating her into society after giving birth. This has been considered contribute to the elevated and prolonged postpartum depressions observed among immigrant women (Williams and Charmichael, 1985). The immigrant’s lack of the usual support network to perform popular religious rituals following birth has been associated with the elevated maternal psychiatric morbidity in their host countries (Upadhyaya et al, 1989, Watson and Evans, 1986) References: Al-Majed S A, Harakati M S, “The Effect of Henna Paste on Oxygen Satureation Reading Obtained by Pulse Oximetry” Tropical and Geographical Medicine 46 #1, 1994, p 38 – 9 Barnett B, Matthey S, Gyaneshwar R, “Screening for Postnatal Depression in Women of Non-English Speaking Background” Archives of Women’s Mental Health, 2: 67-74, 1999 Bashiri N, Spielvogel A M, “Postpartum Depression: a Cross-Cultural Perspective” Psychiatry Update, Elsevier Science Inc, 1999, 82 - 87 Brockington I F, Oates J, George S, Turner D, Vostanis P, Sullivan M, Loh C, Murdoch C; “A Screening Questionnaire for Mother-Infant Bonding Disorders” Archives of Women’s Mental Health 2001, 3: 133 - 40 Cosminsky S, “Childbirth and Midwifery on a Guatemalan Finca” Medical Anthropology 1, 69 - 104, 1977 Cox J L, “Postnatal Depression: a Comparison of Scottish and African Women” Social Psychiatry, 1983, 18, 25 - 28 Ghubash, R. Abou-Salen MT, “Postpartum Psychiatric Illness in Arab Culture: Prevalence and Psychosocial Correlates” British Journal of Psychiatry, 171: 65-68, 1997 Kleinman A, “Culture, Illness and Care – Clinical Lessons from Anthropological and Cross-Cultural Research” Annals of Internal Medicine, 88, 251-258, 1978 Lee, Yip, Chiu, Chan, Chau, Leung, Chung, “Validation of the Chinese Version of the Edinburgh Depression Scale” British Journal of Psychiatry, 172: 433-437, 1998 Legey, Francoise; “The Folklore of Morocco” George Allen and Unwin Ltd. London, 1926 Maira, S, “Henna and Hip Hop, the Politics of Cultural Production and the Work of Cultural Studies” The Johns Hopkins University Press, JAAS, 2000, 329-369 Malville J.M, Singh RPB, “Visual Astronomy in the Mythology and Ritual of India: the sun Temples of Varanasi Pergamon, Vistas in Astronomy, Vol 39, pp 431 – 49, 1995 Elsevier Science Ltd, Great Britain Moon Park E-H, Dimigen G, “A Cross-Cultural Comparison: Postnatal Depression in Korean and Scottish Mothers.” Psychhologia 38: 199-207, 1995 Pillsbury BLK,” “Doing the Month”: Confinement and Convalesence of Chinese Women after Childbirth” Social Science in Medicine, 12: 11-12, 1978 Saksena, Jogendra, "Art of Rajasthan, Henna and Floor Decorations" Sundeep Prakashan, Delhi, India, 1979 Schmidt K, Olesen O, Jensen P., “Citalopram and Breast-Feeding: Serum Concentraation and Side Effects in the Infant” Society of Biological Psychiatry, 47:164-165, 2000 Shoeb I H and Hassan G A, “Postpartum Psychosis in the Assir Region of Saudi Arabia” British Journal of Psychiatry, 1990, 157, 427 - 43 Stern G, Kruckman L, “Multi-Disciplinary Perspectives on Postpartum Depression: An Anthropological Critique” Social Science in Medicine, 17: 1027 – 1041, 1983 Upadhyaya A, Creed CF, Upadhyaya M, “Psychiatric Morbidity Among Mothers Attending a Well Baby Clinic: a Cross-Cultural Comparison” Acta Psychiatr Scand 81: 148-151, 1989 Upreti NS, “A Study of the Family Support System: Child Bearing and Child Rearing Rituals in Kathmandu, Nepal” Unpublished Dissertation, University of Wisconsin, Madison, Wisconsin, 1979 Watson E, Evans SJW, “An Example of Cross-Cultural Measurement of Psychological Symptoms in Postpartum Mothers” Social Science in Medicine 23: 869-874, 1986 Williams H, Carmichael A, “Depression in Mothers in a Multi-Ethnic Urban Industrial Municipality in Melbourne”Journal of Child Psychological Psychiatry 26: 277-288, 1985 Westermarck, Edward, “Ritual and Belief in Morocco, Vols. I &II” Macmillan and Company, Limited, London, 1926 Rangoli, also known as Mandana, Alpona and Kolam, are designs executed by women using rice flour, turmeric, spices, flowers, or henna on domestic floors and walls. The designs are auspicious and have ritual significance for the occasion. They purify the domestic space, honor and invite the presence of a deity. In the case of birth patterns, the soul of the child is welcomed with these patterns and directed to the proper place. Bishmillah allahu akbar ‘ala ----In the name of God, God who is Great ---(the name of the child) ben (son) or bent (daughter) – (of so and so) Zgrit: a North African and Middle Eastern loud, shrill celebratory ritual exaltation done by women. The sound is made by loudly singing a high note while flicking the tongue back and forth across the upper front teeth. The Zgrit is intended to frighten away evil spirits. Women in an Amazigh house trill a zgrit seven times at the birth of a son, three times at the birth of a daughter.