Perceptions of Traditional Postpartum Practices With Hmong Women in the United States

Abstract

Introduction

Postpartum care varies widely across cultures, yet research on ethnic minorities, especially Asian American Pacific Islanders subgroups, often masks meaningful differences among ethnic subpopulations. The Hmong, an ethnic minority originating from Southeast Asia, faces cultural shifts since immigrating to the United States. This study examined the perceptions of traditional postpartum practices among Hmong women.

Methods

A cross‐sectional electronic survey was distributed to Hmong women and professional organizations. Participants were included in the study if they were aged at least 18 years, self‐identified as Hmong, were female, and were living in the United States. Data on postpartum knowledge and experiences were analyzed using SPSS.

Results

Of 323 respondents (average age 33.5 years), 89% were women who practiced postpartum traditions, with most having 0 to 5 children. Over 65% reported their health care providers were unaware of traditional Hmong practices, and 77.8% were willing to educate them. Common practices included the chicken diet (95.8%) and belly binding (40.9%) for an average confinement period of 25 days. Knowledge of traditional postpartum practices was moderate; participants correctly answered about 45% of knowledge questions.

Discussion

Although many Hmong women in the United States continue to practice postpartum customs, traditional knowledge appears to be eroding across generations. There is a clear gap between patient practices and provider awareness. These findings highlight the need for culturally competent postpartum care and suggest that health care providers incorporate respectful, informed discussions about traditional practices to support maternal health among Hmong women.

INTRODUCTION

Worldwide, postpartum care practices vary significantly. A systematic review found that the type of care women receive during the postpartum period varies widely across cultures (Korean, Chinese, Thai, etc) and described these practices in detail. ¹ Additional systematic reviews focusing on ethnic minority populations is needed to further diversify the existing body of data. Research involving Asian American and Pacific Islanders (AAPIs) are rarely disaggregated, often portraying AAPIs as a monolithic “model minority.” As a result, the diverse experiences of many ethnic subgroups within the AAPI community are overlooked. It is uncommon for AAPI individuals to be represented as distinct groups in research, limiting the understanding of their unique postpartum care needs.

Understanding how different cultures approach postpartum care provides insight into the diverse ways societies support maternal recovery after childbirth. In Chinese culture, the practice of zuoyuezi (confinement or “doing the month”) involves a month of rest at home, in which new mothers are encouraged to avoid housework, stay warm, and follow a diet of warm foods that promote milk production ² Women often receive help from a pui yuet (nanny), who provides social support, physical support, and herbal remedies for the family. ³ In Korean culture, the postpartum period known as saam‐chil‐il spans 3 weeks and is also focused on recovery, with a strong emphasis on warmth and the consumption of nutrient‐rich seaweed soup to boost milk supply, reduce swelling, and detoxify the body. ⁴ In Vietnam, women are encouraged to rest and avoid cold foods, whereas in Cambodia, women who are postpartum undergo a process of “warming” to restore balance between hot and cold. ⁵ , ⁶ This may include lying on a bamboo bed heated by fire as well as avoidance of cold water or exposure to rain. Hot foods, salty drinks, and herbal steam baths are commonly used to promote postpartum recovery. ⁶ Latin American cultures observe a 40‐day quarantine, or cuarentena, in which women refrain from cooking and cleaning, allowing them to focus on healing and bonding with the newborn. During this time, warm massages, baths, and belly binding (using a postpartum girdle) are common practices to aid recovery and prevent ailments like poor milk supply or abdominal discomfort. ⁷ Although each culture has its own unique traditions, the underlying goal across these practices is to support the physical and emotional healing of women following childbirth.

QUICK POINTS

• ✦This study addresses a critical gap in quantitative research on Hmong postpartum practices in the United States, where data on Asian American subgroups are frequently overlooked because of aggregation in broader studies.
• ✦It highlights cultural preservation challenges, revealing that although 89% of Hmong women maintain traditions such as the chicken diet (95.8%) and belly binding (40.9%), generational knowledge is declining, as evidenced by participants achieving only 45% accuracy on traditional practice questions.
• ✦With 65.4% of providers unaware of Hmong practices, significant knowledge gaps highlight the need for culturally responsive care that acknowledges and supports these traditions.
• ✦Findings serve as a model for studying other underrepresented groups, emphasizing the role of cultural preservation in health care equity and patient‐centered care.

The Hmong are an underrepresented, invisible minority in the United States. The Hmong are an ethnic Asian minority refugee population, with the first wave of immigrants arriving in the United States in the late 1970s. The Hmong were forced out of their land by the communists who overtook Vietnam during the Vietnam War. As the Vietnam War continued, another war was taking place in the same lands, known as the Secret War. In the Secret War, the Central Intelligence Agency recruited thousands of Hmong men to fight alongside Americans in exchange for a promise of a better life in America. After America failed to win the war, thousands of Hmong people were left to defend themselves against the Pathet Lao communists, who began targeting the Hmong population. Fearing for their survival and facing broken promises from the United States, many Hmong were forced to flee across the Mekong River to seek refuge in Thailand. This displacement eventually led to their immigration into the United States. ⁸ , ⁹

For more than 50 years, the Hmong community has made the United States its home. As time has passed, their lives have continued to evolve. Assimilation into Western society has contributed to a decline in younger generations’ knowledge and understanding of traditional Hmong culture. This is especially evident in postpartum practices, in which traditions related to dietary restrictions, lactation, and spiritual observances are increasingly being lost. A study conducted on the Hmong community in Eastern Wisconsin found that generational changes are contributing to increasing levels of acculturation. ¹⁰ However, some Hmong customs are still being practiced in the United States, including weddings, funerals, and postpartum care.

Postpartum care in the Hmong culture consists of a variety of components. After giving birth, it is believed that the woman's spirit may have been weakened or temporarily displaced during labor. Restoring the spirit—often referred to as “bringing the spirit back”—is essential for the woman's physical recovery, emotional well‐being, and protection from illness. This process combines dietary care, rest, reduced household responsibilities, and adherence to specific customs. A traditional Hmong postpartum diet typically consists of boiled chicken soup prepared with medicinal and herbal plants to help nourish the woman's sacred body. ¹¹ One qualitative study was conducted on Hmong postpartum care in Australia, which showcased the different areas of postpartum care, also known as the nyob nruab hli of Hmong women (n = 27). ¹¹ The author also went into details about the dos and don'ts that a woman would have to abide by during her one month postpartum. ¹¹ Women typically drink warm water and eat warm, freshly cooked rice. Additionally, it is common practice to wrap the woman's belly to tighten the skin and support the abdominal muscles, which have been stretched during pregnancy. Wearing a hat is also customary because it is believed to help prevent illness during the vulnerable postpartum period.

Limited research on Hmong postpartum practices was conducted in Australia, California, and Wisconsin and included qualitative focus groups with approximately 15 to 50 Hmong participants. ¹¹ , ¹² , ¹³ To date, no quantitative studies have been conducted in the United States that specifically examine postpartum practices among Hmong women. A large‐scale quantitative survey is needed to better understand the postpartum practices among the Hmong population in the United States. The primary objective of this study was to investigate the perceptions of traditional postpartum practices among Hmong women in the United States.

METHODS

To gain knowledge on Hmong postpartum practices, a cross‐sectional survey was developed and distributed electronically using Qualtrics. Survey design and reporting adhered to the Checklist for Reporting Results of Internet E‐Surveys to ensure methodological rigor (Supporting Information: Appendix S1). The survey consisted of 5 sections with a total of 54 questions. The sections included demographics (age, occupation, country of birth, years in the United States, language spoken, marital status, siblings, household size, education, income, housing characteristics, insurance), experiences with postpartum practice and traditions, and questions to address knowledge of postpartum traditions, lactation/pregnancy restrictions, and herbal use. The knowledge questions were developed based on a review of the literature on Hmong postpartum practices and the lived experiences of the research team. Key practices, including dietary customs, confinement periods, and spirit‐restoration rituals, were incorporated in the survey to ensure cultural relevance and clarity. This approach assisted with aligning the questions with the study objectives and supporting content validity. Knowledge questions were formatted as true/false (eg, “cold showers should be avoided postpartum”) and derived from established qualitative studies. ¹¹ The survey was pilot‐tested with 3 individuals who were similar to the target population. Feedback from the pilot participants was used to refine question clarity and ensure that items were understandable. Additionally, the survey was reviewed by colleagues outside the immediate research team to assess content validity and provide input on question relevance and format. The survey can be found in Supporting Information: Appendix S2. Following the development of the survey, the research team members contacted various Hmong women's organizations nationwide. Eligibility criteria required participants to be aged at least 18 years, self‐identify as Hmong women, and reside in the United States. A list of organizations is provided in Supporting Information Appendix S2. Informed consent was obtained from all participants. The survey was open for collection from March 2021 to May 2021.

This study was reviewed and approved by the Medical College of Wisconsin institutional review board (PRO00038951). All research procedures were conducted in accordance with the ethical principles of the Belmont Report, the Declaration of Helsinki, and applicable US federal regulations (45 CFR 46). Informed consent was obtained from all individual participants included in the study. All participants provided informed consent prior to completing the survey. The purpose, procedures, potential risks, and benefits of the study were explained to participants, who were informed that participation was voluntary and that they could withdraw at any time without penalty. Survey responses were collected anonymously, and all data were handled in accordance with institutional ethical guidelines.

Survey data were collected using Qualtrics and exported into Microsoft Excel for analysis. Descriptive statistics were used to summarize the responses, including frequencies, percentages, means, and standard deviations, as appropriate for each item. The total number of responses for each question was tallied, and individual items were scored according to the survey's coding scheme. For Likert‐scale items, mean scores and response distributions were calculated to evaluate overall trends and patterns. Summary tables and figures were generated to facilitate the interpretation and reporting of the results. The research team included 2 Hmong student pharmacists, 1 Hmong faculty with expertise in survey research, and 1 non‐Hmong fellow in academic pharmacy (3 Hmong and one non‐Hmong).

RESULTS

A total of 323 Hmong women completed the survey. Participants had a mean (SD) age of 33.46 (5.58) years, with the majority reporting high levels of education and household income, indicating a relatively well‐educated and economically stable sample. Nearly half of the participants (45%) spoke Hmong as their primary language at home, whereas the remainder primarily used English or both languages. Most participants were married or in long‐term partnerships, and a substantial proportion reported having children, reflecting a range of family and household structures. Additionally, participants were geographically diverse, representing both urban and suburban communities. This sample offers a comprehensive view of the experiences and practices of Hmong women during the postpartum period (Table 1).

Table 1.

Demographic Characteristics of Hmong Women Survey Participants (N = 323)

Characteristic	Value
Age, n, mean (SD), y	289, 33.46 (5.58)
Occupation, n (%)
Health sciences	74 (24.18)
Education and training	39 (12.75)
Human services	37 (12.09)
Business management and administration	23 (7.52)
Finance	17 (5.56)
Government and public administration	12 (3.92)
Marketing, sales, and services	11 (3.59)
Other	93 (32.18)
Country of birth, n (%)
United States	219 (71.57)
Thailand	63 (20.59)
Laos	18 (5.88)
Other	6 (1.98)
Language spoken at home, n (%)
English	292 (53.28)
Hmong	249 (45.44)
Other	7 (1.28)
Marital status, n (%)
Married	235 (76.8)
Single, never married	33 (10.78)
Living with partner	31 (10.13)
Widowed	4 (1.31)
Divorced	3 (0.98)
Age of parents, n (%)
30‐39 y	8 (2.61)
40‐49 y	19 (6.21)
50‐59 y	124 (40.52)
60‐69 y	115 (37.58)
>70 y	38 (12.42)
Refused	2 (0.65)
Number of siblings (full and half‐siblings), n (%)
0 to 4	62 (20.46)
5 to 9	178 (58.75)
Over 10	63 (20.79)
Number of people living in a household, n (%)
0‐4	62 (20.46)
5‐9	178 (58.75)
>10	63 (20.79)
Highest level of education obtained, n (%)
Never attended/kindergarten only	1 (0.33)
High school diploma, GED, or equivalent	16 (5.28)
Some college education	31 (10.32)
Associate's degree	27 (8.91)
Bachelor's degree	140 (46.2)
Master's degree	54 (17.82)
Professional or doctoral degree	32 (10.56)
Declined to answer	2 (0.66)
Total family income within past 12 mo, n (%)
<$20,000	10 (3.32)
$20,000‐$40,000	19 (6.31)
$40,000‐$60,000	30 (9.97)
$60,000‐$80,000	56 (18.6)
$80,000‐$100,000	47 (15.61)
$100,000‐$120,000	31 (10.3)
$120,000‐$140,000	36 (11.96)
$140,000‐$160,000	19 (6.31)
>$160,000	46 (15.28)
Declined to answer	7 (2.33)
Religious affiliation, n (%)
Christian	99 (33.11)
Traditional animism	89 (29.77)
Mix of ≥2 religions (eg, Christian and traditional animism)	42 (14.05)
Catholic	14 (4.68)
Other	44 (14.72)
Declined to answer	11 (3.68)
Housing characteristics, n (%)
Own a property (house, condo, or apartment)	206 (68.67)
Rent a property (house, condo, or apartment)	84 (28)
Live in public housing	1 (0.33)
Other	9 (3)
Health insurance, n (%)
No insurance	3 (1)
Medicare	14 (4.67)
Medicaid	21 (7)
Private insurance	249 (83)
Other insurance (eg, military/VA insurance)	9 (3)
Declined to answer	3 (1)
Participants with children, n (%)
Yes	241 (89.3)
No	29 (10.7)
Number of children, n (%)
1	55 (23)
2	84 (31)
3	40 (17)
4	43 (18)
≥5	19 (7)
Gestational diabetes (N = 225), n (%)
Yes	57 (25.3)

Abbreviations: GED, General Educational Development; VA, Veterans Affairs.

Postpartum Practices

Of the Hmong women, 241 (89%) had children. Women with no children responded that 19 (70.4%) planned to practice postpartum traditions. Of the Hmong women with children, 229 (95%) practiced the herbal chicken diet after birth. Many of these women had 2 children, and the average age at the birth of the first newborn was 25 years. The majority (65.4%) stated their provider did not know about Hmong postpartum practices, and 77.8% were willing to educate their provider on the traditions. Although 70% of respondents reported facing no barriers during their postpartum period, women encountered challenges, citing limited availability of herbs, lack of knowledge about the traditions, and personal disbelief in the practices. Below are illustrative quotes that reflect common barriers faced by Hmong women who practice postpartum traditions. There was a lack of partner support and unequal expectations: “My husband was supposed to cook for me during my 30 days after giving birth but he never did. I would struggle to cook for myself. This happened each time after I gave birth” (participant 244). Women also experienced social isolation because of cultural restrictions:

During our first month of postpartum, we are NOT ALLOWED to visit our birth parents’ house due to Shamanism practices. Due to this, regardless that even thought I was a single mother with no husband at the time, I couldn't even go to my parents' home to get help. That broke my heart the most. (participant 274)

Hmong women's experiences with health care providers during the postpartum period reveal important insights into cultural sensitivity in care. When asked whether their provider was knowledgeable about traditional Hmong postpartum practices during their most recent visit, only 34.6% of respondents felt that their provider demonstrated this understanding. A larger proportion of Hmong women (77.8%) reported feeling comfortable sharing postpartum practices with their provider. These findings suggest that although many Hmong women may encounter gaps in provider knowledge about cultural postpartum traditions, the majority still feel able to communicate openly about their practices. Some women experienced positive health care experiences, as illustrated by the quote below:

The hospital I stayed at was pretty inclusive. For postpartum meals in the hospital they offered boiled chicken with rice and hot water minus the herbs. The nurses and doctors were very considerate and offer to continually refill me with hot water if needed. (participant 109)

Other women described negative experiences, reflecting challenges in both cultural understanding and clinical care:

They didn't fully understand the diet. It was also incredibly challenging that they don't have an in home service to meet with new mothers and infants instead of requiring new moms and babies to come into office at such a fragile stage of recovery. (participant 145)

During my labor, I didn't feel like the nurses and doctors listened to my needs. When my body was ready to push, the nurses told me to wait since there was no doctor present. This led to an emergency C‐section due to their negligence because they made me wait. It was a traumatizing labor. I didn't care to inform the health care system above my postpartum practices. (participant 186)

Regarding specific postpartum practices, many of the respondents (95.8%) reported adhering to the traditional postpartum herbal chicken diet, which consisted of boiled chicken and hot chicken broth, accompanied by freshly cooked white rice and herbs. The next most common practice was abdominal binding (40.9%). The average reported duration of postpartum confinement was 25 days. More than 83% of respondents learned about postpartum practices from their parents, whereas 35.5% learned from extended family. Hmong women predominantly reported learning about postpartum practices from mother figures in their lives. When asked about the perceived usefulness of the chicken diet, 55.5% of respondents described it as somewhat useful, and 39.5% considered it very useful. Mothers and mothers‐in‐law were the most common sources for providing herbs to our respondents (73.3%). Additional results of postpartum practices are detailed in Tables 2 and 3.

Table 2.

Participant‐Reported Barriers Regarding Hmong Postpartum Traditions

Category	n (%) a
Barriers to postpartum care
Yes	64 (30.1)
Barriers faced b
Lack of support from mom/mother‐in‐law	16 (16.7)
Lack of support from spouse	18 (18.7)
Lack of belief in tradition	33 (34.1)
Limited knowledge on tradition	35 (35.9)
Limited availability of herbs	44 (44.6)
Other	49 (50)

^aCounts (n) vary by question because of optional response rates. Percentages are calculated based on the number of respondents for each item.

^bPercentages total >100 because respondents could choose multiple answers.

Table 3.

Experience of Traditional Hmong Postpartum Practices

Category	n (%) a
Postpartum practices b
Herbal chicken diet	248 (95.8)
Belly binding	106 (40.9)
Visitation restrictions	79 (30.5)
Clothing needs	147 (56.8)
Labor	53 (20.5)
Other	53 (20.5)
Source of postpartum education b
Parents	215 (83)
In‐laws	83 (32)
Family (more than just 1 family member, excluding parents)	92 (35.5)
Other	28 (10.8)
Practiced herbal chicken diet
Yes	229 (95.4)
No	11 (4.6)
Support from spouse and family during 30‐d confinement
Yes	219 (96.1)
No	9 (3.9)
Traditional family c
Yes	208 (82.9)
No	43 (17.1)
Usefulness of diet
Very useful	79 (39.5)
Somewhat useful	111 (55.5)
Not useful	10 (5.0)
Source of herbs
Mom/Mother‐in‐law	151 (73.3)
Family/friends	23 (11.2)
In store	22 (10.7)
Personal garden	10 (4.9)

^aCounts (n) vary by question because of optional response rates. Percentages are calculated based on the number of respondents for each item.

^bPercentages total >100 because respondents could choose multiple answers

^c Traditional family: a family that actively practices Hmong cultural traditions and customs, maintaining practices and values passed down through generations.

Knowledge of Postpartum Practices and Herbal Medicines

Participant knowledge of postpartum practices and herbal medicines was evaluated. Participants responded correctly to approximately 45% of the knowledge questions. The results of these questions are presented in Table 4. The questions that were answered incorrectly primarily pertained to lactation restrictions, house departure restrictions, and specific dietary practices. Among Hmong women in the United States, adherence to additional postpartum restrictions varies widely, and practices differ between families.

Table 4.

Survey Questions on Hmong Pregnancy, Lactation, and Postpartum Traditions

Question	% Correct a
Pregnancy and Lactation
There are visitation restrictions for a mother who is lactating to go to the home of a woman who is pregnant.	51.04
There are lactation restrictions on carrying bags or wearing shoes in a lactating mother's home as those things can take away the mother's milk.	19.25
A new mother should not be allowed to visit other's home as it may “weaken” the clan's spirit.	72.95
A new mother should be prohibited from entering/exiting her home through the front door.	20.83
Postpartum Traditions
The first meal after birth consists of a poached egg with white pepper.	2.15
Sexual intercourse should be avoided during the 30 days of postpartum following birth.	89.47
Cold showers should be avoided to limit the risk of aching bones.	75.2
Eating vegetables and fresh fruits can cause asthma, coughing, and swelling in old age.	24.49
After giving birth, you are able to eat pork and fish after 10 days.	13.82

^aQuestions were true or false.

DISCUSSION

Overall, 95% of Hmong women in this study reported practicing postpartum traditions after birth. Although the traditional confinement period is 30 days, the average reported duration was slightly shorter, at 25 days, suggesting generational shifts in adherence to traditional confinement practices. Knowledge of postpartum practices also varied across respondents, further indicating that postpartum traditions are evolving across generations. These findings underscore the cultural significance of postpartum traditions for many Hmong women and highlight an opportunity for health care professionals to support culturally grounded postpartum care through open and informed conversations.

Traditional Hmong Postpartum Practices

Traditional postpartum practices among Hmong women have been well documented across qualitative and ethnographic studies. In 1995, Jambunathan's qualitative study of 52 Hmong women in Wisconsin found widespread adherence to postpartum traditions, including confinement, consumption of “hot foods” such as chicken and herbal broths, rest, fluid and dietary restrictions, and temporary limitations on physical activity and sexual intercourse. ¹² These practices are part of a broader Hmong tradition known as nyob nruab hli, a 30‐day postpartum confinement period rooted in beliefs that new mothers are physiologically vulnerable and require warmth, rest, and spiritual protection.

Ethnographic work among Hmong immigrants in Australia confirms this continuity of practice even after migration. Key elements—such as lying near a fire during the early postpartum days, consuming herbal soups, adhering to dietary restrictions, and observing a period of isolation—remain central to postpartum rituals in diaspora communities. ¹¹ , ¹³ More broadly, traditional postpartum care in many Southeast Asian cultures incorporates hot‐cold balancing, restoring warmth to the body, cleansing “cold” or “bad” blood, and using herbal remedies to support uterine healing and recovery. ¹⁴

Postpartum Practices and Mental Health

Traditional postpartum practices may also provide mental health benefits. Early US research on Hmong women showed fewer postpartum depressive symptoms than expected, despite the pressures of migration, socioeconomic barriers, and language isolation. ¹⁵ The authors proposed that cultural postpartum practices—including structured rest, family support, and ritual protection—may act as protective factors. Similar themes appear across studies of Southeast and East Asian immigrant mothers, wherein maintaining postpartum traditions helps women adapt, but challenges such as limited social support, assimilation pressures, and logistical constraints can lead to modifications of those traditions. ¹⁴

Integration With Our Findings

Our findings align with the persistence of these cultural practices and introduce an important new insight: A mismatch exists between widespread adherence to postpartum traditions and limited provider awareness. Although most participants felt comfortable discussing their practices with health care professionals, they perceived that providers lacked adequate knowledge of traditional postpartum care. This disconnect highlights an important gap in culturally responsive postpartum support.

By quantifying women's perceptions of provider knowledge and their comfort sharing postpartum practices, this study expands the literature that has largely been qualitative or ethnographic. Our results demonstrate that although traditional practices remain meaningful, they are not fully reflected within mainstream postpartum care. Improved provider understanding and engagement could help bridge this gap, allowing for more culturally responsive counseling and fostering stronger connections between ancestral knowledge and contemporary clinical care.

Limitations

This study has several limitations. First, the lack of geographic data prevented assessment of regional clustering, which may influence provider familiarity with Hmong postpartum practices. Second, our sample was disproportionately highly educated (75% with a bachelor's degree or higher), which limits its applicability to Hmong women with lower educational attainment. Third, as an online survey, older Hmong women—often key connectors with traditional knowledge—were likely underrepresented, potentially impacting knowledge of traditional postpartum practices. Finally, the sample consisted mainly of younger women with fewer children, which may not reflect the experiences of older or multiparous women.

CONCLUSION

Hmong postpartum practices are traditionally passed down orally, and although some customs are still observed in the United States, many are evolving or being displaced by Western practices. Knowledge of these traditions is diminishing across generations, yet Hmong families continue efforts to preserve their cultural heritage. Health care providers can support this preservation by creating inclusive spaces, offering culturally relevant materials, engaging community elders, and accommodating traditional practices, including confinement periods. Despite ongoing cultural observance, gaps in knowledge highlight the need for increased education and integration of culturally competent care within health care systems. By fostering open dialogue, respecting individual preferences, and raising awareness of Hmong postpartum customs, clinicians can support informed decision‐making, strengthen trust, and improve outcomes, ultimately promoting a more inclusive and patient‐centered approach to postpartum care.

CONFLICT OF INTEREST

The authors have no conflicts of interest to disclose.

Supporting information

Appendix S1. Checklist for Reporting Results of Internet E‐Surveys (CHERRIES)

Appendix S2. Internet Survey of Hmong Postpartum Practices