The Fourth Stage: Sharing the Asian Way

Editor’s note: This article first appeared in Midwifery Today, Issue 117, Spring 2016.
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The fourth stage of labor, the time after the baby has been born (second stage) and after the placenta is safely delivered (third stage) has been defined medically as one to two hours postpartum. Culturally, I define it as the first 42 days following childbirth. I believe the fourth stage never really ends, as a postpartum woman is forever transformed by the significant rite of passage of childbirth.

Photo by Robin Lim

At Bumi Sehat Bali and Aceh, we serve people of many adat, religions and traditions. The Hindu, Muslim, Christian, Jewish, Catholic and Buddhist families all have specific rituals to honor a new baby and the postpartum mother. All of the many islands in Indonesia and the mountain communities I have served in the Philippines, as well as the Ayurvedic people of India and the Chinese-Malay-Indian people of Singapore and Malaysia, agree on a very special lying-in time of 42 days for each new mother. This means she is excused from all work and is expected to rest, recover and breastfeed her baby.

Each culture prescribes special easy-to-digest nutritious foods to encourage healing and establish a flowing milk supply. The Ayurvedic people make thin soupy dahl which is used as the mother’s staple food. The Javanese families prepare jamu, concoctions of turmeric plus healing and balancing herbs for the postpartum mother. Jamu is taken internally and also massaged into the mother’s skin. The results are astonishing, as these mothers really glow.

A favorite balancing drink for new mothers in Indonesia and India is young coconut water. This dispels excess heat from the body. In Bali, bu-bur porridge of red rice with the tiny young leaves of kayu manis (cinnamon tree) is served. Research has proven that red rice cereal does bring the milk in faster. Red rice, called beras merah, is a slow-growing indigenous crop normally grown organically without chemicals and always nutritious.

Keeping the new mother and child warm and out of the wind is essential. Even in equatorial climates, exposing postpartum women to the wind is unwise. The mother and the baby’s chests must be kept covered, as sweating is a cooling process, and a naked chest could cause masuk angin (the wind entering), a risk for respiratory distress. In old Bali, women often wore only sarongs and were naked from the waist up. However, at night they covered their chests from the wind, cold and damp heat.

Considering that in most of the world, women’s lives are difficult and challenging and their work is exhausting and demanding, lasting from predawn into the late night, the postpartum time of rest is a true blessing. The lion’s share of women in my part of the world cook on wood fires, wash all the family clothing by hand, iron with cast iron and hot coals and work in the rice fields. On top of this, many of them must be at their job by 8 am looking tidy and feeling strong and ready to put in 8 to 10 more hours of hard work. By the time these women give birth, they are so exhausted and low on Qi, essential energy, that once they have had the baby, their bodies find it difficult to muster the Qi to safely deliver the placenta and close the uterus properly. This, and the fact that white rice with nearly no nutritional value is their staple food, is why hemorrhage after childbirth is one of the leading causes of death in the world.

Every single day, 981 women die on earth from complications of pregnancy and childbirth. These are not old, sickly people; they are women doing the most natural thing in the world—they are giving birth. Many of these are women in the prime of their lives, and most of them die in the early postpartum. Some, like my own sister, Christine (Feb. 16, 1958–Oct. 16, 1990), die during pregnancy. However, most maternal deaths occur in the more immediate postpartum, during and in the hours following the birth of the placenta. Mothers will use every last bit of Qi they have to bring the baby earth-side, even if it means they won’t make it themselves. During the first six weeks after childbirth, many new mothers die from sepsis, trickle bleeding or hidden complications resulting from surgical birth. Most of these mothers die because they are poor and malnourished; many of them either cannot afford to have a midwife or one is not available.

My sister, however, was in the US. She had insurance and was under the care of an Ob/Gyn. She asked questions, but the doctor was too busy; he never explained to her that she had hypertension and was at grave risk. He never even addressed the problem. I often wonder if my sister had found a midwife (and believe me, she was looking for one), would the special midwife-to-mother care have saved her life?

In the villages of Indonesia and the Philippines, I have seen the families take over every possible responsibility so that the new mother will recover her full strength and then some. Even the bathing of her baby is looked after.

Until the baby’s pungsud (umbilical cord) has dried and fallen away, the new mothers in Bali may neither wash their hair (risk of wind entering the body) nor enter their own kitchens. Also, until the cord is gone, the entire family may go to work, but never to temple, weddings, celebrations or outings. This ensures everyone stays close to home to be helpful and to protect the sacred bubble around mother and baby. It is said that until the cord has dried and fallen away, the ancestors are still taking care of the new baby and testing the family to see if they deserve to be joined by such a special soul. Every evening at sunset, until the pungsud has fallen off, the grandfather will run around the family compound with an armload of burning palm fronds, to chase away any spirits who could disturb the new baby or the postpartum mother. The small children run behind the smoky fire-bearing grandfather, shouting, banging bamboo sticks and making a joyful ruckus; demons don’t come near a joyful noise.

This may sound like an ideal life, but remember, the people of Bali have one foot sliding around precariously in the modern world, chasing after prosperity, motorcycles and television sets, acquiring modern possessions and modern style debt. The other foot is still firmly planted in their ancient Bali Hindu Dharma traditions. This means they are being torn in two vastly different directions. An example is the treatment of postpartum women by their employers. Traditionally, new mothers cannot go out or work at all around the home for the first 42 days, yet their bosses often demand they return to work within one to two weeks after having a baby. The work schedule is usually six to seven days per week, with long eight-to-ten hour shifts, and no breaks. These poor mothers all too often cannot afford to quit, as their income may be the only money supporting their husband’s extended family.

Komang was three weeks postpartum with her second baby when she collapsed at work. She was working as a massage therapist, doing eight- to ten-hour-long work days. Her husband would bring the baby on motorbike, even in the rain, to breastfeed between her clients. They carried her into the Bumi Sehat birth center with a blood pressure of 80/50. We midwives were shocked, as on her last home visit, before she resumed working, she was glowing and in perfect health. Even though the boss had promised her a three-month maternity leave (which is still not long enough), he demanded she return after only two weeks because he could not find a skilled replacement for her. Ibu Komang needed intravenous fluids and lots of tender loving care. She so enjoyed staying in bed at Bumi Sehat, just breastfeeding and being fed. A dear friend, who is on our board of directors of Bumi Sehat and owns the Bali Buddha café, was so upset about Komang’s work situation that she purchased a cell phone for her. We then made Komang promise to stay home for a minimum of six more weeks; we provided a small salary to make this possible. We distributed her phone number among friends who we knew would love a good massage. She began doing one massage a day making six times what her boss was paying her. Today Ibu Komang is trained in Esalen, Ayurvedic, Lomi-lomi and Shiatsu massage. She runs a beautiful spa and is now planning to have one more baby. Her old boss was furious with us for helping her quit.

Women in Bali make very little money, a monthly pay the equivalent of $50 to $100 for full-time work. Unwisely, the mothers who cannot get time off from work to breastfeed will wean the baby onto infant formula. The cost of infant formula in Indonesia is nearly as high as it is in the US, but the salaries are much lower. Extra cooking fuel and frequent trips to the doctor and pharmacist because a formula-fed baby is often sick adds up to extra costs. A bottle-fed child in Indonesia is 300 times more likely to die in her first year of life compared to a breastfeeding baby, due to water and sanitation issues. Families cannot afford milk substitutes, so they water them down or replace the milk powder with thin, white rice gruel. I say, without reservation, that failure to respect the postpartum lying-in, which in turn protects breastfeeding, is responsible for an untold number of infant deaths due to bottle-feeding. Many of these deaths are unreported.

At Bumi Sehat Bali and Aceh we give new mothers from our team six months of maternity leave with full pay. If the baby or mother is not ready after six months, the paid maternity leave is extended. Once the mothers return to work, they know they are welcome to bring the baby along, and they do! It is not unusual for our bookkeeper to have her baby on her breast at any time during the day. In between feeds Baby Kadek is off being cuddled by the housekeeping team or the midwives or she is sleeping in a basket in the office by her mother.

A few days ago one of our Bumi Sehat nurses had a lovely daughter. She is a single mom, which is very rare and brave for Indonesia. In fact, she ran away from her village in Java, where she feared to be stoned to death for refusing to marry the man who had raped her (most Muslims are not this extreme, and the Muslim respect for family and women is quite caring). Now, after having a lovely, gentle waterbirth, Niza does not want to leave the birth center until her baby’s lotus placenta has released. She is very comfortable in the postpartum recovery room with the other families. At her little rental, Niza is surrounded by a very supportive Balinese family. They are Hindu and she is Muslim; they have vastly different beliefs, yet they share a deep love. Normally in Bali Hindu tradition, a non-family new mother may not come into the family compound until after the 42 days of lying-in have passed. This is because it is believed that the blood of a woman, either menstrual or lochia, is kotor—it puts everyone at risk spiritually. The extended family’s home, where Bumi Sehat has rented Niza a room, has decided to go against tradition and allow her to move back in with their family compound as soon as the baby’s umbilical cord releases. This is considered a foolish spiritual risk to let a kotor Muslim girl into their home. Yet, the middle-aged mother of the big family only had sons and is devoted to Niza and willing to endure any criticism to protect this single mother. This I feel is a wonderful thing and a sign that in this small village, love is reinventing tradition. The compassion of a woman in her forties for a young stranger can be bigger than centuries of prejudice.

About Author: Robin Lim

Ibu Robin Lim, CPM, had been a midwife for over 20 years when she studied with Debra Pascali-Bonaro to become a DONA Doula. Ibu Robin is the mother of eight and the grandmother of Zhouie, Bodhi, Tashi, Rimba, and Bear. Ibu Robin splits her time between Bumi Sehat Community Health and Birth Center in Bali; the Philippines, where the Bahai Arugaan ni Maria Birth Center Palawan will open in 2019; and Lombok, Indonesia, where Bumi Sehat is operating a disaster relief clinic in tents since the north half of the island was destroyed by earthquakes. “Birth in the Era of Climate Change,” a MEAC-accredited course, is offered by Ibu Robin and Jacquelyn Aurora upon request. Along with The Farm midwife Deborah Flowers, Ibu has developed a website for families called Awakening Birth ( Also, visit

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