INTRODUCTION
I put a necklace on my baby's neck and when a midwife from the hospital came to visit me saw it she said: "don't do this because it may choke your baby". How could it choke the baby? We Hmong people have been doing this for 1,000 and 1,000 years and no baby has died from being choked by a silver necklace.
The quote given above shows different cultural beliefs and practices among health care providers and women from a non-Western cultural background. In this case, there is little doubt that the carer had good intention in protecting the infant. However, putting a necklace around the infant's neck is a means of protecting the infant from ill health and harmful agents in the Hmong culture. The carer would have been more understanding and could have handled the matter better if she was knowledgeable about different cultural beliefs and practices among the Hmong women. Confusions and conflicts, therefore, could have been avoided.
In this chapter the experiences of several Hmong and Vietnamese women who had their babies in Australian maternity hospitals are examined. The chapter is divided into three main areas: Pregnancy, Birth, and Confinement. In each of these three areas important issues which are the main concerns and worries among Hmong and Vietnamese women will be presented. However, these important issues will be presented within the following themes:
-Cultural beliefs and practices in relation to childbearing.
-What can women do in Australia?
-Their experiences in Australian hospitals.
-Perceptions of their own health now since being unable to observe their
traditional practices and having to accept hospital regulations.
THE STUDY AND METHODOLOGY
The study reported in this chapter stems from an ongoing ethnographic study concerning childbearing, childrearing and cultural beliefs and practices in Southeast Asian communities in Australia. The groups in this study include Hmong, Lao, Vietnamese, Cambodian, and Thai communities.
I conducted ethnographic interviews with 24 Hmong women and 8 Vietnamese women who are now living in Melbourne. All Hmong women had experienced childbirth while living in Laos or in a refugee camp in Thailand as well as in a western hospital in Melbourne. The Vietnamese women also had experienced birth in Vietnam and in Australia. The women were individually interviewed in their own homes. All Hmong interviews were conducted in Hmong language with the assistance of a bi-cultural researcher (BL) who is a Hmong native born woman. She has worked for and represented the Hmong community in Melbourne for more than ten years. Thus she is well known and accepted by most Hmong here. Most Vietnamese interviews were conducted in Vietnamese, with the assistance of a Vietnamese interpreter. Three of the interviews were conducted in English by the author since the women felt comfortable to speak in English.
Each interview was tape-recorded. The length of the interview varied, depending on the women's responses. In general, each interview took between two and three hours. Most women were interviewed once. There were, however, a number of occasions when we needed to obtain more information. Those women were then visited for a second time.
In addition, a participant observation method was used. For example, I attended a number of Hmong ceremonies and participated in Hmong activities. These allowed her to observe and record the women's cultural beliefs and practices and their experiences in Australia more accurately. The interviews and participant observations were conducted between April and November 1993.
Informed consent was obtained after the information about the research and the woman's participation were clearly explained to her.
A content analysis approach was used to derive patterns in Hmong and Vietnamese women's beliefs and practices. Put simply, recordings of interviews were transcribed for detailed analysis. The transcripts were examined for statements of knowledge related to childbearing and childrearing. Verbatim examples from the interviews were produced in order to illustrate examples of women's explanations.
HMONG WOMEN: WHO ARE THEY?
In this chapter I only present a brief description of Hmong women although I also discuss childbirth experiences of the Vietnamese. This is because, first, the Hmong are not as wellknown as other groups of Southeast Asian refugees such as the Vietnamese and Cambodian. Second, the descriptions of the Vietnamese and Cambodian are given in other chapters in this volume (see Douglas, Tran and Cape chapters).
Hmong women are refugees from Southeast Asia. They have been accepted as immigrants in Australia since 1975. However, the majority of them arrived recently. The Hmong in Australia come from Laos where they are hilltribes living in the high mountainous areas. They were unfortunately involved in the fighting between the American forces and the Pathet Laos, the communist group in Laos. As a result of the war, the Hmong were forced to move out of their homeland in the mountains and escaped to Thailand. The majority were accepted by the USA. In Australia the main concentration of the Hmong is in New South Wales. In Victoria the Hmong live in close knit group, mainly in the Fitzroy highrise flats and some are in Coolaroo.
In general the Hmong are much poorer than other Southeast Asian refugees. Because most Hmong are recent arrivals, they are still learning English for migrants. The majority are unemployed. Most Hmong did not have any form of formal education in Laos because of the war and their geographic position. The majority of Hmong are Animistic and follow Ancestral worship.
THE FINDINGS
PREGNANCY
Vaginal Examination
The most important and most frequently raised issue is that of a vaginal examination. This is particularly important for Hmong women. Very often women said that it was embarrassing to be examined in that area, particularly by a male doctor. The genital area is considered 'secret', 'private', and should not be seen by others. In the Hmong tradition, "only your husband can touch you there and no other man is allowed to touch you.
Some Hmong women refused to be examined internally. No such examination is practised in the Hmong culture. One woman said:
The doctor said she would do an examination there, but I explained to her that traditionally the Hmong did not practice such thing and it was very embarrassing for me. I refused to have it examined.
Some, however, avoided being examined vaginally by not attending for antenatal check ups early in their pregnancy. The reason given is:
I was afraid of being examined vaginally so I just did not go for check ups early. I went when I was 7 months pregnant.
After the interview, all the Hmong women asked me to emphasise this issue whenever I have the opportunity since it is the issue that worries them most when they have their babies here.
Vietnamese women are not as worried as the Hmong about vaginal examinations, however, most say that they prefer to be examined by a female doctor. As one woman said:
I did not mind if it was a man or a woman, but I knew that if it was a woman it was easy for me to go for check ups. With a man, sometimes I felt uneasy when I wanted to ask about women's things. Sometimes during my pregnancy I wanted to see a woman doctor, but they told me I would have to wait for a long time, and that was very inconvenient for me.
BIRTH
There are several issues raised by women around birth.
Family Members At Birth
It is common practice in hospitals here for the husband/partner to be present at birth. This is certainly very practical and a good source of support for women. However, with some Southeast Asian groups this may not be the case. In the Hmong culture, birth is managed at home. There is no doctor or midwife to deliver the baby.
We traditionally give birth without doctors.
With the first baby most women give birth with the help of their own mother and mother-in-law. The subsequent births she manages on her own. Her husband will be around to help with cutting the cord and washing a newborn infant.
I delivered my second baby by myself. My husband was there after the baby was born to cut the cord and wash the baby.
However, a woman who is having a difficult labours could be assisted by an old woman who has delivered her own children and has helped other women deliver. She is knowledgeable and experienced about birth, but she is not regarded as a traditional midwife. There is no word to describe this role in Hmong culture. The Vietnamese, however, have a particular term for a traditional midwife; she is called "ba do".
This tradition is still the one that most Hmong women prefer. However, they realise that when giving birth in this country they have to go to a hospital and have a midwife or doctor deliver their baby. What they would like very much though is to have their mother or mother-in-law present at birth as a first choice, not their husband.
When I had my baby there were two nurses and a doctor in the room. My mother, brother and husband were told to wait outside, they were not allowed to stay in the birth room with me. I would like very much to have my mother in there to help me. This is what we always do in our country.
Vietnamese men rarely participate in the births of their children. There is a common belief that the husband should not be present at birth since this may result in difficult labour. The following explanation was given:
In my country when a woman is giving birth there are only herself and a midwife or a doctor. Her husband should never be there. (Why should not he be there?) Because they say if the husband comes in the room the baby will not come out. This means she will have a difficult birth.
Birth Position
In some Australian hospitals women are required to lie down on a bed when giving birth. However, in Southeast Asia many women have traditionally giving birth in a sitting or squatting position. This is still the preference of many of them when they have their babies here. A Hmong woman gave the following explanation:
We traditionally give birth not lying down but in a sitting position. Because if you lie down then your baby is in a horizontal position and he does not have energy to come out. You must give birth in a sitting position so that your chest pushes down on the baby and so you have quick birth.
One Hmong woman who was fortunate enough to give birth in a birth centre at one hospital, was told by a midwife that she could give birth in a sitting position if she wished. The midwife prepared a mat on the floor for her. This woman did give birth in a sitting position on the mat, and felt grateful to that midwife because she made it possible for her to follow her traditional practices.
Caesarean Birth
The Hmong have great concern about caesarean birth. This is particularly so for a caesarean operation under a general anaesthetic since this involves the body being cut open and being unconscious.
The doctors said that the baby is in the wrong place and that I must have a caesarean operation, they did not let me have a normal birth. I wander why because I have had many children already and I had no problems, why did they say this to me? Having an operation is not as good as giving birth on your own. If your body is cut open your soul may go away. I was worried about that.
Why I was worried about a caesarean birth? Because I had never had it done before and because I had only given birth myself. I was afraid that the operation might kill me and that was why I was worried about it. Old people say that I might lose my soul. Even the operation was okay I might get sick and then die, this is the Hmong belief. So when I came home from the hospital the family had to "hu plig" for me.
This concern is related to one of the Hmong cultural beliefs and practices, namely the concept of soul loss. The Hmong believe that each person has three souls (plig). One soul is to look after the body when a person is still living. This soul travels to the other world and awaits the opportunity for rebirth. A second soul stays to look after the grave of the person after his/her death and it is not reincarnated. A third soul travels to live with their ancestors in the other world when the person dies (Lee, 1981; Symonds, 1991).
If all souls reside in the body, a person is well and healthy. A soul is able to wander off occasionally and it usually is able to return to its body. Ill health occurs when a soul leaves the body because it is frightened away for various reasons and is unable to find its way home. The causes of soul loss exist in many forms, for example, injury and wound, a great fall, a loud noise, being alone in darkness, being unconscious, and feeling sad and lonely (Chindasri, 1976; Thao, 1984; Symonds, 1991). Common symptoms include feeling tired and weak, having a headache and fever, loss of appetite but having extra need to drink water, being unable to sleep, and having frequent dreams of being in a strange place and with a stranger.
To restore a person to wellness, "hu plig" (a soul calling ceremony) must be performed at the place where the soul has left the body. If the soul has left its host for a lengthy period of time the soul calling ceremony must involve the shaman to travel to the other world to bring the soul back (Chindasri, 1976; Thao, 1984; Symonds, 1991). The soul calling ritual requires the burning of an incense, an egg, a plate of raw rice, and a live chicken. Traditionally, the time of the performance of the ceremony must be either early morning or late afternoon. However, the ceremony does not require a specific date. The ceremony may take from 10 minutes to one hour or even longer, depending on how long the soul has been lost and how quickly it agrees to come home.
As caesarean section when performed under a general anaesthetic, makes a woman unconscious, most Hmong women strongly resist this intervention. They insist that they would be able to give birth vaginally even though the foetus is in a transverse lie. One Hmong woman gave the following explanation to illustrate the resistance among Hmong women.
One Hmong lady, who had her baby at the same time as mine, was told by the doctors that she must have a caesarean birth but she swore at them, yelled at them and hit the bed and the doctors, she was not nice to them at all and they all got very angry with her. A few days later she gave birth to her baby by herself.
Necklace On An Infant After Birth
The majority of Southeast Asians are Buddhist who also believe in animism, which means that many of them have strong beliefs about spirits and souls. For a newborn infant, if all souls are not secured in the body, the infant will have ill health and will not grow well. The ceremony to lock the souls of the newborn infant is therefore essential. In the Hmong culture one way to do this is putting a silver necklace around the newborn's neck. If this is not available due to the poverty, a white string can be used instead. Traditionally, this must be done before the cord is cut.
As soon as the baby is delivered, we put the necklace around its neck. It must be put on before cutting the cord. The elders say it is something to do with the baby's life and as soon as the baby is born we must tie his life with the necklace before his cord is cut.
When Hmong women gave birth in Australian hospitals they would bring in the necklace, but they were reluctant to put it on their newborn before the cord is cut. A Hmong woman said:
I brought a necklace into the hospital with me. As soon as we got to the ward I put it on my baby. I wanted to put it on him before his cord was cut, but I did not dare to ask the midwife or the doctor to do this for me because they would not understand my customs.
This practice has been seen as harmful by some Western health care providers. The woman said:
I put a necklace on my baby's neck and when a midwife from the hospital came to visit me saw it she said: "don't do this because it may choke your baby". How could it choke the baby? We Hmong people have been doing this for 1,000 and 1,000 years and no baby has died from being choked by a silver necklace.
Placenta
In many Southeast Asian cultures, the placenta is perceived as an important part of a person's life and well-being. In Hmong tradition, an infant's placenta is buried inside the house of its birth. In Hmong villages in Laos and Thailand, a house is built on the ground. The Hmong believe that when a person dies he/she must collect his/her placenta in order to enter the heaven. Kao Vue, a Hmong born community health worker explained that:
We say the placenta is the 'black jacket' within the spiritual world. When you die you put on your 'black jacket' as a symbol of humility and atonement for your life on earth. Before meeting your ancestors with a clear conscience you must re-visit the place of your birth. (quote from Crofts, 1993, p.4)
One woman gave the following account:
We have to bury the placenta so the baby knows where to look for his jacket and so when he goes back to heaven he can bring it with him so that he can be reborn again.
Many Hmong women are worried about what happens to their newborn's placenta in Australian hospitals. One said:
In this country we give birth in a hospital I am very worried about my children's future life and about what we can do for them.
The Hmong realise that it is no longer feasible for them to bury the placenta inside the house because they live in a highrise flat or in a house with concrete floor. They prefer to have it buried inside the hospital where they give birth.
I would like a hospital to bury the placenta, let it rot in the ground, because if we carry out our traditional practice then the baby will know where to find his 'black jacket'.
When they are told that they can ask to bring the placenta home, they said:
Bringing it home I would not be able to do anything with it. Because I live in a flat, I really cannot do that (to bury), but if I live in a ground house then I would like to take the placenta home and bury it there.
Baby Born With A Caul
The Hmong believe that an infant who is born with a caul is special. The infant was a monarch in his previous life and died as a monarch. This life it is born with the caul which is the "clothe" from his previous life.
When we were in a refugee camp in Thailand, my aunt gave birth to one baby with a caul. These children are special. The elder say that they are monarchs, only monarchs are born with the caul.
Children born with a caul are believed to lead a prosperous life. They are intelligent and able to achieve easily. They are also healthy and strong. However, the caul must be dried and kept in a safe place in the parents' home. It is given to the child when he/she grows older and particularly when he/she dies. At the funeral ceremony the "clothe" must be given to the dead person in order to be reborn with prosperity.
The Hmong have their concerns about this issue when they have their baby in Australian hospitals. A woman said:
With people who have this they have to keep it safe and when their child grows up he will lead a good life, he will be rich. I think that in this country even if the child is born with a caul they will throw it away because they do not know how important it is. I think if a child is born with the caul we ask to bring it home with us so we can keep for the child.
Praising The Newborn
When we see a newborn infant it is usual to say something positive, like "isn't she beautiful?, oh, she is so cute!", and so on. This may distress many Southeast Asian mothers who believe that praising the newborn attracts the attentions of spirits who may take the baby with them; meaning the newborn may die (see also Tran, this volume). A Vietnamese woman said:
You cannot say good things about the baby. If you say "Oh you are beautiful", the ghost will come and take the baby. Some people are really scared to say that, and if you say that to their baby that will upset them.
Hmong women have similar beliefs and practices. They do not like to boast about their baby since this may lead to illness or perhaps death of their newborn. Usually the newborn will be greeted with the opposite expression such as you are ugly instead of you are beautiful, I hate you instead of I love you and so on.
CONFINEMENT
In most Southeast Asian cultures a period after birth is perceived as a critical time for a new mother. During this period a woman is considered to be in a weakened state. In Vietnamese culture women are compared with a crab.
When you give birth you resemble a crab which really has two levels of skin. There is the outer shell which is very strong but once this shell breaks, it is very soft and weak. You are like a crab. So that during the time of birth you lose a lot of blood and so your strength is not as it normally would be.
Because a woman is weak she is vulnerable to all sorts of harmful agents. She is susceptible to all sorts of illnesses and diseases. Therefore, there are a number of cultural beliefs and practices which she must observe in order to regain her strength and to avoid bad health and illness.
Keeping Warm
A common requirement emerging in this study is keeping warm after childbirth. Because a woman loses so much blood during childbirth her body is in the state of being "cold". This "coldness" I refer to is humoral coldness, not physical coldness. The concept originates from the 'Yin' and 'Yang' concepts of Chinese medicine (see also Tham, this volume). In order to restore the heat lost in childbirth a woman must keep herself warm. Traditionally, this can be done in several ways.
Lying Near/On The Fire
During the confinement period a new mother lies on a wooden bed, with a fire burning near or underneath, in a room where the windows and doors are kept closed in order to keep her away from draughts. The woman then roasts herself for most of the day for the entire confinement period (see also Manderson, Douglas and Tran, this volume). In Vietnamese culture, this takes about one month. The Hmong, however, practice this only for three days, though the confinement extends to 30 days. In Australia women realise that it is not possible to observe this ritual. In stead they cover up the body by wearing several layers of clothes and socks, covering the head with a scarf or a piece of cloth, even when the room is quite warm. They also use a heater to warm the body up. Most of them sleep on a mattress next to the heater for the entire confinement period.
In this country because the flats are warm and there are adequate clothing like socks, shoes and warm clothes to wear, the main thing to keep yourself warm is to put on warm clothes, stay in the home, and use a heater to help heat up your body.
However, for some women whatever they are able to do when they have their babies here is by no mean as correct as it should be. Some say:
Since I had my baby here I have felt the cold easily. I feel cold most of the time.
Do you know why?
I don't know why, even now I still feel cold easily. Perhaps I did not do the "nam lua" (lying near the fire) here, it may be that, I think.
Avoidance Of Coldness
By coldness I mean cold water and cold wind in particular. In Vietnamese culture, taking a shower or washing hair soon after giving birth is prohibited. Traditionally this prohibition extends for the entire period of confinement. Breaking this taboo results in bad health. Women believe that if one has a shower and washes hair soon after birth one will have recurring headaches and one's hair will drop out quickly in old age.
With our Vietnamese customs, when you give birth you cannot take a shower for one month. Old people say if you have a shower too early, later on you will have headaches and your hair will drop out.
My parents say that if I wash my hair earlier then the water, especially the cold water, will seep into my hair follicles. Then I am more prone to head problems and I will not feel very well at all.
Vietnamese women keep their body clean by a number of methods. Most commonly they sponge the body with warm water. Traditionally, however, women use the "Xong" method (steamed bath) to clean their body. A pot of water with several kinds of herbs, mainly comprise leaves, barks, branches and roots of herbal trees are boiled together. A woman then sits near the pot, with minimum clothes on, and covered be a blanket. The steam makes her sweat, then when she wipes the sweat off she is clean. The steamed bath method is not only for cleaning, but also for getting rid of the "coldness" inside the body which occurs at childbirth. It is another method of regaining health after childbirth.
Old people tell me that if I use our traditional method it is very helpful for my body. The water inside the body will come out and this help my feel stronger because my body is able to get rid of the coldness from childbirth in my body.
Because traditionally women are prohibited from taking a shower for one month, when they have their babies in Australia they feel somewhat uneasy. All the women said that they were told to have a shower very soon after birth. Because they were told to do so they thought that it was a hospital regulation which they must follow. One woman said:
The nurse told me to take a shower. With us Vietnamese, we do not take shower as such, but rather just clean ourselves. Because if we follow by what they do here we will not feel too well or strong because we have different habits. But when I gave birth to this one I did not understand English and the nurse, through signs and gestures, told me to take a shower. She helped me to get to the bathroom and when I got there she turned the cold shower on and told me to step in, and so I did.
When questioned why they had to follow the instruction, typical answers were:
You had to accept what they said, not to oppose it and so after the shower that was what happened to me.
If I did not have a shower the sister would think that Asian people were probably a bit dirty, so it made me feel a little bit confused and made me, after that, take a shower.
Unfortunately, the consequences of following this instructions is as one woman said:
After the shower, a little later on, I was feverish. But because I did not know any English I did not know how to say I needed a blanket. Luckily, my friends came and saw that I was shaking, they asked for some blankets to cover me. They covered me with four blankets, but I was still shivering. Within a month after I came home I had three feverish attacks. I was shaking and sweating and the whole bed was damp. Each attack lasted about two hours. Since then I always felt weak and unwell. It was only when I used Chinese medicines that I recovered.
In Hmong customs, touching cold water is also prohibited. It is believed that if she touches cold water a woman will have cold bones and this results in aching all over the body in old age. Itching and tender skin are also resulted from touching cold wager. However. a warm shower is allowed several days after birth.
In confinement you only touch warm water and shower with very warm water. I do not mean only taking a shower but the one you touch as well. Not talking about when you are old but when you have had a few children and you touch cold water, your skin will be itchy. It is the same as when you take a cold shower, later when you have given birth to a few children then you will have an itchy body. Also if you are in confinement and you touch water a lot you will experience tenderness in your hand, tender as in soft and if you touch anything that is a bit rough, then it will hurt.
Dietary Restrictions
Diet during confinement plays an important role in a woman's health in all Southeast Asian groups. Women are required to restrict themselves to certain types of food as a means of regaining and maintaining their health. Hmong women, for example, eat only hot rice and chicken soups cooked with special green herbs in the first ten days after birth. Within the one month confinement period she must restrict herself to this diet though she may also eat some chicken eggs, pork and some fish. All fruits and vegetables are proscribed for the entire confinement. Cold drink is especially prohibited during this period.
Old people say that you must eat hot food so that your blood will run properly. So after 30 days you will be able to gain weight and be strong. But if you eat cold food then you will be unhealthy and sick all the time. This will stop you from being able to support yourself.
Eating cold food gives you heartburn immediately and your stomach will feel hard and you can die from this.
Nearly all Hmong women whom I interviewed said they did not eat any of the hospital food during their stay.
I did not eat any of the hospital food. I only drank hot water there. The chicken dish had sweet and sour sauce in it so I did not want to eat it. They gave me some bread but I did not want that either. I believe that it may make my skin swell up when I get older like many of the white people. I believe that if you eat according to our custom then it will make you healthy and this will be good for you.
When questioned what they did with food, a common answer given was:
I had to wait for my husband to bring food for me. He brought it for me to eat twice a day. Sometimes I nearly starved because he brought the food in too late. He had to look after and feed the children before he could come into the hospital.
Vietnamese women also adhered to their postpartum diet during confinement (see also Tran, this volume). All food must be eaten when it is hot and it must be cooked well. This also applies to water.
Most food you eat everyday is not good when you have just given birth because your body is very weak. All food must be cooked well, even drinking water must be boiled. We must eat food when it is hot.
In Vietnamese culture certain food is prohibited during confinement. Beef and seafood, for example, is believed to cause skin allergy, and sour food and fruits cause incontinence.
Vietnamese women mentioned that during their stay in a hospital here they only chose to eat some of the food provided. They avoided fresh salad and some sour fruits, such as oranges and apples. They avoided beef, lamb and seafood. They only chose pork and chicken when it was on the menu. As in the case of Hmong women, food was brought from home by family members if they had this familial support. Those who had no mothers or sisters here did not have much to eat in hospital. Some ate the proscribed food, only to bear its consequences now.
In the hospital they gave me some fruits, oranges and apples, and I had it. I did not listen to my parents, I tried, and now I have that experience.
What happens?
Whenever I have a cold my nose is warm and sometimes I have mucus and so many times now that my urine just leaks, it keeps leaking. Now I believe it, my parents are right.
Vietnamese women also consume salty food during this period. Salty food is believed to have many beneficial results. First, it is meant to stimulate breast milk as one woman said:
If you eat salty food you will feel thirsty and then you can drink a lot of water which is very good for you and your baby if you breastfeed. It helps you have more breastmilk.
Second, because of salty food, women need to drink a lot, and this helps her body to digest better: a way to overcome constipation after childbirth.
Physical Activities
After birth a woman is required to refrain from most physical activities, for example, walking around, performing household chores, carrying heavy loads and so on. The Hmong believe that doing so results in the collapse of the internal organs.
Our traditional practice is not to walk around after giving birth. Because your womb is still quite hollow, and if you walk soon after birth then your internal organs might fall down very low.
Vietnamese women also avoid physical activities in order to recover after birth and also to avoid the collapse of the internal organs. These beliefs and practices are in conflict with the Western norm. In most hospitals women are encouraged to walk and perform postnatal exercises very soon after birth in order to gain their health and their figure back to normal. A Vietnamese woman said:
The sister told me to walk around. She said that if I walked soon after birth I would gain my health back quicker and it would be good for my pelvic floor. But, my parents told me that I must rest for a month for recovering. My mum did not let me do anything, like carry heavy stuff, and walk around. Anything to do with my back and my head she would not let me do it. She said because all parts of my body is weak, so I need to rest to regaining my strength.
Postnatal Check Up
It is a common practice in Australian maternity hospitals to ask women to attend a postnatal check up at six weeks after birth. This presents similar problems to those of the antenatal check ups. Most women do not feel comfortable to be examined vaginally after giving birth. Hmong women avoid this by not attending the six weeks check up. Most Vietnamese women do attend, but with reluctance and anxiety.
They asked me to go back for the post-natal check up about six weeks afterwards. They asked me if I wanted to go back to the hospital or go to the Health Centre. I said that I would not go back there and I would go to the Health Centre. But I did not go because I was afraid that they might do the vaginal examination, I did not want that done either.
IMPLICATIONS FOR BIRTHING SERVICES2
The findings of this study have several implications for birthing services. Firstly, they indicate that health care providers need to be more sensitive to different cultural beliefs and practices of the Hmong and Vietnamese women. Most simple of all is to ask the women about their particular cultural beliefs and the practices which they must observe. Normally if the carers show signs of approval and understanding most women will talk about their particular needs in following their cultural practices. Their fear when coming into contact with health care services is that they are seen as bizarre if they do something which is very different from the western norms. This fear has stopped many women from following their cultural practices and many have ended up with distress. In addition, hospitals need to provide staff training to improve knowledge of cross- cultural beliefs and practices related to childbirth. This will reduce misunderstanding and mismanagement in providing care to many Hmong and Vietnamese women.
Secondly, the continuity of care should be a prime concern in providing care to Hmong and Vietnamese women. If the woman has an opportunity to have continuous contacts with her own carers such as a medical practitioner and a midwife she may feel more comfortable in discussing about her need to follow her cultural practices. This was one of the recommendations made in the "Final Report of The Ministerial Review of Birthing Services: Having a Baby in Victoria", conducted by the then Health Department Victoria in 1990 (HDV, 1990).
Thirdly, a birth plan seems to be an ideal solution since the women are able to plan for the birth and they are given the opportunity to raise the issue of their cultural beliefs and practices in relation to childbirth. Issues of, for example, female carers, confinement practices, and caring for the newborn can be easily planned between the woman and her carers. This will avoid unnecessarily distressing situations for many of them. However, the existing birth plan which has been used in many birthing services needs to be modified to be more culturally appropriate. A possible format for a birth plan needs to include such items as have been mentioned in the main concerns in this chapter. The birth plan needs to be organised with the assistance of a bi-lingual health worker or an interpreter.
Fourthly, attempts need to be made to provide more culturally appropriate services to Hmong and Vietnamese women in maternity hospitals. Food provided in a hospital, for example, should meet the women's need to observe their traditional practices in confinement. The choices on a menu need to include more rice based dishes. Hot water could be served instead of cold water with ice. Additionally, women should not asked to take a shower soon after giving birth and perform certain physical activities such as walking and postnatal exercise during their stay in the hospital.
Fifthly, bi-lingual health workers need to be employed in maternity hospitals and community health centres. With the assistance of these health workers with language skills women from non-English speaking backgrounds may increase their knowledge of available care and have better access to birthing services.
Lastly, an interpreter needs to be available at all times. This should be offered to a woman even though she may not ask for one since she may not know that she has a choice. Some women may not choose to have an interpreter present. This should not be seen as a refusal of service. She may have her own reason for not having an interpreter with her, for example, confidentiality and comfort. It is also essential to find out what language a woman would like to speak. Many Vietnamese women, for example, are from Chinese background. A Vietnamese woman may feel more comfortable to speak Cantonese than Vietnamese (Rice, 1993).
CONCLUSIONS
Childbearing is universally treated as a life crisis event. Jordan (1980:2) wrote:
In most societies birth and the immediate postpartum period are considered a time of vulnerability for mother and child; indeed, frequently a time of ritual danger for the entire family.
Most societies, therefore, tend to have certain sets of beliefs and practices for coping with this life crisis and for dealing with the danger and the uncertainty associated with childbirth. The beliefs and practices of each society have common goals, namely, the maintenance of well-being and preservation of life of a new mother and her newborn (Muecke, 1976). Jordan (1980:2) has also pointed out that:
it is not surprising, therefore, that whatever the details of a given birthing system - its practitioners will tend to see it as the best way, the right way, indeed the way to bring a child into the world.
In this chapter the experiences of several Hmong and Vietnamese women are given for analysing cultural interpretations of childbirth in Hmong and Vietnamese societies. The chapter presents several important issues surrounding childbirth which were raised by the women in the study. Some of these issues are of great concern for many women.
A knowledge of existing patterns of childbirth beliefs and practices amongst Hmong women need to be a prime concern in establishing maternal health programs in Australia. This knowledge can potentially improve our understanding of women's acceptance or rejection of certain practices and health resources. When misunderstanding and mismanagement are eliminated, there will be better health care delivery for consumers from different cultural backgrounds. This is particularly important among the Hmong since the majority of Hmong women are of childbearing age. Because the Hmong put a high value on having many children they will be major users of mainstream health services. This means health care providers will have more contacts with them.
I would like to thank Blia Ly and Lan Voung for assisting in the interviews with Hmong and Vietnamese women, and to Minh Nguyen for transcribing-translating the Vietnamese interviews.
NOTES
1. An early version of this paper was presented at the Fourth Women in Asia
Conference, The University of Melbourne, Melbourne, 1-3 October 1993.
2. These implications are based on my recent book entitled "My forty days: Cross-
cultural resource book for health care professionals in birthing services, published by
The Vietnamese Antenatal/Postnatal Support Project in Melbourne in 1993.
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