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February 2003

Presented to

World Health Organization

BByy SStteeeevvee DDAAVVIIAAUU

Beliefs, taboos, practices and behaviors around birth in Lao

PDR

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Content

Content .......................................................................................................................... 2 Survey Background ..................................................................................................... 5 Methodology............................................................................................................... 5 Limitations of previous works ..................................................................................... 6 Ethnographic Literature Review .................................................................................. 8 Findings ...................................................................................................................... 9 Areas needing further investigations.......................................................................... 10 Proposed methodology for the survey........................................................................ 11 Demographical figures .............................................................................................. 11 MMR ........................................................................................................................ 11 Maternity Waiting Home........................................................................................... 12

Obstetrics: current trend and alternatives................................................................. 12 Childbearing practices ............................................................................................... 12 Feminist literature and modern obstetrics .................................................................. 13 Development of Western thought and medicine......................................................... 13 Authoritative knowledge ........................................................................................... 13 Beliefs Systems ......................................................................................................... 15 WHO-UNICEF: the Alma-Ata Declaration (1978) .................................................... 15

Ethnicity ...................................................................................................................... 15 Cultural change ......................................................................................................... 16 Changes in practices.................................................................................................. 17

Socio-economic and political Factors influencing women’s health ........................... 18 Poverty...................................................................................................................... 19 Women and the Environment .................................................................................... 19 Women and Food Security ........................................................................................ 20 Environmental degradation and the status of women ................................................. 20

Beliefs, Cultural Attitudes and Practices regarding Pregnancy................................ 21 Cultural construction of the Body and health ............................................................. 21 Beliefs and Knowledge about Conception ................................................................. 22 Health problems during pregnancy ............................................................................ 25 Food taboo/nutrition/ Dietetic restrictions during pregnancy...................................... 25 Restricted places ....................................................................................................... 26 Traditional medicine during pregnancy ..................................................................... 26 Proscribed activities .................................................................................................. 27 Miscarriage: Hmong’s Falling of the Baby ................................................................ 27 Antenatal care ........................................................................................................... 29

Delivery........................................................................................................................ 30 Location.................................................................................................................... 30 Assistance during delivery......................................................................................... 33 Payment of the delivery assistant ............................................................................... 34 Delivery process........................................................................................................ 34 Position..................................................................................................................... 35

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Cutting the cord......................................................................................................... 35 Difficult delivery....................................................................................................... 36 Health seeking behavior ............................................................................................ 36 Delivery characteristics ............................................................................................. 38 Placenta..................................................................................................................... 39 Recognition of the newborn....................................................................................... 40 Newborn care ............................................................................................................ 42 Abnormal birth.......................................................................................................... 42 Stillbirth and death of the mother .............................................................................. 43 Hygiene..................................................................................................................... 44

Postpartum.................................................................................................................. 45 Yu kham (nang fie, yu fai)......................................................................................... 45 End of yu kham (vang yu kham) ................................................................................ 48 Health staff and postpartum practices ........................................................................ 48 Postnatal dietetic restriction, food intake and taboos.................................................. 49 Sexual abstinence...................................................................................................... 51 Resettlement, housing and loss of natural birth control mechanism............................ 52 Back to work............................................................................................................. 52

Breast Feeding............................................................................................................. 54 Colostrum ................................................................................................................. 54 BF <1 hour after birth................................................................................................ 55 No liquid or fluid given to the baby ........................................................................... 56 Exclusive Breastfeeding up to 4-6 months ................................................................. 56 BF up to 2 years ........................................................................................................ 56 Introduction of first food at 6 months ........................................................................ 56 Food with a thick consistency.................................................................................... 57 Give food with nutrients............................................................................................ 57 Supplementary feeding.............................................................................................. 58 Nutritional practices .................................................................................................. 58

Child Health ................................................................................................................ 58 Common health problems.......................................................................................... 58 Recognizing the signs of a ill child ............................................................................ 58 Care of a sick child.................................................................................................... 59 Prevention of illness .................................................................................................. 59 Abortion.................................................................................................................... 59 Postnatal care: Health seeking behavior..................................................................... 59

Utilization of health facility ........................................................................................ 61 Experiences with public health services..................................................................... 62 Use of community based health providers ................................................................. 63 Postnatal care ............................................................................................................ 65 Decision making process ........................................................................................... 65 Language .................................................................................................................. 66 Communications ....................................................................................................... 66 Alternative healing .................................................................................................... 67 Recommendation for Safe Motherhood ..................................................................... 67

Research calendar....................................................................................................... 71

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List of interviews carried out by the international consultant: .................................... 71 Personal communications with relevant informants: .................................................. 71

Glossary ....................................................................................................................... 71

Ethnic Group per target provinces............................................................................. 75

Questionnaire for Health Staff ................................................................................... 76

Individual Mother Questionnaires ............................................................................. 78

Focus Group Discussions ............................................................................................ 82

TBAs, Grannies, Healers ............................................................................................ 85

Selected Bibliography ................................................................................................. 87

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Survey Background A National Maternal Mortality and Newborn Death Reduction Plan 2001-2005 was developed in 2001 and defined Safe Motherhood as a part of the Reproductive Health Programme. This plan formed the basis for setting objectives, identifying strategies and priorities for the Safe Motherhood Programme in the Lao PDR. UNICEF, UNFPA and WHO has agreement to support the Ministry of Health in a number of health related activities including safe motherhood, which target women and children. The MCH Center with the financial and technical support from UNICEF, WHO and UNFPA, is responsible for the implementation of the national Safe Motherhood programme. The programme aims to encourage women to use the health facilities before the emergency, to reduce the number of maternal deaths by increasing the proportion of hospital deliveries from 11% to 40% by the year 2006. The project also focuses increased attention to build capacity of health workers, especially at the local levels, to improve quality and utilization of maternal health services, and to empower families to provide optimal health and nutrition care for women and newborns. Before a National Safe Motherhood Programme is implemented nationwide, it is relevant to carry out an anthropological study focusing on two main areas: 1. The cultural views and women’s perceptions on maternal health among various ethnic

groups. 2. The main factors influencing the utilization of maternal health services. The Maternity Waiting Homes project (supported by WHO), Safe Motherhood project (supported be UNICEF) and Reproductive Health programme (supported by UNFPA) have planned to jointly conduct this anthropological KAP study on believes, rituals, taboos, and behaviors around birth. The present study is expected to provide qualitative information on beliefs, practice and behaviors of the women around birth and the views of the women to increase the utilization of maternal health facilities. The results of the study will help in the design of appropriate messages for safe motherhood campaigns, and make practical recommendations for the implementation of an efficient, well-adapted safe motherhood programme.

Methodology Review of literature and other existing information According to then initial agreement with WHO, the consultant had to review the following documents:

1- “Women in reproductive health in the Lao PDR, an anthropologic study of reproduction and contraception in four provinces” MCH Institute, SCF/UK, January 1994,89p.

2- “Socio-cultural and economic determinants of contraceptive use in the Lao PDR: results of a national survey in 7 provinces” Ministry of Public Health Lao PDR, Mother and Child Health Institute, Save the Children Fund/UK, August 1993, 33p.

3- “Traditional child rearing practices among different ethnic groups in Houaphan province, Lao PDR” Somporn Phanjaruniti, UNICEF Lao PDR, April 1994, 86p.

4- “Newborn Care and Child Nutrition in 3 Provinces of the Lao PDR- final report” Anna Gillepsie, Hilary M. Creed-Kanashiro, Rae Galloway, The World Bank, May 2002, 38p.

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5- “Dietary and socioeconomic factors associated with infantile beriberi in breastfed Lao infants” Dr Douangdao Souk Aloun, Mahosot Hospital Lao PDR, 36th annual meeting of Ambulatory Pediatric Association, Washington, May 1996, 7p.

This list isn’t of course exhaustive and many other documents and reports were added in order to cover as much as possible the works available on Beliefs, taboos, practice and behavior around birth in Lao PDR.

Limitations of previous works Use of the Lao Trinity (Lao Loum, Lao Theung and Lao Soung) It is true that ethnographic research on birthing culture of each group found in Lao PDR would be too much ambitious. Nevertheless, past works relied on the tripartite division officially used by the GOL up to 2001. Acknowledging the limitation of the previous division in ecological niches, the Lao Front for National Construction officialized the use of four ethnolinguistic categories found in the Lao PDR: Tai-Kadai (8 groups), Hmong-Iu-Hmien (2 groups), Mon-Khmer (32 groups) and Tibeto-Burmese (7 groups). The new system acknowledged more than 100 subgroups. The review of the literature revealed that only scant amount of quantitative and qualitative socio-economic information exists on ethnic minority women, and most of that data gathered by Phajaruniti (UNICEF, 1994), Gillespie (SCUS: 2002), and others is aggregated too broadly into Lao Loum, Lao Theung and Lao Sung categories, obscuring critical ethnic group distinctions. If the use of ethnic names by the AusAID survey in Houaphan and Phongsaly in 2002 constitutes a progress compared to previous works. Here again, no differences are made between sub-groups of Hmong or Akha for instance. Ethnic Lao Most of the works’ findings claim a broad or national coverage, but in fact, ethnic Lao are mainly targeted. For example, exploring the demands for contraception among the potentially targeted population by the forthcoming birth spacing program, the Socioeconomic determinants of contraceptive use in Lao PDR covered 7 provinces in Lao PDR and constitutes the first large scope study. But, a closer look reveals that 83% of the 4154 married women interviewed belonged to the “Lao Loum” group. LRHS (UNFPA: 2001) pointed out low level of understanding about the traditional practices of the different of the different ethnic groups regarding birth (including food taboos during pregnancy, birthing practices, etc.). If some traditions appear to be directly contradictory to the biomedical approach argue the doctor, women will be reluctant to seek assistance if they fear health service staff will try to influence their practice. Only one previous study is known to have focused on reproductive health but from an anthropological perspective, but even this study was limited in scope.1 Methodology used in previous work Exploring the socio-cultural aspects of RH among women in Lao, focusing on reproductive life cycle including contraception and aiming to gain understanding of

1 UNFPA, Reproductive health situation in Lao PDR, 2001.

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the lay concept of modern/traditional birth spacing methods and the factors and the factors influencing health behaviors, the Women and reproductive health 4 provinces used a impressive array of methodologies. SSI (Semi structured interviews); ethnopsychology, reproduction cycle, KAP, depth anthropological observations, non structured interviews, repeated open discussions, focus groups discussions, as well as key person having role in RH: religious authorities, traditional healers, TBA, health authorities were interviewed. But the scope of the survey has been hampered by then fact that the survey was carried out mainly in the lowlands for access concerns. Near the road Other previous surveys also well intentioned finally had to deal with “reasonably accessible villages. Political reasons (Phajaruniti: 1994) and seasonal calendar concerns have kept previous team rather close to the road. Phajaruniti (1994)2 leaded the survey in Houaphan in 4 villages accessible by road and 2 villages by feet (5 to 17 km from Sam Neua provincial capital); Socioeconomic determinants of contraceptive use in 7 provinces in Lao PDR also targeted “reasonably accessible” couples3; Women and reproductive health 4 provinces also mainly had to focus on lowlanders for access considerations. Newborn care and child nutrition in 3 provinces of the Lao PDR 2002 funded by Save the Children USA also had to limit itself to villages accessible by road because the survey occurred during the rainy season. Aus AID Report, Phongsaly and Houaphan provinces selected the most populous ethnic groups in those two provinces: Akha, Khmu, Lue, Phunoi, Hmong, Phutai, Yao and covers: KAP on women and child health and nutrition: Health and Illness of children <5; children nutrition; women’s Health; maternal health; women’s nutrition; RH; communication: men’s health and nutrition. Furthermore, the study carried out by AusAID in Houaphan and Phongsaly, also distinguish itself from previous works that rely mainly on the use of Lao language as mean to access people’s beliefs practices and behaviors. Language is fundamental in people’s conceptualization and understanding of the world and human culture is linguistically encoded and language represents the only instruments for human to elaborate, maintain, develop and transmit ideas and concepts.4 According to Bob Smith, if the findings of the AusAID report unearthed practices and behaviors around childbirth, the delivery practices and the utilization of health services are both area where further investigations are needed.5 Peri-urbanity and remoteness Any previous report enlightened the differences in practices and beliefs of an ethnic group related to the location, i.e. in remote areas versus in context of resettlement in the lowlands, in the case of ban hom policy (different groups mixed together in a single village unit, etc. Need for in-depth anthropological methodology

2 Traditional child rearing practices in Houaphan 3 Socioeconomic determinants of contraceptive use in Lao PDR 4 J. Chamberlain, Poverty Alleviation for All, 2002. 5 Interview with Bob Smith and Damian Hoy, 14/01/2003.

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Previous work on women’s health, nutrition and childbirth allow elements of answers, but the track of research often don’t lead very far. If practices related to BF, place of delivery, dietetic restrictions, etc. are given, any work allow reaching the unconscious beliefs or cultural premises that underlie observable behaviors and practices. The present study aims to fill this gap. Traditional practitioners are the first referral point for most sick people but very little information is available on utilization of the informal health sector. In order to meet the need of such a diverse population, it is essential that research should be done into traditional practices in order to gain better understanding of patient seeking behavior, so as to target needs more effectively.6

Ethnographic Literature Review Ethnographic works have been exhaustively researched in order to pull out birthing customs information. All those ethnographies target ethnic groups that are found in Laos, but some exhibit results surveyed in the Burmese highland in the 1950’s for the Akha; Hmong in context of migration in the US and Australia; or ancient medicinal text from dawn of civilization for ethnic Lao (Ayurvedic tradition). The consultant undertake the analysis of those documents in order to:

• Access ethnic minority beliefs and cultural factors influencing birthing practices, rituals, behavior, etc.

• Illuminate about decision making process within a community • Understand gender and nutritional patterns • Find key person through which health message could be elaborated • Promote the use of ethnolinguistic categories officially used since 2001

List of authors on the 4 ethnolinguistic superstock found in Lao PDR includes:

1. Tai-Kadai Ethnolinguistic Superstock: Ethnic Lao: Translation of Buddhist mantras, orally transmitted and also from palm leaves manuscript in Bali language in collaboration with the Maha Kheo from the EFEO. Buddhist incantation embodies ethnic Lao practice and beliefs, Whittaker. Leu: Khampheng Thipmuntali, Michael merman, Paul Cohen.

2. Hmong-Iu-Hmien Ethnolinguistic Superstock: Hmong: in Laos, Thailand and in context of migration in the US and in Australia: Rice, Lumley, Lemoyne, Cheon-Klessing, Jambunathan, Nuttal, Flores, Turtle, Reeves, Dewey; Iu-Hmien: Tribal Research Institute, Lemoyne, Chob Kacha-Ananda, Choychiang Saetern; Lenten: Chazee, Lemoyne

3. Tibeto-Burmese Ethnolinguistic Superstock:

6 Pani Sanikhom, Reproductive health situation in Lao PDR, conclusion, p. 42.

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Akha: Leo and Deuleu A. Von Gesau/Choopoh, Gim Goodman, Paul Lewis, Roux and Tran, Khammerer; Lahu: Walker, Schrock, Yoichi Nishimoto, Young, Wongprasert

4. Mon-Khmer: Works on the Katang (Earth and Seng-Amphone Chithtalath), Katu: (Costello, Khamleuang); Khmu: Saysana; Tariang: Tanousone; Lamet: (Irozowitz, Cresner); Nya Hon/Jrhu: Barbara Wall; Brao: Ian Baird; Ngkriang; personal research More ethnographic data on birthing customs of Tibeto-Burmese and Hmong-Iu-Mien ethnolinguistic superstock are coming in February from the Hong=He Ethnographic Research Center, Yunnan Province, Southern China. The present report gathers finding from all relevant documents, articles, monographs, reports, etc. in order to find out about:

1. The cultural views and women’s perceptions on maternal health among various ethnic groups;

2. The main factors influencing the utilization of maternal health services. The present report relies partly on ethnographic research were undertaken decades ago. Unearthed rituals, practices, behaviors and attitudes may have changed in context of cultural contact, resettlement etc.

Findings Childbearing practices in every society occur in accordance with the cultural norms of the society. In most societies, however, childbearing practices share a common value: the preservation of life and maintenance of the health and well being of a newborn infant. The similarity of birthing rituals and practices include:

• Pregnancy is perceived as a period of vulnerability • Squatting position • Rituals to be implemented after delivery

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• Gift to the birth attendant or relationship between the newborn and the attendant

• Burial of the placenta • Staying by the fire • Ritual for the recognition of the newborn • Birth control mechanism after delivery • Restrictions in the postpartum period dietetic, places, relation • Reliance on traditional medicine, healers, herbalist, shamans, etc.

Factors influencing women’s health include: socio-economic status, environment, mode of production, social classes, symbolic structures, community dynamics, gender, environment, government policies, etc. Delivery

1. Ethnic Lao and Hmong-Iu-Mien and Tibeto-Burmese groups all deliver at home. On the contrary, Mon-Khmer groups remain more vulnerable since they traditionally deliver outside the house in a birthing hut, located near the village or deep on the forest.

2. For all ethnic groups, there is a belief that the placenta has impact of the health

of the infant and must be buried according to the tradition.

3. All groups have ceremony related to the recognition of the newborn in the family, community and supernatural realm.

Postpartum

1. All groups practice the stay by the fire 2. Postpartum period involve dietetic restrictions

3. Intake of traditional medicine

4. Natural birth spacing mechanism after birth

Breastfeeding All group widely practiced breastfeeding. The AusAID survey in Phongsaly and Oudomxay 2002 and the World Bank survey in Champassack, Houaphan, Savannakhet (WB, 2002) provide a good understanding of the practices and beliefs regarding breastfeeding. Available information is fragmented and often inconsistent. Furthermore, validation of theoretical finding remains essential.

Areas needing further investigations

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1. Delivery practices 2. The utilization of health services 3. Health seeking behavior (prenatal, delivery, postnatal) 4. Knowledge about signs and symptoms of complications 5. Delivery practices 6. The utilization of health services (knowledge about health services available

perception, use, barriers, etc.) 7. Look for “key person” through which health message should be elaborated in

target groups 8. Evaluate the safe motherhood policy promoting hospital-based obstetrics practices 9. Traditional practitioners (profile and knowledge, remedies) 10. Factors influencing women’s health: socio-economic status, environment, mode of

production, social classes, symbolic structures, community dynamics, gender, government policies, etc.

11. Impact of other health services (private, foreign, etc.) Target area: Southern Laos Target group: Mon Khmer groups should be the main targets of the KAP survey. (See the main ethnic group per provinces in appendix).

Proposed methodology for the survey To be discuss with technical team

1. Interview LWU, Health Department, women, staff at provincial, district and community levels Women, TBA or resource person (herbalist, shaman, granny, elders, etc.), village head, neo hom, etc.

2. KAP survey (individual mother) 3. Focus groups (father and mother)

Demographical figures The population of the Lao PDR is estimated to be 5.2 million (NSC/UNFPA, 2000), growing at a rate of 3.1% a year. The population has very broad base with about 23% of the population aged 10-19 yeas (NSC 1995). The nation’s population is expected to double within 27 years. Despite concerns about RH, the high illiteracy rate in Lao PDR also results in low awareness of RH issues. Life expectancy is one of the lowest in the world at 45 years.

MMR Maternal and infant mortality are among the most important indicators of the socio-economic development of a nation. In Lao PDR, maternal, infant and under-5

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morbidity and mortality are among the highest in the region.7 In remote areas, it is estimated that the maternal rates are extremely high: up to 900 maternal deaths per 100,000 live births. (Reproductive Health in the Lao PDR 2000). The Strategic RH Assessment revealed that the magnitude and causes of maternal death were not well understood by health service providers. Although postpartum haemorrhage and retained placenta appear to the major causes of maternal mortality, the large majority of health facilities were not adequately prepared to manage these complications (no oxytocin in most of the health facilities visited). Health staff often lack the required skills to stabilize a woman’s conditions in case referral to a higher level facilities appears to be necessary. 10 – 15% of pregnancies will require some higher levels care. The small proportion of pregnancy complications attended at health facilities indicates that many complications of pregnancy go unattended. According to WHO: “These high statistics are due to the fact that most births are unattended.”8 Factors contributing to unattended birth include:

• Difficult access to health services from remote areas • High transport cost • Very poor quality of care available in hospital and health centers • Chronic lack of medicine • Lack of medical equipment and laboratory facilities • Lack of current clinical skills of the part of the health care providers

Maternity Waiting Home In order to improve reproductive health, it is necessary to ensure access to basic obstetrical services with staff being able to perform clean deliveries, deal with complications and identify and refer in case of serious complications (WHO 2002). Whereas according to the Lao context, bringing medical services to the women in needs and decentralizing essential obstetrics are not realistic. The only viable options according to WHO is to bring women near basic medical facilities (district hospitals) before the occurrence of any possible complications.

Obstetrics: current trend and alternatives

Childbearing practices In many societies, health is perceived as a harmonious state where the social, religious and supernatural realm clearly impinges on physical and psychological well-being. Anthropological studies have explored childbearing and practices in many societies.

7 WHO, Lao PDR, Current Challenges. 8 WHO, Lao PDR, Current Challenges

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Childbearing practices in every society occur in accordance with the cultural norms of the society. In most societies, however, childbearing practices share a common value: the preservation of life and maintenance of the health and well being of a newborn infant. Whatever the details of a birthing system, its practitioners tend to see it as the best way, the right way, indeed as the way to bring a child into the world.9 Anthropological approach with its emphasis on the cultural construction and special understanding of ritual process provides a crucial dimension to research into women and reproduction.

Feminist literature and modern obstetrics Feminist literature critiques the modern hospital-based obstetrics practices. Nowadays, childbirth is generally experienced in hospital and is associated with increased and routine technological intervention. Feminist literature argues that, with the exception of risky births and women that need caesarean sections, such intervention is not a biological necessity; rather, it reflects the structure of power and decision making within obstetrical situations. The promotion of an increase of technological intervention is seen as a loss of women’s power and control over a dehumanized birth process. The history of reproductive technology is seen in term of oppression of women by science and medicine.

Development of Western thought and medicine In fact, until the end of the seventeenth century attendance on childbirth had traditionally been the preserve of women. Before that time, surgeons were called only when natural birth was not possible. They were organized in the surgeons’ guild since early in the thirteenth century and had the exclusive right to use surgical instruments. In England, from the 1720s onward an increasing number of men were entering midwifery entering in direct competition with women. The Scottish apothecary William Smellie introduced obstetrics forceps by the 1730s. Women weren’t allowed to use tools that were linked with the emerging profession of medicine. The Cartesian model of the body as a machine and the physician as the mechanic emerged in the seventeenth century. This mechanical metaphor continues to dominate modern medical practice and underlies the propensity to apply technology and to see surgery as the appropriate cure.10

Authoritative knowledge

9 B. Jordan, Birth in four cultures, Eden press Publication, Montreal, 1978. 10 Reproductive technology: Delivered into Men’s Hands, p. 65, in Barbara Earth Compiled articles, AIT 1998.

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There is a huge gap between Western knowledge and the traditional knowledge embodied in women’s practices and beliefs. Women are often considered as ignorant, even if they embody clear concept of reproductive cycles different from the scientific concepts of modern anatomy. The gap between Western knowledge and traditional knowledge results in confusion, misconception, fears and anxiety.11 Indigenous people, tribal group and ethnic minorities embody beliefs about their body mechanism and conceptualize differently than biomedical modern diagnostic, illness and sickness that overwhelm their life. In his book on Asian medical knowledge and practice: The Roots of Ayurveda: Selection from Sanskrit Medieval Writings12, Wujastik illustrates four hundred years gap in the conceptualization of the physiological process inside the human body.

“It is sometimes hard to cast oneself back into a mindset predating the momentous change that have taken place in human culture since the sixteen century: to a time before the heartbeat had anything to do with blood, before breath had anything to do with the lungs, before germs existed, before contagion was more important than miasma, when consciousness was located in the heart, not the brain.”

The study of Thai, Lao and Kampuchea medicine all shows evidences of adaptation of some aspect of Ayurvedic medical theory to local medicine traditions.13 This underlines the challenge of setting up culturally sensitive health message, The gap between spiritual world and cosmology of ethnic groups in Lao PDR is also a challenge it itself. The Khamphee Prathom Chindaa (Thai Book of the Genesis) compiled in 1871 in Thailand contains the main text on paediatrics used to teach traditional medicine in Thailand today. Starting with the description of the destruction and recreation of the world; the book then explains about reproduction, early development of the child, and symptoms of child diseases including medicinal recipes, incantation and mystical rituals used to treat diseases.14 The origin of the divine medical knowledge embodied in the book is said to have been acquired by Rokaamarit, whose medical texts have been passed down from doctors since the time of the Buddha Kakusandha (the third Buddha before Gottama; the first lived 91 cycles before Gottama).15 Kroeger and Freeman argue that for ethnic group and tribal people, public health depends on the maintenance of socio-economic well-being, it’s not merely a medical technology problem: development disrupt previously established self-maintaining socio-economic system and does not easily replace them.16

11 MCH Institute, SCF/UK, Women in reproductive health in the Lao PDR, an anthropologic study of reproduction and contraception in four provinces”, January 1994, 89 p. 12 Dominik Wujastyk, The Roots of Ayurveda: Selections from Sanskrit Writings. 13For further analysis about Lao traditional medicine, see Joel Halpern, Laotian Health problems, Laos Project paper No. 19, LA; P. Macey, L’art de guerir au Laos in Revue Indochinoise Vol XIII, Jan-June 1910, pp. 489-502. 14 Jean Muholland, Magic and Evil Spirits, Study on Thai Traditional Paediatrics, Faculty of Asian Studies Monograph: New Series, No. 8, Faculty of Asian Studies. 15 Edward Thomas, Thomas, Life of the Buddha as Legends and History, 3rd Editions, London, 1949, p. 27. 16 Kroeger and Freeman, Cultural Change and Health in Bodley: Tribal People and Development Issues.

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Beliefs Systems All people, whether biomedically trained health professionals or ethnic minority villagers, are tributary to belief systems about the cause of sickness and possible remedial measures. The belief systems of health professionals are supported by substantial empirical evidence, but they are beliefs all the same; and beliefs are constantly revised in the light of new information.17

WHO-UNICEF: the Alma-Ata Declaration (1978) The Declaration called for greater recognition on the importance of community participation and the role of indigenous healer in the organization of health care programs. According to Pertti, the declaration can be seen as a visible signal of that many public health planners recognized the desirability for “pluralistic health care model even though there were few successful demonstrations of integration, or even moderate communication between Western or cosmopolitan health care and traditional system of beliefs and practices.18 Primary Health Care as defined in the Declaration of Alma-Ata Primary health care is essential health care based on practical, scientifically sound and socially acceptable methods and technology made universally accessible to individuals and families in the community through their full participation and at a cost that the community and country can afford to maintain at every stage of their development in the spirit of self-reliance and self-determination. It forms an integral part both of the country’s health system, of which it is the central function and main focus, and of the overall social and economic development of the community. It is the first level of contact of individuals, the family and community with the national health system bringing health care as close as possible to where people live and work, and constitutes the first element of a continuing health care process. After being masked through the century under the fast progress of technological innovations conquered by the curative medicine, the necessity of a holistic approach and not exclusively technical of the human health are emerging. The restitution of the human body in larger entirety in which it lies (social community, socio-economic categories, geographic space, ecology, etc.) and whose own constrains weight is an exigency that modern medicine rediscovers today.19

Ethnicity Like elsewhere in Southeast Asia, from south Yunnan to Northwest Burma, in Laos, north Vietnam, the main socio-economic division is that between highlanders and lowlanders: “…a dichotomy which corresponds, not exactly but closely, to the divide between literate, sedentary, politically centralised, hierarchically conscious,

17 Pertti Pelto, Studying Knowledge, Culture, and Behavior in Applied Medical Anthropology, p. 148. 18 Pertti Pelto, Studying Knowledge, Culture, and Behavior in Applied Medical Anthropology, p. 152. 19 Sociétés, Santé, Développement (SSD),

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Theravada Buddhist, Thai majority people and preliterate, residentially more mobile, politically a cephalous, egalitarian non-Buddhist minority peoples”.20 Until 2001, GOL officially used the on the tripartite classification (Lao Loum, Lao Theung and Lao Soung) elaborated by German geographer W. Credner in 1929 and officialized by Nginn, founder of the Comité Litteraire in 1962. Although the categories of Lao Loum, Lao Theung and Lao Sung, help to create the impression of national unity, they tend to obscure and oversimplify complex cultural and economic differences, crucial for development planning and socio-economic analysis.21 Acknowledging the limitation of the previous division in ecological niches, the Lao Front for National Construction officialized the use of four ethnolinguistic categories found in the Lao PDR: Tai-Kadai (8 groups), Hmong-Iu-Hmien (2 groups), Mon-Khmer (32 groups) and Tibeto-Burmese (7 groups). Customary practices in many cultures prevent women from making and carrying out independent decision on fundamental personal matters such as when to seek health care or family planning, even when the resources are available.22

Cultural change Sir Edmund Leach’s masterwork on the political system of Highland Burma (1964) has already demonstrated ethnic communities are not fixed systems and it cannot be assumed that a “group” denoted by a particular ethnic label is separate from another “group” denoted by another label. There is a “type of social process that overrides cultural distinctions, in a sense that common social and political structures crosscut the conventional, linguistically-derived concepts of tribe and tribal culture”.23 Cultural traditions and the definition of identity among the hill and valley neighbours are then shaped by pattern of social interaction and adaptation. Buddhist ideas can penetrate the cultural fabric of highlander’s culture and vice-versa. A too much rigid traditional dichotomy between animist highlanders and Buddhist lowlanders could lead to misread often very complex cultural configurations. Kammerer asserts further that: In a complex dialectical process, patterns of social interaction and adaptation shape cultural traditions and definition of identity among hill and valley neighbours; these traditions and identities in turn influence pattern of social interaction and adaptation.24

20 Antony Walker, Northern Thailand a Geo-ethnic Mosaic, in The Highland Heritage, pp. 1-93. 21 J.Chagnon, Country Briefing Paper – Women in Development, Lao PDR, ADB, 1996. 22 Jodi Jacobson, Women’s Health: The price of Poverty, p. 4. 23 Edmund Leach, Political System of Highland Burma, 1964, p. 282. 24 G. Kammerer, Gateway to the Akha World, p. 404.

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In fact, both Buddhist and ethnic minorities are committed to an animist worldview.25 The similarity of birthing rituals for the three civilisation of the French Indochina (Vietnam, Cambodia and Laos) is due to the fact that they all have kept ancient Austroasiatic rituals:

• Burial of the placenta; • Staying by the fire and; • Gift to the birth attendant26

The Kata27 Kha from Mon-Khmer origin and recited in Mon-Khmer language by Maha Kheo illustrates this absorption of Mon-Khmer cosmogonic elements in the cultural fabric of the ethnic Lao. Lao traditionally use the lunar calendar. The 15th day corresponds to van sin ngai and ceremony is organized at the local vat temple. Lao believe that the crying of the infant occurring on the 7-8th night or during the 14-15th nights needs the intervention of the mo mone. The mantra is recited 3 times and the ritual usually involves lightning of candles and blowing pao over the child’s body.28 Cultural configurations don’t have sharp boundaries, as put it Chamberlain: “Change is inherent in cultures and the ability to shift ethnicity and the change occurs within the framework of an inter-ethnic socio-cultural symbiosis”.29

Changes in practices AusAID survey in Phongsaly acknowledged changes in practices in a Hmong community due to its proximity to a dispensary. Exposed to health messages and also influenced by neighboring Phu Tay, the Hmong mothers are starting to give colostrums to their babies.30 Demographer Daniel Benoit analyses the feeding of infant in Southern Lao PDR. The demographer observed the cultural mimetism from Mon-Khmer mother that in context of resettlement in the lowlands would copy the Lao habit of feeding the newborn with other food under-3 months of age. Traditionally, Mon-Khmer would exclusively breastfed until 3 months.31 Ethnolinguistic fractionalization and the delivery of health care Analysis of health data has shown that developing countries with higher levels of ethnic diversity tend to have poorer performance of their health sectors as indicated by child mortality statistics. Ethnolinguistic fractionalization is defined as the probability that any two members of the national society are not from the same ethnolinguistic group. For example, moving from a relatively 25 Walker, Transformation of Buddhism in the religious ideas and practices of non-Buddhist hill peoples: the Lahu Nyi of Northern Thai Upland, in Walked (éds) The Highland Heritage, chap. 13, p. 383-409. 26 Marcel Zago, Rites et ceremonies en milieu bouddhiste Lao, p. 213. 27 Kata, from Gatha in Sanskrit means: rhymes, poetry, line, stanza. 28 Maha Kheo is often called upon by worried parent to operate such rituals in Dong Khoy village VTM. 29 James Chamberlain, in Socio-Economic and Cultural Survey, Namtheun II Project Area describe this process in the Nakai Plateau, previously discussed by Condominas in L’Espace Sociale (1980). 30 Bob Smith and Damian Hoy, personal communications. 31 Danial Benoit, Institut de Recherche sur le Development (IRD), personal communications.

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homogenous society like Costa Rica (0.07 probability) to Bolivia (0.70 probability) is associated with a rise in mortality of 40% (Pritchett and Filmer, 1997). In many instances, minority groups have living standards lower than those of the majority group. In such situations, the larger the disadvantaged group, the higher the rate of "ethnic fractionalization" and the higher the rate of child mortality.32

Socio-economic and political Factors influencing women’s health Factors influencing women’s health include: socio-economic status, environment, mode of production, social classes, symbolic structures, community dynamics, gender, environment, government policies, etc.

Ethnic Minority Women: the Most Disadvantaged Ethnic minority women and girls represent 49.5 % of the female population and are clearly the most disadvantages of the Lao society. They perform 70 % of the agricultural and household tasks, have little access to labour-saving devices and annually lack rice for about 3 months. They are the majority of the poorest quintile. Their infant and child mortality rates are some of the highest in the world – one out of every four die before age one, and three out of twenty do not reach five years. Their exposure radius – the furthest distance these women travel from home - is about 20 kilometres. Many have never seen the nearest district town or market. They comprise the largest segment of illiterates (about 70 %), non-school attendees and primary school dropouts, usually leaving after grade one or two. Reverse literacy or backsliding – learning then loosing literacy – is common among women in minority villages, as it is difficult for them to retain non-mother-tongue language they may not hear or see for months. As a result, few ethnic minority women engage in formal or non-formal businesses or, are employed in manufacturing or government work. Of 7,000 paid female government employees interviewed for the Urban Labor Force Survey (1995), less than 1% claimed they were from ethnic minorities. Given such constraints, fitting ethnic minority women in to standard development programs faces a triple challenge. First, only scant amount of quantitative and qualitative socio-economic information exists on ethnic minority women, and most of that data is aggregated too broadly into Lao Loum, Lao Theung and Lao Sung categories, obscuring critical ethnic group distinctions. Second, there are few local development staff who speak any of the ethnic minority group languages or have been trained in socio-ethnic concerns. Third these women’s traditional "shyness" often restricts their participation in public meetings.

Source: Jacquelyn Chagnon, 1996 Human Development Index (HDI) rank of Lao PDR in 1995 was 136 out of 174 nations, indicating a low life expectancy at birth, low educational attainment and standard of living. The Gender-related Development Index (GDI) rank for Lao PDR was 125 of 174 countries. The rank difference between the HDI and GDI is +11. This means that although Lao PDR has succeeded in building basic human capacities of women and men, substantial gender disparities prevail.33

32 John V. Dennis, Jr., Introduction to Key Social Issues: Regional Report, Regional Environmental Technical Assistance 5771 Poverty Reduction & Environmental Management in Remote Greater Mekong Subregion Watersheds Project (Phase I). 33 Dr Leena M Kirjavainen Gender Specialist, Gender Issues in Lao DPR, Regional Environmental Technical Assistance 5771 Poverty Reduction & Environmental Management in Remote Greater Mekong Subregion (GMS) Watersheds (Phase I)

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Poverty Through Southeast Asia, at least 70% of the female labor is engaged in agriculture. Jacobson argues that the impact of poverty and social status on women’s health is a universal issue. Lack of access to education and income has adverse impact on reproductive health. Reproductive health may have been too much emphasis, especially when fertility rates are high, argues Jacobson, because the invisible nature of women’s productive contribution, their reproductive role receives the most attention.34 Birthright and gender Gender bias in the allocation of resources usually begins at birth. Poverty and cultural beliefs about the value of women’s work conspire to deprive females from infancy of the very resources they need to be productive members of their community through their life.35 Nutritional status of girl goes worsening in growing up relatively to the combined demands of childbearing and increase of workload, and loss of iron stores through menstruation. Stunted growth and anemia is the result of this nutritional deficiency, which are main factors behind complications of pregnancy and childbirth.36

Women and the Environment A number of environmental trends have an impact on rural livelihood in general and on women’s lives in particular. Women are usually disproportionately affected because they are more dependent on natural resources in order to carry out their farm and household activities. Deforestation and soil erosion caused by illegal logging and shifting cultivation threatens not only natural resources and biodiversity in Lao PDR, but also the chance for many rural communities to have sustainable and secure livelihoods. The lowland rice production causes declining land productivity due to mono-cropping practice and inadequate use of fertilizers.37 Forests form an economic resource base for rural communities, providing for household food security. Women collect mushrooms, wild berries, fruits, nuts, honey and earthworms, and also medicinal herbs. Men hunt wild animals. In periods of drought or floods, which tend to occur about once every five year, hunting and gathering forest products become important mechanisms to cope with food shortages.38

34 Jodi Jacobson, Women’s Health: The price of Poverty, p. 5. 35 Jodi Jacobson, Women’s Health: The price of Poverty, p. 18. 36 Jodi Jacobson, Women’s Health: The price of Poverty, p. 20. 37 Dr Leena M Kirjavainen Gender Specialist, Gender Issues in Lao DPR, Regional Environmental Technical Assistance 5771 Poverty Reduction & Environmental Management in Remote Greater Mekong Subregion (GMS) Watersheds (Phase I). 38 Dr Leena M Kirjavainen Gender Specialist, Gender Issues in Lao DPR, Regional Environmental Technical Assistance 5771 Poverty Reduction & Environmental Management in Remote Greater Mekong Subregion (GMS) Watersheds (Phase I).

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Women and Food Security Rural households depend on agriculture and its related sub sectors of livestock raring, fisheries and forest resources for their living. Agricultural production in Lao PDR is largely subsistence oriented and farm technology is characterized by low inputs, low risks and low outputs. Crops account for about 55% share of agricultural GDP, with rice contributing about 40%, livestock 39%, fisheries 1% and forestry 5% (World Bank, 1995).39

Environmental degradation and the status of women Food security is realized by copying mechanism such as natural resource collection. The depletion of natural resources (depletion of soil fertility, reduction in fresh water supplies, etc.) directly increase women’s time and labor to meet their family’s basic needs, then compromising their health.40 Health care strategies must be oriented to meet women’s needs More fundamentally real improvements in women’s health require far-reaching socioeconomic and cultural change extending far beyond the health care system.41 The issue of empowerment needs to be address remain the key of women’s health improvement.

39 Dr Leena M Kirjavainen Gender Specialist, Gender Issues in Lao DPR, Regional Environmental Technical Assistance 5771 Poverty Reduction & Environmental Management in Remote Greater Mekong Subregion (GMS) Watersheds (Phase I). 40 Jodi Jacobson, Women’s Health: The price of Poverty, p. 15. 41 Jodi Jacobson, Women’s Health: The price of Poverty, p. 24.

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Beliefs, Cultural Attitudes and Practices regarding Pregnancy All communities have their own distinct cultural attitudes and practices related to pregnancy and childbirth which are reflected in diet, work pattern, the use of herbs, traditional healers and healing ceremonies, etc. These cultural and personal beliefs and customs often have a strong influence on whether women will seek out and use appropriate health services (MPH, UNICEF 1998).

Cultural construction of the Body and health Ethnic Lao Ethnic Lao women have a naturalistic view of the body and see themselves as an element of nature. The metaphor of the lotus flower dok boua is commonly designates the locus of fertility and female reproduction cycle. The lotus is also a symbol of purity and perfect balance that needs a balanced combination of four elements (earth, air, water sunlight/fire). The word use to describe menstrual period means season ladu and derives from a Sanskrit word meaning “season under cosmic influence”. For ethnic Lao, women’s cycle and womb has positive attribute.42 Healthiness is believed to be the result of the balance between the four elements composing the body: water, earth, air and fire. An excess or lack of one of those elements can constitute an obstacle for conception.43 Hmong Pregnancy associated with the dreaming of seeing or receiving pumpkin, cucumber, knives and needles.44 The Hmong believe that the children are sent from heaven with the permission of Txoov Kap Yeeb the spirit parents who are responsible for the birth of the Hmong people.45 Akha Akha concept related to birth are directly linked to their mythology. They call the sun younger sister and the moon older sister. They believe that during an eclipse, the sun and the moon are having intercourse and they are afraid that the blood of the sun (the female) will drop down on them, causing death. During pregnancy, women must not look at an eclipse of either the sun or the moon, and go out their head covered by a leaf.

42 Quoted by Carol Ireson, Field, Forest and Family; Women’s Work, Power and Status in Rural Laos, 1996. 43 MCH Institute, SCF/UK, Women in reproductive health in the Lao PDR, an anthropologic study of reproduction and contraception in four provinces”, January 1994, 89 p. 44 Rice, When the baby falls!: The Cultural Construction of Miscarriage Among Hmong Women in Australia, p. 100. 45 Rice, Baby, souls, name and health: traditional customs for a newborn infant among the Hmong in Melbourne, Early Human Development 57 (2000), p. 196.

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Akha believe that birth and death come from the great Akha progenitor (sm mi o) appearing at the very beginning of their genealogy. Patrilineal, the worst fear for the Akha is having one’s line dead out.

Beliefs and Knowledge about Conception Childbearing practices in every society occur in accordance with the cultural norms of the society. In most societies, however, childbearing practices share a common value: the preservation of life and maintenance of the health and well being of a newborn infant. Conception: for ethnic Lao, palm leaves manuscript conserved in pagodas reveal the cultural construction of birth, close to the Ayurvedic theory: the seeds of the woman and the man bring specific elements (tad) which contributes to the making of the child. Male’s Tad din (earth element) comprises 20 elements: akhan, flesh, teeth, etc) and the female’s Tad nam includes 12 elements such as blood, marrow, etc. So a combination of earth and water elements is essential for the making of the physical realm. Conception results of the combination of the substance of the man and of the woman. 46 Those 32 visible parts correspond to the 33 consonants and, added to the 20 invisible parts, forms the 52 human parts.47 Women have clear ideas of development stages of the fetus. According to Buddhist tradition, there are 5 steps in the embryo evolution: drop, flesh ball, thickening stage, firmness stage and stages of the five extremities. Sexual relation need to be continued during pregnancy since digested food transforms into blood sperm is also believed to be highly nutritive. The fetus is believed to be sitting in the womb with legs crossed, like a small Buddha; the head will turn downward at delivery.48 Menstrual flux is associated with impurity that leave the body; when close the male’s semen can’t penetrate in.49 Zago described ethnic Lao beliefs about conception. The set of 32 kuans (spirits) that will constitutes the coming being, in a previous stage chose its own parents and haunt them. The area where the jar traditionally is located symbolizes fertility. After the 6th night, the 32 kuans are believed to get in the creases father’s saran; when he go at night for a glass of water close to the jar. After 3 more days, the kuans get in the mother womb by the natural union of both sexes. The conception resulting from both the action of phi; the kuans have belonged to another being that had already existed and the body given by both parents.50 Akha 46 MCH Institute, SCF/UK, Women in reproductive health in the Lao PDR, An anthropologic study of reproduction and contraception in four provinces. 47 The number 52 also corresponds to the Bali alphabet that count 52 elements. 48 MCH Institute, SCF/UK, Women in reproductive health in the Lao PDR, An anthropologic study of reproduction and contraception in four provinces. 49 See Pascal Brun, Representations, rites et pratiques actuelles du Post-partum au Laos, Faculté d’Ethonologie et d’Anthropologie, Université de Lyon II, Juin 2001, p. 24, for further details about female’s representation of the uterus. 50 M. Zago, Rites et cérémonies en milieu bouddhiste Lao.

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Akha believe that pregnancy is the result of an intercourse between man and a woman but to produce a birth, there is a notion of right time both partners. This may be associated with the belief of the three child-maker spirit (za m-eu, za sah and a ma) living in each person that allow a woman to become pregnant by releasing water from the lake of children (zeu za zeu la). If a baby is born and dies within one, two or three days, Akha believe the child-maker spirit has decided to take the child back.51 Pregnancy or childbirth is sometimes considered to be impure or un-holy (ma shaw). For instance, the husband cannot attend ceremonies because he is impure from the pregnancy of his wife. Also, following the birth, a ritual of making-pure must be performed. The couple, their friend and neighbors must not talk about the pregnancy. Goodman explains that: “the child-maker spirits that grant an Akha woman the chance to bear a baby are quite spiteful and will take back the child at their slightest pleasure”. The greatest violation of this rule would be to speculate loud, remark or even joke about the possibility of chaw-peh – unnatural birth. 52 The Akhazan Translated as ¨religion, way of life, custom and tradition¨ and ¨as handed down by fathers¨, Akhazan claims the authority of a succession of sixty-four generations of patrilineal ancestors. It includes the whole of Akha life at all level; describe when, where and how a forest has to be cleared and burned; rice and vegetables have to be planted and harvested; hunting by traps or driving have to be performed; village and houses have to be founded or built; husbandry or task have to be taken care of; game and animal have to be slaughtered and divided; food has to be cooked; children have to be conceived and brought up; and transaction have to be managed…contains prescriptions indicating how to relate to many different categories of groups and persons within the Akha milieu, etc.53 Mien Mien believes that during a woman's pregnancy the souls of the unborn baby do not yet reside in the fetus, but in various locations, depending on the month of the year. During the first and seventh months, the souls reside in the door of the house. The second and eight months they live in the stoves. The third and ninth months find them in the rice pounder and the maize mill, and during the fourth and tenth in the floor near the altar. During the fifth and eleventh months the souls live in the mother's body, and during the sixth and twelfth in the mother's bed. Pregnancy: a period of danger: Every minute, a woman dies because of complication of pregnancy and childbirth. That’s 585, 00 women a year put forward WHO (2002) that listed three leading

51 Paul Lewis, A proposal for the development of a family planning program among the Akha of Thailand, p. 17. 52 Gim Goodman, Meet the Akha, p. 49. 53 Leo Van Gesau, Dialectics of Akhazan, p. 249.

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causes of maternal death: severe bleeding (25%), infection (15%) and unsafe abortion (13%). Unsafe abortion is the most neglected and most easily preventable cause of maternal death. In the Lao PDR, the most frequent causes of maternal death are haemorrhage and infections during delivery. Both would be easily preventable or treatable under medical care. Failure of the uterus to contract after the delivery (uterine atony) and retained placenta are the two major causes of haemorrhage. The first event can be easily treated with simple intervention – use of the partograph and active management of the third stage of the labor – and retention of the placenta can be treated by a skilled birth attendant. Most infections can be prevented through basic hygiene and practices during labor and delivery or by timely treatments with appropriate antibiotics. WHO The low rate of hospital delivery found in Lao PDR (7 to 10%) can partly be explained because the families belief that pregnancy and delivery are normal physiological events and therefore do not required the assistance of skilled medical personal and services (WHO 2002). In fact, childbearing is universally considered as a life crisis even. In most societies, birth is seen as a time of vulnerability for a mother and the newborn. As Jordan pointed out: 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.54 Every society elaborates its system of knowledge, behavior, belief and practices to cope with this life crisis and these systems all aims the well-being and the preservation of the life of the mother and the newborn.55 Whatever the details of a birthing system, its practitioners tend to see it as the best way, the right way, indeed as the way to bring a child into the world.56 Ethnic Lao Ethnic Lao’s popular saying: mi thong mi man confirms this statement. According to the ethnic Lao indigenous knowledge: bearing child before mature age (35 years old) is one of the natural mean to prevent maternal mortality. Child bearing periods are seen as threat to women’s health, increasing the woman’s age.57 The Reproductive Health Strategic Assessment come to a different conclusion asserting that most of the community members, including women interviewed during the assessment did not recognize the risk associated with pregnancy and childbirth. The report also pointed to the ignorance of the women about the importance of prenatal care and of the signs and symptoms that call for immediate referral.

54 B. Jordan, Birth in four cultures, Eden press Publication, Montreal, 1978. 55 P.L. Rice and J. Lumley, Soul loss (Poob plig) following a caesarean operation, p.2, quoted from M.A. Muecke, Health care system as socializing agent: Childbearing the North Tai and Western ways, Social Sciences and medicine, 10, 377-383, 1976. 56 B. Jordan, Birth in four cultures, Eden press Publication, Montreal, 1978. 57 MCH Institute, SCF/UK, Women in reproductive health in the Lao PDR, An anthropologic study of reproduction and contraception in four provinces.

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Findings from AusAID survey in Phongsaly seem to contradict this universal perception of pregnancy as a period of vulnerability. Respondents considered as normal event and not a cause of concern but worries for. But Houaphan finding clearly showed that Hmong and Yao do corroborate this universal perception of pregnancy as being a period of vulnerability for the woman. Fear and worry, had been expressed, respondents said that complications drain on household’s scarce resources.58

Health problems during pregnancy LRHS 2000 reveals that ¾ of the most recent births encounter no pregnancy related diseases. In their last pregnancy, 11% of women suffered from nervous diseases; 9% heart diseases, 7% diseases of digestive system, 5 % of kidney diseases. Mainly older women (+35) suffer from those 6 diseases. The survey also pointed out that better educated urban women suffer less from those diseases, except the diseases of the digestive system. WHO states that repeated pregnancy and frequent deliveries jeopardize maternal health. 87% of the women who gave birth in the last 5 years reported that they had no difficulties with their last pregnancy. 14% mentioned they had some difficulties during last pregnancy such as high blood pressure (2%), swelling (3%), wrong position of the uterus (2%), and 7% for other including: placenta too low, ruptured uterus, narrow pelvis, too much fluid, etc. (LRHS 2000). The main health problems faced by women included: oedema and dizziness, miscarriage and stillbirth. In Phongsaly, lower back, waist and abdominal pain, fever was also mentioned, as women’s frequent loss of child. Health problems of women Tai Deng decreases the workload during pregnancy and acknowledges the effect of hard labor on pregnancy. Khmu are dependent on women labor for production and also believe that working contribute to ease delivery. Hmong: no change in the amount of work until the womb gets too big.59

Food taboo/nutrition/ Dietetic restrictions during pregnancy Generally, dietetic restrictions during pregnancy are much less important than after delivery. In the case of the Hmong, there is no restriction unless the woman is sick. Hmong wouldn’t eat tiger or animals killed by a tiger. Any dietetic restriction is subject to the advise of elders. There is a general tendency of eating less fearing big baby hard to deliver (AusAID 2002). Lao Loum and Khmu proscribe few items that seem not to have much impact on nutritional status except potentially taro and sweet potatoes. Both groups believe it

58 AusAId: Developing Healthy Community Project – Qualitative Survey 2002, Phongsaly 59 Somporn Phanjaruniti, UNICEF, Traditional child rearing practices among different ethnic groups in Houaphan province, Lao PDR.

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make women fatter and cause difficult delivery. This belief make sense comment the authors since at 9 months the consumption of such food would make the baby bigger and so more difficult the delivery. The problem is that these dietetic restrictions start right at the beginning of the pregnancy. Also, in the case of village facing rice shortage, these dietetic restrictions would definitely cause problem since the proscribed aliments are the only substitute available to rice.60 Akha have clear taboos during pregnancy consisting in interdiction of eating wild food 5 month after becoming pregnant, until 5 month after delivery (Aus AID 2002). Interestingly, the focus group discussions in Houaphan showed that the food taboo for women reported in men’s group more detailed than with women themselves (AusAID 2002). Phutai; pumpkin fruits and leaves, dog meat, white buffalo, red cow and deer: diarrhea frogs; eels, turtle/snapping turtle forbidden; teeth fall or sickness. Can eat fish, duck, and chicken.61 Authorized items for Khmu: rice and salt, phak vanh (kind of vegetable).

Restricted places Ethnic Lao: women must not sit in front of a door; Khmu: must not thresh rice for others, cannot go to temple or participate in festival, go to dark places, the father must not make a garden spade crooked: the legs of the child would be crooked as well.62

Traditional medicine during pregnancy Ethnic Lao Herbal potion are commonly taken in order to strengthen the child in the womb (bab loung luk nay thong) and women’s health (bab loung me mi thong), especially for fatigue and anemia (kan pe lom).63 Hmong Curative herbal medicines are widely taken by the Hmong who believe that herbs are effective in curing organic illness. Childbirth pain is eased or reduced by consuming herbal potion. By tradition, Hmong herbal knowledge is passed through young women relatives. Other treatments includes the practice of coining, cupping, paper burning, pinching, tying on strings, bracelets, talismans to protect newborn from soul loss, etc. Coining is the process of using a coin and scraping on the child’s body to cure headache, colds, vomiting, and other minor illness.64

60 Somporn Phajaruniti, UNICEF, Traditional child rearing practices among different ethnic groups in Houaphan province, Lao PDR. 61 AusAId: Developing Healthy Community Project – Qualitative Survey 2002, houaphan 62 Somporn Phajaruniti, UNICEF, Traditional child rearing practices among different ethnic groups in Houaphan province, Lao PDR. 63 MCH Institute, SCF/UK, Women in reproductive health in the Lao PDR, An anthropologic study of reproduction and contraception in four provinces. 64 Rice, 1986.

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Proscribed activities There are traditional beliefs and taboos that influence or might help delivery. Tai Deng prohibit women from sitting in front of a door. Khmu women must not thresh rice for others, cannot go to temple or participate in festival, go to dark places, the father must not make a garden spade crooked; the legs of the child would be crooked as well.65 Ngkriang Taboo for the woman include prohibition to close holes tchiak, patching up clothes, putting a lid on a pot, etc. Women are also forbidden to sit on the doorway of one’s house. Ngkriang believe the non-respect of this taboo results in difficult delivery. Men also face taboos in the pregnancy period. They can dig, but it is forbidden to put something in the ground. It is also forbidden for men to block the natural river course tak nier. This seems to be related to fluids that naturally must follow their course.66

Miscarriage: Hmong’s Falling of the Baby67 The understanding of miscarriage by the Hmong is explained by two main categories: the natural world, which is related to the human body and the woman’s behavior, and the supernatural world. Precaution against the loss of the child involves avoidance of rigorous physical activities, illness and caution about going to uninhabited areas and provoking the spirits.68 A falling baby is not human and the body is buried in the forest without any special ritual. The most common reason cited is bleeding during early pregnancy. Carrying heavy load is believed to disconnect the bloodline or food line of the baby inside the womb.69 Reaching up and jumping from a high place is also believed to disconnect the line. The falling of the women may causes the turn of the baby in a wrong position; without proper care, end in miscarriage. The testimony of a Hmong woman from Laos interviewed in Australia illustrates the danger of falling during agricultural work, but also the ethnomedical knowledge embodied in Hmong practice: …I went to the farm and rolled down and I fainted and rolled down the hill for quite a distance. I rolled over and over again and while I was pregnant. My husband new how to turn the baby but he was at work at another farm. I asked other people to find

65 Traditional child rearing practices, p. 46. 66 Personal communications, Tanum village, Sekong province, November 2002. 67 Rice, When the baby falls!: The Cultural Construction of Miscarriage Among Hmong Women in Australia, Women & Health, 30 (1), 1999. 68 For this section about miscarriage, I rely exclusively on the work of Pranee Liamputtong Rice: When the baby falls!: The Cultural Construction of Miscarriage Among Hmong Women in Australia, Women & Health, 30 (1), 1999, pp. 85-103. 69 Rice, When the baby falls!: The Cultural Construction of Miscarriage Among Hmong Women in Australia, Women & Health, 30 (1), 1999.

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him and tell him that I fell over and my stomach felt very tight and uncomfortable. When he came back, he turned the baby and it

felt comfortable immediately.70 Illness and fever is also considered as potentially dangerous and may lead to miscarriage. But the most feared cause of miscarriage is the one believed to be due to being “Raug Dab” struck by spirits. The spirits may strike the woman or her baby. The violation or perturbation of the domain of the spirits (of the mountain, river, land) may cause miscarriage. Menstruation is also believed to lead to miscarriage, in case where the woman would cross a river, Hmong believe this could cause anger to the spirit, and being able to trace her though the smell of her menstruation and strike her causing miscarriage. Hmong in Australia strongly believe that Western medicine is unable to help them once bleeding occurs. A shamanic ritual called Ua neeb is the only solution that may stop the baby from falling. Hmong also believe that miscarriage can occur when a soul leave the mother’s body and re-enter as her own baby. When this is believed to happen, Hu Plig Hlawv Thiab must be performed immediately in order to burn the reincarnated soul and bring the mother’s soul back, but also resulting in miscarriage. Hmong health seeking behavior in the US71 Kws Tshuaj Medicine Woman Medicine woman called Kws Tshuaj is usually the first choice in case of needed assistance. Offering are required to the medicine woman’s altar and the treatment involves the wearing as prescribed herbs tied around the mother’s waist for protection in case of miscarriage caused by the Raug Dab. Herbal potion is also drank by the mother to prevent against the “falling”. The masseuse Generally an elder woman experienced about pregnancy and birth. Hmong do not have a word for TBAs, so she is not considered as a traditional midwife. In case where the baby’s position is wrong, for falling in the field or accident, she will Theev reposition the baby. This technique involves lifting the mother abdomen and massaging in circular motion. The massage is believed to contribute to stop bleeding and replacing the baby in a normal position. Trix Neeb The Shaman (fertility, protection, curing) A request is required by the couple who need the shaman’s help, at the altar in his house. The shaman then diagnoses the problem, i.e. perform a Ua Neeb Said ritual to see if spirits have struck the woman. If it is the case, the shaman performs the Ua

70 Quoted in Rice, When the baby falls!: The Cultural Construction of Miscarriage Among Hmong Women in Australia, p. 92. 71 Cheon-Klessing, Y. et al. (1988). Folk Medicine in the Health Practice of the Hmong Refugees.

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Neeb Kho to negotiate with the spirits the stop of the bleeding and to pursue normal pregnancy. This ritual traditionally involves the sacrifice of a pig and paper monies. Khawv Koob Magic Healer (broken bones, cuts, burns, childbirth) Drinking magic water heals Bleeding and pain. The water (silver coins are put in the bottle and incense sticks are burnt and waved around the bowl) is also used to rub the woman’s back and abdomen accompanying with chanting; the ritual is repeated 3 days. Severe bleeding involves the digging of 2 holes in the ground of the bed room: one bowl placed upside down in each and covered with the woman’s hair, also accompanied with chanting. The two holes are curried and the spirits trapped in hopefully resulting in the stop of the bleeding. Although all these cultural response to prevent miscarriage, when babies fall, women are encourage to become pregnant rapidly. This is less to compensate for the loss of the child, than to allow a soul to be reincarnated allowing the family, clan and linage to exist.

Antenatal care Hmong Hmong women may refuse vaginal examination, especially by male doctors. This may be a reason for late presentation for antenatal care and non-attendance of postpartum check up.72 The vagina is an area considered as secret, private and only the husband is allowed to touch his wife. Female doctor would definitely reduce of women’s embarrass in regard to ANC without vaginal exam during prenatal visit.73 Jambunathan and Stewart also corroborate this statement of Hmong refugees in the US. Touching by the doctors and nurses (together with communication and procedure concerns) is a factor that delay prenatal visit of Hmong women in Wisconsin.74

72 Community Health profile: Hmong, Hmong Cultural Center, Minnesota, US. 73 P.L. Rice, When I had my baby here, in Rice, P.L. (eds.) Asian mothers, Australian birth-pregnancy, childbirth and childrearing: the Asian experience in an English-speaking country, p. 3. 74 Jambunathan and Stewart, Hmong Women in Wisconsin: What are their Concerns in Pregnancy and Childbirth?, in Birth 22: 4 December 1995, p. 207.

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Delivery The Lao Reproductive Health Survey shows that among the child born in the last 5 years, 86% are born at home, (91% in 1994), 11% are born in Central or provincial/district hospital and <1% in health center or clinic. Older women (+35) tend to use less the facilities than younger counterparts, while the lower parity (3 birth or less) women use more the facilities and less the home delivery. Mainly higher educated urban women use the health facilities (52%) compared to (5%) for rural women. Conversely, 91% of rural women are born at home themselves compared to 44% for urban women (LRHS 2000). Spiritual beliefs about children The spiritual beliefs related to children may offer an interpretation for the location privilege for delivery. For example, Khmu children are not seen as their parent’s, but belonging to spirit of the mountain, forest, etc. up to 4-5 years of age. Phajaruniti puts forward a possible correlation between high child mortality and beliefs that would acts as mechanism to mentally cope with the loss of children. This topic needs further inquiries. Phajaruniti revealed spiritual beliefs about children. For the Hmong, the only information available is that on the 3rd morning a ceremony is held to inform the spirits of the birth of the baby. Le ga ying. The baby is named and the spirit asked for protection. Ethnic Lao and other Buddhist lowlanders, children represent blessing or merit and the parents have the responsibility to raise their child well. Delivery usually occurs in the house, usually near the kitchen earth.75 The same location was observed for Khmu (AusAID, Houaphan).

Location The stereotypic image of ethnic minority women giving birth in the forest has become an emblem of the struggle against primitivism for ethnic Lao officials. Chamberlain suggest that in fact, giving birth in the forest may have survival value since the presence of harmful infectious bacteria may be less in the forest than in the house. 76 Reasons why mothers deliver at home N=290

Reasons Given Number % 1 Nothing happened previously 137 47 2 Assisted by health personal 83 29 3 Far from hospital, lack of transport 65 22

75 MCH Institute, SCF/UK, Women in reproductive health in the Lao PDR, An anthropologic study of reproduction and contraception in four provinces. 76 PPA, ADB 2001, p. 73.

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4 Economic reasons 16 2 5 Assisted by TBA 6 1 6 No medical staff at night in the dispensary 3 1 7 Not aware that home delivery was dangerous 3 1 8 No difference between home delivery and

hospital delivery 1 1

9 Don’t know that they should deliver in hospital

1 1

10 Afraid of hospital 1 1 11 I am healthy 1 1 12 No answer 13 5 Source: A Report on the Rapid Evaluation of Maternal and Child Health and Birth Spacing Services in Selected Areas of Lao PDR, IMCH – UNFPA, 1994-1995

Representative from Tai Kadai, Hmong-Iu-Hmien and Chinese-Tibet ethnolinguistic families seems to all give birth at home, in the house. Akha Akha women prefer having their children at home. But because of the general belief that women have to carry on their task in order to have a normal birth, they often deliver in the field, in a field hut or somewhere in the forest near the village. No matter where the birth occurs, the child must be taken back to the village as soon as possible. All the customs must be carried out within the village boundaries. If the woman becomes sick, she has to move in the smaller house. (Lewis: 1969). If the child is born at home, the standard practice is to deliver in the little house (nym za) build behind the main house (nym ma). This is a mechanism to avoid, in case of the birth of “human rejects” destroying the house where is located the custodian altar which link the birth of the children to the ancestors. If the son and his wife are living with his mother and the father having passed away, the woman must deliver on the covered porch just outside the men’s side of the house (Lewis: 1969). Mon-Khmer Mon-Khmer groups have the highest rate of home delivery: 90%.77 In act, some Mon-Khmer groups are more likely to deliver in a hut, nearby the house –never in front – or days of walk into the forest, although observations throughout Southern Laos reveal that the birthing hut are coming closer to villages (EMI in Saravane and Sekong; CUSO in Sekong; Concern in Saravane). Katang All Katang women in this village are not allowed to give birth at home. They believe that the spirit or the ghost of their family at home eats blood, and then if the women give birth at home, they are afraid that the ghost will eat blood of the mother and the baby and they will die. This is a very strong belief and respected by this village. For that reason, all Katang women deliver outside of the village. When the women are waiting for giving birth, their family member including husband will prepare a small hut made of bamboo and tree leaves for the woman to give birth to the baby. The hut must be on the edge of the village. It can be near the forest or near the rice field, depending on their convenience. After giving birth, the women will stay at the hut

77 Anna Gillepsie, Hilary M. Creed-Kanashiro, Rae Galloway, The World Bank, Newborn Care and Child Nutrition in 3 Provinces of the Lao PDR- final report.

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from one to three days to make sure that the mother and the baby are clean and have no blood on their body; then they can go home.78 The Kado of Samoy district, Saravane province believes that children must be born in the forest. For the Pagnan in Taoy district, Saravane, the husband usually builds a small shelter for delivery. But for other groups belonging to Mon-Khmer linguistic family: Brao, Sou’, Pacoh, Taoy, Brou, etc., birth occurs under the house (PPA ADB 2001). The reduction of the distance of the birthing hut have been observed by Earth and Chithalath in Savannakhet 2001; Benoit in Champassack, 1998-99; EMI in Saravane 2002. Benoit points out that in 1997-98, Mon-Khmer women in Sukuma district, Champassack province, would leave the village for as long as 10-15 days in order to deliver in the forest. Ethnic Lao Usually give birth near the kitchen. Hmong Generally deliver in the bedroom, or on the floor by the bedroom. But in case of baby born out of wedlock, small hut is built outside the village. Hmong parents disapprove and fear it’ll disturb the ancestor’s spirits in the house; which would create problems after. Kin Moun Also called Lenten from Oudomxay also give birth in their bedroom and must stay there for 3 days. Births are recorded in Chinese script in a book; all births of female and male members of the community are recorded and this information are used for determining marital compatibility and for funerals (PPA, ADB 2001). Mien If an unmarried Mien girl has a baby, she must not give birth in her home, but in a hut built for that purpose at the side of front of the house. A married woman gives birth to her child in her bedroom, usually assisted by her mother or mother-in-law. On as auspicious day the baby's birth is recorded in the 'spirit register' so the spirits know another person has arrived. The baby is then carried outside to 'see the sky', indication that bay and mother are now ritually clean (Khob Ananda) Changes in practices has been observed throughout Lao PDR, especially in community settled in more accessible areas that are more likely to receive health messages. As Phajaruniti stated: It is not likely that the custom of delivery will change any time in the near future given the difficulty of access to health facilities as well as the age old practice of giving birth at home. Therefore, concerns expressed in the village revolved around how to make home delivery safer – especially when there are complications – rather than about how to be able to go to the hospital for deliveries.79

78 Seng-Amphone Chithlath, Master degree, AIT, p. 76. 79 Somporn Phajaruniti, UNICEF, Traditional child rearing practices among different ethnic groups in Houaphan province, Lao PDR p. 49.

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Assistance during delivery In the last 5 years, most births were delivered with the assistance of relatives and friends (55%), TBAs (13%), while health professionals delivered 17% of the birth (LRHS 2000). In urban areas, health professionals deliver 63% of the birth, compared to 12% in rural areas. Education level and socio-economic conditions is crucial in the choice of assistance the women will seek for. Higher educated women tend to seek assistance of health professionals and the rate of birth delivered by doctor increases from 2% among women without schooling to 55% among women with higher secondary level; the assistance from relatives declines from 64% to 17% respectively (LSRH 2000). Different patterns of assistance have been observed among different ethnic groups. There is also a significant difference between normal delivery and delivery with complications. Most women still use traditional birthing methods and have no access to external assistance. For many groups: usually the husband, mother, mother-in-law is present. Respected elder women who are healthy and without diseases can also assist I case of normal delivery.80 Ethnic Lao The woman’s husband and relatives. The husband may hold her under the arms. Traditionally, the me mo assist in pregnancy and delivery. Usually the me mo consisted in an elder woman who developed interest in delivery at young age and experienced with practice. The art of assisting during delivery is believed to be a gift from heaven. She is also involve in helping the newborn to have his soul tighten to his body by uttering incantations to chase away evil which may take the child back. The me mo traditionally don’t receive money in return; the parents of the newborn may offer her sin or scarves for her skills.81 The me mo has been replace by the mo tam ye or mo tam mob (TBA), who has often received medical training. Called “accoucheuses rurales” during French period and trained by the army doctors in provincial hospitals, often being the only obstetric person available. Arrays of methods are used to ease delivery: massages, moral support and variety of prayers and formulas, etc. Whittaker portraits the knowledge embodied in the midwife’s care: “As the baby’s head crowns, pressure is placed against the woman’s perineum to minimize tearing. No episiotomies are performed.”82 Khmu Visitors not allowed into the house after delivery Houaphan (UNICEF: 1994)

For ethnic groups belonging to Hmong-Iu-Hmien and Chinese-Tibet groups (the author use the term Lao Soung); out of 17 woman, 7 were assisted by their own

80 Somporn Phajaruniti, Traditional child rearing practices among different ethnic groups in Houaphan province, Lao DPR 81 MCH Institute, SCF/UK, Women in reproductive health in the Lao PDR, An anthropologic study of reproduction and contraception in four provinces, p. 37 82 Andrea Whittaker, Birthing, the postpartum and development ideology and practice in Northeastern Thailand, p. 478.

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mother; 5 doctors; 3 husbands; 2 mother-in-law.83 Hmong: mother-in-law, elder women having special skills. Mien women in Houaphan feel shyness and embarrassment and birth remain a private event (AusAID 2002). Akha The granny usually assists the delivery. The term “a pi” means both old woman and grandmother, but the term is more use in the sense of midwife according to Lewis.84 The A-pi traditionally assist delivery in their community. Taboo: Under no circumstances must any women who have not had children be there. Hmong In Hmong culture, there is no doctor or midwife; the birth is managed at home. For the first birth, the mother and mother-in-law give help. The husband will be around to cut the cord and wash the newborn. The mother or mother-in-law remains the first choice of Hmong women in Australia, not their husband (Rice, 2000). Katang Men’s intervention or assistance seems strictly forbid according to EMI staff’s observations in Saravane. The man assisting his wife during delivery may be fined by the village head. The head of Tumlan district health department accompanied his wife during delivery in the birthing hut.85

Payment of the delivery assistant Akha: In case of normal delivery, the granny is given a present: a bodice (la sha) for a boy and the cloth part of a woman’s dress for a girl (u tsah). Lewis mentions a reciprocity pattern between the newborn and its granny. The child has responsibility later in life to care for the granny in case of sickness for instance, in carrying out prescribed rituals and sacrifices Lao Traditionally sin or piece of cloth was given to the traditional attendant. Nowadays the payment may involve the use of Kip.

Delivery process There is great variability of practices and different patters of preparation and people involve in the process varies greatly. In ethnic Lao group, the husband and grand parents prepare the equipment: scissors, sharp bamboo sticks, jute strings, cotton thread to tie the cord, etc. Khmu: generally more preparation including gathering firewood, fetching water, etc.

83 Anna Gillepsie, Hilary M. Creed-Kanashiro, Rae Galloway, The World Bank, Newborn Care and Child Nutrition in 3 Provinces of the Lao PDR- final report. 84 Paul Lewis, A proposal for the development of a family planning program among the Akha of Thailand, p. 28. 85 Dr. Tintin, EMI Saravane, personal communications, January 2003.

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There is no process of disinfecting equipment or using any cleaning solution or boiling it in water first, but reported cases of infection but 6 villages studied acknowledged a single tetanus case in the last 10 years in Houaphan province.86

Position In many culture of Southeast Asia, women usually give birth kneeling or squatting position. The woman may hold a rope above the head, supported from the back by the mother-in-law or the husband. In case of assistance from medical staff for home delivery, Brun observed women deliver laying on the yukham bed and the cord is cut before the placenta get out.87 Akha women usually give birth in squatting position, sometimes a granny helping to support from behind. They don’t hold onto anything. Some women knell for the birth, meaning that the child when comes out drop onto the mat.

Cutting the cord There is much variation in practice of cutting the umbilical cord. Different factors also influence the practice: women weakness, experience, people available, etc. Here again, generalizations or reductive attempts to provide explanations often results in the misreading the great variability between groups or sub-groups. As it has been heard for Khmu, women would cut the cord themselves because that whoever cut the cord has to yu kham!88 Knowledge: few groups seem aware of the danger of infection since boiling of the tool used to cut the cord is very low. As pointed out by previous works: This should be taken into consideration for the KAP study. Equipment: Ethnic Lao Traditionally the umbilical cord was cut against the root of turmeric (curcuma domestica), a stalk of lemon grass, piece of charcoal, bamboo, oyster shell, etc. Nowadays they are more likely to be using pre-boiled scissors, blade, razor, etc.89 Ethnic Lao usually cut the cord after the placenta has been expulsed out of the womb.90 Mon-Khmer For groups such as Brao, Sou’, Pacoh, Taoy, Brou, etc., the cord is cut with a sharp piece of wood; the specie depends upon the ethnic group. Ethnic Lao equipment include sharpen piece of bamboo, home span cotton thread, and winnowing tray91 86 Somporn Phajaruniti, UNICEF, Traditional child rearing practices among different ethnic groups in Houaphan province, Lao PDR 87 P. Brun, p. 32. 88 Somporn Phajaruniti, UNICEF, Traditional child rearing practices among different ethnic groups in Houaphan province, Lao PDR 89 Andrea Whittaker, Birthing, the postpartum and development ideology and practice in Northeastern Thailand. 90 Pascal Brun, Representations, rites et pratiques actuels du Post-partum au Laos

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Hmong Necklace on an infant after birth. The soul needs to be secured in the body, if not, the infant risks illness. Traditionally, this must be done before the cord is cut, by putting a silver necklace around the newborn’s neck. Sharp piece of wood and knife/scissors) reported (AusAID 2002). Akha After cutting the cord, powder made from sisiet tree bark and known for its antiseptic properties is applied by the Api.92 Phutai Wood uses to cut the cord. The survey revealed that charcoal is sometimes put to sterilize the cord (AusAID 2002). Nya Hön As soon that the cord is cut with bamboo, the father put it in the fire and collect the ashes in a small basket especially made for the occasion and bury it into the forest. (Wall: 1975).

Difficult delivery Complications include: retention of placenta, twins, haemorrhage, foot presentation, prolonged due to position of the baby, pain, bleeding. All groups generally belief that complications result by the actions of spirits.

Health seeking behavior Ethnic Lao Traditionally rely on TBA for help. But Lao other lowland Terravadin Buddhist also believe in the action of spirits. The wrong position of the baby in the womb is believed to be the result of malevolent spirits preventing the child from coming out. Mo mone Monks and spiritualists to chase away evil spirits perform the blowing of mantras on the mother’s belly.93 The mo mone, specialist of mantas written in Tham and carved on a copper roll or tied around the neck as amulet to protect the mother, give her faith, strengthen and confidence. In the case where all traditional healers and spiritualist would not succeed in their task, as a last resort, the mother would be brought to the hospital.94

91 MCH Institute, SCF/UK, Women in reproductive health in the Lao PDR, An anthropologic study of reproduction and contraception in four provinces. 92 MCH Institute, SCF/UK, Women in reproductive health in the Lao PDR, An anthropologic study of reproduction and contraception in four provinces. 93 MCH Institute, SCF/UK, Women in reproductive health in the Lao PDR, An anthropologic study of reproduction and contraception in four provinces. 94 MCH Institute, SCF/UK, Women in reproductive health in the Lao PDR, An anthropologic study of reproduction and contraception in four provinces.

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Hmong Hmong traditionally believe that ill health may be the result of the soul wandering from the body and unable to find its way home. The soul may be lost due to injury, wounds, a fall, a loud noise, being unconscious (including from anesthesia), or feeling sad and lonely. The symptoms of soul loss include weakness, tiredness, fever and headache, loss of appetite with extra thirst, insomnia or dreams of being in a strange place with a stranger. A soul calling ceremony is required to cure the sick person. Hostile spirits, spells or curses, and violation of taboos are other factors believed to cause illness. However, it is also recognized that illness can be a result of external natural forces, such as accidents and infectious diseases. In case of delivery complications, older women usually available in the village knowledgeable about traditional medicine and can solve complications such as prolonged labor. Complication during labor is related to sins they had committed against the ancestors (dead parents). Offering to the ancestors’ altar is seen as the solution for an easy delivery. Case Study: Hmong Cesarean Operation Hmong women requiring a caesarean section under anesthetic may have concern about when her body is cut under anesthetic her soul may be lost. The Hmong believe that each person has three souls. One soul is to look after the body when a person is still alive and travel to the underworld and wait to be reincarnated. The second soul waits by the person’s grave after his death and isn’t reincarnated. The third soul travels to live with the ancestors in the X world when the person dyes. Healthiness is associated with the 3 souls residing in the body. Illness occurs when a soul is frightened away for various reasons and can’t find its way home. Common symptoms includes feeling tired and weak, having headache and fever, loss of appetite, but having extra need to drink water, being unable to sleep, having frequent dreams to be in strange place and with a stranger. To restore a person wellness, a soul calling ceremony hu plig has to be performed at the place where the soul has left the body. If the soul 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.95 Rice analyses the soul loss concept following a caesarean operation illustrated by the case of a 34 years old woman in Australia. She was alone during the operation done with anesthetics; her husband wasn’t allowed to come in the delivery room. During the time she was unconscious, the mother believe one of her soul left her body and was unable to re-enter the body. Hmong believe that illness occurs when a soul leaves the body and can’t find its way back. In order to recover a soul calling ceremony must be performed at the operation room where the loss soul is believe to be waiting to be called back. The hospital greed for the family to performed a soul calling ceremony and the health of the mother. A Hmong shaman performed the soul calling ceremony that requires burning of incense, an egg, a bowl of raw rice, and a live chicken. It this case it took 20 minutes to persuade the soul to come back.

95 See Chindasri 1976, Thao 1984, Symond 1991.

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An epidural anesthetic could have been performed, the husband should have been allowed in during delivery so he could have called back the soul for his wife in the recovery room. Source: Rice, When I had my baby here, 2000. Khmu There is a lack of basic knowledge and equipment for safe delivery and face referral problem in case of complications. All groups use unsafe practices, (such as not sterilizing the cutting instruments for cutting the umbilical cord) combined with the lack of prenatal and postnatal care leads to very high rate of infection of infant and maternal mortality. As Phanjaruniti pointed it out, “inappropriate traditional practices are not the only problem, however, there is also an absolute lack of appropriate outside care available, even when people do want it”.96

Delivery characteristics Among birth that occurred the last 5 years before the LRHS 2000, 86% has no knowledge of birth weight. Of those whose birth is known, 12% of the birth weight more than 2.5 kg while less than 2% weighs less than 2.5 kg. Urban higher educated women tend to have better knowledge about their child weight at birth, as well as appreciation of having heavier baby. The differences of size at birth by age; birth order, educational level, region and residence vary little, mostly in direction of those of weight at birth. Weighing is prohibited in Mien culture: this could constitute a barrier to weighting: access to care.97 Akha Akha leave the child on the ground, the granny quickly cleans out the child’s mouth with her finger. In some cases the father will do that. No one must pick up the child until is has cried three times. Akha believe that a child is not truly born until it is asking for three things: a blessing (gui lah), a soul (sa la) and a life-span (zi) given by god (A po mi yeh). The way in which the god gives those three things will determine the future of this child. Practice After that the baby has cried three times, the granny is in charge of naming the child. This is a precaution against the child being named by the spirits, who would then claim it for their own. Akha also believe that in the case of other birth in the same village, if the second baby to be born would be named before the baby firstly born, the first baby born would die. After the baby has cried and being named, the umbilical cord is tied and cut. Then the baby is bath and wrapped up in long clothes.

96 Somporn Phajaruniti, UNICEF, Traditional child rearing practices among different ethnic groups in Houaphan province, Lao PDR, p. 51. 97 AusAID: Developing Healthy Community Project – Qualitative Survey 2002, Houaphan Province

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Mien The most important things to be done immediately after birth is to report to the Chief Ascendants (also known as the Flower-Giving Ancestor), and register the child’s flower name on the family record. (t’im mien k’u). The Chief Ascendant will protect the child’s soul until the age of twelve for a boy, fourteen for a girl. If death occurs during that period, its soul would return to the “Peach Orchard” and await a new reincarnation.98

Placenta There is a link between the health of the newborn and the placenta. Ngkriang put the placenta in a bamboo container closed tight. The container is then buried outside the village, deep enough so the dog could not dig it out. They believe if the bamboo container must be buried upright. A slanting container results in illness and usually the husband has to dig it out and replace the container upright.99 Ethnic Lao The birth’s place according to Lao saying is: the place where the placenta is buried and where the cord look at the sky.100 The book I of the Khamphee Prathom Chindaa (Thai Book of the Genesis) focus on the immediate period after birth and advise about the burial of the placenta. Traditionally, the placenta was put in a bamboo container, closed off with old piece of cloth and buried under the stairs. Sometimes the placenta is washed with warm water and then salted, wrapped and placed in a bamboo container and buried by the husband or the midwife in a place determined by the sex of the baby.101 This might be linked to the fact that the spirit of the stairs is the most important with the spirit of the fireplace and must be honored on 7-8yh day on the lunar calendar.102 Other favorite places are the yard, near a three, or also near the family paddy field; others buried it to the opposite cardinal direction from the birthing site. Influence of elders within the family, more than education level explains the disposal of the placenta according to the traditional rituals argued Brun.103 Other practice includes hanging the bamboo container to a tree in the forest, out of animal reach; Hmong buried it under the house central beam for a boy; and under the parental bed for a girl. The placenta is thrown unwrapped, but sometimes hot water and insecticide is put altogether with. The burial or hanging of the placenta must take place immediately or few days after the birth. The placenta fixes the infant in his country, maintain the family ties and need to be definitively untied from the infant, to insure harmonious development. On the

98 Jacques Lemoyne, Yao Religion and Society, in McKinnon and Wannat, Highlanders of Thailand, p. 207. 99 Tanum village, personal communications, November 2002. 100 Pascal Brun, Representations, rites et pratiques actuelles du Post-partum au Laos, p. 35. 101 Andrea Whittaker, Birthing, the postpartum and development ideology and practice in Northeastern Thailand. 102 Pascal Brun, Representations, rites et pratiques actuelles du Post-partum au Laos, p. 35. 103 Pascal Brun, Representations, rites et pratiques actuelles du Post-partum au Laos, p. 35.

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contrary, not to bury the placenta could result in the death of the child and the burial of hanging allow this rupture.104 According to Rough, the placenta constitutes a transitional space and when the cord is cut, more than the relation mother-infant, there is a phenomenon of partition between the child and its ego, or double, and its savage identity in order for the child to access to its singularity.105 Akha The placenta is buried under the house dividing-beam, either on the male or female side depending on the sex of the newborn. The mother will pull hot water over the burial site marked with an implanted twig, both morning and evening, s defense against wild animals for 12 days: one full cycle.106 Hmong The Hmong believe that at death, a person must collect his placenta in order to enter the heaven. The placenta is required for reincarnation and so is usually buried at the place of birth. Crofts illustrate the primordial importance of the placenta in Hmong’s cosmogony: The placenta is the black jacket within the spiritual world. When you die, you put your black jacket as a symbol of humility and atonement for your life on earth. Before meting your ancestors with a clear conscience you must re-visit the place of your birth.107 The placenta needs to be buried in the house so the baby knows where to find it and can reborn again. The placenta is then essential element for the reincarnation. In Australia, Hmong prefers have the placenta buried in the hospital, notably because of the housing style of the Hmong that doesn’t allow the burial of the placenta in the house.

Recognition of the newborn Praising the newborn This also refers to a broader belief in Southeast Asian societies that newborn attracts the attention of spirits who may take the baby with them; meaning the baby may die. Usually, the newborn is then greeted by opposite expression such as you are ugly instead of you are beautiful, I hate you instead of I love you, in order to fool the spirits and protect the baby. Ethnic Lao Foak

104 P. Brun, explains that it represents a rupture with the “twin” who lack certain qualities in order to live. This supports Laderman’s thesis asserting that the placenta own human elements such as water and earth, but lack the fire and air. Quoted by Brun, p. 37. 105 Rough quoted in Gokalp. 1989, p. 104. 106 Gim Goodman, Meet the Akha, p. 51. 107 Quoted by Rice, When I had my baby here, in Rice. Crofts, 1993, p. 4.

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Baby lay on blanket in a basket and the practice is to drop the basket gently in front of the door, 3 times or taking an object to hit the basket with. Incantations are involved acknowledging the recognition of a supra-natural realm influencing human’s lives.108 Akha Akha leave the child on the ground, the granny quickly cleans out the child’s mouth with her finger. In some cases the father will do that. No one must pick up the child until is has cried three times. Akha believe that a child is not truly born until it is asking for three things: a blessing (gui lah), a soul (sa la) and a life-span (zi) given by god (A po mi yeh). The way in which the god gives those three things will determine the future of this child. Practice After that the baby has cried three times, the granny is in charge of naming the child. This is a precaution against the child being named by the spirits, who would then claim it for their own. Akha also believe that in the case of other birth in the same village, if the second baby to be born would be named before the baby firstly born, the first baby born would die. After the baby has cried and being named, the umbilical cord is tied and cut. Then the baby is bath and wrapped up in long clothes. Hmong: the Hu Plig Soul calling ceremony Souls, soul calling and a naming ceremony are connected with the family, the society and the supernatural realm. Hmong believe that each living body has three souls. For a newborn infant, the first soul enters his body right after conception. The second soul when he comes the mother’s womb. Here stops the natural process since the third soul has to be called on the third morning after birth. Hmong believe that the health condition of the newborn is directly related to this concept of three souls. If the three souls are secured within the body, the infant is healthy; the contrary would end in illness, even death. An individual cannot become a true human being without three souls in its body. These belief and practices of the Hmong are directly linked to their family and larger society, but also to the supernatural world. Upon death, the three souls leave the body. One soul stays at the grave of the dead person; the second soul travel to the land of its ancestors and the third waits to be reincarnated in another body. Performed on the third morning after birth, the soul calling ceremony starts with the naming of the infant. The Hmong believe that the name of the baby represents his soul. In case of misnaming of a child the soul cannot be called and another name has to be chosen; hence the ceremony may take place several times. The Hmong believe that naming is essential for the health of the newborn. Improper name would result in problem in growth and illness for the infant. When the right name has been chosen, the Hu Plig soul calling ceremony is then performed; the third soul of the newborn will come to reside and be secured in the body. 108 Somporn Phajaruniti, UNICEF, Traditional child rearing practices among different ethnic groups in Houaphan province, Lao PDR, p. 53.

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A child cannot be born without the permission of the spirit parents. After three days, a ritual has to be performed in order to pay gratitude to the Txoov Kab Yeeb. Offering consists in food and the burning of paper money. The last part of the day even in the Hmong culture is a feast. Men gather to prepare the food that the women will cook. A blessing is performed prior to the feast by the shaman who will also tight cotton thread around the wrist of the newborn, parents and siblings. Representing strong social cohesion and support within Hmong community, the feast is also the occasion where the community is informed that a new member has come. This also means that the existence of the community is insured.109

Newborn care In most groups, the newborn is usually bath in warm water, boiled water. Gillespie pointed out that all newborn were bath in boiled water, except those born in hospital where the practice consists in whipping the infant with a clean and dry cloth.

All new born are also usually immediately wrapped after being washed, protected from flies and wind. Umbilical cord washed with warm water/sometimes soap and a preparation is often put on the cord: Houaphan: soot scrapped from a burnt rice steamer; Champassak: wasp’s nest; Savannakhet: wax/burned black cotton put on the cord.110

Abnormal birth Akha In case of premature birth, the Akha will usually not name the child immediately because if he dies (premature baby are generally expected to die), then the parents don’t have to observe ceremonial abstinence in the village. In Akha culture, disabled children not considered as human beings, because they believe they don’t belong to humanity. They have to disappear quickly and be buried in the forest. Purification ritual involves 3 years social ostracism and large fines. The birth of human rejects111 is considered as the greatest tragedy that can befall on the village on a whole, and especially on the household where it occurred. Akha believe that the couple had done something terrible and has been punished – so as the whole village. The couple face social exclusion, their house is destroyed and they must be purified by living in the forest. The village must also be purified. Then the couple can rebuild a house, but the roof must be lower than the other house. They also have to fetch water from another source than the other villagers, for the main source to remain holy. Following children from this same couple must be renamed in another way.

109 Rice, When I had my baby here. 110 Anna Gillepsie, Hilary M. Creed-Kanashiro, Rae Galloway, The World Bank, Newborn Care and Child Nutrition in 3 Provinces of the Lao PDR- final report. 111 Twins, harelips, polydigitals, disabled, etc.

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The birth of human rejects also implicate for the men not to participate in collective action such as hunting party. There is also a “taboo relationship” between the two men who have fathered abnormal birth who cannot speak to each other but by a third person. Parents are labeled as ta pa, falling in a lower category as to be confined in the purgatory for eternity.112 The fathers of human rejects are prohibited to become village priest, nor having any powerful role in the village. Akha consider both parents are as unholy. There must be a whole series of complicated ceremonies for the couple and the whole village and the economic aspects of these rituals is important for Akha since it takes nine pigs, nine dogs, nine chicken in order to make the needed sacrifices for the purification ceremonies.113 As Lewis pointed out, the eugenic infanticide, practiced by Akha, is very delicate aspect of their culture, and should be handed carefully. It isn’t a matter to be brought up by health program advised Lewis, since the words used to talk about it are taboo in polite society.114 Changes in attitudes and practices do occur and has been observed by NCA in Long district. Last March twins were born in an Akha village. Instead of killing the infant, the father brought his daughter and praised the project staff to take the kids. Foster parents were quickly found by the district social affairs and adopted by a family established near the road.115 The adoption of twins happened twice in the last year in Long district. Change has also been observed in Mien community where multi-finger child getting chirurgical operation to cut the surplus out.116 In both cases, if traditionally the infant would have been killed, they are living today. Lamet Lamet believe that the birth of twins predicts the death of the father. A buffalo must be sacrificed to the ancestor’s spirit. If there’s a girl among both twins, she must be killed. The dead body is buried in the earth and a stone is placed on top.117

Stillbirth and death of the mother Ethnic Lao In case of death of the child in the woman, traditionally the mo tam ye TBA would take it out. The body is then buried and a ceremony held in order to prevent the spirit of the dead infant to come back and strike down the family. Lao especially fear the malefic spirit of a dead born child. 112 Paul Lewis, A proposal for the development of a family planning program among the Akha of Thailand, p. 38. 113 Paul W. Lewis, Basic themes in Akha culture, in A. Walker, Contributions to Southeast Asian Ethnography, p. 96 114 Paul Lewis, A proposal for the development of a family planning program among the Akha of Thailand, p. 92. 115 Anne Kristine Angelveit, Chief Technician Advisor, Long District Personal communications. 116 MCH Institute, SCF/UK, Women in reproductive health in the Lao PDR, An anthropologic study of reproduction and contraception in four provinces. 117 Irozowitz, Lamet, p. 104.

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In the case where the mother dies, the siblings or the relatives raise the infant. A ceremony is held to prevent the spirit of the mother to come back as a phi tai houng. If both the mother and the child die, the child has by all means, to be taken out and buried separately. This spirit called phi ti kheng is even more powerful. The husband buries the infant and a ritually smash the small body buried with the shovel to insure that he won’t come back from the grave. Ngkriang In case of death of the child, the mother of both the mother and her child, 3 days kalam need to be observed where no outsiders are allowed inside the village boundaries and no villagers are going out. The village space is closed to the outside world, spirits and forces.118 Akha In case of stillbirth, the child is not named. It is not considered to be a human, then here again, no ceremonial abstinence has to be observed in the village and the burial ceremony is simplified. The body been buried with the bamboo used to carry it, and the steel shovel used left on the top of the cumulus. Akha believe that a woman buried with an unborn child still in her womb will become a special type of tiger (ka la) and will a lot of the community’s animals, even humans. They must somehow take the child out of the womb be it by cutting. Akha will take many precautions to help the woman deliver before she dies. The dead child must be buried in a different grave from the mother. Nya Hön In case of stillbirth, the body of the child is buried in the forest without ceremony. If the buu daak hasn’t been implemented yet (involving the sacrifice of a chicken and the gathering of the community), isn’t considered as a calamity, since the infant wouldn’t yet belong to the human being realm.

Hygiene Ethnic Lao The newborn bath 5-6 times/day + herbal medicine. Herbal medicine used for bathing includes bay kihout, lemon, hin som, salt, pao leaves and bab leaves. Traditionally the woman would also sit in a bath filled with warm water and salt; the practice is known to contribute to kill the bacteria (kha seua) and ease the recovery.119 Khmu Bathing with warm water and herbal medicine drinking. Hmong: herbal medicine to help lactation; for 1 month.

118 Khampay, neo hom, Tanum village, personal communications, November 2002. 119 Pho Ouan, Khoknin village, personal communications, 22/01/2003.

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Postpartum

Yu kham (nang fie, yu fai) The fire is an important in birthing rituals for all ethnic groups in Indochina. Yu kham is a practice widely practice throughout Lao, but there is much variation in the length women stay over the fire between different ethnic groups. Phajaruniti clearly under estimated the duration of yu kham asserting that all three ethnic group will practice for an average of three to ten days: Lao Loum: 7-10 days; Khmu: 5-7 days and Hmong: 3 days. AusAID survey in Phongsaly and Houaphan confirm these figures: 2 to 12 days. In Vientiane, ethnic Lao new mother stay up to 25 days over the fire but the time is reduced in Southern Laos. Ethnic Lao beliefs about yu kham: Literally would mean “to be in pain”120, perceived as a period of imbalance; the 4 elements having been disturbed during pregnancy and delivery and the woman has to adjust to the new state of emptiness and restore her heat quickly. The yu kham allows one to chase away the wicked blood (nam khao pa) and restore health quickly. Keyes suggest that the term yukham should be translated by “living in karma” and notes the same term use in Northern Thailand and describe a period of seclusion observed by new ordained monks for three days and a traditional rite involving monks withdrawing on a cremation ground to mediate the dissolution of the body.121 As discussed above, the book I of the Khamphee Prathom Chindaa (Thai Book of the Genesis) focus on the immediate period after birth and mention when the woman is “lying by the fire” and give a list of auspicious signs and symbols of each year of 12 years cycles. An elder man with recognize spiritual power mi kata implements a ritual called pab fai, “fix the fire” allowing the woman to stay on the fire or endure the heat. The phu tao’s task also involves the protection of the area around, against vampire phi phay, by tying cotton thread around the neck, wrists and legs (red & black, yellow or white) and candles and flowers (5 pairs of each). The length of the yukham varies also depending on the number of birth. For the first baby, ethnic Lao in Vientiane may stay as long as one month on the bed, over the fire. If the bamboo bed is usually located near the kitchen floor, some Lao in Pakse traditionally yukham outside in a hut especially built for the occasion.

120 MCH Institute, SCF/UK, Women in reproductive health in the Lao PDR, An anthropologic study of reproduction and contraception in four provinces. 121 C.F. Keyes, Ambiguous Gender. Male Initiation in a Northern Thai Buddhist Society, in Gender and Religion: On the complexity of symbols, p. 81.

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Lao women are believed to be vulnerable to spirits having lost blood and her power of resistance is too low (moun) for her to resist alone against spirits. Traditionally, relative and friends usually gather in order to protect the infant from malevolent spirit. Lao believe the phi phay attracted by the smell of blood may take the mother away. The ceremony last overnights and people sit on the ground, playing cards, talking loud in order to insure that the phi pop wouldn’t dare to come. At least one of both parents must stay awake. The fire underneath the women must stay alive; all relative are involved in the ngan kham “night ceremony”. Yukham is believed to delay next pregnancy. Intense heating combined with dietetic restrictions and help the womb to close and dry up and cannot produce the “women seeds” nam seua mee nging and therefore will delay the next pregnancy. Here again, cultural beliefs support the practices: careless postpartum practices will leave the womb wet piak and the seeds will come out allowing the next pregnancy to come soon.122 Combined with massage, yukham is believed to produce a lot of milk and make the woman’s body souk or ripe, and her breast full of milk and avoid permanent ill health due to cold state.123 Furthermore, according to Hanks, yukham is regarded as rite of passage through which the woman reach full maturity; “one of the series of rite in the life cycle which marked the course of an individual from birth to death. Hanks suggest that: “the symbolic equivalent for men is the monk hood, which also make a young men souk. For both men and women, the use of the term implies a threshold marking a significant change in one’s karma or destiny and the fulfillment of that destiny”. The fire symbolizes the rebirth of the woman that becomes mother; the child reborn as a human being or in a social environment; as a cooking process from rear to cooked souk, humid (bad, immature, impure) to dry (pure, strong, accomplished).124 In case of hospital delivery, the practice associated with the stay by the fire take the form of warm liquid intake and tying cotton strings to the women’s wrists. The fireplace is prepared at the home and the women may starts from the return on or wait according to the woman’s condition (cesarean or episiotomy may delay yu kham). Modernization and the viability of the yu kham Interviews realized by Brun with woman who had just given birth in Mahosot revealed that 2/3 of the women planned to lay by the fire regardless of the educational level (some had university degree). 2/3rd of the women had also followed dietetic restrictions during pregnancy. Reasons evoked not to follow the tradition includes cesarean, personal choice, availability of relatives, socioeconomic status of the family, etc. (Brun 2001) Function of the yu kham

122 MCH Institute, SCF/UK, Women in reproductive health in the Lao PDR, An anthropologic study of reproduction and contraception in four provinces. 123 Andrea Whittaker, Birthing, the postpartum and development ideology and practice in Northeastern Thailand, p. 489. 124 J.R. Hanks, Maternity and its rituals in Ban Chan, p. 71, quoted by Whittaker, p. 492.

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Brun asserts the three function of the yu kham practice: curative, preventive and integrative. The curative function (1) relates to the restoring of the balance in the body between the elements; recover the heat and strength loss, etc. At personal level, yu kham prevent (2) ulterior disorders and diseases. If not sufficient, the woman exposes herself to risk of leucorrhoea long khao that could lead to bleeding long deng and ultimately in uterine cancer maleng motlouk. The fire is also believed to blow the wind of the blood, encouraging circulation and chasing away blood clots leuat kam. On social level, the practice that aims the protection against evil spirits also involves the confinement from human. Finally the respect of the traditions and obedience to the parental prescriptions transmitted from elders allows the individual integration (3) in the social sphere. (Brun: 2001) Complementary practices Brick beforehand heated and wrapped in old cloths and disposed on the back or the womb to dry up the motluck uterus. Sometime, herbal preparations are put with the brick; 1 hour for the first 3 days, or after bathing or even during the whole period of yu kham. Yu Kham yen In the case where a woman could not stay by the fire, she traditionally has to yu kham yen. Yen means cold, so the confinement does not involve fire. This alternative way to recover from delivery involves more dietetic restrictions. Also, women don’t drink warm water or boiled water. The herbal infusion isn’t boiled; instead, the herbalist would grind the medicine that is put into water and drank away.125 The woman is allowed to stop the yu kham yen when she feels healthy. Healthiness is expressed for example by the capability to split firewood or fletch water from the well. Tai Deng, Tai Dam During the stay by the fire, the woman doesn’t lie on a bed but sit instead, on a round shaped rotten stool. We then use the term nang fai (sit by the fire); the back turned against the fire. Generally short period.126 In Houaphan Tai Deng and Khmu use the same fire as the family cooking spot, but remains only few days after that the woman leave and rest in another room. In case of double fireplace, the woman is forbidden to stay by the fire used for cooking rice.127 Other figures available for other ethnic groups includes: Mien: 3 days-1 week and also bathing with traditional medicine. Khmu mother and their child also bath 3 times before yu kham and take 15 days of rest. For Hmong and mien, no visitors are allowed inside the house. Yu kham usually involve the intake of large quantity of liquids and herbal potion. Health concerns during postpartum: tiredness, abdominal and lower back pain (AusAID, 2002).

125 Pho Ouan, Khoknin village, personal communications, 22/01/2003 126 50 years ago in Bolikhan district, Bolikhamsay province, women would stay 5 days and 5 nights sitting on the stool, fearing that if laying, the blood instead of evacuating would get up to the head. After this period, the woman would rest laying on the bed for few days. 127 For further information concerning the wood species used for yu kham, see Brun, p. 44.

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Katu Katu stay 2-3 days on the fire and light work in the field. The violation of this would results in sickness; believe to be caused by witch (tabok) or vampire (phanah). Nya Hön They also practice the staying by the fire. The buu daak “turn over the water” starts right after the naming ceremony where the ancestors spirits are informed of the coming of the new family member (Wall: 1975) Hmong Nam lua During the confinement period, a woman lies on a wooden bed with a fire burning near or underneath; she will try to avoid wind draft. The Hmong women ‘roast’ her for three days, but the confinement period extends to 30 days. Akha Akha women also lie by the fire (za nah a ma ja ci) 2-3 inches above the floor, for the first month after delivery. After this period, they moved it away, but if the child cries, they have to put it back in place (Lewis: 1969). Mien After giving birth the mother stays near the fire to keep warm because her body is 'raw'. She must eat only hot, cooked food, chicken and fermented rice being preferred. Even cooked vegetables are not allowed the first ten days. She must do no heavy work or enter other houses for 30 days. An opening is made in the wall of her bedroom so she will not pass through doors in the house until after the 'cleansing ceremony.128

End of yu kham (vang yu kham) A ritual performed by the husband involves throwing the ashes under the bamboo bed outside, better if it is near the feet of a tree; the bed is also taken out of the house.129 The practice of Yu kham is found overall positive (Phajaruniti) because it allow the woman to rest, be with the baby and stay warm by the fire. The fluid intake helps the women with clotted blood or retained placenta (retained placenta: (thong kang) to expel the blood/membrane. Traditionally, the end of yu kham involved the mo mone the following preparation; roots potion, formulas, a comb and a piece of broken bowl. The newborn was bathed and the parent would have its feet to touch the ground while saying: “stamp this grass, stamp the earth, this is your comb, this is your mirror, you had walked on the earth, so you are human being…”130 The phi heuan (house’s spirit) was also venerated during the end of yu kham ceremony.

Health staff and postpartum practices 128 Chob Kacha-Ananda, Yao: Migration, Settlements and Land, in McKinnon and Wannat, Highlanders of Thailand 129 Maha Kheo, mo mone, personal communications. 130 Archaimbeault, Rite de la naissance, PRL, 1956, p. 824

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Brun bring forward that informal discussions with district hospital staff revealed that most of the interviewees did not have any particular objections about the practice of staying by the fire, other than dietetic restrictions. Other recommendations aren’t contradicted by the practice of yu kham, for instance: hygiene, rest, fluids intake, etc. Advises concerning moderating the heat; wait in case of suturation, relax on dietetic restrictions, reduce salt intake, interdiction to drink alcohol and rest accompanied with physical activities. Furthermore, Brun asserts that the TBAs and some medical doctors interviewed follow themselves the practice of yu kham for their own postpartum period. (Brun: 2001, p. 76.)

Postnatal dietetic restriction, food intake and taboos Potential negative impact of food taboos on women’s nutritional status especially in poor communities where the alternative are limited and the prohibited food are an important source of protein. Gillespie argues that dietetic restrictions are not for the sake of the mother, but the child’s health. The survey also shows that the connection between nutritional intake and milk production is clearly made.131 Un-boiled water and cold drinks are all universally prohibited. On the contrary, chicken and rice with salt and ginger is a staple of allowed diet. Ethnic Lao Herbal potion to encourage lactating is taken during confinement period. Restricted food includes crab, deer, barking deer, red tailed fish, kha vegetables, mushrooms het bot, frogs, rice noodles khao poun, sour food ahan dong, MSGs. Authorized food include in the past: ginger, galanga, sticky rice in bamboo (khao kham) that contains high carbohydrate food and a lot of salt and sugar. Nowadays: pa kho, indigenous chicken, Chinese cabbage, morning glory, vermicelli (but cooked with salt), not fish sauce, sugar. Tai Deng and Khmu They proscribe few items that seem not to have much impact on nutritional status except potentially taro and sweet potatoes. Both groups believe it make women fatter and cause difficult delivery. This belief makes sense comment Phajaruniti since at 9 months the consumption of such food would make the baby bigger and so more difficult the delivery. The problem is that these dietetic restrictions start right at the beginning of the pregnancy. Also, in the case of village facing rice shortage, these dietetic restrictions would definitely cause problem since the proscribed aliments are the only substitute available to rice. Tai Deng After 5 weeks: meat and bamboo shoots; 3 months allowed to eat with the family and sour food allowed. Lactating women are prohibited from eating white buffalo, beef, pig, frog, eels, some varieties of fish (pa nay, pa kham, pa saed) and lard; 1 year and 10 months in case of more than 1 child. But they are allowed to eat: vegetables,

131 Anna Gillepsie, Hilary M. Creed-Kanashiro, Rae Galloway, The World Bank, Newborn Care and Child Nutrition in 3 Provinces of the Lao PDR- final report.

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chicken, pig feet, ginger and king fish (Phajaruniti). Lue’s restrictions include white buffalo and chicken, paderk, alcohol, smoking, 14-15 days after birth (AusAID 2002). Khmu Preference for cooked food and the dietetic restriction for lactating women, similar to ethnic Lao, include: white meat (buffalo, pig), eels, frogs, red haired animals and fruits. Only rice and salt for 2-3 days Hmong Many authors (among them; Rice, Janbunathan and Stewart) mention that the Hmong do not have food taboos, except in case of sickness for lactating women and child. Postpartum women, especially in the first month, usually eat Rice and chicken soup and herbal medicine to help lactation. After childbirth, the woman’s body is considered to be weak and vulnerable to outside forces. Health is believed to depend on maintaining the body in balanced state. Pregnancy is considered to be a hot condition and having lost so much blood and heat or yang, the body is considered as cold. This concept finds its origin in Chinese concept of yin-yang. In order to regain the heat lost she must keep warm. Touching cold water postpartum is prohibited. This belief is directly linked to the dietetic restriction during the postpartum period. The most effective way to restore the yang component lost is to eat yang food such as chicken.132 Avoidance of coldness Also a common belief in Southeast Asian cultures, cold water and wind for instance are perceived as harmful and are proscribed. The non-respect of this taboo would result in bad health. According to Rice, women believe that shower and hair wash right after the birth possibly mean frequent headache and loss of hairs at early age. The breaking of this taboo results in bad health and has potential implication of health in the future. In Hmong culture, even touching cold water is prohibited (it is believed one will have cold bones resulting in aching in old age). Eating cold food is also to be avoided, and many other food restrictions need to be followed. For the first 10 days, only hot rice and chicken soup improved with traditional herbs, but chicken eggs, pork and fish may also be eaten. Fruits and vegetables are prohibited during the entire confinement period. Hmong also believe that cold food results in heartburn immediately; the stomach feels hard and it can be fatal. Seng Saly In Phongsaly: vegetables with yellow flowers and non-scaly fish (PPA, ADB 2001). Phunoi dietetic restrictions include deer; the word means shortage and the violation of this taboo would result in shortage of milk (AusAID 2002). Ngkriang For 3 days following the birth, Ngkriang women in Sekong province will only eat dry fish, salt, red ants eggs, and hot water. For the confinement period, the woman is prohibited to eat meat. Bamboo shoots, pumpkin, mack bouak have to be also voided; the transgression of this taboo would results in illness.

132 Jambunathan, Hmong postpartum period, p. 341.

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Lamet No salty food for 1 month

Sexual abstinence The conventional view shared by historians and demographers is that in pre-industrial societies women were victims of their own fecundity. It is assumed that earlier generations were prevented from practicing birth control because they lacked the necessary technology. But there is evidence from old medical texts and from anthropological studies that women have almost universally sought to control their fertility. In fact, reproductive knowledge and practice has always been part of women’s folklore and culture. The relatively recent establishment of men’s hegemony in medicine has obscured the existence of earlier methods developed and practiced by midwives and handed down from generation to generation.133 Linda Gordon argues that social institutions and cultural values, rather than medical or technical considerations, have shaped modern contraceptive technology.134 Previous works have also unfolds social mechanism about birth spacing, particularly in the period following delivery. All ethnic groups practice sexual abstinence up to 6 months after delivery (ethnic Lao up to 3 months; Akha 5 months). This universal taboo constitutes an excellent birth spacing mechanism. All groups fear that the violation of this universal taboo would drag along dangerous consequences for health, up to the death of the culprit. Ethnic Lao follow sexual abstinence up to 3 months after birth and the non-observance would lead to illness.135 Akha The woman must sleep with her child for ten cycles of days after birth (ba geu nah jah, or ma gui nah jah) or about 5 months.136 Lewis’s interpretation is that this 5 months equal the sexual abstinence that the couple must observe; the couple being fined by the village priest in case of early pregnancy. Akha believe that a baby born within a 12 months delay from another to be a human reject.137 During those 5 months different taboos must be strictly observed. The mother is restricted from sitting on the same piece of bamboo on the floor with a man, or taking a man’s pants onto her lap. In both cases, the women would become anemic. Those taboos reinforce the sexual abstinence imposed after birth. The men sleep on the men’s side of the house and the woman on women’s.138

133 Reproductive technology: Delivered into Men’s Hands, p. 65, in Barbara Earth Compiled articles, AIT 1998, p. 74. 134 Linda Gordon, Birth control in America, 1977. 135 MCH Institute, SCF/UK, Women in reproductive health in the Lao PDR, An anthropologic study of reproduction and contraception in four provinces. 136 Lewis, 1970:381) 137 Paul Lewis, A proposal for the development of a family planning program among the Akha of Thailand, p. 43. 138 Deuleu Choopoh & Marianne Naess, Deuleu: A Life Story of an Akha Woman, in McCastill and Kampe, Development or Domestication, Indigenous People of Southeast Asia, p. 192.

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Resettlement, housing and loss of natural birth control mechanism In resettled villages, the lay out follow the Lao Loum house on stilts style house. The consequences of this change in architecture, more than treating cultural diversity might break the symbolic reproduction of the group in time is abruptly disrupt, not mentioning social impact of such change. For example, traditional Akha houses are sexually divided; each sex using its door and the inside space also being sexually divide. Now they live in Lao style shacks without concern to the traditional division, which is not only a curiosity that can be observed, but constitute a social mechanism for the natural control of birth. If further research is here needed, the impact in housing supported by wide vaccination campaign in the district (Long) will certainly have consequence on the population growth and then an increased pressure on the environment.

Back to work Most of Southeast Asian culture period after birth to be critical for the new mother perceived s weak and vulnerable. There are beliefs and practices to be followed for the mother in order to regain her strength and avoid illness. The length of the rest conditioned by the socio-economic status of the household, the need for labor in the field, availability of other childcare providers in the household. Seng Saly in Phongsaly usually rest for 3-4 days and go back to work in the field; Kim Moun in Oudomxay have to observe 1 month’s rest (PPA, ADB 2001). Some Lao Loum up to 3 months. Although according to the Lao Law, a woman can take up to 3 months vacation after delivery, in fact only civil servants or private sectors employees can afford it. In poor household the woman might start working immediately after yu kham (or 7-10 days after delivery). In the case of a household without grandparents, the child is usually carried with to the field. Hmong Usually 1 month. The husband works the hardest during this period and takes care of the family. The period is associated with dietetic restrictions of chicken and rice. The woman is dressed in warm clothes. This period of seclusion is reported in the literature concerning Hmong in pattern of migration139. Physical restrictions The confinement period constitutes a resting time for the mother. Hmong, and also Vietnamese believe that physical activities may result in damaging internal organs. Tradition practice even restricts from walking around, in order to avoid the collapse of the internal organs. Jambunathan mentions that many of Hmong practices and beliefs during the postpartum period are believe to have implications for current and future health.

139 See Morrow for Hmong living in California, Potter & Wirren, Galanti.

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Hmong believe that the adherence to cultural practices not only ensures the maintenance of current health, but also prevent future illness.140 Ngkriang: restricted places Ngkriang women are forbid to go to the field up to 3 days after birth. After 3 days the women are authorized to work in area nearby the village.141 Lamet The woman stays in bed for one day, but one-month commitment where she is not allowed to leave the village space.

140 Jambunathan, Hmong postpartum period. 141 Personal communications, Tanum village Neo hom, Sekong, November 2002.

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Breast Feeding In Lao PDR 95% of women breastfeed their newborns, compared to 89% in 2001. All group widely practiced breastfeeding. Economically speaking, it save family resources and is good for the baby’s health. In the case of the woman’s incapability to produce milk, different solutions include giving the infant to other women will help feeding, condensed milk or rice water may also been given to the baby. Leu acknowledges the relation between the milk and the woman’s health.142 Hmong traditional beliefs meet the scientific one since they acknowledge that breastfeeding is benefit for the child, prevent diarrhea, provides vitamins and make the child strong and give good immunity (Gillespie). Khmu Information is contradictory between previous works. In Oudomxay, Khmu newborns are going without any food for the first day of their life.143 But AusAID 2002 asserts that Khmu from immediately to 2-3 days after; Gillespie maintains that Lao Theung (Khmu is among them) wait for the milk to come. Ethnic Lao traditionally would pinch the nipple with bamboo (as they use to grill chicken) in case where the women couldn’t breastfed. The practice called ngip houa nom is accompanied by the intake of traditional medicine to help lactation.

Colostrum Beliefs Colostrum is described as the sour milk, bad tasting and many groups believe it give stomachache to the baby even diarrhea. Gillespie argues that some mother do not distinguish the difference between colostrums or milk since they start breastfeeding right away.144 Lao, Hmong and Khmu traditionally believe that colostrum sour and give diarrhea. In Oudomxay, AusAID reported that 50% does give colostrum; this may be due to health education in near village. The opposite is observed in Phongsaly: the colostrum is mostly not given 4 ethnic groups (AusAID 2002). 2/3 of the women interviewed in Houaphan and Savannakhet, and 50% in Champassak give colostrum. For those three provinces, by ethnicity: Loum and Theung: 2/3; Lao Soung: none.145

Traditional beliefs of the Mien promote directly colostrums intake. They believe that if the milk drops on ground, it would result in the breast milk to dry up. Breastfeeding starts immediately after delivery. 142 AusAID: Developing Healthy Community Project – Qualitative Survey 2002, Phongsaly 143 Daniel Benoit, personal communications. 144 Anna Gillepsie, Hilary M. Creed-Kanashiro, Rae Galloway, The World Bank, Newborn Care and Child Nutrition in 3 Provinces of the Lao PDR- final report. 145 Anna Gillepsie, Hilary M. Creed-Kanashiro, Rae Galloway, The World Bank, Newborn Care and Child Nutrition in 3 Provinces of the Lao PDR- final report.

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BF <1 hour after birth Hmong Hmong people don’t give colostrums but do start breastfeeding right away. 91% of the Hmong women interviewed assert their infant received milk right away from a wet nurse or another mother.146 According to Jambunathan, Hmong and other Southeast Asian delay breastfeeding until the milk has come in order not to deprived the “mother’s vital heat and fluids”.147 Akha start breastfeeding immediately after birth; Leu: 1-2 hours/later; Phunoi: wait for breast milk to come and may give pre-chewed rice and glucose as alterative (AusAID 2002). Another survey shows that half of the women interviewed in three provinces said they give milk within the first hour, and the KAP methodology revealed even a higher percent: 73%. Divided by ethnicity: Lao: 25% and Mon-Khmer: 23%.148 Main common barrier to frequent and exclusive BF include the need for the woman to return to the field and leave the care of the child to someone else. There is also a belief that milk is not sufficient for the child and that additional food is necessary.

Reasons for women to stop breastfeeding before 24 months include: • The mother being pregnant again; • She wants to eat prohibited food; • A general belief breastfeeding weaken the mother and that milk loses its

nutrients after 1 year. • Belief that the milk is not enough for growth149

In case of milk insufficiency: Akha: condensed milk, boiled rice, chewed rice and sugar, chicken, egg, fish. In order to increase the milk production, Akha and Leu may boiled pig or chicken, water; herbal potion. Phunoi: some give instant milk; Khmu: glucose, honey, powdered milk and rice; Leu: rice, sugar, water, grinded sticky rice (AusAID 2002). Khmu and Phunoi believe that breastfeeding right after working hard is harmful to the baby (AusAID 2002). Illness and BF: BF but dietetic restrictions for mother Akha no pumpkin leaves, bamboo shoots, fish, oily food, crabs, wild meat. Chicken and pig allowed.

146 Anna Gillepsie, Hilary M. Creed-Kanashiro, Rae Galloway, The World Bank, Newborn Care and Child Nutrition in 3 Provinces of the Lao PDR- final report. 147 Jambunathan and Stewart, Hmong Women in Wisconsin: What are Their Concern in pregnancy and Childbirth, p. 207. 148 Anna Gillepsie, Hilary M. Creed-Kanashiro, Rae Galloway, The World Bank, Newborn Care and Child Nutrition in 3 Provinces of the Lao PDR- final report. 149 AusAID: Developing Healthy Community Project – Qualitative Survey 2002, Phongsaly

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No liquid or fluid given to the baby Half of the women interviewed believe that pre-lacteal feeding is good for the baby. But the KAP survey revealed that 73% don’t. Differences by provinces include: Houaphan: 2/3 don’t; Champassak: <1/2 don’t; Savannakhet: <1/3 don’t. Differences by ethnicity: Loum: 50%, Theung; <50%, Soung 100%.150

Exclusive Breastfeeding up to 4-6 months

All: 1/3. Houaphan: 2/3; Savannakhet: ¼; Champassack 1/5. Loum: 1/3; Theung: 1/5; Soung: 100% KAP: 29%; 50% at 1 month give liquids; 76% no food before 4 months; 62% before 6 months. Working pattern remains a major obstacle for breastfeeding up to 4-6 months, as the incapability for the woman to produce enough milk.151

BF up to 2 years

All: 5 months to 4 years, average:

Usual Age for Weaning by Ethnic Group by province (in months)

Ethnic Group Houaphan Savannakhet Champassak Lao Loum 24 18 18 Lao Theung 18 24 24 Lao Soung 12 0 0 Barriers: new pregnancy, belief that milk lose its nutritional qualities, desire to end dietetic restrictions, drying up of milk when women can’t breastfeed in time of harvest, planting, etc.152

Introduction of first food at 6 months

This seems to be currently the norm, Khaomok (chewed sticky rice in banana leave, baked). Katang The introduction of un-boiled liquid and solid food starts few days after birth among the Katang. Some mothers started even after a few hours. The mothers use cooked sticky rice, chewed up by mother, then put in the banana leafs, and roasted up, let it cool then feed the baby with un-boiled water from the pond. They will do that until the babies are six months or the baby has teeth and can eat normal rice then they stop 150 Anna Gillepsie, Hilary M. Creed-Kanashiro, Rae Galloway, The World Bank, Newborn Care and Child Nutrition in 3 Provinces of the Lao PDR- final report. 151 Anna Gillepsie, Hilary M. Creed-Kanashiro, Rae Galloway, The World Bank, Newborn Care and Child Nutrition in 3 Provinces of the Lao PDR- final report. 152 Anna Gillepsie, Hilary M. Creed-Kanashiro, Rae Galloway, The World Bank, Newborn Care and Child Nutrition in 3 Provinces of the Lao PDR- final report., p. 16. The KAP survey revealed that 23% of the children under 24 months have been weaned (78 out of 333).

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feeding chewed rice. Then fish, chicken, and meat are added to baby's diet (Chithalath: 2001). Hmong starts giving food around 6 month; Yao 1-3 months; Phutai & Khmu: right after birth. Type of food given: chewed rice, rice and meat (AusAID 2002, Houaphan). In Phongsaly, the Akha are reported to starts weaning at 6 months; reasons of milk shortage, breast pain and delayed growth are mentioned. Type of food given includes: rice, vegetables, meat, fruit, sugar, biscuit and the survey mentioned a lack of knowledge of appropriate food for children (AusAID 2002).

An Akha child’s first rice meal After an Akha mother has eaten the purification meal, she will carry her thirteen-days-old infant out of the village to the fields. She will take along some cooked rice, wrapped in a banana leaf, in her shoulder bag. When she gets outside the village, she will unwrap the banana leaf and “feed” some rice to the infant by rubbing a little of it on its lips. This is the child first rice meal.153

Food with a thick consistency

Khao niao: good source of calories but nutritional value low. Proximate Nutrient Composition per 100g edible portion glutinous rice (steamed): Energy 230 Kcal Protein 4.1 g. Fat 0.6 g. Carbohydrate 52.2 g. Minerals Calcium Phosphorous Iron trace

18 12

Mg Mg

Vitamin Thiamine Riboflavin Niacin Retinol, b-Carotene, Total A (RE) and Vitamin C

0.03 0.10 1.0 None

Mg Mg Mg

Source: Nutrition Division, Department of Health, Ministry of public Health, Thailand, Sept. 1992.

Give food with nutrients

6 categories of nutritious food were defined: animal; other animal food; pulses and seeds; dark green leafy and orange vegetables, fruits. The food exploration and Healthy Baby Interviews highlighted the interest of the mothers in the nutritional aspect of food for their children; 24 hours recall produce the most revealing information: the lack of diversity in child’s nutrition.154

153 Paul W. Lewis, Basic themes in Akha culture, in A. Walker, Contributions to Southeast Asian Ethnography, p. 96. 154 Anna Gillepsie, Hilary M. Creed-Kanashiro, Rae Galloway, The World Bank, Newborn Care and Child Nutrition in 3 Provinces of the Lao PDR- final report.

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Supplementary feeding Introduce at early age because: stop baby from crying, baby grow fat and healthy, take less time than cooking rice soup, allow women to go to work in the field. Lao Loum & Khmu: chewed sticky rice in banana leave, baked. Lao Loum: 1-2/day for <1-month-old baby.155

Nutritional practices Soukaloun analyses connection between dietary thiamine intake and socioeconomic factors in lactating mother and the development of beriberi in their children. The findings show that beriberi was associated with poor and less educated mothers, more likely to adhere to food taboos.156 Thiamine rich food includes pig, fruits, and milk. Rice is the staple food in Lao PDR. Normal rice, when cooked, throw away water surplus; sticky rice soak too long and throw water away: both practice means loss of thiamine contained in the rice. A poor practice in feeding more than shortage of valuable food items was pointed by the World Bank’s nutritionist; GTZ in Bolikhamsay also come to the same conclusion.

Child Health

Common health problems Diagnostic capability is very low at village level. IDD Iodine Deficiency Disorder, malaria, URI Upper Respiratory Infection, GI Gastrointestinal problems, frequent pregnancy, opium addiction, convulsion, smoking, diarrhea, ARI, worms, malaria, parasites in Phongsaly. In case of child sickness, all ethnic groups food taboos that include: chilli, fermented and sour food, and fruits. Preparation and handling of food: mastication practice by all, put on the fire first’ Phunoi, Khmu, Leu.157

Recognizing the signs of a ill child

155 Anna Gillepsie, Hilary M. Creed-Kanashiro, Rae Galloway, The World Bank, Newborn Care and Child Nutrition in 3 Provinces of the Lao PDR- final report. 156 Douangdao Soukaloun MD, PhD, Dietary and Socioeconomic Factors associated with beriberi in breastfed Lao infants, paper presented to the 1996 APA International Health Award Winner, Washington DC. 157 AusAID: Developing Healthy Community Project – Qualitative Survey 2002, Phongsaly

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In Houaphan, healthy signs include: energy, activity, smiling, playful, grow fast, etc., while in Phongsaly the signs of illness: fever, crying, loss of appetite, hot lips

(AusAID 2002).

Care of a sick child Akha, Leu, Hmong, Mien, Khmu and Phutai are all reported using traditional medicine and modern medicine as well. Cost remains main barrier to modern treatment, with the fear of side effects, the distance, transport and cost are barriers to use system. Ethnic minorities also mentioned that the loss of the yellow card forbid villagers to vaccinate (AusAID 2002).

Prevention of illness Immunization (widely provided by mobile team) remains the most popular method of prevention of illness. The loss of the Yellow card was also mentioned as factor influencing the use of health services. There is a low awareness about the prevention of malaria because of lack of understanding and confusion; they know about the mosquito but breeding site have been observed during transect walk in the villages visited. Diarrhea is associated with breastfeeding after hard work in Houaphan. ARI is related to the socioeconomic conditions of the household. Even if people are awareness in warmth; lack of finance forbid some family to keep child well dressed/covered (AusAID 2002).

Abortion 90% of overall abortion occurs in private clinics. The reform of the working schedule of the public sector brought about a reduction of the working week (the working day end at 4 instead of 5 and the half-day Saturday have been dropped) allowing a second sideline for most of the civil servants. This relates to the low income of the civil servants.

Postnatal care: Health seeking behavior Maternal need assessment reveal that community awareness in LPB is low, see non-existent; if women feel well, they are not likely to go to hospital for routine check up. The same conclusion was found in Houaphan (AusAID) where both antenatal and postpartum care is not attended unless there is something wrong. Akha Akha still rely much on traditional healing. Financial considerations influence choice,158as linguistic barrier. Akha are also not comfortable with allopathic treatment/drugs. 158 AusAID: Developing Healthy Community Project – Qualitative Survey 2002, Phongsaly

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Hmong reject surgery and prefer to rely on their own people for medical treatment159

159 MCH Institute, SCF/UK, Women in reproductive health in the Lao PDR, An anthropologic study of reproduction and contraception in four provinces.

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Utilization of health facility Lack of access to timely and effective basic maternal health services is a critical problem for all third world women and contributes mightily to maternal health problems. Too far, few trained birth attendance, poorly equipped to identify or handle complications, deficient in quality of cares.160 The Ministry of Public Health is responsible of the management of health services throughout the country. The Maternal Health Need Assessment pointed out that maternal health services are mostly provided through vertical, centrally planned systems.161 In 1989 the MCHC was established under the department of preventive services and its task includes: formulating maternal and child health policies and coordinating the nation wide provision of maternal and child health services. In 1994, only 20 out of 117 district hospitals were operational because of lack of money, vehicles, medical supplies and essential drugs.162 It is often argued that traditions hamper access to development and medical care. If it is true that in some case spiritual beliefs delay the referral to medical care, it isn’t the main obstacle. Trust in the medical system and staff, all together with logistic, affordability and perceptions of life-threatening conditions constitutes the main obstacles to the utilization of health facilities.163 The reduction of maternal mortality depends on logistical possibility of referring emergencies to well equipped health center with competent staff.164 Accessibility of maternal health services Designed by the National Immunization Program and adopted by the NIOPH and overall agencies involved in the health sector, a zonal strategy categorizes people’s access to health services in Lao PDR. Zone 0: area within 3 km radius of static health services (26%); Zone 1: villages that health worker by foot or by bicycle within a day; Zone 3 refers to the villages reachable by motorized vehicle within a day; Zone 3: villages more than 1 day travel away from health services (54%; health facilities remain inaccessible for a large proportion of the population). The coverage of medical facilities and health personnel is still limited and remains of poor quality (World Bank, 1999). For example, only 19 percent of childbearing women have access to family planning (WHO, 1999). Referral systems

160 Jodi Jacobson, Women’s Health: The price of Poverty, p. 21. 161 Results and Recommendation from a Maternal Health Need Assessment in Tree Provinces of the Lao PDR, p. 7. 162 Pani Sanikhom, Reproductive health situation in Lao PDR, p. 6. 163 Women and reproductive health in Laos, an anthropological study of reproduction and contraception in 4 provinces, p. 40. 164 MCH Institute, SCF/UK, Women in reproductive health in the Lao PDR, An anthropologic study of reproduction and contraception in four provinces.

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Transportation and communication systems linking the periphery to higher level of health services is fundamental in view of the inaccessibility of health care and the incapacity of district level health services to provide adequate obstetric care. The MHNA pointed to the inadequacy of the referral system as the main factor undermining women’s access to trained attendance and quality obstetric care. The virtually non-availability of private vehicle in the countryside constitute an additional challenges for women needing immediate medical attention. 165 Unsafe practices Doctors systematically practice curettage in Southern Laos. Keeping in mind there is no running water; question to which extends the practice of the practitioners does not imperil women’s health and lives.166 The insertion of the Program of Family planning in the health system, which is the doctrine held in Lao PDR deserves a reflection in regard to its rationale and to the condition of its success, if we take into consideration the low resort of the health service by the women. The Maternal Health Need Assessment stated that the large majority of health facilities were not adequately prepared to manage postpartum hemorrhage and retained placenta, even though considered as the most important factor of maternal mortality.167

Experiences with public health services The anthropological study of reproduction and contraception in 4 provinces notices that although the impressive amount of health workers at provincial; and district level but remains a tremendous difference in the use of the services, even when distances are shorts.168 The use of health services by women is greatly influenced by women’s expectation of the service and whether those expectations are met or not. Miscommunication and poor relationship customers-health staff jeopardize the use of services by women. Unfriendly attitude and behavior of the health care providers also contribute to the dissatisfaction toward health services, especially in the case of unmarried women. The Maternal Health Needs Assessments findings underline that the use of health services is influenced by the woman’s expectations of the services and whether those expectations are met or not.169 If most of the women in Lao DPR do not use health services for antenatal, delivery and postpartum care, the one who did go to health services have expressed their dissatisfaction with staff attitudes and behaviors,

165 NIOPH, UNICEF, Results from the Maternal Health Needs Assessment in Three Provinces of the Lao PDR, p. 23. 166 Daniel Benoit, IRC, personal communications. 167 The assessment reveals that :”oxytocin was not present in the majority of the facilities visited”, p. 3. 168 MCH Institute, SCF/UK, Women in reproductive health in the Lao PDR, An anthropologic study of reproduction and contraception in four provinces. 169 Maternal Health Assessments Needs, p. 32.

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(absenteeism, poor explanations and counseling, unfriendliness, etc). The same report also underline the fact that even though the access to district hospital may be relatively easy for some women, they tended to prefer the comfortable atmosphere of home deliveries seeing few benefits in using health facilities.170 Consistencies and quality of routine MCH services varies considerably and the factors related to MCH delivery extends beyond services issues to include lack of awareness of the demand for services by the women (Maternal Health Needs Assessments). Health care utilization by the Hmong in the United States Modern health care is believed to be beneficial, but traditional diagnosis and treatment (either herbal or spiritual) may be used before biomedicine, thus delaying treatment. Some biomedical treatments may conflict with Hmong belief. In particular surgical removal of a body part may conflict with belief of reincarnation, and as noted, people may fear unconscious as a result of anaesthetic. After an anaesthetic it may be necessary to perform a soul calling ceremony in the operating theater where the soul was lost. People may have a problem when a practitioner is seen to force a decision or treatment, or fails to respect the patient’s wishes. There may also be problem of adherence of treatment regime, which requires long-term sustained use of medicine. Community Health profile: Hmong, Hmong Cultural Center, Minnesota, US Cheon-Klessing notifies that Hmong, like many Southeast Asian cultures, distrusts autopsies, dental filling, blood tests, believing that a person after reincarnation will be born with handicap if these procedures are performed. This may explain why Hmong women in Wisconsin dislike episiotomy and prefer natural tearing and healing. Hmong also fear that blood tests will “sap the strength” and that this withdrawal of the soul is a withdrawal of the soul; this may also explain why they refuse newborn blood test. 171 In a survey conducted in Hmong community in California, traditional healing practices used by Hmong parents to cure child acute illness comprises: herbal remedies, shamanism, spirit worship, use of talisman, vows and promises, rituals such as soul calling and ancestor worship.172

Use of community based health providers The first point of contact of formal health system is the community-based workers to assist in communication, mobilization of communities in areas of health, sanitation and nutrition. Women feel also more comfortable with the community health worker. TBAs Nation-wide, TBAs attend about 15% of all deliveries, twice as many as institutional birth (7%) (UNICEF). UNFPA, UNICEF and many other organization in Lao PDR 170 Pani Sanikhom, Reproductive health situation in Lao PDR, p. 34. 171 Jambunathan and Steward, Hmong Women in Wisconsin: What are Their Concern in pregnancy and Childbirth, p. 208. 172 P. Nuttal and F. Flores, Hmong Healing Practices Used for Common Childhood illness, in Pediatric Nursing, May-June 1997, Vol. 23:3, p. 250.

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has recommended the training of TBAs to provide basic maternal health services, supported by supervision and monitoring system. According to WHO, research has shown that even trained traditional birth attendants (TBAs) have not significantly reduced a woman’s risk of dying in childbirth, largely because they are unable to treat pregnancy complications. Training of TBAs and the improvement of the referral system remains the compromise in developing countries that usually face shortage of health professionals. But the long-term goal remains the skilled attendance at delivery. Akha communities traditionally rely on the help of the A-pi for delivery. Hmong people also help by an elder women. There is no word in Hmong language for TBA. Usually, the assistance of those TBAs mo tam ye or mo tam mob do not involve financial remuneration; the woman is given sin or scarf (ethnic Lao); food, etc.

Supervision visit to 147 trained TBAs in LPB has revealed that:

• The delivery of care and counseling services to women in hamper because the women are too shy to ask for assistance and has difficulty to change their traditional beliefs and practices for new ideas and practices

• 78% of TBAs reported having visited women for prenatal care 28% didn’t because of shyness of the women (44%); didn’t as for help (24%); attend birth facility (16%).

• 78% have provided delivery care and (98%) neonatal care • About 98% of TBAs reported visiting women for postpartum care and counseling.

Common reasons mentioned for not using the services of TBAs included:

• Shyness • The TBA was not at home • Lack of financial mean to remunerate the TBA

Recruitment of TBAs remains a crucial issue. See MSF project in Champassak Gender Practitioners Challenging traditional practitioners may impact the gender balance within a given community. For instance, in some groups, after menopause, women are ritually clean/not ritually polluting, freed – to a certain extend – from patriarchal domination. In some group, those women become mediator between humanity and the inhabitants of the unseen world; the men remaining in power in the regularized social world.173

173 Barbara Kerewsky-Halpern reveal also that post-menopause Serbian women in Yugoslavia are ritually clean and operate as medium between both human and spiritual realm.

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Postnatal care After the yu kham period, ethnic Lao women are believed to be out of problems. Pottier observed already in the 1970s the low level of postnatal attendance of health care (Pottier: 1970). Consultations in Vientiane aim mainly the vaccination for the infant and to look for contraceptives (Brun 2001).

Decision making process The recent anthropological thinking regarding health care seeking behavior emphasis the decision making process. The growth of an “ecological framework” theory emphasis sets of causal elements such as: environment features, material/economic constrain, political considerations, etc.174 Customary practices in many cultures prevent women from making and carrying out independent decision on fundamental personal matters such as when to seek health care or family planning, even when the resources are available.175 Ethnic Lao The matrilocal pattern of residence of the Ethnic Lao allows the woman to keep strong ties with her family, get immediate parental support; which is determining factor of survival in context of life-threatening conditions. In case of postpartum haemorrhage and the need of referral to health services, the decision to transfer the woman may be made more quickly.176 Ethnic Lao are described as having greater equality between sex: the author even noted a preference for female over male child. Daughters are responsible in looking after the parents at old age. Female are in power to control family size, (also the case for the Tai Leu). For the ethnic Lao women, Terravadin Buddhists, control of fertility remains more an autonomous decision.177 Hmong, Akha and Khmu wife reside in their husband’s household after the wedding. Female participation in decision-making is quite low. The position of the woman is dictated by the attitudes of the in-laws toward her, the economic status of the household she moves in and the prestige acquired bearing sons. Before the first pregnancy and delivery, the status of the woman depends much on the head of the household. All have patrilineal descent and women’s duty is to bear sons, who will carry on rituals for the ancestors and the linage. In case where the woman’s incapability to bare sons, she can be divorced and is not authorized to remarry. Her children remain under the husband clan. This practice jeopardizes women’s health since they have to keep bearing children beyond mature age, which increases the risks

174 Pertti Pelto, Studying Knowledge, Culture, and Behavior in Applied Medical Anthropology, p. 153. 175 Jodi Jacobson, Women’s Health: The price of Poverty, p. 4. 176 MCH Institute, SCF/UK, Women in reproductive health in the Lao PDR, An anthropologic study of reproduction and contraception in four provinces. 177 MCH Institute, SCF/UK, Women in reproductive health in the Lao PDR, An anthropologic study of reproduction and contraception in four provinces., p. 51.

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for maternal mortality. Village elders monopolize the decision making process and the interest of their community prevails on individual women’s concerns.178 Akha Akha woman is under complete subjection to her husband as suggest the proverb: “wife is the buffalo, husband is the rope” (mi za nyi, yo za ca). The man is the head of the house, the village and all Akha culture. RH Program should target the husband; by convincing him, the family members would all follow. This male supremacy of the family unit gives cohesiveness and constitutes a good starting point for RH program.179

Language Language remains the most important barrier in the transmission process of health message by health services. Ethnic women are often shut away in remote swidden fields and their isolation prevents them from direct health message. Direct information isn’t available for ethnic-remote communities that rely on indirect information. Transmitted by males, this information is often biased, distorted, enormous and fragmented.180 This is the case for the Akha The Mekong basin with its myriad of remote tributary watersheds, has, over a period of several thousand years, been an incredible incubator of cultural and linguistic diversity and of agroecosystem biodiversity. The linguist, R.M.W. Dixon, has written: "Each language has a different phonological, morphological, syntactic, and semantic organization from every other…encapsulates the world-view of its speakers—how they think, what they value, what they believe in, how they classify the world around them, how they order their lives. Once a language dies, a part of human culture is lost, forever (p.144).181

Communications AusAID survey analyses the communication channels through which ethnic people had received health messages in Houaphan and Phongsaly provinces. Health staff from ethnic minority origin seems to be one of the most effective solutions to overcome linguistic and cultural barrier. If some groups (Phunoi, Khmu, Hmong, Leu) are more capable to receive health message through mass communication devices (TV, radio, other villages, VHV, posters, etc.) linguistic barrier hamper the reception of health message, even when health staff do visit ethnic communities (Akha).

178 MCH Institute, SCF/UK, Women in reproductive health in the Lao PDR, An anthropologic study of reproduction and contraception in four provinces. 179 Paul Lewis, A proposal for the development of a family planning program among the Akha of Thailand, p. 71. 180 Women and reproductive health in Laos, an anthropological study of reproduction and contraception in 4 provinces, p. 53. 181 John V. Dennis, Jr., Introduction to Key Social Issues: Regional Report, Regional Environmental Technical Assistance 5771 Poverty Reduction & Environmental Management in Remote Greater Mekong Subregion Watersheds Project (Phase I)

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Culturally appropriate approach Health planners and providers must take into account the cultural specificity if they want their programs to be accessible and accepted by the greatest number of women.182 The Survey on Development of a Culturally Appropriate Community-based Reproductive Health Strategy in Selected Local Area in Lao PDR was conducted by IMCH/JOICF in 1997. The main objective was to identify people’s needs for birth spacing/reproductive health services and to develop culturally appropriate community-based approaches and strategies based on existing community support system, networks and organization in order to improve access and quality of care at the grassroots level. 457 women and 230 married men were interviewed. No ethnic data are available. Traditional villages in Southeast Asia were corporate as self-sufficient units where resources and labor were shared for many purpose. The report states that the integration of local resources (people, financial, we can add cultural) and participation in service positions may be considered as culturally appropriate.183 The degree of local resources utilization and participation directly influence the effectiveness of this model, in creating a team of VHV, and a village revolving fund, to generate financial resources and allow community to buy drugs, contraceptives and cover transportation cost in case of emergencies. These 2 elements will contribute to increased integration of birth spacing activities and more community participation.

Alternative healing Field survey conducted in 1999 in Phongsaly indicated that the rate of maternal mortality among the Hmong and the Yao in Phongsaly province was not so much different that from in the Leu villages yet nevertheless closer to services. Hmong and Yao rely on herbal medicine and other homeopathic remedies during pregnancy and after delivery.184

Recommendation for Safe Motherhood Studies and long-term activities in a few provinces show that simple and repeated educational messages are able to change family and communities practices. Nevertheless, any teaching should involved:

• The elders of the community (oral culture rely on elders) • Use models and illustrations to facilitate experimental learning

182 MCH Institute, SCF/UK, Women in reproductive health in the Lao PDR, An anthropologic study of reproduction and contraception in four provinces. 183 Chai Podhisita, Manisone Oudom and P. Sananikhom, Report of the Survey on Development of a Culturally Appropriate Community-based Reproductive Health Strategy in Selected Local Area in Lao PDR, p. 14. 184 ADB, Health and Education Needs of Ethnic Minorities in the Mekong Sub-Region, 2000, p. 83.

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• Nonverbal communication (pointing a finger, direct eye contact and signaling to a person to come closer) are generally considered as offensive

• Use of female provider for antenatal, delivery and postpartum care • Promote the hire of staff from minority background or use of interpreter

remain crucial • Strengthen the traditional role of the father and men so that they can better

support the mother and take decision, in needs of referral for instance by IEC in the village

Contraception

• Increase contraception availability Injection would probably be the most culturally acceptable method of contraception for Akha women. Injection is called ja ga tsaw –eu “injection of medicine”. The AusAID survey also underlined the popularity of the injection for other Tibeto-Burmese and Hmong-Mien groups (AusAID 2002) Messages about contraception focusing on men should emphasis must be put on sex satisfaction not jeopardized by medicine interventions and benefits for the community having healthy child. But politico-social considerations; the belief wealth = many children. Religious practice constitutes also a barrier since there is a blessing pronounced upon by the spirit priest encouraging the couple to have many children. The realization of this: having many children then reveal that the couple hasn’t committed adultery, nor broken any taboos.185 Antenatal care Many cultures believed the head and shoulders to be sacred parts of the body. Touching a women head or shoulder shouldn’t be allowed during antenatal, delivery or postpartum séances. Hmong women may refuse vaginal examination, especially by male doctors. This may be a reason for late presentation for antenatal care and non-attendance of postpartum check up.186 The vagina is an area considered as secret, private and only the husband is allowed to touch his wife.187 Female doctor would definitely reduce women’s embarrass in regard to the use of prenatal visit. The continuity of care should be a prime concern for health services, by frequent contacts with the health staff, midwife, etc. in order to establish a comfortable relationship where the woman fells confident enough to discuss about the practices she must follow. Delivery Home delivery 185 Paul Lewis, A proposal for the development of a family planning program among the Akha of Thailand, p. 107. 186 Community Health profile: Hmong, Hmong Cultural Center, Minnesota, US. 187 P.L. Rice, When I had my baby here, in Rice, P.L. (eds.) Asian mothers, Australian birth-pregnancy, childbirth and childrearing: the Asian experience in an English-speaking country, p. 3.

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• Distribute delivery package (1 clean piece of cloth, 1 razorblade in a wrapper, 1 piece of clean cotton string) available in small shops all around the country

• Train birth attendance, male and female, for men to take more participation and assist TBA

Delivery in hospital

• Promote the hire of staff from minority background or use of interpreter in order to increase the knowledge about the available maternal services

• Insure that the woman is accompanied by the people of her choice • Placenta given back to the mother/father in order for rituals to be performed • Alternative modes of delivery should be promoted, such as squatting position • Information sessions held about pregnancy, childbirth, nutrition of the mother

and the infant, etc. • Vaccination and micro-elements supplement are given • Professional

Return back home In many cultures, rituals have to be carried over after birth. The mother and their newborn are then likely to get back home as ASAP. Breastfeeding For the Hmong women in Wisconsin, hospitals have purchased WIC materials translated in Hmong language to teach nutrition to the mothers. Teaching material in Lao PDR should be translated in local languages, rely on illustrations, Key persons in the community Akha

1. The granny (a pi) is the key person for RH in Akha community being the knowledgeable and respected person by all women in reproductive health age188. Any community development activity/message must be elaborated through the a pi, in order keep intact her ability and prestige. In Akha community, the most important grannies are: the wife of the village priest; any woman who has performed the post-menopause ceremony (ya yeh m-eu). In some case, a single woman could fulfill both position, she would then be powerful and respected in the community.

2. Further research is needed to evaluate the role of the head of the sub-clan in

RH program that should maintain this important cornerstone of Akha culture. The success of any programs depend on the (to convict) household heads that it is the best option for their family, household, clan and village. 40 Any wife is going to be very reticent to adopt a course of action that is not accepted by her husband.

Postpartum period

188 Paul Lewis, A proposal for the development of a family planning program among the Akha of Thailand, p. 30.

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Reduce the excessive heat during yu kham Possibility to lie down for groups where woman has to sit on a bench Attenuate dietetic restrictions The continuity of care should be a prime concern for health services, by frequent contacts with the health staff, midwife, etc. in order to establish a comfortable relationship where the woman fells confident enough to discuss about the practices she must follow.

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Research calendar

List of interviews carried out by the international consultant: Date Name Responsibility Organization 17/11/2002 Ursula Schmid Lao-German Family Health Project GTZ 11/12/2002 Anne Kristine Angelveit Chief Technician Advisor, Long District NCA 13/12/2002 Sosonephit Phanouvong Deputy Director of Department of Ethnic Affairs LFNC 19/12/2002 Dr. Xaysana Boualavong Health Technical Supervisor Concern Worldwide Daniel Benoit Country Representative IRD 20/12/2002 Damian Hoy Information Management Coordinator Developing Health

Communities Project, AusAID

Dr. Heio Hohmann Uublic Health Specialist GTZ 03/01/2003 Sengthip Kariavong Responsible de Projet, Soins de Sante Primaire EED 06/01/2003 Laurent Romagny Head of Mission ACF 07/01/2003 Cecile De Sweemer MD DrPH Public Health Consultant Mr. Thanousone Head Ethnographic Database, Institute of

research on Culture IRC

13/01/2003 Kelly F. Gary Gender Specialist AIT, LWU 13/01/2003 Emma Townsend Community Development Curriculum QUAKER Services 14/01/2003 Bob Smith, Damian Hoy Developing Healthy Community Project AusAID 20/01/2002 Maha Kheo Palm Leave Manuscript translation, Buddhist EFEO 21/01/2002 Dr. Akjemal Country Representative UNFPA 29/01/28 Jacques Lemoine Anthropologist CASPI, MRC

Personal communications with relevant informants: Date Name Responsibility Organization 10/2002 16/01/2003

Barbara Earth Gender Research, Katang birthing customs, Concern Worlwide

AIT

12/10/2002 Dr. Deirdre Meintel Multiethnic Specialist, Montreal, Canada Universite de Montreal 12/31/2002 Dr. Paul Cohen Anthropologist (Northern Laos) University of Maquarie,

Australia Dr. Gerard Diffloth Ethnolinguist (Mon-Khmer groups) EFEO, France Leo Alting Van Gesau Anthropologist (Akha) University of

Chiangmai 24/12/2002 Sylvie Gravel Culture and Migration Research Team Public Health

Department, Montreal, Canada

30/12/2002 Mr.Choy Chiang Saetern Iu-Hmien Development Officer CARE International 02/01/2003 Dr. Jean Michaud Anthropologist (Hmong, Socio-cultural

Development) University of Hull, England

01/11/2003 Ian Baird Development Officer Canada Fund, GAPE Alykhanhty Lynhiavu Ethnologist (Hmong) Universite de Montreal 01/10/2003 Development Agriculture and Education Project for Akha DAPA 08/01/2003 Li Xueliang Researcher ethnic groups in Yunnan Central University for

Nationalities in Beijing 08/01/2003 Seng-Amphone Chithalath Master, Gender and development in Lao PDR Concern Worldwide 13/01/2003 Paul Cunnington Development Officer CARE 13/01/2003 Vanina Boute Researcher LASEMA (CNRS) 13/01/2003 Vatthana Pholsena PhD Anthropology York University UK 14/01/2003 Arbya Yeuvchehvq Akha Self Help Primary Health Care, Thailand SEAMP 15/01/2003 Florent Bernard Researcher Development process of Akha Paris 16/012003 Noriko Higashide Anthropologist (Akha) SEAMP 21/01/2003 David Boisson Country Representative MSF

Glossary KAP SURVEY

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English 쾸 Français

Abortion Abortive potion Abortive massage

¡¾­-¹ì÷-ìø¡ µ¾-¹ì÷-ìø¡ ®ó®-ªó-´

Avortement Potion avortive Massage avortif

Accident º÷®ñ©-ªò-À¹© Accident

Anaemia º¾¡¾­-¢¾©-Àìõº© Anémie

Analgesic §‡¤-®ñ­-Àêö¾-¹ìôì½-¤ö®-¯¸© Analgésique

Anaesthetics µ¾-´ô-­¹ìô-À»ñ©-ùÉ-¦½¹ìö® Anesthésique

Appetite £¸¾ -µ¾¡-º¾¹¾­ Appetit

Behavior ¡¾­-¯½ªò®ñ©-ªö­ Comportement

Belief £¸¾ -À§õº«õ Croyances

Birth Natural birth spacing

¡¾­À¡ò-© ¡¿-À¡ò-© ìø¡-¹¾¤

Naissance Espacement des naissance

Bleeding ¡¾­-ìø¡-À¦- -Àìõº© Saignement

Blood Wicked blood

-Àìõº© -Àìõº©-»¾¨

Sang Mauvais sang

Breastfeeding ¡¾­-ìɼ¤-ìø¡-©º -­ö -Á´È Allaitement

Breathing ¡¾­-¹¾ -Ã¥ Respiration

Caesarean ¡¾­-°È¾-ªñ©-êɺ¤-§Éº -Àºö¾-ìø¡-ºº¡ Césarienne

Colostrum ­Õ­ö ¦ö Colostrum

Cramps ¡É¾ -§­¯­ Crampes

Curettage Curetage

Disease °½-¨¾© Maladie

Disinfection ¡¾­-¢É¾-À§œº Désinfection

Doctor ÊȾ­-¹ ð Médecin

Emergency -À¹©-¦÷©-À¦ó Urgence

Equipment -À£º¤-¯½¡º® Equipement

Fetus -À©ñ¡-í-´ö©-ìø¡ Fetus

Fever -Ä¢É Fievre

First aid ¡¾­-¯½«ö ²½¨¾®¾­ Premiers soins

Gynaecology ­¾-ìò- ò-꽨¾ ò-§½-²½¨¾©- ò¤-¦½-À²¾½-꾤-ì½®ö®-¦õ®-²ñ­

Gynécologie

Haemorrhage ¡¾­-ªö¡-Àìõº© Hémorragie

Herbalist ­ñ¡-¦½¹­÷ -IJ Herbaliste

Headache º¾¡¾­-À¥ñ®-¯¸©-¹ö Maux–-de–tete

Hospital -»¤-¹ ð Hopital

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Infection ¡¾­-§ô -À§œº Infection

KAP (Knowledge Attitudes Practices)

£¸¾ -»ø êñ©¦½­½-£½ªò –Áì½ ²¾¡-¯½ªò®ñ© CAP (Connaissance Attitudes Pratiques)

Maternal §‡¤-¡È¼ -¡ñ®-Á È Maternel

Miscarriage ¡¾­-¹ì÷-ìø¡--© -ê¿-´½-§¾© Fausse---–couche

Mother -Á È Mère

Nausea º¾¡¾­-£›­-Ä¦É Vomissement

Nurse ­¾¤-²½¨¾®¾­ Inifirmière

Nutrition -²-¦½-­½-¡¾­ Nutrition

Obstetrics ¦øªò-¦¾© -Á²©-ê…¡»¸¡ñ®-¡¾­-©ø-Áì-¡¾­-«õ²¾-¡¾­-¯½¦÷-©-Áì½-²¾¸½-¹ìñ¤-¦ø©

Obstétrique

Pain º¾¡¾­-À¥ñ®-¯¸© Douleur

Placenta Retention of the placenta Revision of placenta

-Á»È -Á»È-®Ò-ºº¡

Placenta Rétention du placenta Révision du placenta

Post natal care -Á È- ò¤-¹ìñ¤-À¡ò-©ìø¡ Soins post nataux

Post--–delivery haemorrhage --Àìõº©-ºº¡-®Ò-À§í¾ Hémorragie post-natale

Pregnancy

¡¾­-«õ-²¾ Grossesse Grossesse extra-uterine

Public Health Center ²½-Á­-¡¦¾ê¾ì½­½-¦÷¡ Centre de Santé Publique

Ritual ²òêó Rituel

Salpingitis Salpingite

Sperm ­Õ-º¾-¦÷¥ò / ­¿-À§õº Sperme

Stillbirth ¡¾­-À¡ò-©-À©ñ¡-­Éº -ê†-ª¾ -µøÈ-í-´ö©-ìø¡ Mort–né

Spiritualist ¹ ð-²º­ Spiritualiste

Surgery ¡¾­-°È¾-ªñ© Operation

Taboo ¡¾­-¡¾-¹ì¾´ Tabou

TBA ¹ ð-ª¿-Á¨ Sage femme

Traditional medicine ¡¾­-çÉ-µ¾- õ­-À õº¤ Médecine traditionelle

Unconsciousness ¡¾­-¦½¹ìö® Inconscience

Uterus Neck infection Uterine atony

´ö©-ìø¡ Uterus Infection du col Atonie utérienne

Vagina §Èº¤-£º©- Vagin

Vomiting ¡¾­-»¾¡- Vomissement

Weight ­Õ¹­ñ¡ Poid

Womb Sein, utérus, entrailles

LWU ¦½¹½²ñ­-Á È- ò¤-쾸 ¦²¨ Association des Femmes Lao

MCHC ¦÷¡¢½²¾®-Á È-Áì½-À©ñ¡ Centre de Santé de la Femme et de l’enfant

MMR ºñ©ª¾-¡¾­-ª¾ -¢º¤-Á´È Taux de Mortalité Maternel

NIOPH Institut National de Santé Publique

NGO ºö¤-¡¾­¥ñ©ª¤ê†-®Ò-¢œ­¡ñ®-ìñ©«½®¾­ ONG

UNFPA FNUP

UNICEF UNICEF

WHO ºö¤-¡¾­-º½­¾-Ä -Âì¡ OMS

µøÈ¡¿

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Bamboo used to cut umbilical cord

-Ä Éð¡½-Á¦­¦¿-¹ìñ®-ªñ©-Á»È Bambou utilisé pour couper le cordon ombilical

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Ethnic Group per target provinces Area Province Ethnic

Group Population

% Prov Pop

Ethnolinguistc Superstock

Central Lao PDR

Bolikhamsay Puthai Lao Hmong

41 40,2 9,2

Tai-Kadai Tai-Kadai Miao-Yao

Northern Lao PDR

Louangnamtha

Khmu Akha Leu Lentene

24,7 23,9 15,8

Austroasiatic Tibeto-Burmese Tai-Kadai Hmong-Iu-Mien

Southern Lao PDR

Saravane Lao Katang Souay Taoy

60 13,3 8,1

Tai-Kadai Austroasiatic Austroasiatic Austroasiatic

Southern Lao PDR

Sekong Katu Tariang Alack Nge/Nkriang

16,673 14,128 11,918 6,804

23,24 19,69 16,61 9,48

Austroasiatic Austroasiatic Austroasiatic Austroasiatic

Source: NLHS 2001

Ethnic Distribution per Province, (NLHS 1999)

Province Population Groupe le plus

% Second % Troisième % % de

important Groupe Groupe Non Lao

Attapeu 87.229 Lao 36.90% Lavae 17.40% Oey 16.40% 63.10%

Bokeo 113.612 Khmu 23.80% Leu 20.60% Lao 13.40% 86.60%

Borikhamxay 165.589 Phutai 41.00% Lao 40.20% Hmong 9.20% 59.80%

Champassack 501.387 Lao 84.80% Laven 4.90% Xuay 2.40% 15.20%

Huaphanh 244.651 Phutai 31.50% Lao 30.00% Hmong 20.30% 70.00%

Khammuane 272.463 Lao 59.40% Phutai 21.70% Makink 13.40% 40.60%

Luang Namtha 114.741 Khmu 24.70% Kor 23.90% Leu 15.80% 97.70%

Luang Prabang 364.84 Khmu 45.90% Lao 28.60% Hmong 15.20% 71.40%

Oudomxay 210.207 Khmu 57.70% Hmong 13.10% Leu 15.20% 90.90%

Phongsaly 152.848 Khmu 24.40% Kor 20.00% Phunoy 19.40% 95.70%

Saravane 256.231 Lao 60.00% Katang 13.30% Xuay 8.10% 40.00%

Savannakhet 671.758 Lao 57.50% Phutai 18.90% Katang 8.70% 42.50%

Sayaboury 291.764 Leu 26.90% Khmu 20.00% Lao 19.00% 81.00%

Sekong 64.17 Katu 24.30% Talieng 21.80% Alack 15.50% 91.40%

Vientiane Mun. 524.107 Lao 92.60% Phutai 3.10% Hmong 1.40% 7.40%

Vientiane Prov. 286.564 Lao 64.80% Phutai 14.00% Khmu 12.50% 59.80%

Xaysomboun SR 54.068 Hmong 53.70% Lao 19.40% Khmu 16.70% 80.60%

Xieng Kouang 200.619 Lao 44.30% Hmong 34.20% Phutai 10.20% 55.70%

Total 4,574,848

Remarks: Both data were collected during the 1995 national census.

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Questionnaire for Health Staff Beliefs, taboos, practice and behavior around birth in Lao PDR

Name of the center Location (village, district, province) Year of construction Name of the staff Male/female Age Ethnic group Obstetrical service provided Position Staff Number Ethnic

group % Other

Doctor Assistant doctor Nurse Midwives Other Antenatal consultations in the last 12 months Frequency Provincial District Other <1/week Btw 1-3/week Btw 4-7/week Btw 8-13/week More than 14/week Delivery in the last 12 months Number Ethnic group % Other Total At term Premature Caesarean Delivery using forceps Delivery using suction pads

Equipment This includes: health education material for demonstration, blood pressure apparatus, stethoscope, infant weighing scale, fetal stethoscope, sterilizer, clinical oral thermometer, protective clothing, obstetric forceps, running water, electricity, etc.

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Instruments This includes: scale, refrigerator, boiling machine, drugs, contraceptives etc. Referral system

• Is there any mode of transportation available: walk, horse, bicycle, boat, tuk-tuk, bus, other?

• Who should accompany the mother in case of emergency: nurse/midwife/health personal, family member, other?

Characteristics of the Family Number of family members accompanying the mother? Are there relative present during delivery? In which position do the women deliver? Where goes the placenta? Maternal Death in the last 12 months? During pregnancy, during delivery or after delivery? What are the main causes of complications? Haemorrhage Placenta retention Uterine atony Characteristics of the newborns Number of birth <2500g Abnormal birth (twins, disables, stillbirth, other)? Number of hospitalizations after delivery? Left facility day of delivery Left facility next day Stayed more than more than one day at facility? Reasons influencing the length of time spent after delivery? Number of sterilization? Postnatal consultation number in the last 12 months Frequency Provincial <1/week Btw 1-3/week Btw 4-7/week Btw 8-13/week More than 14/week

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Most frequent diseases cases in the last 12 months Infection postnatal Salpingitis Neck infection Financial issue Price of delivery– normal With forceps With caesarean Price hospitalization/ 1day Accompanying people? Use of maternal health services

• What are the main factors influencing use of services? (access, service, linguistic/cultural issues, lack of medicine, lack of equipment, cost, etc.)

• Are there any staffs from ethnic background or with linguistic capabilities to provide services

to patient from ethnic background?

• Can you give reasons why the women should come to deliver in the hospital?

• Can you suggest reasons explaining the low level of utilization of maternal health services? (Antenatal visit, delivery in hospital and postpartum follow up)

• Services provided in villages in the last 12 months (antenatal, postnatal, vaccination, etc.)?

• Did you ever notice any treatment, actions or routine that would have negative impact on

services attendance by ethnic minority patient (touching, male practitioner, deliver alone, etc.)?

• How do you evaluate the quality of the obstetric services provided in this institution?

• Suggestions, strategies or activities that should be implemented in order to increase the use of

maternal health services? We may further develop questions related to the knowledge and practices of the health staff

Individual Mother Questionnaires Beliefs, taboos, practice and behavior around birth in Lao PDR

Province: Village: District: Access: Personal information: Name: Father

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Age: Ethnic group of the father: Ethnic Group: Number of Pregnancy: Number of living children: PREGNANCY How do women become pregnant? Behavior Food restriction Restricted people, places, activities Do you take any traditional medicine taken to facilitate delivery? Knowledge What pregnant woman does to keep healthy? What family should do in order to have healthy birth? Do you know any signs of complications? What do you do if you feel any problems during pregnancy? Buy medicine, take tm, see traditional healer, shaman, granny, etc. DELIVERY Where did you deliver? In, under, behind the house; in the forest, hospital, etc. Factors influencing the location of delivery. Position What was used to cut the umbilical cord? Did you sterilize the tool? Did you put anything on the cord? When do you cut the cord (do you wit for the placenta to come out?) What do you do immediately after the child is born? Assistance during delivery: describe who is present and functions. If TBA, explain payment mode. Did you have any problems during labor? What did you do? Did you receive any assistance from TBA, VHV, traditional healer, etc.? Placenta Is there any relation between the placenta and the child health? How is disposed the placenta (buried, dried, eaten, etc) POSTPARTUM Did you stay by the fire? Duration: Recognition of the newborn? Did you observed any dietetic restriction? Items, reasons, duration, etc.) Did you have any restrictions in activities, when did you go back to work? Child health and care Symptoms or signs of healthiness? Can the tradition/community help to improve the child’s health?

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What do you do in case of abnormality? Any difference in rearing for a boy or a girl (diet, quantity of food, etc.)? BREASTFEEDING After delivery (colostrums feeding) Wait till milk white (colostrums withdrawal) Exclusive breastfeeding? BF and pre-masticated glutinous rice BF and other food Introduction of other food? Introduction of solid food? Duration of BF? How many months? Cessation of BF? What is the best age to stop BF? Reasons: child died/ill/sick, mother ill/sick, no milk, child refuse, other. If not, substitute? Condensed milk, sugar, etc. Do you know that giving colostrum can contribute to immunization and is good for digestion? Do you know that breastfeeding contribute to delay pregnancy? TRADITIONAL MEDICINE Traditional medicine (herbal, animal, NTFPs, etc.) Did you take traditional medicine? For what occasion? Stimulate pregnancy For fever Treatment of obstructed labor At delivery Kill pain Treatment of bleeding Stimulation of contractions Change sex of the babe Avoid abortion Stimulate appetite Stimulate breastfeeding Other USE OF SERVICES Did you go to health services for antenatal care? Postnatal check up? Is the child received any immunization? Did you receive vitamins and iron supplementary? Do you have a yellow card? How many tines have you been to the district hospital before? Reasons for women to deliver at home Nothing happened previously Far from hospital/health transport Financial No medical staff @ night in dispensary Not aware that homedelivery are dangerous Afraid of hospital Language barrier

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Feeling of can’t perform rituals, details Health intervention/procedures susceptible to have impact on women health Unconsciousness Shyness Gender (doctor male) If the woman has been to the hospital? How was the service? (waiting time, courtesy, information given, other) Did someone translated for you? Do you plan to go back again? You saw a male or female practitioner? What question would you have liked to have asked but you did not? If delivered in hospital, how long did you stay?

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Focus Group Discussions Beliefs, taboos, practice and behavior around birth in Lao PDR

Province: Village: District: Access: Number of women present: Age of mothers: Number of birth in the village in X period of time Diachronical change in practice/beliefs Place of delivery Village TBA (How many, who, male/female) PREGNANCY How the women explain pregnancy Father role/behavior Mother role/behavior Taboos Food restriction mother and father Restricted places mother and father Restricted people mother and father Change in rituals/practice mother and father Restricted activities mother and father Special diet mother and father Pregnancy and sexual restrictions (family planning, natural mechanism of birth restriction?) If complications, health seeking behavior. Buy medicine DELIVERY Who assist (family/community members) Role father TBA Y/n (Payment of the TBA; if girl or boy) Location? (Changes between previous pregnancy) Position? What was used to cut the umbilical cord? Did you sterilize the tool? Did you put anything on the cord? When do you cut the cord (do you wit for the placenta to come out?) What do you do immediately after the child is born? In case of stillbirth? Birth of abnormal/twins, etc? Physiological characteristics of the babe influencing the rearing (disability, malformation, stillbirth, premature babe, etc.) Social integration/social exclusion and purification in case of abnormal birth) father and mother. Any community ritual involved? Miscarriage, reasons for? Main problems during pregnancy? Location of delivery? Factors influencing place? Dietetic restrictions? Did you have any problems during labor? What did you do? Did you receive any assistance from TBA, VHV, traditional healer, etc.?

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Placenta Is there any relation between the placenta and the child health? How is disposed the placenta (buried, dried, eaten, etc) POSTPARTUM Did you stay by the fire? Duration: Recognition of the newborn? Did you observed any dietetic restriction? Items, reasons, duration, etc.) Did you have any restrictions in activities, when did you go back to work? Child health and care Symptoms or signs of healthiness? Can the tradition/community help to improve the child’s health? What do you do in case of abnormality? Any difference in rearing for a boy or a girl (diet, quantity of food, etc.)? Did you take traditional medicine for the following reasons? Stimulate pregnancy For fever Treatment of obstructed labor At delivery Kill pain Treatment of bleeding Stimulation of contractions Change sex of the babe Avoid abortion Stimulate appetite Stimulate breastfeeding Other Did you go to health services for antenatal care? Postnatal check up? Is the child received any immunization? Did you receive vitamins and iron supplementary? Do you have a yellow card? How many tines have you been to the district hospital before? Did some women deliver in hospital? If yes reasons. Reasons for women to deliver @ home Nothing happened previously Far from hospital/health transport Financial No medical staff @ night in dispensary Not aware that homedelivery are dangerous Afraid of hospital Language barrier Feeling of can’t perform rituals, details Health intervention/procedures susceptible to have impact on women health Unconsciousness Shyness Gender (doctor male)

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If the woman has been to the hospital? How was the service? (waiting time, courtesy, information given, other) Did someone translated for you? Do you plan to go back again? You saw a male or female practitioner? What question would you have liked to have asked but you did not? If delivered in hospital, how long did you stay? BREASTFEEDING After delivery (colostrums feeding) Wait till milk white (colostrums withdrawal) Exclusive breastfeeding? BF and pre-masticated glutinous rice BF and other food Introduction of other food? Introduction of solid food? Duration of BF? How many months? Cessation of BF? What is the best age to stop BF? Reasons: child died/ill/sick, mother ill/sick, no milk, child refuse, other. If not, substitute? Condensed milk, sugar, etc. Do you know that giving colostrum can contribute to immunization and is good for digestion? Do you know that breastfeeding contribute to delay pregnancy?

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TBAs, Grannies, Healers Beliefs, taboos, practice and behavior around birth in Lao PDR

Province: Village: District: Access: Personal information: Name: Father Age: Ethnic group of the father: Ethnic Group: Number of Pregnancy: Number of living children: How long do you assist women in pregnancy and childbirth? Where did you learn? Did you receive any training about safe motherhood? Did someone in the village receive training? Have you been assisting many deliveries? Did people from neighboring village have requested you for help? PREGNANCY What the woman should do ion order to have secure pregnancy? Signs and symptoms of problems in pregnancy? Treatment given? Medicine/treatment used to improve the woman’s health or the health of the child in the womb? DELIVERY Where should women deliver? What do you do for helping during long labour? Any medicine/treatment to reduce pain? Change position of baby? In case of retained placenta? If the blood wouldn’t stop? If the baby dies in the womb? To prevent miscarriage? What do you use/put on the cord for sterilization/do you boil/burn the knife/bamboo used to cut the cord? Dietetic restrictions, places, activities, persons?

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In case of complications? Placenta retained, hemorrhage, [add other] Traditional medicine Herbal potion, ointment, antiseptic, sterilizer, Placenta? Mode of payment for delivery? POSTPARTUM Dietetic restrictions, places, activities, persons? Person to avoid, natural phenomenon (lunar /solar eclipse), position, etc. Do you prescribe any modern medicine? In case of complications, where do you refer? What about the district/provincial hospital? BREASTFEEDING Is colostrum good for the baby? Introduction of other food? Cessation of breastfeeding In case of milk insufficiency, alternatives (wet nurse, condensed milk, etc.)? Natural birth control mechanism (sexual abstinence, medicine, practices, etc.)?

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Selected Bibliography ADB, RTI, 2000, Lao PDR Report, Health and Education Needs of Ethnic Minorities in the Greater Mekong Sub-Region. AusAID: Developing Healthy Community Project – Qualitative Survey 2002. J.Chagnon, 1996, Country Briefing Paper – Women in Development, Lao PDR, ADB. Chai Podhisita, Manisone Oudom and P. Sananikhom, Report of the Survey on Development of a Culturally Appropriate Community-based Reproductive Health Strategy in Selected Local Area in Lao PDR Dennis, John V. Jr., Introduction to Key Social Issues: Regional Report, Regional Environmental Technical Assistance 5771 Poverty Reduction & Environmental Management in Remote Greater Mekong Subregion Watersheds Project (Phase I). Enfants et Developpement (1995) Nutrition and primary Health Care in Louang Namtha Province, Lao PDR. Fauvreau, Souphantong and Pholsena. (1994), Women in Reproductive Health in the Lao DPR. An Anthropological Study on Reproduction and Contraception in 4 Provinces. MOH, Save The Children UK, UNDP. Gillespie, Anna, 2002, Newborn Care and Child Nutrition in 3 Provinces of Lao PDR, World Bank, Save the Children “USA. Kirjavainen, Dr Leena M,1999, Gender Specialist, Gender Issues in Lao DPR, Regional Environmental Technical Assistance 5771 Poverty Reduction & Environmental Management in Remote Greater Mekong Subregion (GMS) Watersheds (Phase I) Ministry of Health, 1994-1995, Study on Main Determinants of Low Utilization of Health Centers in Savannakhet Province. Ministry of Education and Church World Services (CWS), 1998 (Evaluation Report) 1999 (Extension, phase II) of the Education Upgrading and Vocational training for Ethnic Minorities in Sing District, LNT Province. Ministry of Health and UNICEF (1998), Results and Recommendations from a Maternal Health Needs Assessment in Three Provinces of the Lao PDR. Phajaruniti, Somporn, 1994, Traditional Child Rearing Practices among Different Ethnic Groups in Houaphan province, Lao PDR. UNICEF.

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Phimmasone, Udon and All, 1993, Socio-Cultural Determinants of Contraceptive Use in Lao PDR. Reslut of a National Survey in 7 provinces, MOH, M and Child Institute, in collaborationwith Sthe C UK Research Triangle Institute (RTI), 1999, Inception Report: Addressing Health and Education Needs of Ethnic Minorities in the GMS. Soukaloun, Douang Dao, 1996, Dietary and Socio-Economic Factors Associated with Infantile Beriberi in Breastfed Lao Infants. APA 36th Annual Meeting. UNICEF 1992, Children and Women in the Lao PDR, Vte.

1994, Traditional Child Rearing Practices Among Different Ethnic Groups in Houaphan Province, Lao PDR 1996, Children and their family in Lao PDR. 1996, Situation Analysis of the Children and their family in Lao PDR (in Lao) 1998, Development for Women and Families. 1998, Early Childhood Development, 1998-2000 Operational Framework.

UNICEF and LWU, 1994, Traditional Child Care of Three Ethnic Groups in Houaphan, Vientiane, (Lao) UNFPA

1997, Component Project Strengthening of Reproductive Health Through Health Services Through the Lao Women’s Union.

2000. Reproductive Health Survey. World Education, 1995, Daily Workload, Health and Education: Focus Group Discussion with Women in Four Villages in Saravane and Attapeu. WHO, 1998, A Reproductive Health Needs Assessment in the Lao PDR. Ethnic group Archaimbeault, Rite de la naissance, PRL, 1956. Chamberlain, James, 1999, Ethnic Group in the Lao PDR.

Indigenous Peoples Profile, Lao Democratic Republic. CARE International, Vientiane, Prepared for the World Bank.

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Poverty Alleviation for all, Potentials and Options for People in the Uplands, Embassy of Sweden, 2001. Socio-Economic and Cultural Survey, Namtheun II Project Area, 1999.

Chazee, Laurent, 1999, The People of Laos: Rural and Ethnic Diversity, white Lotus, Bangkok. Earth, Barbara Between the Forest and the Clinic: Birth Practice Among the Katang People, Lao PDR Hanks, J. Maternity and its rituals in Ban Chan, Ireson, Carol J. and Randy Ireson. Ethnicity and Development in Laos. Leach, Edmund, 1964, Political System of Highland Burma. Keyes, Charles, Ambiguous Gender. Male Initiation in a Northern Thai Buddhist Society, in Gender and Religion: On the complexity of symbols. Thomas, Edward, Life of the Buddha as Legends and History, 3rd Editions, London, 1949 Walker, Anthony, Transformation of Buddhism in the religious ideas and practices of non-Buddhist hill peoples: the Lahu Nyi of Northern Thai Upland, in Walked (éds). Whittaker, Andrea, Birthing, the postpartum and development ideology and practice in Northeastern Thailand Wongprasert, Sanit, 1977, The Sociological and Ecological Determinant of Lahu Population Structure. Tribal Research Centre, Chiang Mai, Department of Public Welfare, Ministry of Interior Zago, Marcel, Rites et ceremonies en milieu bouddhiste Lao, France Asie. Akha Goodman, Gim, 1996, Meet the Akha, White Lotus. Leo Van Gesau, Dialectics of Akhazan, in Highlanders of Thailand. Lewis, Paul, 1969, A proposal for the development of a family planning program among the Akha of Thailand.

Basic themes in Akha culture, in A. Walker, Contributions to Southeast Asian Ethnography.

Lewis, Paul and Elaine Lewis, 1984, People of the Golden Triangle: Six Tribes in Thailand, London: Thames and Hudson.

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Hmong Cheon-Klessing, Y. et al. (1988). Folk Medicine in the Health Practice of the Hmong Refugees. Western Journal of Nursing Research 10 (October 1988): 647-660. Corlett, JL; Cleg, MS; and Grivetti, LE (2002). Mineral content of culinary and medicinal plants cultivated by Hmong refugees living in Sacramento, California. International Journal of Food and Sciences and Nutrition 53 (2): 117-128. Jambunathan, J. & Stewart, S. (1995). Hmong women in Wisconsin: what are their concerns in pregnancy and childbirth? Birth, 22(4):204 . Jambunathan, Jaya. (1995). Hmong Cultural Practices and Beliefs. The Postpartum Period. Clinical Nursing Research. 4 (3): 335-345. Judkins, R.A. and A.B. Judkins. (1992). Commentary: Cultural Dimensions of Hmong Birth. Birth 19 (September 1992): 148-150. Morrow, K. (1986). “Transcultural Midwifery: Adapting to Hmong Birthing Customs in California.” Journal of Nurse-Midwifery 31 (November-December 1986): 285-288. Nuttal, P. & Flores, F.C. (1997). Hmong healing practices used for common childhood illnesses. Pediatric Nursing, 23(3), 247-251. Rice, P.L. (2000). “Nyo dua hli - 30 days confinement: traditions and changed childbearing beliefs and practices among Hmong women in Australia.” Midwifery. 16(1): 22-34. Rice, P. L. (2000). Baby, souls, name and health: traditional customs for a newborn infant among the Hmong in Melbourne. Early Human Development. 57(3): 189-203. Rice, P.L. (1999). The cultural construction of miscarriage among Hmong women in Australia Women and Health 30 (1): 85-103 Turtle, Cynthia Reeves and Dewey, Kathryn G. (1996) Potential cost saving for Medi-Cal AFDC, food stamps, and WIC programs associated with breastfeeding among low-income Hmong women in California. Journal of the American Dietetic Association Turtle, Cynthia Reeves and Dewey, Kathryn G. (1995). Breastfeeding promotion program for Hmong women at selected WIC sites in Northern California, Journal of Nutrition Education, 27 (2): 69 +. Iu-Hmien Chob Kacha-Ananda, Yao: Migration, Settlements and Land, in McKinnon and Wannat, Highlanders of Thailand Lemoine, Jacques, Yao Religion and Society, in McKinnon and Wannat, Highlanders of Thai

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Alternative healing Etkin, N. L. 1991 Herbal Medicine Past and Present - Crellin, Jk, Philpott, J. Medical Anthropology Quarterly. 5(3): Pp. 286-288. Gaskin, I. M. 1996 Intuition and the emergence of midwifery as authoritative knowledge. Medical Anthropology Quarterly. 10(2): Pp. 295-298. Halpern, Joel, Laotian Health problems, Laos Project paper No. 19. Macey, L’art de guerir au Laos in Revue Indochinoise Vol XIII, Jan-June 1910, pp. 489-502. Johnson, A.E. & Baboila GV. Integrating Culture and Healing. Meeting the Health care Needs of Multicultural Community. Minnesota Medicine. 79(5): 41-45, 1996 May. Kroeger and Freeman, Cultural Change and Health in Bodley: Tribal People and Development Issues. Jordan, B, 1978, Birth in four cultures, Eden press Publication, Montreal. Laderman, C. 1990 Women as Healers - Cross-Cultural Perspectives - Mcclain,Cs. Medical Anthropology Quarterly. 4(4): Pp. 470-472. Leslie, C. 1999 The roots of Ayurveda: Selections from sanskrit medical writings. Medical Anthropology Quarterly. 13(3): Pp. 384-386. Mason, C. 1991 Births and Power - Social-Change and the Politics of Reproduction - Handwerker,Wp. Medical Anthropology Quarterly. 5(3): Pp. 283-285. Muholland, Jean, Magic and Evil Spirits, Study on Thai Traditional Paediatrics, Faculty of Asian Studies Monograph: New Series, No. 8, Faculty of Asian Studies Renne, E. P. 2000 Childbirth and authoritative knowledge: Cross-cultural perspectives. Medical Anthropology Quarterly. 14(2): Pp. 277-281. Wujastyk, Dominik, The Roots of Ayurveda: Selections from Sanskrit Writings Methodology Knafl, K & Webster, D. (1988). Managing and interpreting qualitative data: A description of tasks, techniques and materials. Western Journal of Nursing Research, 10(2), 195-218.

92

Anthropology and public health Forrest, D.V. (December 1997). "Writing at the Margin: Discourse Between Anthropology and Medicine." American Journal of Psychiatry. 154(12):1781-1782. Glittenberg, J. 2000 Anthropology in public health. Medical Anthropology Quarterly. 14(4): Pp. 626-627. Nichter, M., and C. Kendall 1991 Beyond Child Survival - Anthropology and International Health in the 1990s. Medical Anthropology Quarterly. 5(3): Pp. 195-203. Pelto, P. J., and G. H. Pelto 1997 Studying knowledge, culture, and behavior in applied medical anthropology. Medical Anthropology Quarterly. 11(2): Pp. 147-163. Powers, B. A. 1991 Cross-Cultural Nursing - Anthropological Approaches to Nursing Research - Morse,Jm. Medical Anthropology Quarterly. 5(4): Pp. 412-413.