com/ l oi/ rgph20 Deconstructing ‘ barriers’ to access: Minority ethnic women and medicalised maternal health services in Vietnam Joanna Whit e a , Paul ine Oost erhof f b & Nguyen Thi H
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Deconstructing ‘ barriers’ to access: Minority ethnic women and medicalised maternal health services in Vietnam
Joanna Whit e a , Paul ine Oost erhof f b & Nguyen Thi Huong c a
Cent re f or Research in Ant hropol ogy (CRIA-IUL), Inst it ut o Universit ário de Lisboa, Lisbon, Port ugal
b Royal Tropical Inst it ut e, Amst erdam, The Net herl ands c
Harvard Medical School AIDS Init iat ive in Viet nam, Hanoi, Viet nam
Version of record f irst publ ished: 17 May 2012
To cite this article: Joanna Whit e , Paul ine Oost erhof f & Nguyen Thi Huong (2012): Deconst ruct ing
‘ barriers’ t o access: Minorit y et hnic women and medical ised mat ernal heal t h services in Viet nam,
Gl obal Publ ic Heal t h: An Int ernat ional Journal f or Research, Pol icy and Pract ice, 7: 8, 869-881
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Trang 2Deconstructing ‘barriers’ to access: Minority ethnic women and
medicalised maternal health services in Vietnam
Joanna Whitea*, Pauline Oosterhoffb and Nguyen Thi Huongc
a
Centre for Research in Anthropology (CRIA-IUL), Instituto Universita´rio de Lisboa, Lisbon, Portugal; b
Royal Tropical Institute, Amsterdam, The Netherlands; c Harvard Medical School AIDS Initiative in Vietnam, Hanoi, Vietnam
(Received 20 June 2011; final version received 30 January 2012)
Low maternal health service utilisation amongst minority ethnic women in Vietnam is often attributed to ‘traditional customs’ Drawing on secondary data and original, qualitative research amongst Hmong and Thai communities, this paper analyses minority behaviour related to childbirth The informed selectivity
in service attendance identified can be considered, in part, a rejection of current medicalised approaches at health facilities, where supine delivery is compulsory and family members are prohibited from attending women in labour The paper reveals how conventional analyses of barriers to minority maternal health service utilisation inhibit scrutiny of the ways services fail to engage with or accommodate local preferences Participatory identification of mutually accep-table delivery methods by maternal health staff and local women is recommended
to enable the development of culturally inclusive services
Keywords: minority ethnic groups; childbirth; Vietnam; culture; medicalisation
Introduction
Increasing medicalisation of childbirth is a worldwide trend (Buekens 2001, De
Brouwere and Van Lerberghe 2001, Van Teijlingen et al 2004, Lumbiganon et al.
2010) Yet, user responses to medicalised services range from compliance to resistance and indifference, and are often based on pragmatic calculations as to how interventions might enhance (or not) women’s lives (Lock and Kaufert 1998,
Oosterhoff et al 2008) Maternal health-seeking behaviour is rarely an individual
matter; practices pertaining to pregnancy and childbirth are influenced by the families and communities to which women belong and the socio-cultural institutions with which they engage (Jordan 1997, Lock and Kaufert 1998)
Maternal health services in Vietnam
Vietnam’s transition to a modern state with a market-oriented economy, which commenced in 1986, involved several phases of health service reform The socialist preventive model was replaced with western-oriented public health training, and increasingly technological approaches (Tuan 2004) While national-level health indicators have improved (United Nations [UN] 2008), Vietnam now has one of
*Corresponding author Email: jowhite67@yahoo.co.uk
Vol 7, No 8, September 2012, 869881
ISSN 1744-1692 print/ISSN 1744-1706 online
# 2012 Taylor & Francis
http://dx.doi.org/10.1080/17441692.2012.679743
Trang 3the highest rates of caesarean section in Asia The particular application of new maternal health technology is significant Ultrasound and prenatal screening now
proliferate in urban areas (Gammeltoft and Nguyen 2007, Oosterhoff et al 2008), for
instance, and pregnancy is increasingly understood by the majority ethnic Kinh population as a medical condition requiring technical surveillance (World Health Organization [WHO] 2003) The National Standard Guidelines on Reproductive Health define the delivery position as ‘lying on the back’ (Ministry of Health [MOH] 2009); standard practice at all health facilities is for the parturient to recline on a delivery bench with her legs in stirrups, attended solely by medical staff Yet, maternal health service attendance is inconsistent (United Nations Population Fund [UNFPA] 2007b), which has been attributed to a range of factors, including education, income, geographical isolation, perceptions of service quality and
ethnicity (Duong et al 2004, Adams 2005, Trinh et al 2007).
Minority utilisation of maternal services: limitations of current understanding Vietnam is home to 53 diverse minority ethnic groups, many of whom inhabit rural, mountainous areas and live in relative poverty (McElwee 2008, World Bank 2009) Prohibitive cost is no longer understood to be a significant obstacle to minority access to health services due to various state measures, including the introduction of the nationwide Health Care Fund for the Poor, offering free healthcare through a designated ‘first-stop’ health post, normally the commune health centre (CHC), the
facility most accessible to poor, rural communities (Axelson et al 2009) Yet,
available data suggest that maternal health service utilisation by minority women
remains especially low (WHO 2003, Sepehri et al 2008, UNFPA 2008b, UNICEF
2009) Furthermore, maternal mortality amongst minorities is understood to be relatively high four times higher than Kinh maternal mortality according to one recent estimate (WHO 2005) adding urgency to concerns about low attendance for ante-natal care (ANC) and delivery Yet, current understanding is based on scarce and often insufficient information: a recent situational analysis which reviewed all available studies on maternal mortality failed to distinguish ethnicity as a
contributory factor due to data limitations (Knowles et al 2009) Furthermore,
the various issues influencing maternal mortality are not disaggregated in current analyses, hence CHC staff skills, referral to adequate emergency services which can
be problematic in mountainous areas as well as ‘local customs’ are conflated (see e.g UNFPA 2007b and UN Vietnam 2010)
Limitations in current data underscore the need for greater research on minority maternal health-seeking behaviour Low service attendance is often ascribed to geographical remoteness (WHO 2003, UNFPA 2007b, Humphreys and Vu 2008) Yet, many CHCs are located within several kilometres of villages, and as many minority families routinely travel long distances to pursue their livelihoods, the concept of ‘remoteness’ is relative (UNFPA 2007a) Vaguely-defined ‘traditional customs’ are also regularly posited as a barrier to reproductive health service utilisation (Doan 2007, UNFPA 2007b, UNFPA 2008b) Such representation of minority cultural practices as obstacles to service attendance can be seen to conform
to prevailing stereotypes within Vietnam regarding the ‘otherness’ and ‘back-wardness’ of minorities inhabiting mountainous areas (Humphreys and Vu 2008, World Bank 2009, Nguyen 2010, Turner 2010) Similar depictions are common in
Trang 4other South-east Asian settings which are home to minority populations, and are rarely challenged (Duncan 2008) As observed elsewhere in the region, this discourse inhibits reflexive examination of the nature and quality of maternal services, and whether these best serve minority users’ needs (WHO 2003, UNFPA 2008a) A preference for delivery environments not offered in state facilities has already been
identified within certain communities (Humphreys and Vu 2008, Sepehri et al 2008).
The fact that most health staff in Vietnam are Kinh and rarely speak local languages
(Humphreys and Vu 2008, Sepehri et al 2008, Integrated Regional Information
Networks [IRIN] 2009) and that stigmatisation of minority users by Kinh health staff (UNFPA 2008b) may also serve to discourage attendance
Drawing on secondary data and original research conducted with Hmong and Thai communities in north-western Vietnam, this article explores current minority practices and utilisation of services pertaining to maternity Primary data were collected through a prevention of mother-to-child transmission (PMTCT) of HIV programme During a 2008 assessment conducted by the programme in Dien Bien and Ha Giang, provinces with large minority populations, government staff expressed concern about poor maternal health service uptake, attributing this to poor education, physical remoteness and minority ‘traditions’ The study was therefore devised to enhance understanding of childbirth practices and maternal health-seeking behaviour among local Thai and Hmong villagers
Methods
Secondary data were gathered through a literature review of published material and unpublished reports produced by international agencies Two studies were then conducted by a team of eight female researchers in Ha Giang and Dien Bien between March and June 2010 Ethical approval was obtained from the commissions of scientific research within the relevant provincial departments of health.1The studies conformed to universal ethical principles and followed a similar methodology Several neighbouring communities, situated close to health facilities, were selected,
so that geographical distance was unlikely to be a factor influencing service attendance For the Hmong study, two communities were chosen from the same commune in a remote district of Ha Giang bordering China Village A was located immediately next to the CHC, which was established in 2000 and Village B was situated 12 km from this facility The district hospital was 12 km from Village A and 0.51 km from Village B Research with the Thai took place in three villages in the same commune in Dien Bien: two long-standing Thai communities (Villages C and D) and one Kinh village which became predominantly Thai over recent decades due to land transactions (Village E) All three communities were situated less than 2
km from the local CHC, which was established in 1995, and 3 km from the district hospital
In-depth interviews were conducted to gain insight into experiences and decision-making pertaining to childbirth; questions were focused particularly on the most recent delivery The interviews were structured around an open-ended questionnaire Interviewees were selected according to a random, proportional, age-stratified sample of women of reproductive age (1549 years) who had delivered at least one child, using village population lists A total of 56 Hmong and 87 Thai women were interviewed (Table 1) To provide broader understanding of traditional practices
Trang 5related to pregnancy and childbirth and explore inter-generational differences, focus group discussions (FGDs) were held with women from different age groups randomly selected from village lists, excluding those selected for interview A total
of five FGDs were consequently conducted with 36 women (Table 1) The discussions followed thematic guidelines Study participants provided informed consent, and received a small remuneration for their time
The research team was trained in interview techniques and FGD facilitation, and all study tools were pre-tested and refined prior to fieldwork Given language barriers, Hmong and Thai women from outside the study communities were hired as interpreters These individuals were trained in elementary research methods All data were transcribed, translated into English and analysed according to a content analysis approach Initial analysis was guided by the thematic areas defined by the interview structures and FGD guidelines, while a second stage identified sub-themes,
as well as variant views Some descriptive analysis of quantifiable data was conducted
to contextualise findings
The study has several limitations Studying minority communities in Vietnam can
be difficult due to political sensitivities, and the research process is often closely controlled by government (Turner 2010) The fieldwork team benefited from the long-term relationship between the Vietnamese Government and the PMTCT programme; local state health providers facilitated access to communities However, using government staff as gatekeepers may have created biases in how the researchers were perceived Furthermore, the study took place over a short space of time within five distinct villages and cannot claim to represent the situation amongst wider Thai and Hmong communities
Hmong childbirth as reported in secondary literature
Hmong people first moved from Southern China to South-east Asian countries including Thailand, Myanmar and Vietnam during the eighteenth and nineteenth century The Hmong are understood to be among the least assimilated, most impoverished ethnic group in the Northern Mountains region of Vietnam, due to their relatively recent arrival and settlement in marginal lands The current Hmong population stands at over 787,000, around 1% of the total Vietnamese population (World Bank 2009) Hmong poverty rates rank among the highest in the country, at just under 90% (World Bank 2009).2 Education levels are the lowest of all ethnic
Table 1 Study sample (n 179).
Hmong (n 72)
Thai (n 107)
Trang 6groups, with Hmong female access to education particularly limited (Baulch et al.
2004, World Bank 2009) The health status of the Hmong is the lowest in Vietnam (WHO 2003)
Published data on Hmong maternal health practices from Vietnam, or indeed wider South-east Asia, were found to be scarce, the exception being a recent ethnographic study from Thailand In this analysis, the role of the Hmong family house as a site for ancestral and other spiritual activities associated with delivery is emphasised Hmong women are described as remaining clothed during childbirth, and delivering in a squatting or sitting position at home Childbirth is presented as a largely female domain, with the father of the newborn responsible for ritual activities such as cutting the umbilical cord and burying the placenta inside the family house (Symonds 2004) Available literature on Hmong childbirth in Northern Vietnam similarly high-lights the importance of ritual processes related to delivery and the dominance of home birth, although husbands are often reported as present during childbirth (Do
2002, UNFPA 2007a, UNFPA 2008b) Low rates of facility delivery are attributed variously, to geographical remoteness, men’s reluctance for their wives’ bodies to be examined by outsiders (and associated female ‘shyness’) and rituals which are better performed at home (UNFPA/PATH 2006, UNFPA 2007a, UNFPA 2008b) The centrality of customary practices in childbirth to the Hmong has prompted recommendations that health facilities are culturally adapted to attract local communities (UNFPA 2007a, UNFPA 2008b, IRIN 2009), although there is no evidence that this has occurred
Childbirth amongst the Hmong in Meo Vac
field study findings Focus group discussions conducted with the Hmong elicited a range of childbirth narratives It was common for women over the age of 60 years to have delivered without assistance from family members One elderly participant recounted:
I came from the mountain when I had labour pains; no one was home I sat next to the bed to give birth and afterwards laid my child on the bed I took a string from the lining of my skirt and used it to cut the placenta I delivered four children on my own without any help.3
A culturally informed emphasis on silence and resilience, associated with rapid delivery outcome, was articulated by many of the older FGD participants, corresponding with details provided in secondary sources (Symonds 2004, UNFPA 2008b)
Role of husband in delivery
Elderly FGD participants contrasted how in the past women were more likely to deliver alone at home while the current generation prefers to have their husbands attending them; a cultural shift confirmed by younger participants One 41-year-old woman described the role of her husband during delivery:
My husband was with me during my labour He hugged me until I delivered and made
me feel less pain He held me in his arms until I finished giving birth
Trang 7cooked chicken and rice Several hours after the delivery he cooked egg soup with pepper for me.4
Points of consensus amongst FGD participants of all ages were the importance of sitting or squatting during labour, and the use of a low stool for this purpose Specific rituals associated with childbirth, such as the burial of the placenta, and the exercising of food taboos following delivery, were also detailed The frequency of home births within Hmong communities was confirmed and was attributed to the speed of delivery In the words of one participant, ‘I had a very quick delivery I had
no time to go to the CHC’.5
The few FGD participants who had given birth at a health post remarked upon the difference between home and facility delivery One woman noted:
When I was in the district hospital, they took care of my baby and me very well, but they did not allow my husband to be beside me
This observation has added resonance if one considers the known limited Kinh language ability of most Hmong women, and hence their probable communication problems with health staff Several cases were described of CHC staff providing the family with the placenta for burial at home, but this appeared to be an informal, unsystematic arrangement
Choice of delivery setting
The predominance of home deliveries amongst the Hmong was confirmed by interview data Only a minority of respondents, of all ages, reported delivering their last child at a health facility (21/56; 37.5%).6 Yet, many more of the Hmong interviewees (37/56; 66%) had attended ANC at least once during their last pregnancy, highlighting a selective use of available services None of the home births reported were attended by health staff but in most cases women reported their husband being present (29/35; 83%) as well as other relatives or friends (28/35; 80%) A variety of perspectives regarding services were expressed by respondents within the same communities Of the women who reported attending a health facility to give birth, some attributed this either to a difficult delivery which had necessitated their being moved to a maternal health facility, others to their belief that a facility delivery would be safer, and others to the proximity of the health post Among those who had given birth at home, the most dominant explanation was the speed or the ease of the delivery Women’s shyness was rarely cited as an explanation
Thai childbirth as reported in secondary literature
The Thai (Tai) people inhabit areas of mainland South-east Asia, southern China and North-east India They are the third largest ethnic group in Vietnam, composing over 1.3 million people, around 1.7% of the total population (World Bank 2009) The Thai played an important role in Vietnam’s independence wars (Xiaobing 2010) and are understood to be economically integrated, while remaining
culturally and socially separate (Baulch et al 2004, Trong 2007) Similar to the
Trang 8Hmong, many Thai communities maintain strong ‘markers’ of their identity in terms of the decorative clothing and accessories worn by women, house structure,
as well as traditional ritual and social practices (Oosterhoff et al 2011) Thai
poverty rates stand at just under 60% (World Bank 2009) Thai net primary school enrolment rates are high, but secondary and higher education levels remain low (Humphreys and Vu 2008)
Scholarly or other literature on Thai maternal health beliefs and practices are scarce The sole study identified details how childbirth usually takes place in a corner
of the family house, normally close to the kitchen As is common in many South-east Asian cultures, the Thai place significant emphasis on women remaining warm or
‘cooking’ both during and following delivery, to restore equilibrium During the final stages of labour the pregnant woman kneels on the floor, both heels supporting her
anus, while she holds onto a long, home-woven scarf (locally known as a pieu),
suspended over a beam in the home Her husband physically supports her as she delivers, and she is also often attended by a traditional midwife and other family members or neighbours (Dai and Hinh 2006)
Childbirth amongst the Thai in Dien Bien
field study findings Thai FGD participants of all ages described traditional home delivery according to the process outlined above The communal nature of the enterprise was described:
the delivering woman is held from behind as she holds the pieu, while another
individual sits in front to help with the emerging newborn Participants emphasised
the importance of the kneeling position, the aid provided by the pieu and the support
of their husband in assisting them through the latter stages of labour As one 50-year-old woman described:
We have more power when we hold the suspended cloth and squat and push The cloth swings from side to side and helps us to push more strongly
A 49-year-old participant detailed:
When we deliver, we press our heels into our anus, then we have more power to push the baby out our husbands support us from behind
The importance of delivering close to a fire and keeping warm during and following delivery was also emphasised:
We give birth close to the kitchen and afterwards we go into the kitchen to warm up
we need to stay warm after delivering
A number of FGD participants suggested a historical trajectory, whereby formerly, women delivered at home due to lack of services In the words of one 70-year-old woman:
We give birth in the kneeling position But when we go to the clinic we have to lie down In the past, there was no CHC so we had to give birth at home, now we have the CHC so we go there to deliver
Trang 9This statement can be interpreted as a public statement of knowing compliance with state desires (namely available services are attended if possible) As will be detailed below, interview findings challenge this representation, and it may be an important reminder of how problematic it is for minority women to criticise state services Other FGD participants distinguished delivery behaviour, however, depending on whether a labour was difficult or easy ‘If the labour is easy, it is still better to deliver
at home’ commented one woman, while another observed ‘we only go to the CHC when we are having a difficult labour’ Some negative observations were made about the fact that husbands are not allowed to attend facility deliveries ‘It is just better if the husband is inside the room’, commented one 22-year-old participant
Choice of delivery setting
Interview findings confirmed the continuing importance of home birth The majority
of interviewees (78/87; almost 90%) reported the family house as the location for their most recent delivery Similar to the Hmong, a certain selectivity in the use of services was identified; overall, just over half (50/87; 57.5%) of Thai study respondents attended ANC at least once during their most recent pregnancy Yet,
of those who reported attending ANC during their last pregnancy, almost all (43/50; 86%) delivered at home
While the majority of Thai interviewees reported being involved in the decision of where to deliver, some described how family discussions were held before a final decision was taken In some instances the discussion included not only the expectant couple but parents and parents-in-law, highlighting the importance of elder advice and how decision-making is rarely an individual matter The most commonly reported scenario was a discussion between a couple, as described by one respondent:
I discussed things with my husband and we decided that if the delivery was easy I would deliver at home If the labour was difficult, I would go to the CHC
Many interviewees presented home birth as a logical choice within their community, frequently providing the explanation ‘many women deliver at home’, a statement which reflects both the influence of the wider community and the deemed suitability of home birthing to women’s needs, at least in the case of non-problematic labour Local health facilities are used for emergency cases The few Thai interviewees who delivered at a facility attributed this to their labour being difficult or (less commonly) because they felt safer Yet local perspectives concerning health services were not uniform; several women who had delivered at home described their fear of giving birth at a facility One interviewee highlighted the absence of a regular electricity supply at the local CHC as a deterrent to attendance As already noted, the Thai place considerable importance on women staying warm during and following delivery, a scenario more easily afforded at home than in under-resourced local facilities
Role of husband in delivery
The vast majority of respondents whose most recent delivery was at home not only reported that female relatives were present during the birth (69/78; 88.5% in most
Trang 10cases at least two other women), but that their husband also attended the delivery (61/78; 78%) A number of interviewees reported that their home birth was attended
by a traditional practitioner (23/78; 29.5%), but this was not the dominant scenario Few of the many home deliveries reported were attended by health staff (3/78; 3.8%)
The fact that husbands are not allowed to attend facility births caused concern, and even distress, to a number of interviewees who had experienced this prohibition
Of those women whose most recent delivery had taken place at a health post, most reported that they and/or their husband had directly requested for him to be present
at the delivery, but this was refused One 25-year-old respondent recounted her experience:
My husband asked to stay but the health staff didn’t agree He stayed with me a while then they scolded him and told him to go out I was sad and cried
Not every case was presented so negatively A 44-year-old interviewee’s description of her experience highlights the variability of local engagement with health services:
The health staff told my husband to go out, so he didn’t stay I wanted him to be there
so I felt sad and afraid However, I trusted the health staff
Discussion and conclusions
Current data concerning maternal health utilisation by the many varied minority ethnic groups in Vietnam are limited The secondary and primary data reported in this paper provide new insight into Hmong and Thai childbirth practices and current engagement with maternal health services As government health facilities (particu-larly the CHC) were situated relatively close to the communities included in the field study, conventionally cited barriers such as geographical remoteness do not adequately explain low service attendance
The study identified an informed preference and selectivity in behaviour related
to maternity Despite some use of ANC services, overall attendance at health services for delivery was low Home birth without the presence of health staff was the dominant scenario Facility delivery was reported largely on occasions of proble-matic labours (some of which may have been emergency cases) or by those who felt a facility birth offered greater hygiene and safety than home birth These findings confirm existing knowledge regarding women’s responses to services being based on pragmatic calculations as to how these services might enhance their lives (Lock and Kaufert 1998) Field study findings challenge present notions of the less ‘engaged’ Hmong and ‘more assimilated’ Thai, highlighting the need for more comprehensive data collection across minority ethnic groups in Vietnam in order to deepen current understanding of maternal health-seeking behaviour
Current presentation of ‘traditional customs’ as a specific obstacle to maternal service utilisation not only implicitly places the onus on minority women to change behaviour and engage more comprehensively with services, but simultaneously inhibits examination by policy-makers and practitioners of the cultural divide between existing health services and local practices, and the ways in which service provision may be failing to meet the needs and preferences of minority women Both