144
BIRTH 19:3 September 1992
Hmong Women: Characteristics and Birth Outcomes, 1990 Helen Stewart Faller, RN, BSN, EdD ABSTRACT: Current demographic characteristics and pregnancy outcomes of immigrant Hmong women in a small town in southeastern United States were documented in a retrospective study. Interviews and review of existing records were used to determine prenatal practices and perceived problems. Sixteen health professionals and two women from the community were interviewed, and the labor and delivery records from 1985 to 1990 were reviewed for parity, child spacing, and health status of the women and newborns. The greatest concerns voiced by health caregivers were multiparity and the need for contraceptive compliance. Seventy-eight full-term infants were born to 64 women in five years, with 2 stillbirths. No eclampsia, diabetes, or R h incompatibilities were noted. Evidence is limited that birth frequency or outcome for Hmong women is a problem. Their perinatal difficulties were thought to be sociocultural rather than medical. Further study of the effects of acculturation on maternal family position, perinatal risks, and birth outcomes is imperative as lifestyle and environment change for these immigrant women. (BIRTH 19;3, September 1992)
For more than a decade, Hmong women who came to the United States after the Vietnam conflict continued their practice of self-care during pregnancy, making limited use of prenatal health care resources (1-4). Their entry into the health care system late in pregnancy or not at all is similar to that of other immigrant groups (5-8). However, the positive outcome of their pregnancies, good health practices (9), and absence of common prenatal health risks are unique (1). Only more recent studies (4,9) cite occurrence of preeclampsia and diabetes, conditions previously not reported in Hmong women. The community in this study, located in a southeastern rural, mountainous area in the United States, is somewhat reminiscent of the homeland in the hills above Laos, and is where a few Hmong families have lived since their immigration in the mid-1970s. However, as part of employment incentive grants, most of the nearly 100 families were relocated more recently from other parts of the country. Most are young adult families with chil-
dren from birth through adolescence, with approximately 50 to 60 women of childbearing age; only a few are elderly. Local leadership and support are provided through the Hmong Natural Association. Although the people tend to be mobile, they remain in closely knit kinship groups, clustered in an area west of the nearest town where health care facilities are available. Both men and women are employed in the mills and factories, and although many jobs are low paying, insurance and health benefits are frequently provided. Reports on the health needs of Hmong women have been in general agreement; however, the findings are 5 to 15 years old. Therefore, this study focused on the current perinatal health needs of women in this community during the spring of 1990. The purpose was to document demographic characteristics and pregnancy outcomes of childbearing women by using existing records and organizational resources, as well as assessing the perceptions of various professionals responsible for health and social services to these families.
Helen Stewart Fafler is an Associate Professor in the School of Nursing, University of North Carolina at Wilmington, North Carolina. She has studied the perinatal health of Hmong women since 1976. This study was funded in part by the University of Carolina at Wilmington School of Nursing research fund.
Methods
Initial contacts were made with the president of the Hmong Natural Association and the nursing direc-
145
BIRTH 19:3 September 1992
tor of the local health department. Through them was established a network of 16 professionals who had significant contact with childbearing Hmong women, and 2 women from the community. General descriptive data were obtained by interviews conducted by the nurse who worked primarily with Hmong women at the health department. Objective data were obtained from the labor and delivery records at the community hospital. Clan names that were most common in the area according to the Hmong Natural Association were used to identify women who had given birth during the period of study (July 1985-June 1990). The professionals worked at the health department maternity and pediatric clinics, a local hospital with maternity services, junior high and high schools attended by Hmong children, and the community college. The group consisted of seven nurses, three physicians, two social workers, a nutritionist with the Women, Infants, and Children (WIC) program, a teacher, and two school counselors. In interviews with these individuals the names of two women from the community surfaced as persons who could provide valuable information regarding attitudes and beliefs of the Hmong. Interviews were conducted with both women, one of whom had been in the United States since age 5 years and spoke English fluently. The second, a Western woman from the area, had done volunteer work for eight years with Hmong families and was called on frequently by them to provide transportation to the prenatal clinic or to the hospital at the time of delivery. The interviews, carried out by the author, were semistructured with postinterview notes. With the exception of the counselors who were contacted by telephone, all interviews were face to face. The health care professionals were interviewed in their workplace, the teacher and Hmong woman in a restaurant, and the volunteer woman in her home. Each interview began with a personal introduction and statement of expressed interest in developing programs for Hmong women in the community. The purposes of the interviews were to gather data on potential risk factors, and to determine professional perceptions of the problems associated with pregnancy for Hmong women. The following questions were asked: What prenatal resources are available for Hmong women? 2. Are there problems with access to prenatal care? 3. When do Hmong women begin prenatal care? 4. Do they continue care after initial entry? 1.
5. What risk factors do they present? 6. What problems occur most frequently? 7. If an intervention were to be planned for these women, what is the area of greatest need? Results
Health care services and access for childbearing women in this community were described as positive. Prenatal care is provided by local private physicians for private patients and those who attend the health department clinic. Women give birth at the local community hospital, which has 210 beds and an average of 700 births per year. One mother who experienced difficulties early in her pregnancy was referred to a large university medical center about 100 miles away. At the local health department, nursing, nutrition, and social services are readily available and used by Hmong women. The community provides motivation, transportation, and interpretive services as necessary. Hmong Natural Association leaders were somewhat ambivalent about the relationship of the nurses to the Hmong women. Initially, they reported that the nurses did not like the women, and later recounted that the nurses took good care of the women and denied the existence of any problems for childbearing families. Perceptions of Health Caregivers All health caregivers expressed acceptance of and concern for the Hmong people, and believed that part of their role was to assist with the process of acculturation. Cultural family practices mentioned by many interviewees, both positive and negative, were associated with pregnancy outcome. From the positive perspective, the women tend to enter the health care system at five months, the point at which they define pregnancy, and continue prenatal visits regularly thereafter. After childbirth they return to the physicians for one postpartum visit and to the health department for WIC assistance, child health care, and immunizations, There were no reports of alcohol, drug, or tobacco use by Hmong women. From the negative perspective, the practice of arranged marriages for very young women (age 9-13) has a potential for early adolescent pregnancy with associated health risks and interference with education. In addition, some health caregivers believe that families lack concern for the immediate postpartum needs of women and expect them to return to work prematurely. Although the women
146
BIRTH 19:3 September 1992
reportedly do not use alcohol, drugs, or tobacco, one physician expressed grave concern for the excessive alcohol consumption by the men that often led to abuse of the women. Many Hmong women are employed, but they are not necessarily in settings where they learn English. In the health care setting, instructional material written in English or Hmong is not useful to those who cannot read in either language. Both nurses and physicians observed two problems encountered by Hmong women that concerned contraception and nutrition. “They have a baby every year” was a resounding theme. “They refuse to take the pill, but are willing to have an abortion,” was also heard. Infant formula, which the women find desirable, was readily available through WIC and linked to immunization responsibility. Nutrition problems were not clearly defined; however, Western peer influence for young people in school, knowledge of nutritional options in the supermarket, and food preparation seemed to be challenges. Programs developed by the home economist were scheduled, but only the men attended. Some health professionals believed that the men wanted to screen instructions that their wives were to receive, whereas others thought that the actual desire was for someone to come into their homes to do the housework and prepare the meals. In summary, the expressed belief of the health care providers was that, with the exception of birth rate and child spacing, perinatal health care for Hmong women was not the issue; rather, the problems were sociocultural. Perceptions of Two Women
The Hmong woman and the volunteer agreed that health care for Hmong women is available and accessible, even though language deficits make many women dependent on their husbands and children. The Hmong Natural Association supports and promotes Western health care by providing transportation and interpretive services. The contraceptive issue generated a mixed response. “Our children are our wealth,” was an initial response, followed by, “but in United States, children cost so much.” The women like to avoid pregnancy, but the contraceptive pills make them feel pregnant; they get “fat” and “sick at their stomach.” Some use condoms, and others have heard about medical abortions or know of herbs that end pregnancy. Although families agree to send young children to school, teen marriages are supported. Unwed pregnancy is considered to be a disgrace to the fam-
ily, and the unmarried pregnant woman may be put out of her home. The Hmong woman stated that her family wants her to marry and have children, but she has chosen to finish her education first. This interaction presented the author with a vivid contrast between the timid, nearly withdrawn Hmong women whom she interviewed with a translator in 1980, and this poised young woman whose verbal and body language expressed assertiveness. The volunteer expressed grave concern for the number of very young Hmong women who are taken out of school so that arranged marriages can take place. In addition, she believes that health caregivers have to clarify the purpose of prenatal tests that we take for granted, such as collection of blood and urine specimens. Since the Hmong people have cultural rites in which both blood and urine are ingested, the women have questioned this practice at the clinic, since they do not understand the reasons for it. Pregnancy Outcomes
The women give birth at the local hospital without medical complications; no eclampsia, diabetes, or Rh incompatibilities were reported. To validate the number of births, frequency, and risk factors, the hospital labor and delivery records for five years were reviewed (July 1985-June 1990). The number of Hmong births doubled in 1989 (Table 1); however, the increase coincided with the economic incentives grant, which more than doubled the community. In the five-year period there were 78 births, as identified by the unique spelling of Hmong family names on labor and delivery records; 76 were live births and 2 were stillbirths. The only preterm delivery was associated with fetal death, and the remaining birthweights were comparable with fullterm newborns. Sixty-four women delivered the 76 live infants: 53 had single births, 10 had 2 each, and only 1 had 3 births in the five years. Thirty-five Table 1. Total Deliveries and Hmong Deliveries at a Local Hospital ~
~
Year
Total Deliveries
1985 1986 1987 1988 1989 1990
727 692 707 724 787
* Figuresfor six months of the year.
~~
~
Hmong Deliveries 5*
13 13 12 23 12”
147
BIRTH 19:3 September 1992
(45%) of these births were to women who had experienced one to three pregnancies, and 22 (25%) had more than six. Given the “baby-every-year’’ response of many of the health professionals, the findings were unexpected. These data were taken to the health department nurses, who, although surprised by them, confirmed with their records that the frequency of deliveries for individual women had not been as high as the nurses had thought.
Discussion Prenatal services are available and accessible to these Hmong women, and a positive working relationship appears to exist between health caregivers and the community. The women enter the health care system during their second trimester, with subsequent visits scheduled through the puerperium. Although they do not ask for medical guidance for conception or confirmation of pregnancy, they seem to comply with current U.S. Public Health Service recommendations (10). Their self-care practices are effective for healthy pregnancies, and the outcome of their pregnancies is good. They have not experienced symptoms of hypertension, diabetes, or Rh incompatibility. The babies are delivered in the hospital at term, with birthweights comparable with those of other healthy newborns. If their continued resistance to use of oral medications such as vitamins, iron, and contraceptive pills is a true problem, perhaps their actual need for these agents should be investigated. Vitamins and iron are not widely prescribed outside the United States, and pregnancylike side effects of oral contraceptives may indicate the need to consider reduced dosages for Hmong women, who tend to be of smaller stature than many other American women. Further investigation of cultural beliefs regarding the age for childbearing and the use of abortion and herbs could shed light on adolescent pregnancy and pregnancy spacing. Evidence is limited that medical problems exist for these childbearing women. However, practices involving individual and family function, including illiteracy, may threaten women’s position. The young Hmong woman who was interviewed, obviously a sample of one, clearly demonstrated knowledge of language and customs to which these immigrants are exposed. However, the professionals and the community volunteer suggested that women who have not learned the language or the customs may lose respect and position within the family. We found no evidence that birth outcome or frequency is a problem in this community; however,
the position of women in the family may be changing. As acculturation progresses, the potential for early adolescent pregnancy and exposure to abusive behaviors such as smoking and drug use may lead to pregnancy risks. Although 25 percent of the women studied were grand multipara who may have been nearing the end of their reproductive cycle, thus explaining the single births, nearly one-half were experiencing their first, second, or third pregnancy during the five-year study period. These people are clearly doing something to space children, and further investigation would be useful. Since outcomes of this rural study may not be generalizable to urban sites of relocation, additional study of Hmong women in this and other communities is advised. Questions that should be addressed are the potential for risks to family roles and function, and to pregnancy. Eclampsia, diabetes, and Rh incompatibility may become issues as environmental and lifestyle changes affect Hmong women. These observations and conclusions have been made by persons whose culture differs from that of the Hmong people. They are therefore based on clinical expectations that may be clouded by unintentional bias. It is, however, gratifying to observe the childbearing successes of these women in the United States in 1990. The findings allay personal concerns that arose some 15 years ago that the Hmong would become a part of the underserved immigrant population with accompanying high levels of infant mortality. Could the attempts of the health caregivers to provide culturally sensitive care in part be successful, in addition to the selfcare practices of Hmong women? In fact, perhaps the answer to prenatal health for all women is the combination of self-care supported by culturally sensitive health caregivers. References 1. Faller H. Perinatal needs of immigrant Hmong women: Surveys of women and health care providers. Public Health Rep 1985;100:340-343. 2. Hopkins D, Clarke N. Indochinese refugee fertility rates and pregnancy risk factors, Oregon. A m J Public Health 1983;73:1307-1309. 3. Swenson D, Erickson D, Ehlinger E, Swaney S, Carlson G. Birthweight, Apgar scores, labor and delivery complications and prenatal characteristics of southeast Asian adolescent and older mothers. Adolescents 1986;21:711-721. 4. Edwards L, Rautio B, Hakanson E. Pregnancy in Hmong refugee women. Minn Med 1987;70;633-637. 5 . Harris K. Beliefs and practices among Haitian-American women in relation to childbearing. J Nurse Midwif 1987;32: 149-155. 6. Ragucci A. Italian-Americans. In: Harwood A, ed. Ethnicity and Medical Care. Cambridge: Harvard University Press, 1981:211-263.
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7. Ailinger R. A study of illness referral in a Spanish-speaking community. Nurs Res 1971 ;26:53-56. 8. Meleis A , Sorrel1 L. Arab-American women and their birth experience. Maternal Child Nurs 1981;6:171-176. 9. Richman D, Dixon S. Comparative study of Cambodian,
Hmong, and Caucasian infant and maternal perinatal profiles. J Nurse Midwif 1985;30:313-331. 10. Caring for Our Future: The Content of Prenatal Care. Washington, DC: U.S. Public Health Service, Department of Health and Human Services, 1989.
Commentary: Cultural Dimensions of Hmong Birth Russell A. ]udkins, PhD, and Ann €3. ludkins, C N W N P , M A [Tlhe sense of superiority and moral requiredness that is built into every functioning system keeps its practitioners specifically uninformed about alternate ways of doing birth . . . the extraordinary extent to which practitioners buy into their own system’s moral and technical superiority. . . (I).
These insights offer a familiar and timely reminder of the anthropologic truth that ethnocentrism is insidious, especially in dominant cultures and for those holding powerful positions within those cultures, which certainly includes Western health care providers at all levels. Sophisticated clinicians, however, cannot afford the misperceptions and lack of effectiveness generated by ethnocentrism. Crosscultural understanding and insight enrich care, not only for the minority patient but ultimately for all. In working with people who participate in their own integrated cultural system, such as the Hmong, it is imperative to use the methods and perspectives of established cross-cultural research, including ethnography. When this is not done, it will be impossible to achieve even accurate description, let alone significant understanding, except as an outsider. The Hmong, also known anthropologically as Miao, have been ethnically distinct since pre-Han times in China. Their cultural traditions for centuries have been significantly tuned to allow their adaptation and survival, even, in fact, their growth and colonization of new regions. This has occurred throughout a long history in which the Hmong have been subject to and often oppressed by much larger, politically powerful societies. Yet they have survived and expanded, carrying on an intact cultural life spread over wide areas, in small communities of 50 to 250 people (seldom over a few hundred at the
Russell Judkins is Associate Professor and Chairperson, Department of Anthropology, SUNY College at Geneseo, Geneseo, New York. Ann Judkins is Director of the Prenatal Care Program, Wyoming County Community Hospital, Warsaw, New York, and Adjunct, University of Rochester, School of Nursing, Rochester, New York.
most), among the Chinese, Vietnamese, Laotians, Burmese, and Thai, and now among Westerners. Wherever they live, the Hmong distinguish themselves by their adaptability and organizational gifts, their independence and love of freedom, and by their highly effective collective, corporate strategies for retaining their cultural identity (2). Hmong have brought to America their culture, social, and community organization, as well as values and world view. It is most important to realize that in their case one deals with a whole and integrated culture and its attendant social organization. They are not “fragments” of some former or “primitive” entity, but they live in the same culture-bearing, small-scale, formally organized community units of cultural life that they have always generated, whether in China, southeast Asia, or the United States. Because to Westerners they are different, are “refugees,” and are often “indigent” (examples of subtle labeling by professionals and agencies with stereotyping implications), the tendency is to make assumptions about the Hmong that are untrue and counterproductive in terms of offering health care. These unexamined and subtle assumptions, coupled with unrecognized ethnocentrism, may even keep people from making accurate assumptions, as they certainly did the health department nurses cited in the article. Not only were their perceptions of Hmong women’s birth rates erroneous, one also strongly suspects that these nurses subtly and effectively conveyed their nonacceptance to the women themselves. Although they may have indeed given good care in some limited, formal senses, there can be little doubt that the observation of local Hmong leaders that “the nurses did not like Hmong women” is a plain and innocent statement of the truth. In all likelihood it is, in fact, Hmong culture, or what they incorrectly think it is, that disturbs these nurses. This type of ethnocentrism reassures health care professionals of the goodness and correctness of their own culture in the face of
BIRTH 19:3 September 1992
Hmong Women: Characteristics and Birth Outcomes, 1990 Helen Stewart Faller, RN, BSN, EdD ABSTRACT: Current demographic characteristics and pregnancy outcomes of immigrant Hmong women in a small town in southeastern United States were documented in a retrospective study. Interviews and review of existing records were used to determine prenatal practices and perceived problems. Sixteen health professionals and two women from the community were interviewed, and the labor and delivery records from 1985 to 1990 were reviewed for parity, child spacing, and health status of the women and newborns. The greatest concerns voiced by health caregivers were multiparity and the need for contraceptive compliance. Seventy-eight full-term infants were born to 64 women in five years, with 2 stillbirths. No eclampsia, diabetes, or R h incompatibilities were noted. Evidence is limited that birth frequency or outcome for Hmong women is a problem. Their perinatal difficulties were thought to be sociocultural rather than medical. Further study of the effects of acculturation on maternal family position, perinatal risks, and birth outcomes is imperative as lifestyle and environment change for these immigrant women. (BIRTH 19;3, September 1992)
For more than a decade, Hmong women who came to the United States after the Vietnam conflict continued their practice of self-care during pregnancy, making limited use of prenatal health care resources (1-4). Their entry into the health care system late in pregnancy or not at all is similar to that of other immigrant groups (5-8). However, the positive outcome of their pregnancies, good health practices (9), and absence of common prenatal health risks are unique (1). Only more recent studies (4,9) cite occurrence of preeclampsia and diabetes, conditions previously not reported in Hmong women. The community in this study, located in a southeastern rural, mountainous area in the United States, is somewhat reminiscent of the homeland in the hills above Laos, and is where a few Hmong families have lived since their immigration in the mid-1970s. However, as part of employment incentive grants, most of the nearly 100 families were relocated more recently from other parts of the country. Most are young adult families with chil-
dren from birth through adolescence, with approximately 50 to 60 women of childbearing age; only a few are elderly. Local leadership and support are provided through the Hmong Natural Association. Although the people tend to be mobile, they remain in closely knit kinship groups, clustered in an area west of the nearest town where health care facilities are available. Both men and women are employed in the mills and factories, and although many jobs are low paying, insurance and health benefits are frequently provided. Reports on the health needs of Hmong women have been in general agreement; however, the findings are 5 to 15 years old. Therefore, this study focused on the current perinatal health needs of women in this community during the spring of 1990. The purpose was to document demographic characteristics and pregnancy outcomes of childbearing women by using existing records and organizational resources, as well as assessing the perceptions of various professionals responsible for health and social services to these families.
Helen Stewart Fafler is an Associate Professor in the School of Nursing, University of North Carolina at Wilmington, North Carolina. She has studied the perinatal health of Hmong women since 1976. This study was funded in part by the University of Carolina at Wilmington School of Nursing research fund.
Methods
Initial contacts were made with the president of the Hmong Natural Association and the nursing direc-
145
BIRTH 19:3 September 1992
tor of the local health department. Through them was established a network of 16 professionals who had significant contact with childbearing Hmong women, and 2 women from the community. General descriptive data were obtained by interviews conducted by the nurse who worked primarily with Hmong women at the health department. Objective data were obtained from the labor and delivery records at the community hospital. Clan names that were most common in the area according to the Hmong Natural Association were used to identify women who had given birth during the period of study (July 1985-June 1990). The professionals worked at the health department maternity and pediatric clinics, a local hospital with maternity services, junior high and high schools attended by Hmong children, and the community college. The group consisted of seven nurses, three physicians, two social workers, a nutritionist with the Women, Infants, and Children (WIC) program, a teacher, and two school counselors. In interviews with these individuals the names of two women from the community surfaced as persons who could provide valuable information regarding attitudes and beliefs of the Hmong. Interviews were conducted with both women, one of whom had been in the United States since age 5 years and spoke English fluently. The second, a Western woman from the area, had done volunteer work for eight years with Hmong families and was called on frequently by them to provide transportation to the prenatal clinic or to the hospital at the time of delivery. The interviews, carried out by the author, were semistructured with postinterview notes. With the exception of the counselors who were contacted by telephone, all interviews were face to face. The health care professionals were interviewed in their workplace, the teacher and Hmong woman in a restaurant, and the volunteer woman in her home. Each interview began with a personal introduction and statement of expressed interest in developing programs for Hmong women in the community. The purposes of the interviews were to gather data on potential risk factors, and to determine professional perceptions of the problems associated with pregnancy for Hmong women. The following questions were asked: What prenatal resources are available for Hmong women? 2. Are there problems with access to prenatal care? 3. When do Hmong women begin prenatal care? 4. Do they continue care after initial entry? 1.
5. What risk factors do they present? 6. What problems occur most frequently? 7. If an intervention were to be planned for these women, what is the area of greatest need? Results
Health care services and access for childbearing women in this community were described as positive. Prenatal care is provided by local private physicians for private patients and those who attend the health department clinic. Women give birth at the local community hospital, which has 210 beds and an average of 700 births per year. One mother who experienced difficulties early in her pregnancy was referred to a large university medical center about 100 miles away. At the local health department, nursing, nutrition, and social services are readily available and used by Hmong women. The community provides motivation, transportation, and interpretive services as necessary. Hmong Natural Association leaders were somewhat ambivalent about the relationship of the nurses to the Hmong women. Initially, they reported that the nurses did not like the women, and later recounted that the nurses took good care of the women and denied the existence of any problems for childbearing families. Perceptions of Health Caregivers All health caregivers expressed acceptance of and concern for the Hmong people, and believed that part of their role was to assist with the process of acculturation. Cultural family practices mentioned by many interviewees, both positive and negative, were associated with pregnancy outcome. From the positive perspective, the women tend to enter the health care system at five months, the point at which they define pregnancy, and continue prenatal visits regularly thereafter. After childbirth they return to the physicians for one postpartum visit and to the health department for WIC assistance, child health care, and immunizations, There were no reports of alcohol, drug, or tobacco use by Hmong women. From the negative perspective, the practice of arranged marriages for very young women (age 9-13) has a potential for early adolescent pregnancy with associated health risks and interference with education. In addition, some health caregivers believe that families lack concern for the immediate postpartum needs of women and expect them to return to work prematurely. Although the women
146
BIRTH 19:3 September 1992
reportedly do not use alcohol, drugs, or tobacco, one physician expressed grave concern for the excessive alcohol consumption by the men that often led to abuse of the women. Many Hmong women are employed, but they are not necessarily in settings where they learn English. In the health care setting, instructional material written in English or Hmong is not useful to those who cannot read in either language. Both nurses and physicians observed two problems encountered by Hmong women that concerned contraception and nutrition. “They have a baby every year” was a resounding theme. “They refuse to take the pill, but are willing to have an abortion,” was also heard. Infant formula, which the women find desirable, was readily available through WIC and linked to immunization responsibility. Nutrition problems were not clearly defined; however, Western peer influence for young people in school, knowledge of nutritional options in the supermarket, and food preparation seemed to be challenges. Programs developed by the home economist were scheduled, but only the men attended. Some health professionals believed that the men wanted to screen instructions that their wives were to receive, whereas others thought that the actual desire was for someone to come into their homes to do the housework and prepare the meals. In summary, the expressed belief of the health care providers was that, with the exception of birth rate and child spacing, perinatal health care for Hmong women was not the issue; rather, the problems were sociocultural. Perceptions of Two Women
The Hmong woman and the volunteer agreed that health care for Hmong women is available and accessible, even though language deficits make many women dependent on their husbands and children. The Hmong Natural Association supports and promotes Western health care by providing transportation and interpretive services. The contraceptive issue generated a mixed response. “Our children are our wealth,” was an initial response, followed by, “but in United States, children cost so much.” The women like to avoid pregnancy, but the contraceptive pills make them feel pregnant; they get “fat” and “sick at their stomach.” Some use condoms, and others have heard about medical abortions or know of herbs that end pregnancy. Although families agree to send young children to school, teen marriages are supported. Unwed pregnancy is considered to be a disgrace to the fam-
ily, and the unmarried pregnant woman may be put out of her home. The Hmong woman stated that her family wants her to marry and have children, but she has chosen to finish her education first. This interaction presented the author with a vivid contrast between the timid, nearly withdrawn Hmong women whom she interviewed with a translator in 1980, and this poised young woman whose verbal and body language expressed assertiveness. The volunteer expressed grave concern for the number of very young Hmong women who are taken out of school so that arranged marriages can take place. In addition, she believes that health caregivers have to clarify the purpose of prenatal tests that we take for granted, such as collection of blood and urine specimens. Since the Hmong people have cultural rites in which both blood and urine are ingested, the women have questioned this practice at the clinic, since they do not understand the reasons for it. Pregnancy Outcomes
The women give birth at the local hospital without medical complications; no eclampsia, diabetes, or Rh incompatibilities were reported. To validate the number of births, frequency, and risk factors, the hospital labor and delivery records for five years were reviewed (July 1985-June 1990). The number of Hmong births doubled in 1989 (Table 1); however, the increase coincided with the economic incentives grant, which more than doubled the community. In the five-year period there were 78 births, as identified by the unique spelling of Hmong family names on labor and delivery records; 76 were live births and 2 were stillbirths. The only preterm delivery was associated with fetal death, and the remaining birthweights were comparable with fullterm newborns. Sixty-four women delivered the 76 live infants: 53 had single births, 10 had 2 each, and only 1 had 3 births in the five years. Thirty-five Table 1. Total Deliveries and Hmong Deliveries at a Local Hospital ~
~
Year
Total Deliveries
1985 1986 1987 1988 1989 1990
727 692 707 724 787
* Figuresfor six months of the year.
~~
~
Hmong Deliveries 5*
13 13 12 23 12”
147
BIRTH 19:3 September 1992
(45%) of these births were to women who had experienced one to three pregnancies, and 22 (25%) had more than six. Given the “baby-every-year’’ response of many of the health professionals, the findings were unexpected. These data were taken to the health department nurses, who, although surprised by them, confirmed with their records that the frequency of deliveries for individual women had not been as high as the nurses had thought.
Discussion Prenatal services are available and accessible to these Hmong women, and a positive working relationship appears to exist between health caregivers and the community. The women enter the health care system during their second trimester, with subsequent visits scheduled through the puerperium. Although they do not ask for medical guidance for conception or confirmation of pregnancy, they seem to comply with current U.S. Public Health Service recommendations (10). Their self-care practices are effective for healthy pregnancies, and the outcome of their pregnancies is good. They have not experienced symptoms of hypertension, diabetes, or Rh incompatibility. The babies are delivered in the hospital at term, with birthweights comparable with those of other healthy newborns. If their continued resistance to use of oral medications such as vitamins, iron, and contraceptive pills is a true problem, perhaps their actual need for these agents should be investigated. Vitamins and iron are not widely prescribed outside the United States, and pregnancylike side effects of oral contraceptives may indicate the need to consider reduced dosages for Hmong women, who tend to be of smaller stature than many other American women. Further investigation of cultural beliefs regarding the age for childbearing and the use of abortion and herbs could shed light on adolescent pregnancy and pregnancy spacing. Evidence is limited that medical problems exist for these childbearing women. However, practices involving individual and family function, including illiteracy, may threaten women’s position. The young Hmong woman who was interviewed, obviously a sample of one, clearly demonstrated knowledge of language and customs to which these immigrants are exposed. However, the professionals and the community volunteer suggested that women who have not learned the language or the customs may lose respect and position within the family. We found no evidence that birth outcome or frequency is a problem in this community; however,
the position of women in the family may be changing. As acculturation progresses, the potential for early adolescent pregnancy and exposure to abusive behaviors such as smoking and drug use may lead to pregnancy risks. Although 25 percent of the women studied were grand multipara who may have been nearing the end of their reproductive cycle, thus explaining the single births, nearly one-half were experiencing their first, second, or third pregnancy during the five-year study period. These people are clearly doing something to space children, and further investigation would be useful. Since outcomes of this rural study may not be generalizable to urban sites of relocation, additional study of Hmong women in this and other communities is advised. Questions that should be addressed are the potential for risks to family roles and function, and to pregnancy. Eclampsia, diabetes, and Rh incompatibility may become issues as environmental and lifestyle changes affect Hmong women. These observations and conclusions have been made by persons whose culture differs from that of the Hmong people. They are therefore based on clinical expectations that may be clouded by unintentional bias. It is, however, gratifying to observe the childbearing successes of these women in the United States in 1990. The findings allay personal concerns that arose some 15 years ago that the Hmong would become a part of the underserved immigrant population with accompanying high levels of infant mortality. Could the attempts of the health caregivers to provide culturally sensitive care in part be successful, in addition to the selfcare practices of Hmong women? In fact, perhaps the answer to prenatal health for all women is the combination of self-care supported by culturally sensitive health caregivers. References 1. Faller H. Perinatal needs of immigrant Hmong women: Surveys of women and health care providers. Public Health Rep 1985;100:340-343. 2. Hopkins D, Clarke N. Indochinese refugee fertility rates and pregnancy risk factors, Oregon. A m J Public Health 1983;73:1307-1309. 3. Swenson D, Erickson D, Ehlinger E, Swaney S, Carlson G. Birthweight, Apgar scores, labor and delivery complications and prenatal characteristics of southeast Asian adolescent and older mothers. Adolescents 1986;21:711-721. 4. Edwards L, Rautio B, Hakanson E. Pregnancy in Hmong refugee women. Minn Med 1987;70;633-637. 5 . Harris K. Beliefs and practices among Haitian-American women in relation to childbearing. J Nurse Midwif 1987;32: 149-155. 6. Ragucci A. Italian-Americans. In: Harwood A, ed. Ethnicity and Medical Care. Cambridge: Harvard University Press, 1981:211-263.
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7. Ailinger R. A study of illness referral in a Spanish-speaking community. Nurs Res 1971 ;26:53-56. 8. Meleis A , Sorrel1 L. Arab-American women and their birth experience. Maternal Child Nurs 1981;6:171-176. 9. Richman D, Dixon S. Comparative study of Cambodian,
Hmong, and Caucasian infant and maternal perinatal profiles. J Nurse Midwif 1985;30:313-331. 10. Caring for Our Future: The Content of Prenatal Care. Washington, DC: U.S. Public Health Service, Department of Health and Human Services, 1989.
Commentary: Cultural Dimensions of Hmong Birth Russell A. ]udkins, PhD, and Ann €3. ludkins, C N W N P , M A [Tlhe sense of superiority and moral requiredness that is built into every functioning system keeps its practitioners specifically uninformed about alternate ways of doing birth . . . the extraordinary extent to which practitioners buy into their own system’s moral and technical superiority. . . (I).
These insights offer a familiar and timely reminder of the anthropologic truth that ethnocentrism is insidious, especially in dominant cultures and for those holding powerful positions within those cultures, which certainly includes Western health care providers at all levels. Sophisticated clinicians, however, cannot afford the misperceptions and lack of effectiveness generated by ethnocentrism. Crosscultural understanding and insight enrich care, not only for the minority patient but ultimately for all. In working with people who participate in their own integrated cultural system, such as the Hmong, it is imperative to use the methods and perspectives of established cross-cultural research, including ethnography. When this is not done, it will be impossible to achieve even accurate description, let alone significant understanding, except as an outsider. The Hmong, also known anthropologically as Miao, have been ethnically distinct since pre-Han times in China. Their cultural traditions for centuries have been significantly tuned to allow their adaptation and survival, even, in fact, their growth and colonization of new regions. This has occurred throughout a long history in which the Hmong have been subject to and often oppressed by much larger, politically powerful societies. Yet they have survived and expanded, carrying on an intact cultural life spread over wide areas, in small communities of 50 to 250 people (seldom over a few hundred at the
Russell Judkins is Associate Professor and Chairperson, Department of Anthropology, SUNY College at Geneseo, Geneseo, New York. Ann Judkins is Director of the Prenatal Care Program, Wyoming County Community Hospital, Warsaw, New York, and Adjunct, University of Rochester, School of Nursing, Rochester, New York.
most), among the Chinese, Vietnamese, Laotians, Burmese, and Thai, and now among Westerners. Wherever they live, the Hmong distinguish themselves by their adaptability and organizational gifts, their independence and love of freedom, and by their highly effective collective, corporate strategies for retaining their cultural identity (2). Hmong have brought to America their culture, social, and community organization, as well as values and world view. It is most important to realize that in their case one deals with a whole and integrated culture and its attendant social organization. They are not “fragments” of some former or “primitive” entity, but they live in the same culture-bearing, small-scale, formally organized community units of cultural life that they have always generated, whether in China, southeast Asia, or the United States. Because to Westerners they are different, are “refugees,” and are often “indigent” (examples of subtle labeling by professionals and agencies with stereotyping implications), the tendency is to make assumptions about the Hmong that are untrue and counterproductive in terms of offering health care. These unexamined and subtle assumptions, coupled with unrecognized ethnocentrism, may even keep people from making accurate assumptions, as they certainly did the health department nurses cited in the article. Not only were their perceptions of Hmong women’s birth rates erroneous, one also strongly suspects that these nurses subtly and effectively conveyed their nonacceptance to the women themselves. Although they may have indeed given good care in some limited, formal senses, there can be little doubt that the observation of local Hmong leaders that “the nurses did not like Hmong women” is a plain and innocent statement of the truth. In all likelihood it is, in fact, Hmong culture, or what they incorrectly think it is, that disturbs these nurses. This type of ethnocentrism reassures health care professionals of the goodness and correctness of their own culture in the face of
