Crossing the river: Khmer women’s perceptions of pregnancy and postpartum

CROSSING THE RIVER: KHMER WOMEN’S PERCEPTIONS OF PREGNANCY AND POSTPARTUM Patrice M. White,

CNM, MS, DrPH

ABSTRACT In Cambodia, a setting of high maternal mortality, little is known about cultural perceptions of pregnancy. Often, cultural perceptions of what is considered normal or problematic guide a woman’s decision to seek care. In some settings, the difference between the emic, or cultural insider’s perception, and the biomedical perception of what is a serious obstetrical problem may delay lifesaving care. A qualitative study was undertaken to describe an emic perspective of what Khmer women view as normal and view as complications during pregnancy, birth, and postpartum. Focus group and key informant interviews were held to answer the questions: What do Khmer women and their birth attendants view as complications during pregnancy, birth, and postpartum? How are these complications defined? Eighty-eight rural and urban women of childbearing age participated in focus groups in three rural provinces and Phnom Penh. In-depth, semistructured interviews were held with 41 rural and urban women, traditional birth attendants, and trained midwives. Sixty-six hours of taped interviews were transcribed, translated, and analyzed, and descriptions of emic conditions during pregnancy and postpartum were developed. This report details emic categories of antepartum and postpartum conditions identified by these Khmer women. Specific emic categories of normal pregnancy and postpartum are described in detail as well as abnormal emic conditions occurring during the postpartum period. Recommendations are made for use of traditional emic taxonomies as a foundation for explaining biomedical complications and the need for similar studies to guide the development of safe motherhood programs in areas of high maternal mortality. J Midwifery Womens Health 2002;47:239 –246 © 2002 by the American College of Nurse-Midwives. INTRODUCTION

Each year nearly 600,000 women die from conditions related to pregnancy and childbirth (1). The overwhelming majority of these deaths occur in developing countries (2). Recent studies confirm that women in Cambodia have fertility rates among the highest in Southeast Asia and maternal mortality rates among the highest in the world. According to a recent study, the total marital fertility rate in Cambodia is estimated to be 6.7 (3). According to 1998 World Health Organization (WHO) figures, maternal mortality is estimated to be 473 per 100,000 live births (4). In this setting of high fertility and Address correspondence to Patrice M. White, CNM, MS, DrPH, Assistant Professor (Clinical), Nurse Midwifery Program, University of Utah College of Nursing, 10 S 2000 E Front, Salt Lake City, UT 84112-5880.

mortality, a Khmer woman’s lifetime risk of dying from pregnancy-related causes is 200 times that of a woman in North America (5), which is probably why the colloquial expression for giving birth is: “crossing the river (chlong tonlee).” Navigating across the Mekong, Tonle: Sap, or one of their many tributaries can be a risky venture just as giving birth can be a dangerous experience for Khmer women. Biomedical determinants of maternal mortality have been well known and documented for decades. Throughout the developing world, hemorrhage, sepsis, hypertensive disorders, obstructed labor, and complications of abortion remain the most common direct causes of maternal mortality (6,7). Despite the fact that these are preventable or treatable conditions, there is no evidence that maternal mortality has declined in the last decade (8). Many safe motherhood initiatives have focused on training midwives and physicians to provide emergency obstetric care with little or no recognition of how women in specific cultures perceive or define obstetric problems. Birth is a universal human experience that takes place in a specific cultural context. Cultural perceptions of what symptoms are considered normal and abnormal during pregnancy influence health-seeking behaviors, which, in turn, ultimately affect maternal mortality. In their analysis of the determinants of maternal mortality, Thaddeus and Maine (9) identified delays that lead to maternal mortality. The first delay, the delay in the decision to seek care, is at least partly due to failure to recognize the problem as potentially serious and, in some populations, may account for one third of all maternal deaths (10). Often cultural perceptions of what is normal and problematic during pregnancy differ from biomedical perceptions. For example, in an African study, dependent edema, one of the signs of pregnancy-induced hypertension, was believed to be an indication that the fetus was male or that the woman had twins. Labor was not defined as prolonged until it lasted more than two days (11). Similarly, obstructed labor in many parts of Africa is thought to be a sign of a woman’s infidelity (9). In some cultures, complications of pregnancy are believed to be the result of a woman’s sins and are accepted as punishment rather than recognized as problems requiring biomedical intervention (12). If efforts to address safe motherhood are to be effec-

Journal of Midwifery & Women’s Health • Vol. 47, No. 4, July/August 2002 © 2002 by the American College of Nurse-Midwives Issued by Elsevier Science Inc.

239 1526-9523/02/$22.00 • PII S1525-9523(02)00266-0

tive, they must address underlying cultural factors (13– 15). Knowledge of specific beliefs and practices of women is essential for those who give care to pregnant women. Public health and anthropologic literature indicates that an understanding of culture-specific factors is vital to the effectiveness of interventions (16 –19) and that interventions fail when culture-specific factors are not considered (20 –24). The extant literature concerning beliefs and practices during pregnancy and childbirth in Cambodia is limited. Some anecdotal reports and studies of Khmer refugee women in camps along the Thai-Cambodian border or Khmer women resettled in Australia (25,26), France (27), Canada (28), and the United States (29 –34) do contain limited information about beliefs and practices during pregnancy and birth. It is impossible, however, to know if the beliefs and practices of Khmer refugees along the border or resettled in third countries represent the current beliefs and practices of Khmer women in Cambodia. Several recent background studies for specific nongovernmental (NGO) organization projects and one ethnography of rural, pre-1975 Cambodia have included limited specific information concerning beliefs and practices during pregnancy (35–38). No research has been specifically undertaken to explore the emic perspective of complications during pregnancy. The absence of this information in an environment where maternal mortality is high served as the major impetus for this research. This study was undertaken to develop an emic perspective of what Khmer women view as normal and as complications during pregnancy, birth, and postpartum. The research questions included in this report addressed: ● What do Khmer women and their birth attendants view

as complications during pregnancy, childbirth, and postpartum? ● How are these complications defined? METHODS

This article is based on field research conducted in Cambodia from February to November 1995. For 2 years

Patrice M. White is clinical faculty in the Nurse Midwifery Program at University of Utah College of Nursing. She received her master’s degree in parent child nursing from the University of Colorado Health Science Center School of Nursing in 1983 and received her doctorate in international population family health from UCLA’s School of Public Health in 1996. She has been involved in international health for more than 2 decades, during which time she lived and worked for 8 years in East Africa (Somalia) and Southeast Asia (Cambodia and Indonesia). Her experience includes working at community, district, provincial, and national levels as a trainer of midwives and traditional birth attendants, curriculum developer, and policy advisor. Before her most recent return to the United States, Dr. White worked with ACNM’s Special Projects Section/Global Outreach as a technical advisor on the PRIME project based in Jakarta.

240

before this study, the researcher lived in a rural area of Cambodia and worked with an NGO as a clinical trainer of primary midwives and traditional birth attendants (TBAs). Her observations and experiences with childbearing women and birth attendants during those years provided a foundation for the study. A pilot and 11 subsequent focus group interviews were held with a purposive sample of 88 ethnically Khmer women of childbearing age who had delivered a child within the last 3 years. Because of the age deference present in Khmer society, multiparas more than primiparas volunteered to participate in the focus groups. During the time of data collection, Cambodia experienced continued political turmoil and instability that intensified normal suspicions of outsiders. For this reason, communities for data collection were selected using criteria that included the presence of an NGO with Khmer staff who would be willing to introduce the research team to community leaders and help identify potential participants and key informants. Without the assistance of persons known to the community, it is doubtful that the research team would have been received as openly or that most of the women approached would have agreed to participate in the study. Focus groups were held in the Phnom Penh metropolitan area and three rural provinces in the Tonle Sap (Great Lake) and Mekong River basin, where most of the Khmer population resides (Figure 1). Each group had between seven and nine participants and lasted on average 110 minutes. Subsequently, 41 key informant interviews were held in Phnom Penh and three rural provinces with 21 women and 20 birth attendants. All birth attendants met criteria for the focus group women except age. In addition, they had to be in current practice, which was defined as having attended five births in the last year. In rural areas, all birth attendants were TBAs. In Phnom Penh, the key informants also included professional midwives who attended home births. Informant interviews lasted, on average, 70 minutes. Approval from UCLA’s Human Subject Protection Committee was obtained for this study. After obtaining verbal consent and discussing issues of confidentiality as required by the Human Subject Protection Committee, all focus group discussions and individual interviews were audio-recorded. Two bilingual Khmer midwives served as research assistants for this research and led the focus groups and individual interviews. More than 20 hours of focus group interviews were transcribed verbatim into Khmer and then translated into 183 pages of singlespaced English text. Forty-six hours of semistructured individual interviews were also transcribed into Khmer and translated into 319 pages of English text. English text was entered into a word-processing program. Transcripts of one focus group and one individual interview were

Journal of Midwifery & Women’s Health • Vol. 47, No. 4, July/August 2002

FIGURE 1. Map of Cambodia.

back translated by an independent translator to check accuracy of the translation. Transcripts were translated as soon as possible after data collection. Immediately after translation, emerging emic themes were identified, and clarifying questions about these themes were asked in subsequent focus groups and interviews until no new information emerged. After final translation of all the focus group and individual interviews was completed, all the text files were merged. Specific emic variables were identified from the emic themes. By using the search command of a wordprocessing program, all text, which contained specific

emic variables, was identified and saved in a separate file. Descriptions of each emic variable were developed from further analysis of the file for each variable. RESULTS

Description of the Sample Selected demographic variables of the sample are presented in Table 1. As this table illustrates, demographic characteristics of women in the focus groups and individual interviews were similar.

Journal of Midwifery & Women’s Health • Vol. 47, No. 4, July/August 2002

241

TABLE 1

Selected Demographic Variables of the Sample Means of Selected Variables

Age Years of education Number of pregnancies Number of living children

Focus Groups n ⫽ 88

Individual Interviews n ⫽ 41

36.8 1.9 6.4 4.6

43.4 4.1 6.9 4.5

Several emic categories that emerged from interviews were congruent with biomedical categories. Women in this study identified swelling which was associated with seizures and bleeding that led to miscarriage as problems during pregnancy. Most emic descriptions of intrapartum problems were congruent with those defined as biomedical problems including prolonged labor or stuck babies, noncephalic presentation, retained placenta, and fever. This section focuses on emic descriptions of both normal and abnormal conditions, which differ from standard biomedical categories. ANTEPARTUM EMIC CONDITIONS CONSIDERED NORMAL

Swelling from the Baby Women in all groups interviewed thought that some swelling during pregnancy was normal and caused by the baby. In fact, in Khmer the literal translation of the term is “swelling from the baby” or “baby swelling.” The following quote from a woman in a focus group expresses the general belief: “I heard the old women say that in the last month of pregnancy all women swell. [they have] swelling on the legs. They swell three times, and then the baby is born . . . The swelling comes and goes three times, and then after the baby is born, the swelling goes away.”

“Swelling from the baby” generally seemed to refer to dependent edema at term without other symptoms. Some women, however, described “baby swelling” as including conditions considered potentially dangerous by biomedical definitions, including edema, which began as early as 5 or 7 months and occurred on the woman’s face, arms, or all over her body, or was associated with shortness of breath. Bleeding to Wash the Baby’s Face Although the definitions of “bleeding to wash the baby’s face” were not precise, most often women stated that it

242

occurred spontaneously, was pink colored, less than a menstrual period, lasted for only a day or two, and was not associated with cramping. “Bleeding to wash the baby’s face” was reported at different points during pregnancy. Some women stated that it occurred in early pregnancy, around the time they missed their first period. Others reported that it occurred right before delivery. The rest said it occurred anytime from 3 to 8 months of pregnancy. Although the etiology was usually thought to be menstrual blood left inside, some thought that the bleeding was a result of the woman moving suddenly or working too much. Most women believed that the bleeding was self-limiting and that no treatment was indicated. Others, however, suggested a variety of treatments including vaginal washes, massage, injections, and ingestion of traditional medicine or vitamins. “There was a woman who had bleeding like this. She was three months pregnant and had bleeding. She asked the old woman, ‘Auntie, I am three months pregnant. I have bleeding. I am afraid I will miscarry.’ The old woman told her to wait and watch the bleeding a little while to see if the bleeding was a lot or a little. Then the old woman asked her if she had more bleeding. She answered that she hadn’t, that it was just a little bleeding once, and then it stopped. The old woman said that it was bleeding to wash the baby’s face and wasn’t a problem.”

“Bleeding to wash the baby’s face” was often defined retrospectively. If the bleeding did not become more serious or if it resolved on its own or with minimal interventions, then the women knew it was “bleeding to wash the baby’s face.” As with descriptions of “baby swelling,” some descriptions of “bleeding to wash the baby’s face” included symptoms which would, from a biomedical perspective, signal potential danger, including bright red bleeding, bleeding with uterine cramping, and bleeding that lasted more than a day. POSTPARTUM EMIC CONDITIONS CONSIDERED NORMAL

Sawsaye Kjey/Immature Veins During the postpartum period, women are considered to be in an altered state called “sawsaye kjey,” which literally means new or immature veins (“sawsaye” literally means fiber and refers to all long, stringlike structures in the body, including blood vessels, nerves, and ligaments). Women explained that because they used their “sawsaye” so strenuously while pushing during the delivery, in the postpartum period, their “sawsaye” are new, immature, and fragile. Certain symptoms indicate when women have new “sawsaye” in contrast to mature or old “sawsaye.” Weakness, shortness of breath, diarrhea, shakiness, abdominal swelling, palpitations, and headaches are all associated with new “sawsaye.”

Journal of Midwifery & Women’s Health • Vol. 47, No. 4, July/August 2002

“New sawsaye is when your body is weak. When you do work you feel palpitations. When you are one or two months [postpartum] you feel like your energy increases little by little. When you do hard work, you feel increased shaking in your body. You feel a little better day-by-day, month-bymonth. When you have old sawsaye, you have energy. You don’t shake in your body. You are strong enough.”

New “sawsaye” were reported to last anywhere from two days to twelve months after delivery. Most women, however, felt that it lasted three to four months. When a woman was able to resume normal activities and not feel ill as a result, she was considered to have mature “sawsaye.”

POSTPARTUM EMIC CONDITIONS CONSIDERED ABNORMAL

Toas The postpartum condition called “toas” has no direct translation in English. It refers to a kind of problem or relapse in the woman’s condition after delivery. The symptoms of headache, diarrhea, weakness, palpitations, abdominal pains or cramps, and poor appetite were reported in most all categories. Five major types of “toas” were identified on the basis of the presumed cause: ● ● ● ● ●

from from from from from

food working too hard resuming coitus too soon emotional upset, sadness, or worry walking in the rain or dew

All women interviewed knew two types of relapse— relapse from eating certain foods and relapse from resuming hard work too soon. Elaborate constellations of symptoms exist for each type of relapse. The period women are susceptible to relapse seemed to correlate roughly with the period of new “sawsaye.” Relapse from food appears to be most common type of “toas” and was the reason given for many prohibitions during the postpartum period. As in many parts of Southeast Asia, Khmer women practice roasting, the custom of lying on a bamboo bed over a small stove with a wood or charcoal fire for a period after birth. Women reported that roasting conferred some protection against relapse. Women said they ate as many different foods as possible while roasting so that they could eat them without fear after they finished roasting. Specific prohibitions to avoid relapse from food included any foods women had not eaten while roasting. Other foods considered particularly dangerous for postpartum women included pineapple, jackfruit, different varieties of bananas, field cucumbers, buffalo meat, pig’s head, and different varieties of fish.

“Toas comes from women’s fear. When they eat things, they are afraid they’ll get sick. But some women don’t know what causes toas. When they eat, they don’t get toas. [But] if someone sees these same women when they eat and tells them that what they’ve eaten causes toas, then they are afraid. Then they have toas.”

Symptoms of relapse from food, in addition to those found in all types of relapse, were chiefly gastrointestinal, such as dysentery, nausea, vomiting, and abdominal swelling. Treatment for this type of relapse varied. Many women reported drinking traditional medicine. Others mentioned eating combinations of porcupine stomach or ashes from the middle of the cooking fire mixed with different substances. The most common was taking the food that caused the relapse, drying or burning it, and boiling it with water or mixing it with alcohol to drink. Relapse from hard work came from activities as varied as cutting firewood, carrying water carts, carrying water over the shoulder, transplanting rice, washing clothes, lifting heavy things, falling down, and riding in a car. Symptoms clustered around pain in the “sawsaye,” and pain, twitching, weakness, and cramping in the extremities or joints of the extremities. Treatments were similar to those used with relapse from food. Priey Krawlah Pleung “Priey krawlah pleung” literally means the ghost or spirit, which comes while “roasting.” The most common symptoms of this condition include seizures, fainting, altered consciousness, or in some way acting abnormally— eating sleeping mats, walking around nude, speaking gibberish, or becoming angry or violent. Many women thought that “priey krawlah pleung” was the same as seizures. Some women said they didn’t believe that ghosts or spirits caused this condition but that it came when women had severe swelling during pregnancy or had membranes or blood left inside. Trained midwives stated that what women called “priey krawlah pleung” was caused by high blood pressure made worse by “roasting” and drinking and eating salty things. “I am young. I know about priey krawlah pleung too but not as much as the old women. After delivery you roast. When you’re roasting you feel weak and have no energy. During that time a ghost comes to cover you and you feel faint. After delivery I roasted. I felt sleepy, couldn’t open my eyes. Then I saw a big hand come to cover my face. During that time I tried to wake up and sit up. Then it went away.” “Khmers say that they have a ghost or spirit or witch which comes in the body and eats pus and blood. It causes priey krawlah pleung . . . Whether this is true or not I don’t know. During that time [after birth] they come in our body. So after birth they take thorns to put under the bed because the witches are afraid of thorns.”

Journal of Midwifery & Women’s Health • Vol. 47, No. 4, July/August 2002

243

Prevention measures for this condition depended on the person’s belief about its cause—whether supernatural or physical. Trained midwives stressed prenatal care with frequent checks of blood pressure and urine, low salt diets, diuretics, and manual removal of blood from the uterus postpartum. Most TBAs and women thought that tying strings around their waist or wrists, painting lime crosses in the corners of their houses or on their necks or ankles, putting thorns beneath the roasting beds, or having the TBA or traditional healer recite incantations around their roasting bed, pour lustral water over them, or spit and blow were all effective measures to prevent attack from ghosts or spirits. Treatment for “priey krawlah pleung” ranged from use of diuretics, injections, and intravenous infusions to massaging or manually removing the blood, lowering the heat of the fire or removing the fire from beneath the bed to having the traditional healer blow, spit, and recite incantations, burn incense, or make offerings to the woman’s ancestral spirits. Stuck Blood Women believed that blood could get trapped inside the uterus after delivery and cause problems. Small amounts of postpartum bleeding are believed to be unhealthy because if the woman doesn’t bleed “enough,” she probably has blood trapped inside. Women believe this condition is both uncomfortable and dangerous because ghosts and spirits may be attracted to blood inside the uterus. Not bleeding enough was thought to lead to a range of symptoms, including dizziness, blurry vision, uterine pain and cramping, fever, headache, palpitations, and chills. Some women thought that the “stuck blood” could move upward and cause an obstruction. Ultimately, if left untreated, women explained that “stuck blood” could cause “priey krawlah pleung,” seizures, or even death. “If you have blood left inside, you feel weak, feverish and have no energy. Then you find Khmer medicine to drink to make all the blood come out. You’ll feel better . . .”

Both TBAs and women were concerned that all the blood “come out” after a delivery because of the danger of “priey krawlah pleung.” For this reason, most TBAs stated they removed the blood by massaging the uterus. Some, however, put their fingers inside the vagina or sometimes inside the uterus to remove clots of blood. They believed that the practice of massage combined with “roasting,” which is believed to prevent the blood from clotting, ensures that the woman bleeds “enough.” If the woman thought she wasn’t bleeding enough, help was sought from traditional healers, injectionists, drug sellers, or trained health workers.

244

TABLE 2

Possible Biomedical Conditions Associated with Selected Emic Categories Emic Category/Cultural Condition

Possible Biomedical Condition

Swelling from the baby (Antepartumconsidered normal)

Physiologic edema of pregnancy Hypertensive disorders of pregnancy Severe anemia Cardiac problems

Bleeding to wash the baby’s face (Antepartumconsidered normal)

Implantation bleeding Cervicitis Threatened abortion Placenta previa Placental abruption Bloody show

Sawsaye kjey (Postpartum-considered normal)

Anemia Poor nutrition Intestinal parasites

Toas (Postpartumconsidered abnormal)

Most common types include symptoms of severe anemia

Priey krawlah pleung (Postpartum-considered normal)

Hypertensive disorders of pregnancy Loss of consciousness due to blood loss Infection with high fever Extreme anxiety Psychological trauma

Stuck blood (Postpartumconsidered abnormal)

Severe anemia Occult hemorrhage “After pains” Infection

DISCUSSION

Midwives are involved all over the world in promoting safe motherhood. Whether as clinicians or as designers and managers of maternal health programs, midwives aim to provide safe care to pregnant women. To provide this care, midwives often serve a unique role as cultural brokers interpreting the culture of professional midwifery with its biomedical beliefs to women whose cultural beliefs about pregnancy and birth may be significantly different. To serve as cultural brokers, however, it is necessary to know the beliefs and practices of the specific culture. Khmer women use a different vocabulary than professional midwives to describe problems during pregnancy, birth, and postpartum. They use culturally distinctive categories that overlap but are not congruent with those used by professionally trained caregivers. Table 2 illustrates cultural conditions or emic

Journal of Midwifery & Women’s Health • Vol. 47, No. 4, July/August 2002

categories described by the women studied and possible biomedical conditions associated with these categories. Knowledge of emic categories is critical for midwives giving care to women of any culture. A quick review of the biomedical conditions that potentially overlap the specific Khmer emic categories reveals that midwives risk missing serious problems if they ignore or dismiss women presenting with complaints of emic conditions. If midwives do not carefully consider and investigate these emic complaints, women may choose to seek care elsewhere because practitioners in the traditional system do pay attention to and treat these cultural conditions. Strong traditional beliefs exist surrounding pregnancy and childbirth which affect how Khmer women view complications. Some beliefs described in this study have prevented women from seeking timely intervention, such as beliefs about antepartum swelling and bleeding, “priey krawlah pleung,” postpartum bleeding, and relapse. Any strategies for changing these beliefs or the practices surrounding these beliefs will need to incorporate Khmer views and vocabulary. For example, most women in the study thought that postpartum bleeding was cleansing and, therefore, desirable. Khmer women often bleed in amounts that endanger their lives before measures are taken to stop the bleeding. To ensure the success of any programs aimed at decreasing deaths from postpartum hemorrhage, the program will have to acknowledge the cultural belief—that it is good to have bleeding to get rid of the “bad” blood— before proposing guidelines for what to consider excessive bleeding and when women should seek professional sector care. Similarly, women who think that “swelling from the baby” is inevitable and indeed a signal that the baby will be born soon do not view it as a problem. If the concept of swelling from the baby is further refined, however, it could be used to differentiate normal physiologic edema of pregnancy from other dangerous forms of edema. That is, the emic concept of “swelling from the baby” could be “reloaded” (i.e., taking an emic term whose meaning is close to a biomedical term and altering the meaning so that it is equivalent) and used only to describe dependent edema on the legs not accompanied by headache, blurred vision, or swelling elsewhere. Similarly, “bleeding to wash the baby’s face” could be reloaded to refer only to bleeding that lasts one day or less, is not bright red, is less than a period, and is unaccompanied by cramping. Culturally, both these conditions are considered normal. By reloading the existing terms, so that they include what is biomedically considered normal, women may be more amenable to seeking care if their condition differs from the reloaded definition. Although this study details specific cultural perspectives of women in Cambodia, similar studies are needed in other areas of high maternal mortality. If the delay to seek care in the event of obstetric problems is to be

eliminated, culturally specific knowledge must guide the development of future safe motherhood initiatives. Midwives have a unique opportunity as researchers, educators, program planners, and clinicians to ensure that care given to pregnant women is both clinically safe and culturally sensitive.

Funded by PACT/John Snow, Incorporated under terms of Grant No. 442-0104-A-00-1187-00 from United States Agency for International Development. The opinions expressed herein are those of the author and do not necessarily reflect the views of USAID of PACT/John Snow, Incorporated. Special thanks are due to Drs. Susan Beck, Lee Ellington, and Lee Walker for their comments on early drafts of this article and to Ms. Sue Meeks for her preparation of this manuscript.

REFERENCES 1. UNICEF. Progress of the nations. New York: United Nations, 1996. 2. World Health Organization. Revised 1990 estimates of maternal mortality: a new approach by WHO and UNICEF. Geneva (Switzerland): WHO, 1996. 3. Long C, Soeoung CS, Maekea M, Sprechmann S, Kerr H. KAP survey on fertility and contraception in Cambodia. Phnom Penh (Cambodia): National Birth Spacing Programme, National MCH Centre, Ministry of Health, 1995. 4. World Health Organization. Country health information profile: Cambodia. WHO Regional Office for the Western Pacific. Updated 2001. http://www.wpro.int/chips/default.asp [Accessed April 8, 2002]. 5. Safe motherhood: facts and figures: cause of maternal death. Update December 12, 2001 http://safemotherhood.org/init_facts.htm [Accessed April 8, 2002] 6. Royston E, Armstrong S. Preventing maternal deaths. Geneva (Switzerland): World Health Organization, 1989. 7. Safe motherhood: facts and figures: maternal health around the world. Update December 12, 2001. http://safemotherhood.org/init_facts. htm [Accessed April 8, 2002]. 8. Maine D, Rosenfield A. Safe motherhood initiative: why has it stalled? Am J Pub Health 1999;89:480 –2. 9. Thaddeus S, Maine D. Too far to walk: maternal mortality in context. New York: Prevention of Maternal Mortality Program, Columbia University, 1990. 10 Fawcus S, Mbizvo M, Lindmark G, Nystrom L. A community-based investigation of avoidable factors for maternal mortality in Zimbawe. Stud Fam Plann 1996;27:319 –27. 11. The Prevention of Maternal Mortality Network. Barriers to treatment of obstetric emergencies in rural communities of West Africa. Stud Fam Plann 1992;23:279 –91. 12. Asowa-Omorodion F. Women’s perceptions of the complications of pregnancy and childbirth in two Esan communities, Edo State, Nigeria. Soc Sci Med 1997;44:1817–24. 13. McCarthy J. The conceptual framework of the PMM Network. Int J Gynaecol Obstet 1997 Nov;59(Suppl 2):S15–21. 14. World Federation of Public Health Associations. Improving maternal health in developing countries. Geneva (Switzerland): World Federation, 1984. 15. Zarayk H, Sholkamy H, Younis N, Khattab H. Women’s health problems in the Arab world. Int J Gynaecol Obstet 1997 Jul;58:112–24. 16. Frye B. Use of cultural themes in promoting health among Southeast Asian refugees. Am J Health Promo 1995;9:269 – 80. 17. Nichter M, Nichter M. The ethnophysiology and folk dietetics of pregnancy: a case study from South India. Hum Org 1983;42:235– 46.

Journal of Midwifery & Women’s Health • Vol. 47, No. 4, July/August 2002

245

18. Okolacha C, Chiwuzie J, Braimoh S, Unuigbe J, Olumeko P. Sociocultural factors in maternal morbidity and mortality: a study of a semiurban community in Southern Nigeria. J Epidemiol Commun Health 1998; 52:293–7. 19. Mayhew SH. Integration of STI services into FP/MCH services: health service and social contexts in rural Ghana. Reprod Health Matters. 2000 Nov;8:112–24. 20. Fishman C, Evans R, Jenks E. Warm bodies, cool milk: conflicts in postpartum food choice for Indochinese women in California. Soc Sci Med 1988;26:1125–32. 21. Hay CM. Dying mothers: maternal mortality in rural Indonesia. Med Anthropol 1999;18:243–79. 22. Justice J. Can socio-cultural information improve health planning? A case study of Nepal’s assistant nurse-midwife. Soc Sci Med 1984;19: 193– 8. 23. Kendall C, Foote D, Martorell R. Ethnomedicine and oral rehydration therapy: a case study of ethnomedical investigation and program planning. Soc Sci Med 1984;19:253– 60. 24. Nichter M. Vaccinations in South Asia: false expectations and commanding metaphors. In Coreil J, Mull JD. Anthropology and primary health care. Boulder (CO): Westview Press, 1990:196 –221. 25. Douglas LB. Antenatal and birthing beliefs and practices of Cambodian women. In Rice PL. Asian mothers, Australian birth. Melbourne (Australia): Ausmed Publications, 1994:35– 44. 26. Rice PL. Childbirth and health: cultural beliefs and practices among Cambodian women. In Rice PL. Asian mothers, Australian birth. Melbourne (Australia): Ausmed Publications, 1994:47– 60. 27. Choulean A. Grossesse et accouchement au Cambodge: aspects rituels. ASEMI 1982;XIII:1– 4.

246

28. Kulig JC. Childbearing beliefs among Cambodian refugee women. West J Nurs Res 1989;12:108 –18. 29. Frye B. The process of health care decision making among Khmer immigrants. [Unpublished doctoral dissertation]. Loma Linda (CA): Loma Linda University, 1989. 30. Hansen AR. Crossing the river: the secularization of the Khmer religious worldview. [Unpublished master’s thesis]. Cambridge (MA): Harvard Divinity School, 1988. 31. Kouch T. The midwife. Khmer-Am Health no date;9:3. 32. Sargent C, Marcucci J. Aspects of Khmer medicine among refugees in urban America. Med Anthropol Q 1983;15:7–9. 33. Sargent C, Marcucci J, Elliston E. Tiger bones, fire and wine: maternity care in a Kampuchean refugee community. Med Anthropol 1983;7:67–79. 34. Sargent C, Marcucci J. Khmer prenatal health practices and the American clinical experience. In Michaelson KL. Childbirth in America: anthropological perspectives. South Hadley (MA): Bergin & Garvey Publishers, 1988:70 – 89. 35. Biacabe S. Analysis of TBA interviews in Bakan District Pursat Province Cambodia. Phnom Penh (Cambodia): CARE International, no date. 36. Ebihara M. Svay, a Khmer village in Cambodia. Ann Arbor (MI): University Microfiche International, 1968. 37. Healy G, Chandrovann D. Situational analysis of health service delivery at commune and village-level: Oudong District Kompong Speu Province Cambodia. Phnom Penh (Cambodia): Australian Red Cross & Oudong District Health Centre Planning Team, 1994. 38. Sonnois B. Women in Cambodia: overview of the situation and suggestions for development programmes. Phnom Penh (Cambodia): Redd-Barna Cambodia, 1990.

Journal of Midwifery & Women’s Health • Vol. 47, No. 4, July/August 2002