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Vietnamese Postpartum Practices Implications for Nursing in the Hospital Setting
research and studies Vietnamese Postpartum Practices Implications for Nursing in the Hospital Setting LOIS WADD, RN, MS Twenty Vietnamese families in Salt Lake City, Utah, were interviewed concerning postpartum practices. Results show that special dietary and activity proscriptions are widely accepted for Vietnamese primiparae and less rigidly accepted for multiparae. Activity proscriptions relate to the avoidance of cold, including drafts and showers, and avoidance of sexual intercourse. Bed rest and limitation of activity were also important to the subjects. Implications for nursing practice in the inpatient obstetrical unit are presented.
Since 1975, over 500,000 Southeast Asian refugees have relocated to the United States; approximately 70% of these refugees are Vietnamese. Although Southeast Asians are concentrated primarily in California, Texas, and other West Coast states, smaller numbers live in nearly every state. Even small rural towns have Southeast Asian families as residents because of sponsorship by local churches and other groups throughout America. Due to the refugees’ widespread geographical distribution, every nurse in America may have at least some contact with Southeast Asians. Since most of these refugees are young and of childbearing age, a common meeting ground will be the obstetrical unit. Nurses and other health-care providers need to be aware of the cultural backgrounds of their clients. Leininger stated, “Nursing and health sciences cannot be adequately effective or comprehensive unless cultural aspects of health and illness are given full consid-
252
eration.”’ T h e health belief and medical anthropology literature support the importance of crosscultural understanding in health
LITERATURE REVIEW Tung described the health-care system that existed in Vietnam prior to 1975 and noted that modern day Vietnamese health beliefs and practices have been influenced by three traditions: Southern medicine, thuoc nam, the true folk medicine of South Vietnam; thuoc bac, the more formalized Northern medicine based on Chinese medical principles; and Western medicine, brought to Vietnam by the French and A m e r i c a n ~ .T~u n g pointed out that most Vietnamese, being pragmatic, practice an amalgamation of these medical traditions and choose what seems to work best. Tung also outlined a theory of balance, which he called the A m / Duong principle. It compares to Yin I Yang of Chinese medicine and
to the hot/cold duality of other cultures. According to the Am I Duong theory, good health results from the balance of the two elements. Certain diseases are attributed to excesses of hot or cold and appropriate treatment consists of balancing the body with food or drugs possessing the opposite properties. Diarrhea is believed to be due to excess cold and pimples due to excess hot. Western drugs are considered hot; whereas, Oriental herb medicines usually are considered cold.5 Other important Vietnamese folk concepts include phong or pi,which is a noxious element that can enter a person and cause respiratory tract infections, epilepsy, strokes, or skin disorders. Cao gii, the Vietnamese practice of coin rubbing, literally means “rubbing out the wind” and is used for a number of disorders including colds, headaches, and abdominal pain.5 A study of Vietnamese practices during childbirth and pregnancy was conducted using 25 Chinese-
July/August 1983 JOCiV ~Vvursing
0090-031 1/83/0714-0252$01.15
Vietnamese and 15 ethnic Vietnamese women refugees in Australia.”’ The subjects reported that foods and behavior were important to the maintenance of balance during this period, and the women classified foods into several types including “hot,” “tonic,” “cold,” or “windy.” Certain foods, principally sour foods, were considered “anti-tonic.” During pregnancy and the puerperium, the women consumed or avoided these classes of food to maintain optimum health. T h e Vietnamese considered the first trimester to be “cold”; thus, the woman should have “hot” foods to correct the excess of cold. The second trimester was considered a neutral state and “cold” foods were allowed to be introduced. “Tonic” foods were used during the first and second trimesters, but women avoided tonic foods in the third trimester to prevent a large infant and thus a difficult delivery. In the third trimester, the woman was thought to be “hot” and “tonic” and should have “cold” foods. “Anti-tonic” foods were also to be avoided in the third trimester and postpartum. After delivery, the mother is believed to have an excess of “cold” and should have a “hot” diet. The classification of foods is based on their physical affect on the body and is somewhat arbitrary.6 Generally, “cold” foods are gourd-type plants such as squash, melons, leafy vegetables, and most fruit. Meat, condiments, alcohol, and fatty foods are considered “hot.” “Tonic” foods increase the amount of blood and are high in energy and include high fat, sugar and carbohydrate foods, high protein foods, and medicine. “Antitonic” foods are sour and sometimes raw or cold, and deplete the volume of blood. Raw foods, leafy vegetables, and fruit can also be classified as “windy” as well as “cold” and may cause “wind” ill-
July/August 1983 JOGN Nursing
Figure 1. Vietnamese childbirth experience in the U.S.
nesses such as arthritis, flatulence, or diarrhea. Certain foods were considered dangerous because of their magical properties and were to be avoided. However, the designation of these dangerous foods appeared to be idiosyncratic, and many women were skeptical of the magically-based precautions. Manderson and Mathews also described a period of confinement and “mother-roasting”-the warming of the mother using charcoal fires below or next to the bed. This practice was modified in Australia to include electric blankets and water bottles. Bathing and hair washing also were proscribed for up to 30 days. Manderson and Mathews noted that hospital practices in Australia interfered with the taboos associated with childbirth. Those women unable to observe these taboos were distressed and attributed later health consequences to this delay.6 Dietary practices had changed little since the Vietnamese women relocated to Australia. However, traditional infant feeding practices (ie., breastfeeding up to four months of age with gradual introduction of neutral foods) had been
abandoned for either a short period of breastfeeding or bottle feeding and early introduction of solid^.^,' This switch from breastfeeding to bottle feeding also was noted by Gordon, Matousek, and Lang.’ Hollingsworth, Brown, and Brooten described a special bed for childbirth that protected from the wind which might carry evil spiri t ~ Also, . ~ the Vietnamese fear a loss of heat during labor and delivery and prepare a heated bed and eat a special diet of salty, hot foods. Pregnant Vietnamese avoid cold foods and cold water, sour foods, beef, and seafood and avoid soups and water to prevent stretching of the stomach. After childbirth, ambulation and showering also is re~tricted.~
METHODOLOGY Interviews with 20 ethnic Vietnamese families from the Salt Lake City, Utah, area were conducted during February and March of 1981 with the aid of a native Vietnamese interpreter. The sample was selected from names of Vietnamese families submitted by workers in a government welfare 253
agency, a voluntary resettlement agency, and from the respondents themselves. Vietnamese of Chinese extraction were not included in the study. “Family” was defined as any group of persons living in a household who considered themselves as one household, regardless of blood relationship. Recent childbirth in the family was not a criterion for selecting families for interview, because issues related to childbirth were only part of a larger exploratory study of health beliefs and practices. Of the 20 families interviewed, 10 had experienced childbirth in the United States, and one was pregnant at the time of the interview but had never delivered in the U.S. T h e families were contacted initially by phone and asked if they would participate in the study. T h e questioning and interviewing process was modeled after the techniques outlined by Spradley and by Glaser and Strauss.””’ An interview schedule based, in part, on the work of Chrisman and Kleinman was used as a guideline and outlined basic areas of interest.12-14 T h e questions in the interview schedule appeared to have face validity but were not pretested. T h e questions in the interview schedule that gathered information about childbirth were:
1) Has anyone in your family been to the hospital here or in Vietnam? 2) Why did they go to the hospital? 3) How was the hospital experience here in the U S . ? 4) How could it have been better? 5 ) What should be done o r avoided when you are pregnant? After childbirth? 6) Who should deliver the baby? Who should be present at the birth? Because of the broad exploratory nature and time limitations 254
of the study, one-time interviews were conducted, and the description and understanding of cultural beliefs and concepts were developed from one interview to the next. Information gathered from interviews conducted at the beginning of the study formed the basis for further and more detailed questioning regarding these concepts later in the study. Each interview varied slightly from one family to the next, as did the focus of the questioning. While this flexible interviewing style allowed individualization of each interview, it also makes replication and validation of findings difficult. T h e one-time interview also may have limited the depth of information obtained and perhaps discouraged complete disclosure. Other limitations of this study include the use of a convenience sample rather than a random sample and selection factors such as phone availability, willingness to participate, and selection by community workers or friends. T h e accuracy of information also may have been affected by the communications process necessary for interviewing respondents who speak another language and by cultural differences between investigator and respondent.
FINDINGS T h e sample interviewed was diverse in age, education, religion, and length of residency in the U.S., but was similar in previous urban residency. Eighteen of the 20 families had lived primarily in urban areas in North and South Vietnam. Nine of the interviews were conducted with nuclear families, eight with extended families, and three with households of single adults, some of whom were blood relatives. Male and female participation in the interviews was about equal, and questioning was directed toward all those present
at the time of the interview. Interviews lasted from one and a half to three hours. T h e most distinctive and consistent health practices were related to postpartum health practices. These practices largely involved activity and dietary changes and were considered especially important for primiparae. Most respondents also believed these activity and diet changes were important for later children, but the time period for these practices was usually shorter. O n e respondent explained that one should follow the practices for as long as one “could afford to.”
Activity Proscriptions Some of the practices related to the physical activity of the mother after delivery and included a period of bed rest, confinement in the home, and avoidance of showers, cold environments, and sexual intercourse. Eleven respondents stated that the mother should stay in bed, often with a fire underneath for warmth, from one week to two months. One woman said that the postpartum woman should not “let her feet touch the ground” for one week; however, the others agreed that the postpartum woman should stay in bed as much as possible for one week. In addition to the bed rest period, 14 of the 15 respondents who discussed childbirth stated that the woman should stay in the house for one week to three months, and six of the 14 agreed that three months was the appropriate time. T h e subjects believed that while in the house, heavy work should be avoided; if one must go outside, then one should dress warmly. One respondent stated that when she went outside, she covered her head and put cotton in her ears. Avoiding showers or baths and especially cold water after childbirth was another important prac-
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tice. T h e length of avoidance varied from one week to three months with most respondents citing a time period of up to one month. Three respondents said that a x&g, a type of facial steam bath, was allowed during this time period; another said the hair could be washed if absolutely necessary but then must be thoroughly dried. Two respondents stated that scrubbing the skin during the postpartum period would result in prominent hand veins at an early age. Another postpartum prohibition related to sexual intercourse. Although respondents were not asked specifically about intercourse, three women stated that intercourse should be avoided for three to four months after childbirth. These practices seem to be related to the idea of the women being “open” at childbirth. Several respondents stated that the joints or pores of the woman are open or enlarged at that time, and cold should be avoided or it will enter the body and cause sickness or weakness in old age. One man stated that the old women in America were all “bent over” as a result of not following these good childbirth practices.
Diet T h e proper postpartum diet was another area of special practice. Eleven respondents reported salty, “hot” food should be eaten after childbirth. T h e salty, “hot” food usually consisted of meat, fish, or rice cooked with salt or fish sauce and lots of black pepper. Foods that were less frequently suggested as proper postpartum foods included boiled green cabbage, soup, and fish. Two respondents offered reasons why one should eat the salty foods. One said it helped the stomach to contract after childbirth, and the other said the salty foods made the mother drink more
July/August 1983 JOGN Nursing
water and thus the mother could make more breast milk. T h e respondents listed a number of foods to be avoided after childbirth. T h e most commonly prohibited item among the respondents was cold drinks. Vegetables, raw foods, fat, and citrus or sour foods such as pickles also were listed by many of the respondents as being prohibited from the diet. One respondent said beef should not be eaten, one said bananas and watermelon should be avoided, and another said meat or fish should not be eaten the first week. The range of time given for avoiding these foods was from one to three months. Several respondents gave reasons for avoiding particular foods. One said that drinking cold drinks would cause the bleeding to stop too soon, and it would be retained inside and cause a “fat stomach like American women have after childbirth.” T h r e e respondents said eating citrus fruits or sour things would lead to incontinence in old age. Another said raw foods should not be eaten because it would cause the “stomach to move too much,” which is to be avoided when it is stretched after childbirth.
Breastfeeding Practices and Diet Seven families had breastfed in Vietnam. T h e remaining families were not asked specifically about this practice. Those who breastfed in Vietnam did not breastfeed after giving birth in the United States. Only one respondent who gave birth in the U.S. had breastfed and then only for a few weeks: she “did not like it.” Other reasons for not breastfeeding included unavailability of enough nutritious food, poor appetite and low energy, and excessive weight loss with breastfeeding. Two women stated that they could not breastfeed because they had to work; one was told by her sponsor that bottle feeding was more nutritious; and
one said her milk was not good and had caused diarrhea in her infants in Vietnam. Some respondents suggested foods to be included in a good breastfeeding diet: pork cooked with vinegar, milk, soup made with animal bones, potatoes, papaya, fruit, and juices.
Childbirth Experiences in Vietnam In Vietnam, children were delivered predominantly by certified midwives in a special “birth house.” Eight women had delivered with a certified midwife and six had delivered with assistance from Western-trained physicians in a hospital or birth house. Two women had delivered at home: in one case, the father delivered the children; in the other, a lay midwife who was a neighbor assisted at delivery. These home births occurred 20 to 30 years before, and both families had later children delivered by a certified midwife in a birth house. In Vietnam, only two women had family present at the time of birth, in both cases the woman’s mother. Another woman, who was from a rural area of Vietnam and had her first four children delivered by a lay midwife, stated that no one should be present at delivery because the woman is “dirty” at that time. She also said that if children were present at the delivery, their intelligence would be lowered. This same rural woman said that at one of her deliveries she had a retained placenta for which the lay midwife had placed a type of leaf on her right toe and had given her onion juice to drink. Immediately the placenta was delivered, and the leaves were quickly removed to “prevent the intestines from coming out also.”
Childbirth in the U.S. Of the 20 families interviewed in this study, ten had experienced childbirth in U.S. hospitals with
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physicians assisting delivery. Comments regarding childbirth experiences were elicited from these ten families and from one woman who would be delivering in a few months after the interview and who had heard stories from other Vietnamese women. Of the 11 respondents, six had generally positive feelings and five had negative feelings in regard to their experiences. One woman stated that she liked being able to shower right away and had hated the confines of the house and bed in Vietnam in her previous pregnancies. T h e woman enjoyed American food and thought the American hospitals were better equipped than those in Vietnam. Another woman agreed that the early shower was more comfortable and said her husband had brought food to her in the hospital. Two women said their hospital experiences were satisfactory because they were multiparous and that adhering to Vietnam postpartum practices was not as important for subsequent pregnancies. One woman was afraid to get out of bed so soon after delivery but felt stronger afterwards because of it. Another woman refused the shower and had food brought to her in order to conform with her beliefs about proper postpartum practices. Most of the respondents’ negative comments had to d o with being unable to refuse to shower after delivery. T h e three women who had taken undesired showers now attributed chronic headaches to the experience. They also complained about the food and cold drinks that were given to them. Another woman had been lonely in the hospital because there had been no interpreters available. Although fathers were not present at deliveries in Vietnam, five of the ten men whose wives had children in the U.S. were present at delivery or would have liked to
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have been present. One husband was not present, and two women stated that their husbands would like to have been present but the women had not wanted them there.
Other Findings Another finding from this study is pertinent to the understanding of postpartum practices. T h e health-care experience of Vietnamese in America is that some respondents in this study experienced weakness, dizziness, or headache from routine blood sampling. T h e occurrence of these symptoms seemed to be related to the amount of blood taken.
DISCUSSION T h e findings of this study support those of Mathews and Manderson in regard to Vietnamese postpartum practices, particularly the practices and beliefs regarding the importance of avoiding cold drafts, cold drinks, particular foods, and b a t h i r ~ g .T~h. ~e preference for “hot” and salty food after childbirth seems widespread. However, breastfeeding appears to be decreasing as Mathews and Manderson, and others have Some Vietnamese women have attributed chronic health problems such as headaches to their inability to carry out their traditional postpartum practices, a finding that was also noted by Mathews and Mander~on.‘*~ There were some discrepancies between the findings of this study and those of Mathews and Manderson. Mathews and Manderson’s classification of “windy,” “tonic,” and “anti-tonic” were not offered by respondents in this study. However, the inclusion or exclusion of particular foods are similar in the two studies. Because this study identified and focused only on the classifications of “hot” and “cold,” other classifications may not have come to light. Also, foods with
“magical” properties were not identified in this study. Postpartum confinement to bed and to the home is a practice apparently in flux. This change may have already begun in Vietnam with increasing urbanization and employment of women (only three of the 17 women interviewed were housewives in Vietnam). Since most refugees in the U.S. work at lower income jobs, two incomes are necessary and this may cause further change in the length or nature of postpartum confinement. T h e presence of the father at delivery was favored by some respondents and not by others. This partial acceptance may be a compromise between the Chinese culture, in which the father is not expected to participate or be present at delivery, and the Hmong culture, in which the father’s participation is very i m p ~ r t a n t . ’ ~ , ’ ~ Almost half of the women in this study who had experienced childbirth in the U.S. had negative feelings about their hospitalizations. This dissatisfaction conflicts with the findings of Allen et al. who noted a high degree of satisfaction (94.3%) with hospital care of Southeast Asians in Oregon.17 This discrepancy may be explained by the differences in the study groups. T h e study of Allen et al. included Cambodians and Laotians and was limited to families with an Englishspeaking member. Another factor may be possible differences in hospital practices in the two areas. T h e concept of balance or A m / Duong may influence childbirth beliefs. Mathews and Manderson noted that the different trimesters of pregnancy are regarded as either “hot” or “cold” and particular foods are needed to balance these condition^.^.^ However, in this study no one described pregnancy and the puerperium in those terms, and in the general study respondents were not able to cite many conditions o r illnesses as
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“hot,” “cold,” or “phong” as Tung described.5 Nevertheless, treatments for these conditions appear to be consistent with the hot/cold balancing theory. This may be explained by the exclusion from this study of Chinese/Vietnamese who may have a greater knowledge of the hot/cold theory through their closer ties to Chinese medical thought. A difference inevitably exists between lay and professional understanding of medical treatments. Treatments and practices are accepted and followed because of tradition and practical experience, and not because the theory is understood. In this study, respondents knew which foods and practices were to be used or followed but not why.
IMPLICATIONS FOR NURSING T h e findings show that childbirth practices of Vietnamese in the U.S. have retained strong ties to the folk practices of the past. While some women may be willing or even happy to abandon some of these practices, others will resent and worry about breaking these taboos and may attribute future health problems to these events. Because childbirth is perhaps the most common opportunity for Vietnamese to experience U.S. hospital care, a negative reaction to the care received at this time may influence expectations for future hospitalizations and may foster a less than optimal situation. Obstetrical nurses can make the childbirth experience a positive one. Bridging communication gaps is an obvious need, and the nurse may act as advocate and facilitator in providing interpreters. Simple attempts at communication using the Vietnamese language will signal a willingness and interest on the nurse’s part. Obtaining a Vietnamese glossary for medical terms may be extremely helpful if inter-
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1983 JOGN Nursing
preters are not readily available.* Because of the family oriented nature of the Vietnamese, family members should be allowed to participate in the care of the patient and should be welcomed at the bedside. Before the delivery, it is important to ascertain whether o r not the father o r other family members will be present at delivery or in the labor room. Translating the routine diet of the hospital into food that is acceptable to the Vietnamese postpartum woman is very important, especially for the primiparous woman. Providing the option of warm water or tea instead of the usual ice water, assisting the woman to pick suitable foods from the hospital menu, or encouraging the family to bring in foods from home may allow the Vietnamese woman to follow her traditional beliefs. Concerns about nutrition and the effects of high salt intake may be legitimate in some cases, and the nurse may offset the negative aspects without prohibiting the practice by giving the woman supplemental vitamins a n d carefully monitoring the woman’s blood pressure. Allowing the postpartum mother the option of showering or simply leaving a bowl of warm water and towel .with which to wash may help the woman avoid the conflict of showering shortly after delivery. Early ambulation may be acceptable if the woman is allowed to dress very warmly and keep out of drafts. Because some Vietnamese find routine blood sampling alarming and may experience weakness or
* Medical guides and glossaries in the Vietnamese, Cambodian, and Lao languages may be obtained, for $8.00 each, by writing to the Indochinese Language Resource Center, 3030 SW Second Avenue, Portland, Oregon 97201; or calling (503)241-9393. Translated information on other health problems is also available.
other physical sequelae after blood drawing, minimizing the amount of blood sampling and allowing the woman to rest and drink fluids afterwards may prevent negative reactions. When interacting with Vietnamese, the nurse must remember that many will not voice their concerns or objections for fear of disturbing a harmonious relationship o r seeming to criticize the care they are receiving. T h e nurse should not assume silence or smiles signify agreement or contentment. Unbiased options should be offered to the patient so she may feel free to choose without offending anyone.
CONCLUSION Each Vietnamese is an individual with different experiences that have shaped her/his beliefs. T h e nurse must not assume that all Vietnamese share similar beliefs and practices or that Vietnamese beliefs are also true for other Southeast Asians. As always, the nurse should individualize each patient’s care. T h e nurse’s role also includes assessing and facilitating the special needs of refugees in the community. Providing information on community resources and appropriate follow-up care, and educating other hospital personnel to the unique needs of the Southeast Asian client are vital to the total care of the patient.
REFERENCES 1. Leininger M. Cultural diversities of health and nursing care. Nurs Clin North Am 1977;12:5-18. 2. Carr JE. Ethnobehaviorism and the culture bound syndrome: the case of Amok. Cult Med Psychiatry 1978;2:269-93. 3. Logan MH. Humoral medicine in Guatemala and peasant acceptance of modern medicine. In: Landy D, ed. Culture, disease and healing. New York: Macmillan
Publishing, 1977;487-495.
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4. Zborowki M. Cultural components in response to pain. J SOC Issues 1952;8:16-30. 5. T u n g T M . Indochinese patients: Cultural aspects of the medical and psychiatric care of IndoChinese refugees. Washington, D.C.:A.S.E.A. Action of South East Asians Inc., 1980. 6. Manderson L, Mathews M. Vietnamese attitudes toward maternal and infant health. Med J Aust 198 1 ;1~69-72. 7. Mathews M, Manderson L. Infant feeding practices and lactation diets amongst Vietnamese immigrants. Aust Paediatr J 1980; 16:263-6. 8. Gordon VC, Matousek IM, Lang TA. S.E. Asian refugees: life in America. Am J Nurs 1980; 11:2031-6. 9. Hollingsworth AO, Brown LO, Brooten DA. T h e refugees and child bearing: what to expect. RN 1980;43(I 1):45-8.
10. Spradley JP. T h e ethnographic interview. New York: Holt, Rinehart and Winston, 1979. 11. Glaser BG, Strauss AL. T h e discovery of grounded theory: strategies for qualitative research. New York: Aldine Publishing Co., 1967. 12. Chrisman NJ. T h e health seeking process: an approach to the natural history of illness. Cult Med Psychiatry 1977;1:35 1-77. 13. Kleinman A. Patients and healers in the context of culture. Berkeley and Los Angeles: University of California Press, 1980. 14. Kleinman A, Eisenberg L, Good B. Culture, illness and cure: clinical lessons from anthropologic and cross-cultural research. Ann Intern Med 1978;88:251-8. 15. Chung HJ. Understanding the Oriental maternity patient. Nurs Clin North Am 1977;12:67-75. 16. Lutheran Immigration and Refugee Services. Orientation sup-
plement: Hmong series. N e w York: Lutheran Council in USA, 1979. 17. Allen C, Juris P, Peterson J, Pullen K. Indochinese refugees: health assessment of a special population group. Unpublished research. Available from author at Multnomah County Health Department, Portland, Oregon, 1980.
Address for correspondence: Lois Wadd, RN, 2302 NE Tillamook, Portland, O R 97212.
Lois Wadd is a family nurse practitioner at Kaiser-Permanente Medical Care Program and at Planned Parenthood in Portland, Oregon. Ms. Wadd is certified as a family nurse practitioner by the American Nurses’ Association.
NAACOG DISTRICT FALL CONFERENCES
The 1983 District 111 Conference will be held October 3-4 at Bally’s Park Place Casino Hotel in Atlantic City, New Jersey. The theme of the meeting will be “Don’t Gamble with Women and Neonatesat Risk.” For further information, contact Stephanie Schrader, RNC, Zurbrugg Memorial Hospital, Rancocas Valley Division, Sunset Road, Willingboro, NJ 08046, (609) 877-6000, ext. 461. “Body, Mind and Spirit” is the theme of the 1983 NAACOG I District Conference. The meeting will be held October 2-5 at the Eastland Hotel in Portland, Maine. Conference Chairman: Gloria Stover, RN, 106 Columbia Road, Portland, ME 04103. NAACOG District Vlll will hold its 1983 Conference, “Get to the Point,” September 11-1 5 at the Pointe Resort in Phoenix, Arizona. For further information, contact officers in District VIII. “Highlights of ‘83’ is the theme of the District VI Conference which will be held September 13-14 at the Holiday Inn, Midtown in Milwaukee, Wisconsin. For further information, contact officers in District VI. ”
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July/August 1983 JOGN Nursing
Since 1975, over 500,000 Southeast Asian refugees have relocated to the United States; approximately 70% of these refugees are Vietnamese. Although Southeast Asians are concentrated primarily in California, Texas, and other West Coast states, smaller numbers live in nearly every state. Even small rural towns have Southeast Asian families as residents because of sponsorship by local churches and other groups throughout America. Due to the refugees’ widespread geographical distribution, every nurse in America may have at least some contact with Southeast Asians. Since most of these refugees are young and of childbearing age, a common meeting ground will be the obstetrical unit. Nurses and other health-care providers need to be aware of the cultural backgrounds of their clients. Leininger stated, “Nursing and health sciences cannot be adequately effective or comprehensive unless cultural aspects of health and illness are given full consid-
252
eration.”’ T h e health belief and medical anthropology literature support the importance of crosscultural understanding in health
LITERATURE REVIEW Tung described the health-care system that existed in Vietnam prior to 1975 and noted that modern day Vietnamese health beliefs and practices have been influenced by three traditions: Southern medicine, thuoc nam, the true folk medicine of South Vietnam; thuoc bac, the more formalized Northern medicine based on Chinese medical principles; and Western medicine, brought to Vietnam by the French and A m e r i c a n ~ .T~u n g pointed out that most Vietnamese, being pragmatic, practice an amalgamation of these medical traditions and choose what seems to work best. Tung also outlined a theory of balance, which he called the A m / Duong principle. It compares to Yin I Yang of Chinese medicine and
to the hot/cold duality of other cultures. According to the Am I Duong theory, good health results from the balance of the two elements. Certain diseases are attributed to excesses of hot or cold and appropriate treatment consists of balancing the body with food or drugs possessing the opposite properties. Diarrhea is believed to be due to excess cold and pimples due to excess hot. Western drugs are considered hot; whereas, Oriental herb medicines usually are considered cold.5 Other important Vietnamese folk concepts include phong or pi,which is a noxious element that can enter a person and cause respiratory tract infections, epilepsy, strokes, or skin disorders. Cao gii, the Vietnamese practice of coin rubbing, literally means “rubbing out the wind” and is used for a number of disorders including colds, headaches, and abdominal pain.5 A study of Vietnamese practices during childbirth and pregnancy was conducted using 25 Chinese-
July/August 1983 JOCiV ~Vvursing
0090-031 1/83/0714-0252$01.15
Vietnamese and 15 ethnic Vietnamese women refugees in Australia.”’ The subjects reported that foods and behavior were important to the maintenance of balance during this period, and the women classified foods into several types including “hot,” “tonic,” “cold,” or “windy.” Certain foods, principally sour foods, were considered “anti-tonic.” During pregnancy and the puerperium, the women consumed or avoided these classes of food to maintain optimum health. T h e Vietnamese considered the first trimester to be “cold”; thus, the woman should have “hot” foods to correct the excess of cold. The second trimester was considered a neutral state and “cold” foods were allowed to be introduced. “Tonic” foods were used during the first and second trimesters, but women avoided tonic foods in the third trimester to prevent a large infant and thus a difficult delivery. In the third trimester, the woman was thought to be “hot” and “tonic” and should have “cold” foods. “Anti-tonic” foods were also to be avoided in the third trimester and postpartum. After delivery, the mother is believed to have an excess of “cold” and should have a “hot” diet. The classification of foods is based on their physical affect on the body and is somewhat arbitrary.6 Generally, “cold” foods are gourd-type plants such as squash, melons, leafy vegetables, and most fruit. Meat, condiments, alcohol, and fatty foods are considered “hot.” “Tonic” foods increase the amount of blood and are high in energy and include high fat, sugar and carbohydrate foods, high protein foods, and medicine. “Antitonic” foods are sour and sometimes raw or cold, and deplete the volume of blood. Raw foods, leafy vegetables, and fruit can also be classified as “windy” as well as “cold” and may cause “wind” ill-
July/August 1983 JOGN Nursing
Figure 1. Vietnamese childbirth experience in the U.S.
nesses such as arthritis, flatulence, or diarrhea. Certain foods were considered dangerous because of their magical properties and were to be avoided. However, the designation of these dangerous foods appeared to be idiosyncratic, and many women were skeptical of the magically-based precautions. Manderson and Mathews also described a period of confinement and “mother-roasting”-the warming of the mother using charcoal fires below or next to the bed. This practice was modified in Australia to include electric blankets and water bottles. Bathing and hair washing also were proscribed for up to 30 days. Manderson and Mathews noted that hospital practices in Australia interfered with the taboos associated with childbirth. Those women unable to observe these taboos were distressed and attributed later health consequences to this delay.6 Dietary practices had changed little since the Vietnamese women relocated to Australia. However, traditional infant feeding practices (ie., breastfeeding up to four months of age with gradual introduction of neutral foods) had been
abandoned for either a short period of breastfeeding or bottle feeding and early introduction of solid^.^,' This switch from breastfeeding to bottle feeding also was noted by Gordon, Matousek, and Lang.’ Hollingsworth, Brown, and Brooten described a special bed for childbirth that protected from the wind which might carry evil spiri t ~ Also, . ~ the Vietnamese fear a loss of heat during labor and delivery and prepare a heated bed and eat a special diet of salty, hot foods. Pregnant Vietnamese avoid cold foods and cold water, sour foods, beef, and seafood and avoid soups and water to prevent stretching of the stomach. After childbirth, ambulation and showering also is re~tricted.~
METHODOLOGY Interviews with 20 ethnic Vietnamese families from the Salt Lake City, Utah, area were conducted during February and March of 1981 with the aid of a native Vietnamese interpreter. The sample was selected from names of Vietnamese families submitted by workers in a government welfare 253
agency, a voluntary resettlement agency, and from the respondents themselves. Vietnamese of Chinese extraction were not included in the study. “Family” was defined as any group of persons living in a household who considered themselves as one household, regardless of blood relationship. Recent childbirth in the family was not a criterion for selecting families for interview, because issues related to childbirth were only part of a larger exploratory study of health beliefs and practices. Of the 20 families interviewed, 10 had experienced childbirth in the United States, and one was pregnant at the time of the interview but had never delivered in the U.S. T h e families were contacted initially by phone and asked if they would participate in the study. T h e questioning and interviewing process was modeled after the techniques outlined by Spradley and by Glaser and Strauss.””’ An interview schedule based, in part, on the work of Chrisman and Kleinman was used as a guideline and outlined basic areas of interest.12-14 T h e questions in the interview schedule appeared to have face validity but were not pretested. T h e questions in the interview schedule that gathered information about childbirth were:
1) Has anyone in your family been to the hospital here or in Vietnam? 2) Why did they go to the hospital? 3) How was the hospital experience here in the U S . ? 4) How could it have been better? 5 ) What should be done o r avoided when you are pregnant? After childbirth? 6) Who should deliver the baby? Who should be present at the birth? Because of the broad exploratory nature and time limitations 254
of the study, one-time interviews were conducted, and the description and understanding of cultural beliefs and concepts were developed from one interview to the next. Information gathered from interviews conducted at the beginning of the study formed the basis for further and more detailed questioning regarding these concepts later in the study. Each interview varied slightly from one family to the next, as did the focus of the questioning. While this flexible interviewing style allowed individualization of each interview, it also makes replication and validation of findings difficult. T h e one-time interview also may have limited the depth of information obtained and perhaps discouraged complete disclosure. Other limitations of this study include the use of a convenience sample rather than a random sample and selection factors such as phone availability, willingness to participate, and selection by community workers or friends. T h e accuracy of information also may have been affected by the communications process necessary for interviewing respondents who speak another language and by cultural differences between investigator and respondent.
FINDINGS T h e sample interviewed was diverse in age, education, religion, and length of residency in the U.S., but was similar in previous urban residency. Eighteen of the 20 families had lived primarily in urban areas in North and South Vietnam. Nine of the interviews were conducted with nuclear families, eight with extended families, and three with households of single adults, some of whom were blood relatives. Male and female participation in the interviews was about equal, and questioning was directed toward all those present
at the time of the interview. Interviews lasted from one and a half to three hours. T h e most distinctive and consistent health practices were related to postpartum health practices. These practices largely involved activity and dietary changes and were considered especially important for primiparae. Most respondents also believed these activity and diet changes were important for later children, but the time period for these practices was usually shorter. O n e respondent explained that one should follow the practices for as long as one “could afford to.”
Activity Proscriptions Some of the practices related to the physical activity of the mother after delivery and included a period of bed rest, confinement in the home, and avoidance of showers, cold environments, and sexual intercourse. Eleven respondents stated that the mother should stay in bed, often with a fire underneath for warmth, from one week to two months. One woman said that the postpartum woman should not “let her feet touch the ground” for one week; however, the others agreed that the postpartum woman should stay in bed as much as possible for one week. In addition to the bed rest period, 14 of the 15 respondents who discussed childbirth stated that the woman should stay in the house for one week to three months, and six of the 14 agreed that three months was the appropriate time. T h e subjects believed that while in the house, heavy work should be avoided; if one must go outside, then one should dress warmly. One respondent stated that when she went outside, she covered her head and put cotton in her ears. Avoiding showers or baths and especially cold water after childbirth was another important prac-
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tice. T h e length of avoidance varied from one week to three months with most respondents citing a time period of up to one month. Three respondents said that a x&g, a type of facial steam bath, was allowed during this time period; another said the hair could be washed if absolutely necessary but then must be thoroughly dried. Two respondents stated that scrubbing the skin during the postpartum period would result in prominent hand veins at an early age. Another postpartum prohibition related to sexual intercourse. Although respondents were not asked specifically about intercourse, three women stated that intercourse should be avoided for three to four months after childbirth. These practices seem to be related to the idea of the women being “open” at childbirth. Several respondents stated that the joints or pores of the woman are open or enlarged at that time, and cold should be avoided or it will enter the body and cause sickness or weakness in old age. One man stated that the old women in America were all “bent over” as a result of not following these good childbirth practices.
Diet T h e proper postpartum diet was another area of special practice. Eleven respondents reported salty, “hot” food should be eaten after childbirth. T h e salty, “hot” food usually consisted of meat, fish, or rice cooked with salt or fish sauce and lots of black pepper. Foods that were less frequently suggested as proper postpartum foods included boiled green cabbage, soup, and fish. Two respondents offered reasons why one should eat the salty foods. One said it helped the stomach to contract after childbirth, and the other said the salty foods made the mother drink more
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water and thus the mother could make more breast milk. T h e respondents listed a number of foods to be avoided after childbirth. T h e most commonly prohibited item among the respondents was cold drinks. Vegetables, raw foods, fat, and citrus or sour foods such as pickles also were listed by many of the respondents as being prohibited from the diet. One respondent said beef should not be eaten, one said bananas and watermelon should be avoided, and another said meat or fish should not be eaten the first week. The range of time given for avoiding these foods was from one to three months. Several respondents gave reasons for avoiding particular foods. One said that drinking cold drinks would cause the bleeding to stop too soon, and it would be retained inside and cause a “fat stomach like American women have after childbirth.” T h r e e respondents said eating citrus fruits or sour things would lead to incontinence in old age. Another said raw foods should not be eaten because it would cause the “stomach to move too much,” which is to be avoided when it is stretched after childbirth.
Breastfeeding Practices and Diet Seven families had breastfed in Vietnam. T h e remaining families were not asked specifically about this practice. Those who breastfed in Vietnam did not breastfeed after giving birth in the United States. Only one respondent who gave birth in the U.S. had breastfed and then only for a few weeks: she “did not like it.” Other reasons for not breastfeeding included unavailability of enough nutritious food, poor appetite and low energy, and excessive weight loss with breastfeeding. Two women stated that they could not breastfeed because they had to work; one was told by her sponsor that bottle feeding was more nutritious; and
one said her milk was not good and had caused diarrhea in her infants in Vietnam. Some respondents suggested foods to be included in a good breastfeeding diet: pork cooked with vinegar, milk, soup made with animal bones, potatoes, papaya, fruit, and juices.
Childbirth Experiences in Vietnam In Vietnam, children were delivered predominantly by certified midwives in a special “birth house.” Eight women had delivered with a certified midwife and six had delivered with assistance from Western-trained physicians in a hospital or birth house. Two women had delivered at home: in one case, the father delivered the children; in the other, a lay midwife who was a neighbor assisted at delivery. These home births occurred 20 to 30 years before, and both families had later children delivered by a certified midwife in a birth house. In Vietnam, only two women had family present at the time of birth, in both cases the woman’s mother. Another woman, who was from a rural area of Vietnam and had her first four children delivered by a lay midwife, stated that no one should be present at delivery because the woman is “dirty” at that time. She also said that if children were present at the delivery, their intelligence would be lowered. This same rural woman said that at one of her deliveries she had a retained placenta for which the lay midwife had placed a type of leaf on her right toe and had given her onion juice to drink. Immediately the placenta was delivered, and the leaves were quickly removed to “prevent the intestines from coming out also.”
Childbirth in the U.S. Of the 20 families interviewed in this study, ten had experienced childbirth in U.S. hospitals with
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physicians assisting delivery. Comments regarding childbirth experiences were elicited from these ten families and from one woman who would be delivering in a few months after the interview and who had heard stories from other Vietnamese women. Of the 11 respondents, six had generally positive feelings and five had negative feelings in regard to their experiences. One woman stated that she liked being able to shower right away and had hated the confines of the house and bed in Vietnam in her previous pregnancies. T h e woman enjoyed American food and thought the American hospitals were better equipped than those in Vietnam. Another woman agreed that the early shower was more comfortable and said her husband had brought food to her in the hospital. Two women said their hospital experiences were satisfactory because they were multiparous and that adhering to Vietnam postpartum practices was not as important for subsequent pregnancies. One woman was afraid to get out of bed so soon after delivery but felt stronger afterwards because of it. Another woman refused the shower and had food brought to her in order to conform with her beliefs about proper postpartum practices. Most of the respondents’ negative comments had to d o with being unable to refuse to shower after delivery. T h e three women who had taken undesired showers now attributed chronic headaches to the experience. They also complained about the food and cold drinks that were given to them. Another woman had been lonely in the hospital because there had been no interpreters available. Although fathers were not present at deliveries in Vietnam, five of the ten men whose wives had children in the U.S. were present at delivery or would have liked to
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have been present. One husband was not present, and two women stated that their husbands would like to have been present but the women had not wanted them there.
Other Findings Another finding from this study is pertinent to the understanding of postpartum practices. T h e health-care experience of Vietnamese in America is that some respondents in this study experienced weakness, dizziness, or headache from routine blood sampling. T h e occurrence of these symptoms seemed to be related to the amount of blood taken.
DISCUSSION T h e findings of this study support those of Mathews and Manderson in regard to Vietnamese postpartum practices, particularly the practices and beliefs regarding the importance of avoiding cold drafts, cold drinks, particular foods, and b a t h i r ~ g .T~h. ~e preference for “hot” and salty food after childbirth seems widespread. However, breastfeeding appears to be decreasing as Mathews and Manderson, and others have Some Vietnamese women have attributed chronic health problems such as headaches to their inability to carry out their traditional postpartum practices, a finding that was also noted by Mathews and Mander~on.‘*~ There were some discrepancies between the findings of this study and those of Mathews and Manderson. Mathews and Manderson’s classification of “windy,” “tonic,” and “anti-tonic” were not offered by respondents in this study. However, the inclusion or exclusion of particular foods are similar in the two studies. Because this study identified and focused only on the classifications of “hot” and “cold,” other classifications may not have come to light. Also, foods with
“magical” properties were not identified in this study. Postpartum confinement to bed and to the home is a practice apparently in flux. This change may have already begun in Vietnam with increasing urbanization and employment of women (only three of the 17 women interviewed were housewives in Vietnam). Since most refugees in the U.S. work at lower income jobs, two incomes are necessary and this may cause further change in the length or nature of postpartum confinement. T h e presence of the father at delivery was favored by some respondents and not by others. This partial acceptance may be a compromise between the Chinese culture, in which the father is not expected to participate or be present at delivery, and the Hmong culture, in which the father’s participation is very i m p ~ r t a n t . ’ ~ , ’ ~ Almost half of the women in this study who had experienced childbirth in the U.S. had negative feelings about their hospitalizations. This dissatisfaction conflicts with the findings of Allen et al. who noted a high degree of satisfaction (94.3%) with hospital care of Southeast Asians in Oregon.17 This discrepancy may be explained by the differences in the study groups. T h e study of Allen et al. included Cambodians and Laotians and was limited to families with an Englishspeaking member. Another factor may be possible differences in hospital practices in the two areas. T h e concept of balance or A m / Duong may influence childbirth beliefs. Mathews and Manderson noted that the different trimesters of pregnancy are regarded as either “hot” or “cold” and particular foods are needed to balance these condition^.^.^ However, in this study no one described pregnancy and the puerperium in those terms, and in the general study respondents were not able to cite many conditions o r illnesses as
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“hot,” “cold,” or “phong” as Tung described.5 Nevertheless, treatments for these conditions appear to be consistent with the hot/cold balancing theory. This may be explained by the exclusion from this study of Chinese/Vietnamese who may have a greater knowledge of the hot/cold theory through their closer ties to Chinese medical thought. A difference inevitably exists between lay and professional understanding of medical treatments. Treatments and practices are accepted and followed because of tradition and practical experience, and not because the theory is understood. In this study, respondents knew which foods and practices were to be used or followed but not why.
IMPLICATIONS FOR NURSING T h e findings show that childbirth practices of Vietnamese in the U.S. have retained strong ties to the folk practices of the past. While some women may be willing or even happy to abandon some of these practices, others will resent and worry about breaking these taboos and may attribute future health problems to these events. Because childbirth is perhaps the most common opportunity for Vietnamese to experience U.S. hospital care, a negative reaction to the care received at this time may influence expectations for future hospitalizations and may foster a less than optimal situation. Obstetrical nurses can make the childbirth experience a positive one. Bridging communication gaps is an obvious need, and the nurse may act as advocate and facilitator in providing interpreters. Simple attempts at communication using the Vietnamese language will signal a willingness and interest on the nurse’s part. Obtaining a Vietnamese glossary for medical terms may be extremely helpful if inter-
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preters are not readily available.* Because of the family oriented nature of the Vietnamese, family members should be allowed to participate in the care of the patient and should be welcomed at the bedside. Before the delivery, it is important to ascertain whether o r not the father o r other family members will be present at delivery or in the labor room. Translating the routine diet of the hospital into food that is acceptable to the Vietnamese postpartum woman is very important, especially for the primiparous woman. Providing the option of warm water or tea instead of the usual ice water, assisting the woman to pick suitable foods from the hospital menu, or encouraging the family to bring in foods from home may allow the Vietnamese woman to follow her traditional beliefs. Concerns about nutrition and the effects of high salt intake may be legitimate in some cases, and the nurse may offset the negative aspects without prohibiting the practice by giving the woman supplemental vitamins a n d carefully monitoring the woman’s blood pressure. Allowing the postpartum mother the option of showering or simply leaving a bowl of warm water and towel .with which to wash may help the woman avoid the conflict of showering shortly after delivery. Early ambulation may be acceptable if the woman is allowed to dress very warmly and keep out of drafts. Because some Vietnamese find routine blood sampling alarming and may experience weakness or
* Medical guides and glossaries in the Vietnamese, Cambodian, and Lao languages may be obtained, for $8.00 each, by writing to the Indochinese Language Resource Center, 3030 SW Second Avenue, Portland, Oregon 97201; or calling (503)241-9393. Translated information on other health problems is also available.
other physical sequelae after blood drawing, minimizing the amount of blood sampling and allowing the woman to rest and drink fluids afterwards may prevent negative reactions. When interacting with Vietnamese, the nurse must remember that many will not voice their concerns or objections for fear of disturbing a harmonious relationship o r seeming to criticize the care they are receiving. T h e nurse should not assume silence or smiles signify agreement or contentment. Unbiased options should be offered to the patient so she may feel free to choose without offending anyone.
CONCLUSION Each Vietnamese is an individual with different experiences that have shaped her/his beliefs. T h e nurse must not assume that all Vietnamese share similar beliefs and practices or that Vietnamese beliefs are also true for other Southeast Asians. As always, the nurse should individualize each patient’s care. T h e nurse’s role also includes assessing and facilitating the special needs of refugees in the community. Providing information on community resources and appropriate follow-up care, and educating other hospital personnel to the unique needs of the Southeast Asian client are vital to the total care of the patient.
REFERENCES 1. Leininger M. Cultural diversities of health and nursing care. Nurs Clin North Am 1977;12:5-18. 2. Carr JE. Ethnobehaviorism and the culture bound syndrome: the case of Amok. Cult Med Psychiatry 1978;2:269-93. 3. Logan MH. Humoral medicine in Guatemala and peasant acceptance of modern medicine. In: Landy D, ed. Culture, disease and healing. New York: Macmillan
Publishing, 1977;487-495.
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4. Zborowki M. Cultural components in response to pain. J SOC Issues 1952;8:16-30. 5. T u n g T M . Indochinese patients: Cultural aspects of the medical and psychiatric care of IndoChinese refugees. Washington, D.C.:A.S.E.A. Action of South East Asians Inc., 1980. 6. Manderson L, Mathews M. Vietnamese attitudes toward maternal and infant health. Med J Aust 198 1 ;1~69-72. 7. Mathews M, Manderson L. Infant feeding practices and lactation diets amongst Vietnamese immigrants. Aust Paediatr J 1980; 16:263-6. 8. Gordon VC, Matousek IM, Lang TA. S.E. Asian refugees: life in America. Am J Nurs 1980; 11:2031-6. 9. Hollingsworth AO, Brown LO, Brooten DA. T h e refugees and child bearing: what to expect. RN 1980;43(I 1):45-8.
10. Spradley JP. T h e ethnographic interview. New York: Holt, Rinehart and Winston, 1979. 11. Glaser BG, Strauss AL. T h e discovery of grounded theory: strategies for qualitative research. New York: Aldine Publishing Co., 1967. 12. Chrisman NJ. T h e health seeking process: an approach to the natural history of illness. Cult Med Psychiatry 1977;1:35 1-77. 13. Kleinman A. Patients and healers in the context of culture. Berkeley and Los Angeles: University of California Press, 1980. 14. Kleinman A, Eisenberg L, Good B. Culture, illness and cure: clinical lessons from anthropologic and cross-cultural research. Ann Intern Med 1978;88:251-8. 15. Chung HJ. Understanding the Oriental maternity patient. Nurs Clin North Am 1977;12:67-75. 16. Lutheran Immigration and Refugee Services. Orientation sup-
plement: Hmong series. N e w York: Lutheran Council in USA, 1979. 17. Allen C, Juris P, Peterson J, Pullen K. Indochinese refugees: health assessment of a special population group. Unpublished research. Available from author at Multnomah County Health Department, Portland, Oregon, 1980.
Address for correspondence: Lois Wadd, RN, 2302 NE Tillamook, Portland, O R 97212.
Lois Wadd is a family nurse practitioner at Kaiser-Permanente Medical Care Program and at Planned Parenthood in Portland, Oregon. Ms. Wadd is certified as a family nurse practitioner by the American Nurses’ Association.
NAACOG DISTRICT FALL CONFERENCES
The 1983 District 111 Conference will be held October 3-4 at Bally’s Park Place Casino Hotel in Atlantic City, New Jersey. The theme of the meeting will be “Don’t Gamble with Women and Neonatesat Risk.” For further information, contact Stephanie Schrader, RNC, Zurbrugg Memorial Hospital, Rancocas Valley Division, Sunset Road, Willingboro, NJ 08046, (609) 877-6000, ext. 461. “Body, Mind and Spirit” is the theme of the 1983 NAACOG I District Conference. The meeting will be held October 2-5 at the Eastland Hotel in Portland, Maine. Conference Chairman: Gloria Stover, RN, 106 Columbia Road, Portland, ME 04103. NAACOG District Vlll will hold its 1983 Conference, “Get to the Point,” September 11-1 5 at the Pointe Resort in Phoenix, Arizona. For further information, contact officers in District VIII. “Highlights of ‘83’ is the theme of the District VI Conference which will be held September 13-14 at the Holiday Inn, Midtown in Milwaukee, Wisconsin. For further information, contact officers in District VI. ”
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