International Women’s Day, a day to celebrate the accomplishments of women both past and present, was celebrated earlier this month. During my recent trip to Vietnam helping to care for women patients, I had the opportunity to hear many women’s stories, see their hard work both in the hospital and in the shops and visit the Women’s Museum in Hanoi.
Each day on my walk to the hospital I encountered women that had arisen before dawn to start food preparation at their street-side restaurant or had traveled to the wholesale market to purchase fruit for sale at their sidewalk stall during the day. Many of these women have husbands and children who live hours away in a rural location who they only have the opportunity to visit a few times each month. The income earned in the city makes it possible for their children to attend school, as public school carries fees of $25-30 each month.
Women who remain in rural locations closer to their families are responsible for all the domestic work in addition to working in the families rice plot. The rice plot is a source of not only food for the family, but also cash income as some of the rice is sold. While Communism has afforded women the opportunity to be employed outside of the home, it has not coerced men into assuming any of the household responsibilities. A Vietnamese meal is delicious, but time-consuming to prepare as it contains no processed components. Due to lack of refrigeration, prepared food is consumed immediately and there is not the availability of saving food for a future meal. In the urban areas, many of the married men in their 30-40’s helped with some of the food prep and child care. This cooperative marriage model has not filtered out to the 65% of Vietnamese who live outside of the cities.
Similar to China, Vietnam has a 2 child policy that was implemented in the late 1980’s to control population growth. A patriarchal society that depends on a son to carry on the family name often comes into conflict with the reality of a family that consists of 2 daughters. This has led to utilizing abortion for sex selection and upsetting the gender balance of the society. Although contraception is free there is a lack of sex education and general taboo against pre-marital sex, resulting in many unplanned pregnancies outside of marriage. Young girls bear the brunt of these cultural beliefs, often visiting clinics or hospitals in secret to have an abortion.
Approximately 1/3 of the ob/gyn residents I worked with were women, most unmarried and living at home with their parents. Only a few of the attending physicians were women, a prevalence that was familiar from my early residency days. One of the attending physicians lamented the dual roles that Vietnamese culture places on professional women – achieving personal high educational performance and job status in addition to perfection in raising children and household responsibilities. Young women physicians worried that their “advanced age” of 25-27 years was making them less eligible for marriage. It seems that women in Vietnam and the US share many of the same concerns regarding careers and home.
Family is very important to Vietnamese, influenced by the Confucius culture of China. The most important job for a woman is to bear children and her worth within the community is influenced by this ability. Having sons is considered the highest praise. Adoption is only considered if a couple is unable to have children of their own. Each day as we saw many women in clinic, one of the first items discussed in their health history was whether or not they had children. It was assumed that all women wanted 2 children, without asking the woman. For this reason, there seems to be an unwritten taboo against birth control, as even health professionals falsely believe that it may influence a woman’s future ability to become pregnant. Unfortunately this mindset has resulted in Vietnam having the highest abortion rate in Asia. Abstinence only education doesn’t work in either America or Asia!
Walking the crowded hallways of the hospital on the obstetrical floor afforded me a brief glimpse into the world of women as they supported each other during the process of childbirth. Sisters, mothers and mother-in-laws often surrounded the pregnant women as she labored on a narrow cot or weaving her way down the packed hall. Food was cooked at home and brought in, urine buckets were taken away and emptied, arms were offered for support. Older women help new moms to breast feed and care for newborns. After a 7 day stay in the hospital (compared to 2 days in the US), moms are proudly escorted home by their husbands on the back of a scooter – the primary means of transportation in Vietnam. If employed, they are eligible for 6 months maternity leave.
Compare this family centered care to the medical care of women in labor or gynecology. Acquisition of technology to advance medical care has markedly improved in the past 10 years, but there has not been a similar interest in developing patient centered care. Women deliver their babies on a unpadded metal table with no family or friends nearby and nurses and doctors that are too busy to provide comfort. During gynecology clinic, patients are led into a room containing 10-15 students/residents/attending physicians that are all discussing her medical record. The nurse helps her climb up onto the exam table, again unpadded, so that she can undergo 4-5 pelvic exams while everyone continues to watch and discuss. Sometime after she leaves the room, a physician has a brief conversation with her and her family in the crowded hallway with a treatment plan. Most of these women feel privileged to be able to afford this care as it is only available to those who can pay the yearly fee for health insurance. They have the opinion that “the doctor knows what is best for me” and don’t question recommendations. This is changing as patients in private hospitals are demanding more interaction with their physicians and lawsuits have started to climb.
As in many parts of the world, the power and influence of women is changing age-old traditions. The overall rapid progress of change in Vietnam elevates the voice of women as they advocate for change that benefits their role as well as that of policies that benefit their families. Our role in the West is to provide educational support while allowing leaders within Vietnamese health care to create systems that work for their people.