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Back to Table of Contents | May 2012

Pregnancy and Birth in Minnesotas Hmong Population

Changing Practices

By Trisha Halvorson

■ The arrival of the Hmong in Minnesota starting in the late 1970s brought many challenges to both an ancient way of life as well as to hospitals and clinics trying to care for these new refugees. For Hmong women who were new to the United States, their first encounter with the U.S. health care system was often during pregnancy and birth. This article summarizes how some of the perinatal practices of the Hmong evolved following their arrival in Minnesota as well as how providers adapted in order to provide their Hmong patients with culturally sensitive care.


Between 1975 and 1999 and then again between 2004 and 2006, Minnesota saw a significant influx of refugees from Laos as residents fled the aftermath of the Vietnam War and came here seeking asylum. Today, the Hmong constitute the largest Asian ethnic group in the state,1 and Minnesota is the state with the second-largest Hmong population in the country.2 The Hmong brought with them many traditions including their approach to addressing health concerns. Many relied on shamanism and herbal remedies for treating medical conditions.3 Pregnancy and birth were often the times when Hmong women had their first encounters with the U.S. health care system. During those encounters, their traditional culture clashed with Western values. With time, both the refugee women and the health care system adapted. This article looks at a few of the Hmong’s views of pregnancy and birth, examines how their practices have evolved with time, and explores how Minnesota’s medical system dealt with the unique challenges that working with this population has brought, thus eliminating some disparities in care between Hmong women and others.

Prenatal Care
In Laos, pregnancies were recognized around five months.4 When the Hmong arrived in the United States, they encountered a medical system that expected them to get prenatal care early and often. Used to no such thing in their native country, and confused and uncomfortable with cervical checks and other prenatal procedures, Hmong women often received care late in their pregnancies compared with other women. A study of Hmong births in Minnesota from 1976 to 1983 found that only 16% of women initiated prenatal care in the first trimester, and almost a third delayed care until the third trimester.5 In 1988, Minnesota had the fifth worst record for early prenatal care in the United States, which was attributed by some to the state’s large Southeast Asian immigrant population not receiving timely care.6

To find out what factors were contributing to this low prenatal care rate, in the late 1980s, Spring et al. interviewed Hmong women living in Minneapolis who had experienced a pregnancy during the last four years about their knowledge of and attitude toward prenatal care.7 They found that nearly half of the women did not understand the rationale for the pelvic exam and that almost two-thirds found the pelvic exam unacceptable. The majority of women interviewed stated they were given no warning about their first cervical check and that they found it to be a shameful and embarrassing experience. Hmong women also disliked the hours clinics were open and felt that there wasn’t enough continuity of care. The researchers found that Hmong women wanted full explanations of procedures but were unable to understand such explanations because of the language barrier.

In response to the findings, one Twin Cities clinic that served a number of Hmong patients, the Community University Health Care Center, expanded its clinic hours and added an on-call interpreter. The clinic’s administration also created a video, which described in Hmong the procedures used during prenatal check-ups and the reasoning behind them. In addition, they hired a nurse midwife who spoke some Hmong and decreased the number of pelvic exams during pregnancy to none or one or two. Follow-up interviews conducted in 1993 found that Hmong women felt more positive about their experience with prenatal care than before. They also found procedures were perceived to be more acceptable by the women who viewed the video.7

The prenatal care rate of Hmong women in Minnesota appears have improved. Although rates specifically for the Hmong are unavailable, data concerning the state’s Asian population, of which the Hmong are the largest group, show an improved rate of early prenatal care. Using GINDEX, an index on the adequacy of prenatal care (determined by gestational age at birth, the trimester during which prenatal care began, and the total number of clinic visits), the rate of adequate prenatal care in Minnesota’s Asian population between 1989 and 1993 was 43%. By 2007, the rate had risen to 71.6%. The rate of Asian women who had inadequate or no prenatal care dropped from 20.8% between 1989 and 1993 to 5.1% in 2007.8 Similar trends have been noted among Hmong women in Wisconsin.9

Birth
In Laos, women worked throughout pregnancy, until labor set in, at which time their husbands would assist with the delivery. During thedelivery, the woman would squat in front of her husband, who sat behind her on a stool to support her. The women, who were taught to be stoic about pain, were silent throughout labor.10 If labor was difficult, a medicine woman or a shaman would be called to perform rituals and provide herbal remedies.11 Following delivery, the placenta of the child would be buried either near the center post of the house or near the bed, depending on the infant’s gender. After death, the person’s soul would retrieve it for safe passage to the spirit world.12

For the first 28 days after birth, the mother was served a diet of boiled chicken, eggs, broth, hot water, and rice to restore strength and vitality, in accordance with the Hmong belief that pregnancy is a heat-losing event and must be counteracted by eating only hot foods. To augment this heat gain, the woman would sleep beside a campfire with her infant for three days.13 Failure to do so could result in health problems for the mother such as infertility and arthritis.

Arrival in the United States forced Hmong women to change their birthing practices and hospitals to accommodate the needs of Hmong women. Initially, births in this country were similar to those in Laos, with the addition of birthing attendants and cervical exams. According to Ann O’Fallon, a nurse who worked on the nurse-midwife unit of Hennepin County Medical Center at the height of the Hmong influx, “the Hmong moms labored in seeming serenity. None of the verbal or physical cues common among U.S. moms were present. They sat in bed, often accompanied by their husbands, until the right moment occurred and they got out of bed to squat on the floor, ready for delivery. Their husbands would help support them by holding their arms from behind.”14 Resistance to cervical exams was universal among Hmong women who, because of a combination of factors including modesty, trauma from refugee camps, historical knowledge that exploring a woman’s pelvis with unsterile hands can cause life-threatening problems, and lack of knowledge about the usefulness of the procedure, avoided them.15 During labor and delivery, women generally wore a blouse and sarong-type skirt. If a nurse tried to push the sarong up to do a cervical check, the woman would push it back in place as a form of resistance and self-assertion.14

Once in a squatting position, the women would allow the midwives to assist in the delivery, with the midwives often kneeling or laying on the floor to help with the birth.14 After a mother delivered, she went back to bed to rest and seemed to express little interest in her baby or in breastfeeding. Often, other breastfeeding family members arrived to take care of the baby until the mother’s milk came in.

In Minnesota, hospital staff often made mistakes because of lack of cultural understanding. For example, hospital staff who wanted new mothers to “bond” immediately with their babies didn’t understand that in the Hmong culture, women allowed themselves a much-deserved rest following birth and would re-engage with their babies when their milk came in.14

When the Hmong began arriving in Minnesota, no Hmong interpreters were available to convey new mothers’ needs, and few providers understood the nuances of the Hmong culture. Hospitals and clinics had to try to discern the needs of Hmong women and adjust accordingly. St. Paul Ramsey Medical Center (now Regions Hospital) in St. Paul was one of the first to hire trained interpreters, which attracted Hmong women to the hospital.16 Hennepin County Medical Center worked to incorporate traditional practices to accommodate Hmong mothers. For example, nurses would bring hot tea rather than ice water and the hospital kitchen began serving Hmong women chicken and rice.14 This brought a number of Hmong women to the hospital.16

With time, Hmong traditions also changed. Deliveries began to look more westernized. There were fewer silent births.14 As their birthing practices evolved, new programs were established to teach Hmong women Lamaze and prepare them for labor and delivery in an American hospital.17

Cesarean Sections
In Laos, cesarean sections were unheard of, and cutting the body was feared (some believed it allowed the spirit to escape) in the Hmong culture.11,18 Clashes occurred as Hmong women began giving birth in hospitals where c-sections and episiotomies were common. American providers encouraged c-sections for the health of the mother and child, but the Hmong resisted. As Amos Deinard, M.D., and Timothy Dunnigan, Ph.D., noted in their reflection on caring for Hmong refugees, “OBs were ignored when they advised mothers to have a c-section. Patients chose to deliver at home or to go through a protracted labor despite advice that to do so posed a serious risk to the unborn child’s central nervous system.”19

Also, because of the patriarchal system, women could not make the decision to go to c-section on their own. Instead, community elders and spiritual leaders had to grant permission for them to have the procedure.14 For this reason and others, the Hmong had some of the lowest cesarean rates around. A study of Hmong births in California from 1985 to 1988 found c-section rates for Hmong women were one-half to one-tenth the rate for white women. In other words, about 3.9% of Hmong mothers had c-sections compared with 28.3% of white mothers.20 Another study from 1995 that looked at Hmong births in Wisconsin came up with a similar figure, 3.6%.15 Yet another study of Laotian women living in Washington from 1993 to 2006 showed a cesarean rate around 11%.21 The national rate for all women hovered around 20% during the 1990s. Similarly, data from 1990 to 2001 show Hmong cesarean rates nearly 15% lower than the U.S. average for any given year and approximately 10% lower than the average for other groups in Minnesota during the same time periods.22

The Hmong and Breastfeeding

Breastfeeding was common in Laos but not embraced. Bottle feeding was often perceived as superior. In one study, 58% of women who had given birth in Laos or Thailand stated that they had breastfed their infants because of the unavailability of formula or because of the expense of bottle feeding.1 Many Hmong women believed that colostrum was unhealthy for the baby and would utilize a wet nurse in the early days postpartum until her milk came in.2 An article on infant feeding in Australia reports that Hmong women thought colostrum caused stomach problems such as diarrhea in infants and that they perceived it as “dirty” because its yellowish color was similar to that of pus or other signs of infection.3 Of Hmong women who did breastfeed in Laos, many did so because it was the only option available to them.4

Within six months of arriving in the United States, the percentage of Hmong women who were continuing to breastfeed had dropped to 25%.2 Swora found that Hmong women in the United States were dissuaded from breastfeeding for a number of reasons. For one, breastfeeding was viewed as inconvenient and “unfashionable.” It was associated by some with the chronic fatigue, likely from anemia, that was experienced in the refugee camps, and it conflicted with work and English classes. In addition, bottle feeding was perceived as being healthier for babies. Some thought that with bottle feeding, their infants would grow as tall as Americans. In addition, 65% of women noted a lack of instruction on breastfeeding and that the language barrier made it difficult to request help with it while in the hospital.2 As fewer and fewer women in the Hmong community breastfed, fewer wet nurses were available to women in the early days postpartum, making it more difficult for the women who did wish to breastfeed to do so. In addition, the formula sent home from the hospital as well as a continuous supply of free formula granted to women through the Women, Infants, and Children (WIC) program all deterred women from breastfeeding.

The number of Hmong women who breastfed continued to decrease in the 1980s and into the mid-1990s, with rates hovering near 10%.4,5 Despite targeted education by the state of Minnesota, which produced videos and pamphlets in Hmong on the importance of breastfeeding,6 and Hmong-focused initiatives by the St. Paul Ramsey WIC program,7 rates of breastfeeding are still believed to be lower among the Hmong than among the general population. Findings from a Minnesota Department of Health-sponsored Hmong focus group reveal that Hmong women, especially those who are employed, viewed breastfeeding as inconvenient; that women were getting little information about breastfeeding from their health care providers; and that babies who were breastfed were believed to have more gastrointestinal issues. In addition, the women indicated that breastfeeding is now discouraged by Hmong community elders and family members.8

References
1. Jambunathan J, Stewart S. Hmong women in Wisconsin: What are their concerns in pregnancy and childbirth? Birth. 1995 Dec;22(4):204-10.
2. Swora RJ. Factors that influence Hmong mother preference for breastfeeding and/or bottle feeding. Unpublished thesis, 1984. Box 7, Folder 9. The Refugee Studies Center, University of Minnesota Records, General/Multiethnic Collection, Immigration History Research Center, University of Minnesota.
3. Liamputtong P. Infant feeding practices: the case of Hmong women in Australia. Health Care Women Int. 2002;23(1):33-48.
4. Kornosky JL, Peck JD, Sweeney AM, Adelson PL, Schantz SL, et al. Reproductive characteristics of Southeast Asian immigrants before and after migration. J Immigr Minor Health. 2008 Apr;10(2):135-43.
5. Tuttle C, Dewey K. Impact of a breastfeeding promotion program for Hmong women at selected WIC sites in northern California. Published article, 1995. Box 7, Folder 72. The Refugee Studies Center, University of Minnesota Records, General/Multiethnic Collection, Immigration History Research Center, University of Minnesota.
6. Lee K. Breastfeeding for healthy babies and healthy moms [Motion picture], 2006. United States: Minnesota Department of Health. 7. Minnesota Department of Health. Pregnant women, mothers and infants: Breastfeeding. Available at: www.health.state.mn.us/divs/cfh/na/factsheets/pwmi/breastfeeding.pdf. Accessed April 19, 2012.
8. Minnesota Department of Health. Breastfeeding supports and challenges: Mothers’ perspectives on healthcare, worksites and social influences. Available at: www.health.state.mn.us/divs/hpcd/chp/cdrr/earlychildhood/docsandpdf/Infantfeedingreport2010.pdf. Accessed April 19, 2012.

Pregnancy Outcomes
Despite having numerous risk factors for poor pregnancy outcomes including refugee status, short stature, extremes on both ends of the maternal age spectrum, high parity, late prenatal care, and poor nutrition during the early years of resettlement, Hmong women were found to have superior pregnancy outcomes. A study of Hmong women when they first arrived in Minnesota during the late 1970s through the mid-1980s showed that they had lower rates of both preterm deliveries as well as fewer children born at low and very low birth weights as compared with controls.5 Studies of various Hmong communities throughout the United States showed similar findings.20,23 In addition, other migrant groups had similar pregnancy outcomes during their early days in the United States.24 One theory as to why these women had superior pregnancy outcomes is the healthy migrant effect, which posits that immigrants are healthy when they first arrive in this country. However, factors such as poverty, living in substandard housing, lack of access to medical care, and adopting bad American health habits (such as eating a poor diet, smoking, and substance abuse) are believed to play a role in the deterioration of that health advantage in subsequent years and generations.24,25

The early positive birth outcomes didn’t last. A study by Cripe et al. in 2007 found that in a cohort of Southeast Asian women in Washington, Laotian women were more likely to deliver low-birth-weight babies and were at moderately increased risk for preterm delivery.21 In Minneapolis, rates of both preterm births as well as low-birth-weight infants among Asians were found to be quite similar to the Minnesota state averages between 1990 and 2001.26,27

Conclusion
It often was not until they needed care during pregnancy and childbirth that Hmong women who were new to Minnesota would encounter the U.S. health care system for the first time. At the outset, many medical providers expected that once interpreters and explanations of procedures were provided, Hmong women would readily accept Westernized care.19 This did not turn out to be wholly true. Hospital and medical staff did not help as they brought the wrong foods, attempted to perform unwanted pelvic exams and surgeries, and tried to force bonding between mother and baby immediately after birth.

After the misfires at the outset, hospitals changed their policies in order to accommodate the needs of Hmong women. Hospitals honored Hmong women’s desire for more delicate prenatal care, Hmong interpreters, culturally sensitive education, and traditions surrounding birth. As hospitals and clinics started understanding and meeting the needs of Hmong women, the women began to accept American practices around perinatal care. Early prenatal care, and Western labor and delivery have all become much more prevalent among the Hmong during the last 30 years. Still, cultural beliefs about surgery continue to make this group hesitant to embrace c-sections even when there is the potential for harm to both the mother and child.

Over the years, both hospitals and the Hmong have in many ways adapted their practices. The Hmong have become acculturated to Minnesota, and health care providers have learned a great deal about the traditions and values of this important population. MM

Trisha Halvorsen is a fourth-year medical student at the University of Minnesota.

References
1. McMurry M. Hmong and Koreans are Minnesota’s largest Asian groups. Minnesota planning news release, October, 1991. Box 1, Folder 9. The Refugee Studies Center, University of Minnesota Records, General/Multiethnic Collection, Immigration History Research Center, University of Minnesota.
2. Johnson SK. Hmong health beliefs and experiences in the western health care system. J Transcult Nurs. 2002;13(2):126-32.
3. Helsel DG, Mochel M, Bauer R. Shamans in a Hmong American community. J Altern Complement Med. 2004;10(6):933-8.
4. Faller HS. Hmong women: Characteristics and birth outcomes, 1990. Birth. 1992;19(3):144-8; discussion 148-50.
5. Edwards LE, Rautio CJ, Hakanson EY. Pregnancy in Hmong refugee women. Minn Med. 1987 Nov;70(11):633-7, 655.
6. Koch W. Infant mortality report says state both good and bad. Rochester Post Bulletin. August 14, 1991. Box 11, Book 3. The Refugee Studies Center, University of Minnesota Records, General/Multiethnic Collection, Immigration History Research Center, University of Minnesota.
7. Spring MA, Ross PJ, Etkin NL, Deinard AS. Sociocultural factors in the use of prenatal care by Hmong women, Am J Public Health. 1995;85(7):1015-7.
8. Minnesota Department of Health. Early and adequate prenatal care. Available at: www.health.state.mn.us/divs/cfh/na/documents/prenatalcare2010.pdf. Accessed April 24, 2012.
9. Kornosky JL, Peck JD, Sweeney AM, Adelson PL, Schantz SL, et al. Reproductive characteristics of Southeast Asian immigrants before and after migration. J Immigr Minor Health. 2008;10(2):135-43.
10. Erwin A. A physician’s guide for understanding Hmong health care beliefs. Available at: www.d.umn.edu/medweb/Erwin/hmong.html#Pregnancy. Accessed April 24, 2012.
11. Downing BT. Hmong in the West: Observations and Reports. 1985. Manuscript. Box 20, Folder 1. The Refugee Studies Center, University of Minnesota Records, General/Multiethnic Collection, Immigration History Research Center, University of Minnesota.
12. Helsel D, Mochel M. “Afterbirths in the afterlife: cultural meaning of placental disposal in a Hmong American community.” J Transcult Nurs. 2002;13(4):282-6.
13. Doyle M. Ancient tradition explained- why Hmong mothers eat boiled chicken. Hmong Times. September, 1 1998. Box 5, Folder 67. The Refugee Studies Center, University of Minnesota Records, General/Multiethnic Collection, Immigration History Research Center, University of Minnesota.
14. O’Fallon A. Personal communication. January 17, 2011.
15. Jambunathan J, Stewart S. Hmong women in Wisconsin: What are their concerns in pregnancy and childbirth? Birth. 1995;22(4):204-10.
16. Suzukamo L. Medical interpreters play vital role in effective care. St. Paul Pioneer Press. December 26, 1988. Box 11, Book 3. The Refugee Studies Center, University of Minnesota Records, General/Multiethnic Collection, Immigration History Research Center, University of Minnesota.
17. Hmong Lamaze classes assist women during labor and delivery. Asian Pages. September 10, 1993. Box 11, Book 3. The Refugee Studies Center, University of Minnesota Records, General/Multiethnic Collection, Immigration History Research Center, University of Minnesota. 18. Faller HS. Perinatal needs of immigrant Hmong women: Surveys of women and health care providers. Public Health Rep. 1985;100(3):340-3.
19. Deinard AS, Dunnigan T. Hmong health care- reflections on a six-year experience. Int Migr Rev. 1987;21(3):857-865.
20. Helsel D, Petitti DB, Kunstadter P. Pregnancy among the Hmong: Birthweight, age, and parity. Am J Public Health. 1992;82(10):1361-4.
21. Cripe SM, O’Brien W, Gellaye B, Williams MA. Maternal morbidity and perinatal outcomes among foreign-born Cambodian, Laotian, and Vietnamese Americans in Washington state, 1993-2006. J Immigr Minor Health. 2011;13(3):417-25.
22. Minneapolis Department of Health and Family Support. Minneapolis vital statistics: Percentage of births delivered by cesarean 1990-2001.
23. Weeks JR, Rumbaut RG. Infant mortality among ethnic immigrant groups. Soc Sci Med. 1991;33(3):327-34.
24. Wingate MS, Alexander GR. The healthy migrant theory: Variations in pregnancy outcomes among US-born migrants. Soc Sci Med. 2006;62(2):491-8.
25. Fennelly K. The “healthy migrant” effect. Minn Med. 2007;90(3):51-3.
26. Minneapolis Department of Health and Family Support. Minneapolis vital statistics: Percentage preterm births (less than 37 weeks gestation) 1990-2001.
27. Minneapolis Department of Health and Family Support. Minneapolis vital statistics: Percentage low birth weight births (born less than 5.5 pounds) 1990-2001.

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