Senior Lecturer, Australian Centre for International and Tropical Health and Nutrition, 4th Floor Public Health Building, Medical School, Herston Rd., Herston Qld 4006 Australia. Phone 61 - 7 - 3365 5415 Fax : 61 - 7 - 3365 5599 E-mail: M.Whittaker@mailbox.uq.edu.au
Paper for the Vietnam Studies and the Enhancement of International Cooperation Conference, Ha Noi, July 14 - 17, 1998
Women and men live in bodies that experience a range of feelings and respond to a range of stimuli and circumstances (Good 1994; Martin 1989, Turner 1992). Often these bodies in which they live are not fully understood by them. Their explanation of what happens to them and how their bodies respond are based on a range of contexts : social, economic, cultural, political and environmental (Sholkamy, 1996; Moore 1994).
One of health issues highlighted recently is the experiences of women, often hidden and unspoken, of reproductive tract infections (RTIs) (Dixon-Mueller and Wasserheit 1991; McDermott et al 1992; Wasserheit 1989; Bang 1991; Jacobsen 1991). The medical, social and economic consequences of these health problems and the need for public health programmes to address this problem have been highlighted (UN 1995; Wasserheit and Holmes 1992; McDermott et al 1992; Whittaker and Larson, 1996; IBRD 1993; Brunham and Embree 1992; Meheus 1992; Germain et al 1992; Ronald and Aral 1992). Many feminist activists have highlighted the need for more attention to be paid to RTIs and other aspects of women’s and men’s sexual and reproductive lives and for research on “communities' knowledge, attitudes and practices related to sexuality and RTIs." Since "language and symbols must be interpreted before messages and strategies can be designed” (Antrobus, Germain and Nowrojee, 1994 p.19) for the prevention and treatment of these infections (Goldin, 1994).
In Vietnam, the prevention and management of RTIs has been identified as an important area for development. Recently some efforts have been to:
- define prevalence of RTIs/sexually transmitted infections (STIs),
- gain an understanding of words used by women,
- improve provider knowledge and skills in RTIs and
- review the appropriateness of the syndromic approach to management of STIs
(Elias 1997; Nguyen Thi Loi and Uhrig 1997; Nguyen Thanh Mai 1994; Nguyen Thi Hoai Duc 1995). The need for greater understanding of the contexts and constructs of sexuality, sexual and reproductive health in Vietnam has been highlighted for the development and implementation of a comprehensive reproductive health programme (Do Trong Hieu et al 1996; Alam et al 1995).
Interest has been expressed about the potential and real effects of changing society norms, expectations and political/economic contexts upon people's lives and their health with specific attention in Vietnam on the socio-economic changes since doi moi (economic renovation) (Clement 1996; Turley and Selden 1993; Pelzer 1993; Havanon and Archavanitkul 1997; Le Thi and Do Thi Binh 1997; Forbes et al 1991; Tran Thi Van Anh and Le Ngoc Hung 1997).
In this paper I describe some Vietnamese rural women's perspectives of the modern pressures for productivity and consumerism and the effects on their reproductive health. It focuses on how women describe the relationship between the causes of vaginal discharge and their economic conditions and working lives. This discussion is conceptualised in terms of how women perceive the modern pressures of improving economically and spending more on commodities and services.
The data used is derived from ethnographic field work conducted in the Red River delta in 1997, and a range of small qualitative research, training and consultancy activities conducted in Vietnam since 1993. Other contextual information has been gained from magazines, newspapers and organisation's publications and promotional materials during this time period as well as literature review of published and unpublished materials.ii
Before exploring how women relate the "modern pressures" of economic growth and the impact of changes in financing of social services and goods, upon their reproductive health, one needs to understand women's beliefs of causes. The following briefly details my informants' model of causes of vaginal discharge and may not in all cases reflect a "medical" model.
Women described a range of direct and indirect causes of their vaginal discharges. Prominent amongst these is dirty water. Women described a range of ways that dirty water affected their health especially their reproductive health. These included
- direct contact of dirty water to their vaginal tract during work and bathing;
- absorption of the dirty water through the genital tract, especially during menstruation;
- absorption through the skin pores and therefore entry into the body which could make them weak;
- ingestion through food contaminated by dirty water when watered in the fields, when cooked and through drinking.
The water is dirty through a variety of mechanisms. All of these seem, to women, as inevitable because they are poor and agricultural. These "contaminants" include: animal manure, insecticides, fertilisers, human wastes, duck stools, bacteria, dirty air. Dirty air itself can lead to discharge through its effects on the body. This dirty air included insecticides in the air and "bad air" arising from dirty water:
If you soak your leg in the water, then the water is absorbed and has an effect on the body. It is absorbed through the pores … it is absorbed regularly. It may be absorbed into your pants to the vulva. Dung FGD 8.
During the season, they use a lot of insecticides - poisonous substances. The women breathes in and it has a lot of effect on the woman’s body … Especially when it is absorbed into the reproductive parts, it has more effect. .... Or it is absorbed into the blood and affects little by little the woman’s body. Indepth 20 Mai
Another major cause of vaginal discharge is poor health. Many women described how vaginal discharge is one way the female body "expresses" illness and weakness - like a curette inside the womb. Therefore things that contribute to ill health such as working hard and eating little; menses and childbirth; worry; polluted environments - are indirect causes of vaginal discharge. Ill health and weakness also increase the body's susceptibility to adverse consequences from other "insults" such as IUD insertion or immersion in water. Worry causes women to become weak, eat and rest less. (Gammeltoft. T 1997)iii.
Some typical comments include:
A lot of discharge - eat little, work a lot - so they have a lot of discharge FGD 17 Ngu
Basically we here in rural areas work hard. Because of weakness it is very hard. Have the IUD inserted and have IUD effect. FGD 13 Noi.
Poor personal hygiene practices and conditions were seen as another major cause of vaginal discharge. The need to wash the genital region at least daily, especially after working in dirty fields, and during menses was identified. However many women stressed that because there are other "unavoidable " causes such as absorption through exposure to water in the fields, dirty air and ingestion - hygiene alone cannot prevent discharge.
Bad hygiene causes infection or makes it more serious FGD 2 Thai
They ( health workers) may tell that (it is because) we don't wash cleanly. But even if (we) wash cleanly we are not clean - because it is absorbed. Even if (we) wash, (dirt etc is) still absorbed. FGD 8 Dung
A large number of women hold the health services responsible for their vaginal discharge - by the IUD and poor hygiene conditions of the health services. Although not all women could explain a mechanism for the IUD and its role in causing weakness, some women referred to increased menstrual blood loss and scratching the inside of the womb and the fact that it is a foreign body. The poor adherence to clinic staff and facility hygiene practices eg. sterilising equipment between clients, was identified as an important iatrogenic causes.
Not resting, especially postpartum, post MR abortion, post IUD can directly cause discharge or may cause other health effects which lead to discharge. Many women described how women's bodies were vulnerable to such diseases. They ascribed this to anatomical featuresiv and reproductive functions of the female body and inherent "female weakness"v. A few women discussed how even though men may be exposed to dirty water and may have poor hygiene they don’t get these problems - but may cause these problems for their wives through sexual intercourse.
Women described some vaginal discharges symptomatic of sexually transmitted infections, although most of the rural respondents did not see this as a major cause of their discharges. Only a few types of vaginal discharge were described as physiologically normal.vi
Types of care
Women detailed a range of treatments they used to prevent or manage vaginal discharges. A common mode of prevention was to avoid, if possible, the causes of the discharge, especially during "susceptible times". Therefore they described avoiding soaking their bodies in water especially during menses and after IUD insertion and abortions; avoiding hard work when they should rest such as postpartum, post MR, post IUD and during menses; avoiding sex during menses; and avoiding some foods such as "hot" foodsvii.
They discussed the role of hygiene - including genital washing at least once a day, and more often during menses; changing clothes and under-garments regularly including menstrual cloths or paper during menses; and ensuring husband's genital cleanliness before sexviii as important preventive measures. Some women also discussed the use of prophylactic antibiotics after MR and IUD insertionix.
Washing the genital area was described as a first line " treatment" when women had early signs of discharge disease. This washing was best if clean water (such as boiled water, rainwater) could be used. Often water's "cleansing" action was augmented by women adding salt, guava leaf, Sim (Rhodomyrtus tomentosa) leaves or green tea in the water for "antiseptic and antibacterial" properties. In addition, commercially available "female hygiene washing powders" produced in Vietnam and sold over-the-counter were used. Often these treatments were part of the health workers "prescription" for care and were also utilised for serious infections.
Self treatment is a common resort. Women often discussed asking each other what to do - especially when they first have the discharge eg after marriage or when they experience "new" signs or symptoms. They may "interrogate" a woman who is examined during in the gynaecological health campaignsx to learn more about what was found, what symptoms she had and what was prescribed in order to improve their ability to self treat. This ranges from doing little at all, especially if they feel that they can overcome the problem themselves, through to purchasing drugs and medicinesxi from pharmacies and traditional healers.
If they think that they can overcome (it), they try to overcome by themselves. If (the problem is) excessive, and they cannot treat by themselves, they have to go to the doctor. …. They rarely go to the doctor, because to go to the doctor we must have money. . . . And women are always reluctant to go because of this reason. … If you meet the doctor and have a disease diagnosed but you cannot (afford to) treat it, you will be very worried. So its better that you don't go" FGD 2 Ghi.
Formal medical care was usually sort when:
1. women are experiencing something for the first time
2. it is part of a family planning or gynaecological campaign/consultation and
3. serious signs and symptoms appear such as fever, itch, yellow or green colour, pain, unbearable (and unable to work), bad smell or affecting their "family life" ( ie. sexual relationships).
In these cases usually hygiene and oral and/or vaginal antibiotics were prescribed. In addition, if the cause was felt to be related to IUD use, the IUD may be removed. Partner follow-up and/or treatment was rarely discussed by either women or providers.
Rest and moderation in activities, including sexual, was also often part of women's treatment for serious infection and to prevent worsening of existing "disease". Many health workers also prescribed this - however many women found this instructions impossible (although desirable) to follow. Some women described the role of eating strengthening foods, especially to strengthen the blood. These foods included meats especially duck meat and duck eggs. The use of cooling foods and tonics were also discussed.
Pressure to earn, pressure to produce
Women described their role as producers of food (paddy) which was also the main source of income; providers for the family; keepers of family happiness, and as mother and wife. They also described their role to society and for the State (Le Thi 1997a, Tran Thi Nghia 1997). As described below, many of these roles make it difficult for women to practice the prevention and management practices required for vaginal discharge and reproductive health, and may place them at risk for these health problems.
As one woman said, describing the agricultural work :
(There are) Many low lying lands and women have to soak their bodies in water for a long time. Of course women know that it will cause an effect on their health. A lot or a little (effect) on their reproductive organ. Know that - but they still have to do (the work). Because they have no economics and have to ensure their family life - still have to do it Indepth 20 Mai
In addition to their own familial need to produce paddy there is a State pressure for women to contribute to economic and agricultural development. Part of "economic renovation" is increasing agricultural outputs, through improved agricultural practices, higher yielding rice strains, more intensive agricultural practices and improved household income levels. The pressure to produce and more successfully is reinforced time and time again by State authorities. Tran Thi Van Anh and Le Ngoc Hung (1997) describe how "The quantity of pesticide used tends to increase every year as demands on agricultural development increase" (page 119). Another example of this pressure comes from one of my study communes. On International Women’s Day 1997 the women didn’t get any flowersxii. Instead they received lectures from authorities urging them to increase the productivity of the land and thereby help the commune to be more successful. Some examples of this "bouquet" of exhortations
increase fertiliser and insecticide protection for paddy spraying - and try to produce 57 ta per hectare. … Try to use the new variety of rice for higher yield Phi, VWU Chairwoman
economic development needs the participation of women. Try to increase production to 62 - 65 ta per hectare Commune Chairman.
“wish every women health and success to do all their work, for the sake of the family, household and society. A clean rich and beautiful commune to build a beautiful and rich country” Commune President.
One woman reflected upon these "pressures" from economic reform.
Now each family sees just a few insects and sprays immediately… The old people worked also, but never had to spray insecticide . Only since we have developed economically. In fact the paddy is pretty good - but many more insects. And when see some insects, people are afraid of losing the crop - so have to spray. So of course it has an effect. ". Indepth 24 Ngoc
She went on further to describe how the change in the role of the State has complicated this matter further.
"In previous times it was subsidised. Each cooperative had an insecticide group. The State gave protective clothing. Now we have no subsidies. Each family sprays insecticides. Each family has only one container. … each family had insects on paddy, they go and spray. . . . Previous times always had a special person to spray insecticides. " Indepth 24 Ngoc
A 70 year old woman reflected upon the increased "prevalence" of gynaecological diseases in recent times. When asked why she thought this was happening, she replied :
Maxine : But in your time women went to the fields. Worked in dirty water, used manure. Why didn’t you have this problem?
Ba : In previous time we didn’t have insects like this time. Now we have some kind of insect that we didn’t have before. …. In our time, worked but didn't have to spray insecticide. Only transplanting was enough. No insecticide. Since transplanting the Chinese variety. Transplant the Chinese variety and create disease
Moderator : Do you think the Chinese variety doesn’t suit the Vietnamese situation?
Ba : No it suits. ... Yield are increased. But a lot of insects. … Not so before. Spray insecticide and when it rains - it comes down. It comes to the canal, the river. … - and into the tank and drink. It flows in it”. Indepth 18 Phung
Women feel the need to increase yield - both for the family economically and for the State (Phi Van Ba 1991). The use of higher yielding rice requires more work for preparation of fields, flooding of fields, has more insectsxiii and therefore needs more insecticides and the use of more fertilizers and manure to increased productivity. (Le Thi 1997 a and 1997 b). Women feel that this increases the risks faced in their everyday work in the paddy fields - increases the chances of them having discharge and other health effects. Many Vietnamese intellectuals also reflect this concern about the "unhygienic, harmful and toxic conditions" in which female farmers work (Tran Thi Van Anh and Le Ngoc Hung 1997: 119; Do Thi Binh 1997)xiv.
Women have to worry more now than before - because of everyday life and the effect of society. It means that I have to worry about how to improve my life or how to ensure my children to grow up and have an education. I think about how my family can develop and can help develop the society. Indepth 12 Hanh.
In rural areas, women have a heavy load. They worry about economics. Indepth # 20 Mai
The pressure to produce more is reinforced through the message that a growing economy leads to happier family life, which women desire. An "traditional quality" of a good women is having a happy family life and this is reinforced in State propaganda (Thai Thi Ngoc Du 1997, Le Thi 1997b). Women aim to be good women, wives and mothers. But they also see this as one of the hardest qualities to achieve and maintain, especially when living in their adverse economic conditions. They feel the pressure to produce to ensure this family life. However, doing more hard work, in dirty water, increases their risk and likelihood of having a vaginal discharge. And this can affect their working ability, their sexual life and therefore their family happiness. They worry about this - which also affects their health.
Women are being encouraged to take up secondary jobs and be involved in "development projects" such as embroidery, vegetable growing, animal rearing in their "spare time" (Do Thi Binh 1997). Development policies have identified independent economic roles for women as a means of improving women's status and equality (Vu Manh Loi 1991). This is espoused in Vietnam's development programmes such as those of the Vietnam Women's Union. But again it is a two edged sword for women. There is concern, amongst rural women and researchers about increasing women's labour demands and that conflicting demands may actually worsen rather than improve women's lives, health and well-being (Kabeer 1992). Women identified the need for rest and "spiritual" time as important for their health and well-being - but also felt the pressure to take up secondary jobs such as embroidery, chicken rearing and other animal husbandry activities. These activities mean more work and less rest, and therefore can adversely affect their health.
They are also pressures to increase their children's opportunities. Most do not want their children to have to work on the land - and live such an unhealthy and hard life. So there is pressure to earn enough to allow them to attend school, have accessory classes and let them move away from home, in the process losing their labour on the fields. Many women described the need for their families to work away from home. Husbands and older children commonly go to the coffee plantations, rubber plantations and building areas (Le Thi 1997; Tran Thi Nghia 1997, Vu Manh Loi 1991).
However this "circular migration" means that women left at home have more work to do "as noone else can do it for them" which leads to poor health. They worry about their children living away from home and being led into bad lives, marrying away, or becoming pregnant, and about their husbands being enticed to have a second wife or girlfriend.
Maxine : What difficulties does this cause women if their husbands are away for 2 years?
Net : She has to do both men and women's work
Oanh : All the work she has to do. FGD 15
There are also now more things to pay for. Changes in economic conditions and structures in the country mean that social services such as education, child care and health care now have fees and costs attached to them (Le Thi 1997b, Vuong Thi Hanh 1997; Tran Thi van Anh and Le Ngoc Hung 1997; Vo Nhan Tri 1991, Le Dang Doanh 1991). This affects the household budget - women must earn more and decide on balancing earnings versus expenditures.
There is increasing social and peer pressure for the family to own more "modern" commodities such as television, a bicycle or motorcycle, or have a newer home. Other researchers have noted this increasing materialism since doi moi (Thai Thi Ngoc Du 1997). It has also been noted as an explicit objective of industrialisation "to produce consumer goods to raise the material and spiritual welfare of the peasants" (Beresford 1991). Becoming modern and losing the "ignorant peasant" ways is an image often portrayed in the media , by the Women's Union and other State dialogues. After years of being unable to access such "consumer goods", the open door process has allowed people to aspire to such commodities - they are desired. This pressure to own, increases the pressure to produce.
Many women feel that their poor economic condition means that they cannot reduce their risk of vaginal discharge. If they could eat better and work shorter hours, they could be healthier. In addition they would be able to seek care earlier, when signs of vaginal discharge or infection first appear. With more money, they would be able to build a latrine, bathroom and have a cleaner water supply. The lack of privacy and separate place to bath makes women reluctant to wash as often they may wish or know they should. Yet, as described above, these are only possible if they work hard to earn more money.
They (health workers) say that when we have menses and IUD, we have to avoid carrying heavy loads. But here no-one does it for us. So we carry heavy loads - it has an effect. If we can do as the doctor says, we will not have an effect. FGD 12 Kiu
The State supports the role of family planning and controlled population growth rates as one strategy for development of the nation (Phan Thuc Anh 1997, Duong Thi Cuong 1997, Do Thi Binh 1997, Thai Xuan Dao 1997, Goodkind 1995, Vu Qui Nhan 1991; Pham Bich San 1991, Alam 1995). Women have internalised these messages and often describe the need for smaller family size to ensure economic development of the family, enough to eat, family happiness and health of the children. Family planning is desired at individual, community and State levels (Vuong Thi Hanh 1997, Phan Thuc Anh 1997, Whittaker et al 1998). Women in their conversations directly link smaller family size to improved economic conditions and an ability to improve the quality of life provided to family members. This reflects messages provided by State promotional activitiesxv. However, as described earlier, women also see the use of family planning methods as a potential cause of discharge.
Thus increasing pressure to use family planning, and improve economically puts many women, in their understanding, at risk of infections and discharges. The existing provider bias for IUDs in the family planning programme and limited family planning method choice also has meant that IUDs are the major method available, a risk according to women (Phan Thuc Anh 1997; Do Trong Hieu et al 1996; Jain et al 1993; Gammeltoft 1997).
Balancing costs of living and costs of care - the scales are tipped
Women are the major "managers" of the household budget. They balance their income, mainly the sale of paddy against the costs of living. The women described a range of essential household expenditures for which they needed to pay. These included school fees, insurance, books and clothes; salt and food; vegetables for the pigs; children's health and edcuation; husband's needs; house improvements and renovations; in-laws and parents needs; societal obligationsxvi and feesxvii. Women place their health as secondary to other expenditures. (Ha Thi Mai Hien 1997; Sholkamy 1996)
Maxine : If she has to balance paying for these , where will her health go?
Sim : Usually the last after the others. First family, then herself. … She may deny herself the right care, or delay and deny care. Indepth 14 Sim
Most of the rural women interviewed stated that they could not save money or commodities. Many sell their paddy, often compromising their own food supplies, or borrow from others when they need something. They may repay the lender later when they can sell a pig or chickens.
Most women don't spend a lot of money to treat discharge. They may not have to as it is a minor problem and therefore use preventive measures described earlier. They may not want to because there are other things which they require to spend money upon and may even see the treatment as a "waste" of money. Or they cannot do so, as they don’t have the money.
Women often describe the costs of treatment as comprising the direct costs of official fees and medicine costs, as well as indirect costs. Indirect costs such as the costs of transport, missed work, "strengthening up" foods and bribes to health staff must be paid. Many women perceive the provider's interest being more with women who can pay all costs - rather than for the poor like them. This sort of attitude makes women reluctant to seek care - unless it is very serious condition - since they have to tolerate such behaviour and attitudesxviii. Many informants felt that these providerxix attitudes were getting worse in recent years.
Women always tell each other - we are poor and have no money so doctors don't care for us Indepth 16 Dung
In the … hospital, if have serious disease, go there. If don’t bribe, they wont treat. Have to bribe. Binh Indepth 25
Not enough economic condition to meet this doctor or that doctor …We let it go (the discharge). ... When it is too exaggerated, cannot suffer it anymore, cannot work and don’t eat - hurry. Indepth 8 Nga
Women will often purchase sub-optimal treatment coursesxx - because of their need to balance income and expenditures. Even the "costs" of undertaking preventive activities are seen as "unaffordable" by many women. The process of washing with clean water may involve boiling water, collecting the wood to make the fire to boil the water and collecting the water itself - all activities that take time. The costs of gauze and toilet paper ( for menstrual management) are also economic burdens that a woman may "skimp" on for the sake of other family needs. They know the consequences of not changing regularly or using unclean or damp cloths - but see no option.
they have no time. Have bad economic (situation) - they need medicines but have no money. So women only treat for a time and when they feel better, they stop. Indepth 20 Mai.
Women feel that it is "normal" (some say 90% or more women will have it)xxi and inevitable for women to have vaginal discharge, especially living and working in their rural conditions. So they are reluctant to spend money on it.
Many a tourist guide about Vietnam "romanticise" the rural life and women's work. Many economic review articles discuss the potential for economic growth in Vietnam. However women see hard work, dirty water, increasing worries, decreasing rest and relaxation time, and risks to their health. They aspire to improved family and personal life, but most women find themselves sacrificing their own health and well-being for the family, community and State's benefit. They aspire for their children's lives to be better.
Their concerns should make us carefully consider the policy directions, promotional activities and health messages we provide about women's health and development. Understanding their concerns, working in their realities and addressing their needs are important foundations for effective progressive and women-friendly and empowering development.
Over the years a lot of people have contributed towards my continued learning about Vietnam. These are too many to name here - but their contribution towards my work is acknowledged and appreciated. The women and the officials in the commune made me very welcomed. I thank them and continue to pursue the application of my work to their health and well being. The Centre for Population Studies and Information was the sponsoring agency for my research and their support is greatly appreciated. Funding for my research has been provided by the Australian Centre for International and Tropical Health and Nutrition at the University of Queensland.
1. Alam, I., Khan, A.R., Fajans, P., Paxman, J., Whittaker, M., 1995, Report on Vietnam Reproductive health / Family Planning Sector Review and Analysis PRSD Series 1995 Ha Noi : UNFPA
2. Antrobus, P., Germain ,.A., Nowrojee, S., 1994, Challenging the Culture of Silence : Building Alliances to end reproductive tract infections New York : International Women’s Health Coalition.
3. Bang, R., 1991, The context of reproductive tract infections Paper presented at the 18th Annual NCIH Conference, Arlington Virginia, June.
4. Beresford, M., 1991, The impact of economic reforms on the south Pages 118 - 135 In Forbes DK, Hull, TH., Marr DG, Brogan B (Eds) 1991 Doi Moi : Vietnam's renovation policy and performance Political and social change monograph No 14 Canberra : Australian National University
5. Brunham, R.C., Embree, J.E., 1992, Sexually transmitted diseases: future dimensions of the problem in the Third World p35-58 In Germain, A.., Holmes, KK., Piot, P, Wasserheit, J.N., 1992, (Eds) Reproductive tract infections : Global Impact and priorities for women’s health” New York : Plenum Press
6. Clement, J., 1996, The gendered impact of economic reform in Vietnam Development Bulletin 36: 22 - 25.
7. Dixon-Mueller, R., Wasserheit, J., 1991, The culture of silence New York : International Women’s Health Coalition.
8. Do Thi Binh, 1997, The role of female scientists in Vietnam's market economy. Pages 155 - 165 in Le Thi and Do Thi Binh (Eds.) 1997 Ten years of progress - Vietnamese women from 1985 - 1995. Ha Noi : Phu Nu Publishing House
9. Do Trong Hieu, Pham Thuy Nga, Nguyen Kim Tong, Do Thi Thanh Nhan, Simmons, R., et al, 1996, An assessment of the need for contraceptive introduction in Vietnam. Geneva: WHO
10. Duong Thi Cuong, 1997, The protection of mother's and children's health over the past ten years Pages 226 - 238 in Le Thi and Do Thi Binh (Eds.) 1997 Ten years of progress - Vietnamese women from 1985 - 1995. Ha Noi : Phu Nu Publishing House
11. Elias, C.,1997, Perceptions of Reproductive tract morbidity among women in 2 rural communities of Ninh Binh province, Vietnam Paper presented at workshop on reproductive health and reproductive tract infections Ha Noi 8 Nov 1997.
12. Forbes, D.K., Hull, T.H., Marr, D.G., Brogan, B., (Eds) 1991 Doi Moi : Vietnam's renovation policy and performance Political and social change monograph No 14 Canberra : Australian National University
13. Gammeltoft, T., 1997, Women's bodies, women's worries : health and family planning in a Vietnamese rural commune PhD Thesis submitted to the Institute of Anthropology, University of Copenhagen October 1996.
14. Goldin, CS., 1994, Stigmatisation and AIDS : Critical Issues in Public Health Social Science and Medicine 39: 1359 - 1366
15. Good, B., 1994, Medicine, rationality and experience : an anthropological perspective Cambridge : Cambridge University Press
16. Goodkind, D., 1995, Vietnam's one or two child policy in action Population and Development Review 21 : 85 - 111
17. Ha Thi Mai Hien, 1997, Legislation and the equality between men and women (1985 - 1995) pages 282 - 286 in Le Thi and Do Thi Binh (Eds.) 1997 Ten years of progress - Vietnamese women from 1985 - 1995. Ha Noi : Phu Nu Publishing House
18. Havanon, N. and Archanitkul, K., 1997, Production, reproduction and family well being : the analysis of gender relations in Vietnamese households. Paper presented at the Seminar on Production, reproduction and family well being in Vietnamese households Ha Noi 29 August 1997.
19. IBRD (International Bank for Reconstruction and Development), 1993, World Development Report 1993 “Investing in health” Oxford : Oxford University Press
20. Jacobsen, J., 1991, Women’s reproductive health : the silent emergency Worldwatch Paper 102 June 1991 Washington DC : Worldwatch Institute
21. Jain, S., Kornfield, R., Lecomte J., Guzman, P., 1993, Thematic evaluation : quality of family planning services in Vietnam Ha Noi : UNFPA
22. Kabeer, N., 1992, From fertility reduction to reproductive choice : gender perspectives on family planning Discussion paper No. 299 Brighton : Institute of Development Studies
23. Le Dang Doanh, 1991, Economic renovation in Vietnam : achievements and prospects p79 - 93 In Forbes, D.K., Hull, T.H., Marr, D.G., Brogan, B., (Eds) 1991 Doi Moi : Vietnam's renovation policy and performance Political and social change monograph No 14 Canberra : Australian National University
24. Le Thi, 1997a, Vietnamese women after 10 years of doi moi ( renewal) of the country. p23 - 53 in Le Thi and Do Thi Binh (Eds.) 1997 Ten years of progress - Vietnamese women from 1985 - 1995. Ha Noi : Phu Nu Publishing House
25. Le Thi, 1997b, Conclusion p321 - 340 in Le Thi and Do Thi Binh (Eds.) 1997 Ten years of progress - Vietnamese women from 1985 - 1995. Ha Noi : Phu Nu Publishing House
26. Le Thi and Do Thi Binh, (Eds.) 1997, Ten years of progress - Vietnamese women from 1985 - 1995. Ha Noi : Phu Nu Publishing House
27. Long, L. Le Ngoc Hung, Truitt, A, Le Thi Phuong Mai, Dung Nguyen Anh 2000 Changing gender relations in Vietnam’s Post-Doi Moi era Policy Research Report in Gender and Development Working Paper series No 14, Washington DC : World Bank
28. Martin, E., 1989, The women in the body : a cultural analysis of reproduction Milton Keynes : Open University Press
29. McDermott J., Bangser, M., Ngugi, E., Sandvold, I., 1992. Infection : social and medical realities p.91 - 103 In Koblinsky M, Timyan J, Gay J (ed) The health of women : a global perspective Boulder: Westview Press.
30. Meheus, A.., 1992, Women's health : importance of reproductive tract infections , pelvic inflammatory disease and cervical cancer" p.61 - 91 In Germain, A.., Holmes, KK., Piot, P, Wasserheit, J.N., 1992, (Eds) Reproductive tract infections : Global Impact and priorities for women’s health” New York : Plenum Press
31. Moore, H.L., 1994, A passion for difference Cambridge : Polity Press
32. Nguyen Thanh Mai, 1994, Pilot study of genital infection in two communes in Tien Hai district, Thai Binh Province Vietnam Social Sciences 1: 101 - 102.
33. Nguyen Thi Hoai Duc, 1995, Results of survey on reproductive tract infection in Vietnam Rural Women Unpublished report UNFPA / AFPC Ha Noi
34. Nguyen Thi Loi and Uhrig, J., 1997, The prevalence of reproductive tract infections at the MCH/FP Centre in Hue, Vietnam : a cross sectional descriptive study. Paper presented at workshop on reproductive health and reproductive tract infections Ha Noi 8 Nov 1997.
35. Pelzer, K., 1993, Socio-cultural dimensions of renovation in Vietnam : Doi Moi as dialogue and transformation in gender relations. p309 - 358 in Turley, WS; Selden M (Eds) Reinventing Vietnamese socialism : doi moi in comparative perspective Boulder: Westview Press.
36. Pham Bich San, 1991, Vietnam's fertility problems : a sociological view p175 - 179 In Forbes, D.K., Hull, T.H., Marr, D.G., Brogan, B., (Eds) 1991. Doi Moi : Vietnam's renovation policy and performance Political and social change monograph No 14 Canberra : Australian National University
37. Phan Thuc Anh, 1997, The contributions of women to family planning p214 - 225 in Le Thi and Do Thi Binh (Eds.) 1997 Ten years of progress - Vietnamese women from 1985 - 1995. Ha Noi : Phu Nu Publishing House
38. Phi Van Ba, 1991, How do peasant families in the Red River delta adapt to new economic conditions? p131 - 148 In Liljestrom, R. and Tuong Lai, (eds) 1991, Sociological studies on the Vietnamese Family Ha Noi : Social Sciences Publishing House
39. Ronald, A.., Aral, S.O., 1992, Assessment and prioritization of actions to prevent and control reproductive tract infections in the third world” p199 - 225 In Germain, A.., Holmes, KK., Piot, P, Wasserheit, J.N., 1992, (Eds) Reproductive tract infections : Global Impact and priorities for women’s health” New York : Plenum Press
40. Sholkamy, H.M., 1996, Women's health perceptions : a necessary approach to an understanding of health and well-being Cairo : Population Council Regional Office for West Asia and North Africa.
41. Thai Thi Ngoc Du, 1997, Economic transformation and the life of female intellectuals in Ho Chi Minh City p120 - 126 in Le Thi and Do Thi Binh, (Eds.) 1997, Ten years of progress - Vietnamese women from 1985 - 1995. Ha Noi : Phu Nu Publishing House
42. Thai Xuan Dao, 1997, Raising women's educational levels 1985 - 1995 p249 - 261 in Le Thi and Do Thi Binh, (Eds.) 1997, Ten years of progress - Vietnamese women from 1985 - 1995. Ha Noi: Phu Nu Publishing House
43. Tran Thi Nghia, 1997, Marriage - problems and solutions p271 - 281 In Le Thi and Do Thi Binh, (Eds.) 1997, Ten years of progress - Vietnamese women from 1985 - 1995. Ha Noi : Phu Nu Publishing House
44. Tran Thi Van Anh and Le Ngoc Hung, 1997, Women and doi moi Ha Noi : Woman Publishing House
45. Turley, W.S., Selden, M., (Eds) 1993, Reinventing Vietnamese socialism : doi moi in comparative perspective Boulder: Westview Press.
46. Turner, B., 1992, Regulating bodies : essays in medical sociology London : Routledge
47. U.N., 1995, Population and development: programme of action adopted at the International Conference on Population and Development, Cairo 5 - 13 September 1994. New York ; United Nations
48. Vo Nhan Tri, 1991, Political and social aspects of Vietnam's renovation process p68 - 78 In Forbes, D.K, Hull, T.H., Marr, D.G., Brogan, B., (Eds) 1991, Doi Moi : Vietnam's renovation policy and performance Political and social change monograph No 14 Canberra : Australian National University
49. Vu Manh Loi, 1991, The gender division of labour in rural; families in the Red River delta. p149 - 163 in Liljestrom, R., and Tuong Lai, (Eds) 1991, Sociological studies on the Vietnamese Family Ha Noi : Social Sciences Publishing House
50. Vu Qui Nhan, 1991, Fertility and family planning in Vietnam : trends and challenges p143 - 157 In Forbes, D.K., Hull, T,H., Marr, D.G., Brogan, B., (Eds) 1991 Doi Moi : Vietnam's renovation policy and performance Political and social change monograph No 14 Canberra : Australian National University
51. Vuong Thi Hanh, 1997, The activities of the women's unions for the equality and development of women p76 - 91 in Le Thi and Do Thi Binh, (Eds.) 1997 Ten years of progress - Vietnamese women from 1985 - 1995. Ha Noi : Phu Nu Publishing House
52. Wasserheit, J.N., Holmes, K.K., 1992, Reproductive tract infections : challenges for international health policy, programs and research p7 - 33 In Germain, A.., Holmes, KK., Piot, P, Wasserheit, J.N., 1992, (Eds) Reproductive tract infections : Global Impact and priorities for women’s health” New York : Plenum Press
53. Wasserheit, J.N. 1989 "The significance and scope of reproductive tract infections among Third World Women" International Journal Gynaecology and Obstetrics Supplement 3 : 145 - 168
54. Whittaker, M.A., Larson, A., 1996, Reproductive Tract Infections - The Forgotten and Neglected Component of Family Planning Services Venereology 9 : 40-47
55. Whittaker, M.A., Phan Thuc Anh, Nguyen Thanh Tam, 1998, Vietnamese women's perceptions of quality in the family planning programme. Paper presented at the Vietnamese Studies Conference Ha Noi July 1998.
i Senior Lecturer, Australian Centre for International and Tropical Health and Nutrition, 4th Floor Public Health Building, Medical School, Herston Rd., Herston Qld 4006 Australia. Phone 61 - 7 - 3365 5415 Fax : 61 - 7 - 3365 5599 E-mail: M.Whittaker@mailbox.uq.edu.au
ii All names used in the paper are fictitious.
iii Tine Gammeltoft in her thesis describes in detail the close relationships of worry, weakness, work and ill-health, including poor reproductive health, as described by Vietnamese women. Gammeltoft, T 1997.
iv Anatomical features such as the reproductive organ being internal so more difficult to clean or to know if there is a problem, being "open" to the environment.
v Women described women as weaker than men, less able to cope physically with hard work as well as "suffering" the costs of childbirth and menstruation upon their health.
vi It is beyond the scope of this paper to explore this. The taxonomy of vaginal discharges will be described in later papers.
vii Hot foods included chilli, crab, goat meat, dog meat.
viii Usually the women seeing this as their responsibility tom provide washing bowl and soap for their husband.
ix Indeed the post- IUD insertion antibiotics are often provided free of charge by the health service - reinforcing women's felt need for these and the role of IUD in discharge diseases.
x Provided by the district hospital or provincial health authorities on a six or 12 monthly basis, via mobile teams to the commune health station.
xi These drugs and medicines include oral and vaginal antibiotics, vitamin supplements such as vitamin C and B and simple pain relief such as paracetamol. A range of herbal leaves and mixtures were described by women, although usually their constituents were not known to the women.
xii In Vietnam, on International Women's day it is the normal practice to provide women some flowers and in some cases gifts and congratulate them for the day. This extends beyond family circles, to work colleagues. I have even had male shop attendants wish me congratulations on this day.
xiii This was commonly spoken of by male and female commune members and authorities.
xiv The actual effects of insecticides and pesticides commonly used by men and women on their health needs further study.
xv See Goodkind D 1995 for more discussion of these promotions.
xvi These societal obligations include funeral costs, anniversary celebrations, donations to Women's union collections eg. for flood relief of women in the South, for the women of Cuba; milk and sugar for sick friends.
xvii Fees include fees to be paid to the Commune authorities for their land, seeds, fertilisers and other agricultural activities; school fees, social funds, costs of membership of the party or mass organisations etc.
xviii Women described being scolded, neglected, and refused treatment by health staff. They described cases of themselves or others being refused treatment unless they could pay on the spot.
xix The women described the attitudes and behaviours of health staff at all levels - commune health station, district hospital, provincial authorities and private sector. Some of these health staff live and work in the same communes, others may be perceived as of a different social status.
xx Women described only buying treatment one day at a time as they could afford it, or until they felt they were better. Or they purchase according to how much dong they have at the time. This latter behaviour was commonly observed by me at the pharmacies and markets for over-the-counter sales.
xxi When women describe vaginal discharge as normal in this context, they man common, inevitable, not that they think is non-pathological. Later papers will describe the taxonomy of discharges, wherein there are one or two types of discharge that women feel or physiological, but the majority of discharges are described by women as "pathological".