5. Conclusions and Recommendations for
Future Research
Winding Up the Analysis
The analysis of results presented in chapter 4 has illustrated how we took our starting point in predefined questions and concepts and moved on to discover new ones. Once new concepts were identified, we carried them along with us in the exploration of other parts of the material. The analysis took us towards new insights and new questions, which we will summarize in this final chapter. Again, we would like to remind the reader that our purpose is explorative and methodological. We base our ideas on only three weeks of fieldwork, and we present our results here with the aim of
1) Illustrating the discipline called social anthropology, and the process of qualitative research, and
2) Provide a catalogue of ideas for future research in reproductive health.
Insights
At the community level, our analysis has primarily focused on women’s abilities to act and take control of their own bodies. As we have seen, their abilities to do so are to wide extents shaped by their social relations. Women may obtain assistance through their social relations, but social relations may also cause limitations for women and various kinds of vulnerability. Women living outside marital unions or in violent relationships are in particularly precarious situations, but every woman has to manoeuvre between various levels and kinds of social relations and authorities: state, church, family elders, spouse, neighbours, etc.:
v Many issues on the ‘silent reproductive health agenda’ are silent indeed. The existence of for instance domestic violence, sexual abuse, prostitution, and AIDS is usually denied at first, but even our short fieldwork was long enough for us to realize that domestic violence is part of many women’s lives, that prostitution is highly present in some parts of the communes, and that AIDS is a threat that is likely to become increasingly important in years to come. This makes it even more important to understand the social situations that create vulnerability and diminish women’s control over their own sexuality, not only when living as commercial sex workers but also in unstable marital units.
v Even in well functioning families and marriages, the social context plays a crucial role in health seeking behaviour and in a woman’s reproductive health. A woman rarely makes the decision about where to seek health care on her own. And even if she attempts to do so, her actual possibilities for action (financial means, transport, time off from work in the home, etc.) are shaped by the relatives surrounding her.
v The problem of v« sinh, not giving birth, casts light on the importance of being socially recognized as a parent and the pressure often put by relatives on people with no children. Women who have problems having children often end up in situations of vulnerability through their very attempts to do something about the absence of children: they go from one marriage or partner to another, they accept polygamous marriages or are forced to divorce, or they may seek to become pregnant through extra-marital affairs. Reproductive health is often associated with family planning and the reduction of fertility and therefore the focus is on the individual woman’s fertility. Women with the problem of vo sinh, however, remind us that a woman’s reproductive health is always closely linked to her social life. Her attempts to gain some control over her reproductive health are also attempts to have some control over her social life.
At the health systems level, our attention was repeatedly drawn to the quality of care provided by the various sectors of the health care system - not just in terms of medical quality, but also in terms of people’s perceptions of how they are treated. This is relevant since services need to be not only available but also accessible in terms of cost, atmosphere, interpersonal relations, etc.
v The term ngại, shyness, appears to be central in relation to the use of health services, and hence the quality of care provided. Our material indicated that feelings of shyness play an important role in shaping people’s health care seeking behaviour. The extent to which people feel shy influences whether they turn up at health centre or not, whether they ask others for help, whether they reveal their problem to others or not. Feelings of being shy can be related to economic issues and the reluctance to reveal poverty, to perceptions of the body, but also to questions of morality and whether one feels able to live up to one’s social and moral responsibilities. The interaction with health workers is crucial for people’s feelings of being shy. Somehow, the public health care system seems to create situations of shyness much more than does the private system, and consultation with healers of Oriental medicine. People express many of their concerns with quality of care through the concept of ngại. When attempts are made to improve the quality of care at health centres, attention should therefore be paid to situations and settings creating feelings of ngại.
v Catholics have even bigger problems of feeling shy in relation to the health care system than others do. Our study clearly shows that Catholics are also very interested in family planning and reproductive health services, but have much more trouble making use of the health services provided. They feel more intimidated by the meeting with health workers and less able to find appropriate counselling and assistance.
v The relationship with health workers is central for people’s experience of quality of care, and it is noteworthy how much the institutional setting influences this relationship. People may be wary about making use of a health centre, but not the health worker, once she is off duty. At the commune health centre, where the health workers are usually living in the community in which the centre is placed, there are fewer problems of informal fees and strained atmosphere between health workers and patients than on higher levels of health care. People who may be reluctant to give birth at the health centre may be happy to be assisted by a trained health worker when giving birth at home. All of these examples show that it is not only the relationship between health workers and patients, which should be studied, but also the way in which institutional settings shape these relationships.
v Financial problems play a significant role in shaping health care seeking behaviour. Especially the uncertainty about the total cost at the health centre is a concern to people. Going there they rarely know what it will end up costing them, the system of fees not being transparent, and informal fees often being added to the official cost of the service. Financial issues are also one of the main reasons why people hesitate to give birth at the health centre.
v Western medicine is closely associated with treatment for acute conditions, whereas Oriental medicine is said to improve a person’s health, i.e. give strength to the body. In addition, pregnancy, childbirth and childcare are not associated with sickness, and in particular not with the acute kind of sickness treated by Western medicine. Perceptions of the body, of health and sickness therefore influence the use of public health services in relation to child bearing. Perceptions of what is normal and expected as compared to abnormal and dangerous also influence women’s experience of contraceptive side effects and infections and hence the decisions about when to take action when such problems appear.
v The severe and common side effects in relation to IUDs influence women’s trust in the system and the health workers and raise questions about why so few alternative options of contraception are explored.
v Similar concerns have been raised in relation to abortion. Abortion has for some time been a commonly used method of fertility regulation in Vietnam. Our study showed much sensitivity and fear in relation to abortion. While women regularly rely on abortion for fertility control it still causes them much concern and pain, physical as well as emotional. This raises important questions about quality of care and how to improve it for women who have to undergo abortions.
New Questions
The themes identified above bring with them not only new insights, but also new questions and perspectives for future research. At the community level, we suggest that the following themes be explored further in future research:
v There is a need to explore how best to provide possibilities of action for women in vulnerable situations. One way of improving their ability to take control of their health and their bodies is through improved service provision. This however will obviously not solve all problems. Economic possibilities for single and divorced women may in some situations be as crucial for obtaining improved reproductive health, as is health service provision. But what do women themselves find are the most appropriate ways to provide assistance?
v ‘Women’s diseases’ is a cover term for a range of health problems that men and women may run into. We need to further clarify what it covers, how the term is used, and what actions are considered appropriate for diseases covered with this term. How is the perception of women’s diseases related to broader concepts of health and disease, to concepts of gender, and to issues of responsibility and morality?
v How do people cope with the misfortune caused by v« sinh, the lack of children and what kinds of vulnerability arise from not giving birth? How can we best support them in coping?
v What are the notions of kinship with which people live? What is included in the notion of a ‘real’ child (as opposed to adopted and artificial), and how are these notions of kinship connected to the experience of childlessness and the things people can do to cope with the misfortune of childlessness.
In relation to the health care system, we suggest that the following themes and questions are followed up on:
v Quality of care - in social aspects of care as well as medical aspects - is a crosscutting issue that more research should be devoted to. The contribution of a qualitative approach to the study of quality of care will often be the patient’s point of view on the care provided, and the social interactions taking place between patients and providers. Do providers have the skills required to provide people with adequate counselling and care? With what kind of attitude do they meet the local people who come to them? Do providers themselves feel that counselling is important? What causes people to feel shy (ngại)? It is not only the relationship between health workers and patients, which should be studied, but also the way in which institutional settings shape these relationships. Are people afraid to expose their bodies? Or afraid they will be blamed - for having too many children or for other things? Some of the themes that need particular attention as part of a study of quality of care are:
o What does the term ngại (shyness) include? When is it played out, and what can we do to reduce the extent to which shyness prevents people from using the health care system? The notion of ngại cannot be understood without attention being paid to the way social relations shape feelings of shyness, and shyness is not an issue only in relation to visits at the health centres. We suggest, however, that there are reasons to explore more specifically the role of ngại in relation to quality of care.
o What are actually the costs in relation to health care, and in particular in relation to reproductive health care services? How does the system of payment work? Is it official, unofficial, affordable, not affordable, transparent for the users or a cause of uncertainty and mistrust? What role do different kinds of payment play in the clinical interaction, and how and from whom do women get access to money used for reproductive health?
o What role does religion play, or more generally why is the situation of Catholics so different? Many of the explanations for this seem to have to do with other things than religion as such, e.g. cost, feeling shy (i.e. feeling intimidated by institutional settings), distrust, etc. The experience of Catholic people should be further explored with regard to quality of care in general, and more specifically with regard to childlessness, contraception, abortion, infections, etc.
o What are the barriers to a wider contraceptive choice in rural communities: How come that the alternatives to the IUD that are available locally are not more widely used, and what role does service delivery play in this?
o Maternal health and its social contexts call for further investigation. What role does the midwife play in rural communities? What is the quality of birthing care at home and at different health facilities?
o It will become increasingly important with time to monitor the relationship between private and public services: How does the quality of care differ in public versus private settings? What kind of private or semi-private services are already available?
Other themes which were hardly touched upon in this explorative study, but which our fieldwork suggests anthropological research should look more into in the future, include:
v Childcare. What are the underlying social, cultural and economic factors which shape childcare and child feeding practices in these communities. How come, for instance, that Catholic women tend to wait longer before starting to give their children supplementary foods, and younger women longer than older women? And how come that women with less schooling tend to feed their children fewer daily meals than women with more schooling? To learn about issues as these, we would need to gain insights into the daily living conditions of women, their workloads, their social networks, and their thoughts and ideas about infant and childcare.
v Adolescent reproductive health. We failed to establish rapport with adolescents in our short study. A study should be carried out, which defines a methodological approach and allows for the time needed to establish relations of confidentiality with adolescents in the area.
v AIDS should be monitored as the disease and its consequences, medical as well as social are likely to develop in the years to come.
v Sexuality. Sexual roles and relations are at the core of many reproductive health issues, and yet very little is known about how sexual relations unfold within and outside marriages, how negotiations about safe sexual practices take place, etc.
v Prostitution, and more generally, the sexually vulnerable situation in which many women live, call for further investigation so that it will be possible to identify ways in which to assist this group of women.
v The male perspective. How do men perceive their roles and responsibilities in relation to sexuality, reproductive health and child care?
v Abortion was revealed in our study to be a highly sensitive issue and difficult to approach through survey methods. Future research could develop innovative methodologies to approach such culturally sensitive issues. How are abortion decisions made, how are abortions experienced and what consequences do they have for the women undergoing them?
The Case of Lý - and of Anthropology
We used the case of Lý to introduce our attempt to present a case of anthropological research in a Vietnamese setting. The case of Lý showed the importance of interviews as well as participant observation in anthropological research. It was an example of how informal settings and unexpected situations often become the focal point in anthropological fieldwork. We used our informal interactions by the roadside where we were drinking coconut milk in her shop to explore in an open-ended fashion what her life could teach us about reproductive health in Quỳnh Lưu. But we also started to take this informal setting in a certain direction and bring to the forefront the issues that were of relevance for our study.
In a sense this situation is characteristic of how anthropological qualitative research is carried out on all levels of the process. It is carried out through an open approach, in which the unexpected and the unknown are taken seriously and followed up. But it is also characterized by attempts to structure and focus with an eye to the research problems while in the midst of exploring the potentials of the unexpected. This balancing between openness and focus, between broadening and narrowing, is what the art of anthropology is about. We do it when we define and refine research questions. We do it when we identify informants as we go along in the field, and we do it in the questions we pose to people. We adapt the questions on the way, to be open to the unexpected story that the informant may tell us, while still keeping an eye to the research focus. We do it when we analyze. We keep our original focus in mind, while trying out new concepts and thereby opening up new paths, insights and directions along which to take the material.
In the past five chapters we have been covering a broad range of themes, but we have not moved away from our focus on reproductive health, nor from the research questions on 1) people’s experience of their reproductive health problems and needs, and 2) the health care options available in the area and people’s health care seeking behaviour in relation to reproductive health. Within these broad questions, we were among other things led towards discussions of v« sinh (childlessness), ngại (shyness), peoples perceptions of quality of care in clinical settings, social vulnerability and agency of women, etc. These are all valid insights of relevance for reproductive health and useful in the attempt to realize the Cairo agenda.
So in this continuous circular process of qualitative research, where do we broaden our focus, and where do we narrow it? When do we stay open to the unexpected, and when do we enforce our focus? There are no simple guidelines to this, but we hope that by demonstrating the process of our work from the definition of the problem to the writing up of results, we have provided an example of the process of anthropological qualitative research that will be useful for others who wish to venture into such research. We have tried to show the choices we made on the way, how we were guided by the realities we met during fieldwork, by the theoretical concepts we brought with us, by our existing knowledge of reproductive health problems in Vietnam and by the Cairo agenda. We could have made different choices, and the analysis could have taken us elsewhere. But this does not make the insights obtained any less valid. The validity lies precisely in our constant reflections upon the ways that our results were generated - not as neutral and timeless pictures of a static world, but as the results of social engagements and interactions between the researchers and the people they met in Quỳnh Lưu.