CHAPTER NINE

 

THE STERILIZATION EXPERIENCE

 

Just what conception do Akha women have of sterilization?  Having gone through this procedure with 363 Akha women, I believe there are certain factors which need to be analyzed in order to see how this experience relates to their present practices and concepts regarding health and illness. 

 

                                                        Pre-operation

 

                                                          Filling in the Form

 

The field worker will fill in a form for each woman who asks for the operation.  This is usually done in the home of the couple, or the home of the head of the village.  In either location there are almost always many bystanders.  The husband is ordinarily the spokesman for the couple.  However, in accordance with Akha custom, he will not give his wife's name, nor will the wife give her husband's name.  The woman is usually reticent about speaking her own name, and usually will ask some friend to give it.

 

It is relatively easy for Akhas to give their ages, for every Akha knows the name of the year in which he was born (the year names are based on the Chinese cycle of twelve).

                                                                                                                              p.167

Many Akhas are quite sensitive about answering questions concerning the number of children who have died or the number of miscarriages the woman has had, yet we must fill in these forms and give a copy to the hospital authorities to send in to the national program.  The couple is proud if they have several boys and none of their children has died.  They are ashamed if there were several deaths or miscarriages, however, and may even "forget" some of these, which means that our data are not always accurate.

 

Another question has to do with the last menstrual period that woman has had.  The question is asked especially to find out if she might be pregnant.  The woman does not enjoy blurting out as public news when her last period was, so we try to be discreet when we get this information.

 

We check to make sure the husband agrees to the operation.  This is for our own information, since it does not have to go to the national program.  Even though the field worker asks this question in the village, I also ask it again, since it is very important to the acceptibility of the program by the Akhas that the husband be in full agreement.

 

Another question has to do with whether the woman has used any form of contraceptive aid before.  Slightly more than half of the Akhas from Thailand receiving sterilization have never received used a contraceptive.  This does not mean they were opposed to contraceptives.  Often they have not known about them, or sometimes they have heard vague rumors about them, but did not know how to obtain them.

                                                                                                                              p.168

Akha couples probably wonder why all of these questions have to be asked.  They have no concept of gathering statistics.  I am certainly not opposed to statistics per se, but we must help the Akha maintain their dignity in this situation.  Whenever possible we should reduce the amount of 'cold' statistics, and get more involved in their 'hot' problems--hunger, illiteracy, sickness, and poverty.

 

There are certain positive aspects of this whole procedure for the couple.  They are having their day, and in spite of some of the embarrassment entailed, it is a new experience to be singled out like this.  Sometimes the filling in of a form seems to break down a certain reticence they may have had, and they start talking about the children who died, their poverty, and their hopes for their living children.

 

                                                        Scheduling the Operation

 

After the form has been filled in, it is brought to me at the end of the month.  I try to schedule each person to have the operation at the time and location best suited to her situation. 

                                                                                                                              p.169

When the date of the operation is known, it is broadcast on the Tribal Radio Station.  We announce the date when the women are to come, and tell them whether they are to go first to the Tribal Family Planning Center in Namlat, or directly to Phayao Hospital.  Both the names of the month and the days of the week are given according to the Thai calendar, which is based on the Western calendar.  The Akhas calculate days and years on the Chinese cycle of twelve, which has no relation to the Thai-style calendar.

 

For a brief time we had the young Akha radio announcers living in Chiang Mai give the name of the Akha day when the operation was to be, but we had problems because two of the announcers are quite detribalized, and do not go by the Akha calendar, which meant that they sometimes give the wrong date.  Also, many of the Akha villagers who had heard the announcement tended to be confused as to just which cycle of days was being indicated.  After discussing this with the Advisory Committee, we gave up trying to use the traditional names of the Akha days, and used only the Thai terminology.

 

Once they hear the date scheduled, how will they know when that day arrives?  There are more and more Akha villages with calendars in them but only a few Akhas who can read them.  There are also an increasing number of Akhas wearing watches, many of which indicate the date.  This can be more of a problem than a help, however, in that many do not know how to set the date ahead when a month has fewer than thirty-one days in it.  The calendar part of their watches may be as many as five or six days off as a result.  Most often the couples check with some Thai person in the area to find out how many days they must wait before going to the center.

                                                                                                                              p.170

If the couple is really anxious to have the operation, one way or another they will generally find out the proper time and be sure to be there on time.  Some will go a day or two in advance just to be sure.  Although their coming in early increases the cost for us, it is better than having them come too late for the operation.

 

Although learning the date can be complicated, this is a new experience for the couple, and some of them seem to enjoy it.  They become celebrities in the village and even throughout the Akha world reached by the tribal radio station.

 

                                                        Travel to the Hospital

 

According to tradition, Akhas are supposed to start out on a journey only on an 'auspicious day' (nah mui).  This day differs from family to family.  If the day of departure is not an 'auspicious day' for them, there may be some concern.  While this has not been given directly as the reason for a failure to come in for the operation, I suspect it was involved in a few instances in which women claimed they had been ill at the time they were scheduled to travel.

                                                                                                                              p.171

There are also times when the whole village must observe a 'day of abstinence' (jaw nah), during which no one may leave the village.  There have been a few women who have not been able to come for sterilization because their village was observing jaw nah at the time.

 

When Akhas travel, they are very fearful of meeting up with a special sign of impending tragedy (daw--Lewis 1969:71).  If they see such a sign, they cancel their trip and return home.  One time when I was driving some Akha women from their village in the Nikhom area to the Tribal Family Planning Center in preparation for tubal ligation the next day, a snake crossed the road in front of the car.  This is a bad sign (daw) to Akhas, although none of the Akhas riding with me mentioned it.  Whether this bothered them or not I do not know.  If something had been said about it, they probably would have felt they should turn around and go back.  Since everyone just ignored it, they may have felt there was no problem for them.

 

For an Akha woman to leave her village for a period of time tends to be quite an emotional experience.  Before leaving she has to make sure that everything is in order, that the girls of the house will pound the rice properly and that the livestock will be given proper care.  She misses her children, friends, fields, and even her livestock very much while she is away.

                                                                                                                              p.172

The trip also has its positive aspects.  It gives the woman a chance to get away from the grinding labor in the village and fields for awhile and get out and see a bit of the world.  She rather enjoys the trip, and will experience many exciting things which she will want to recount to her family and friends on her return.  The joys of the new experience can be limited somewhat by travel sickness, but we give them medicine to help prevent this.

 

                                                        Arriving at the Hospital

 

Less than three percent of the Akha women who receive tubal ligation have ever been inpatients in a hospital before, so it is a new experience for most of them.  What they have heard about hospitals is not very comforting: Akhas have traditionally thought of a hospital as a place where people go to die.  They also believe it is inhabited by 'were-tigers' (Lewis 1969:28) which suck the blood from weak people, thus causing them to die.

 

Since I am the one that usually takes them to the hospital, I first show them around, explaining where the bathroom is and how to use it.  Most of them have never used a toilet, so must be taught.

 

The hospital beds are high off the floor.  Akhas are accustomed neither to beds nor to cement floors, as in their home they sleep on the bamboo slat floor.  In this new arrangement they have to be careful that their nursing infants do not fall off the bed during the night and land on the cement floor.  This has happened a few times, although fortunately there have been no serious injuries.

                                                                                                                              p.173

In the midst of what could be a fairly miserable situation, however, the average Akha woman tends to enjoy herself.  She finds many other Akha women there, and immediately starts checking to see if any of them are related to her.  Often they meet friends they have known before, especially some long separated by migration.

 

                                                           Hospital Routine

 

Most Akha women have never been weighed, had their blood pressure taken, or had urine or blood samples tested.  Why someone wants to take some of their urine to 'look at' is beyond their comprehension, until an explanation is given.

 

Instructions about not spitting on the floor, and not pouring left-over water on the floor after they drink are very hard for them to remember.  The polite thing in their culture is to pour out whatever water might be left in the cup after drinking so that the next person using the cup will have a fresh drink.  The logical place to pour it is the "floor," which may be the ground in one type of Akha home, or bamboo slats in another.  It takes considerable adjustment for Akhas to live on a cement floor.

 

Another fairly serious problem is that the language spoken in the hospital is Thai, a language most Akha women do not know.  Problems can develop from this.  For example, a woman may not have been fed when she should have been, while another may be fed when, with surgery imminent, she should have fasted.

                                                                                                                              p.174

                                                       Preparation for the Operation

 

The Akha woman must bathe before the operation, and leave off her headdress until the operation is over.  Most of them are disturbed to appear in public without their headdress, since the only time they ordinarily take it off is in the relative privacy of the water source when they wash their hair.  To appear in public without one's headdress is customarily done only at the time a woman has had 'human rejects,' and is looked upon as a disgrace.  From the first I have explained to them that the operating room must be completely 'holy/clean' (yaw shaw), an important cultural theme Akhas understand to include both physical cleanliness and ceremonial holiness as well.  When they learn this, and also learn that they can put on their headdress the moment they come back from the operation, there is no more problem.

 

At first a standard procedure used to cut down potential infection was to shave the pubic area.  Akha customs prohibit women from pulling or cutting their pubic hairs since they believe it will make them sick.  When the doctor learned of this cultural problem, she asked the nurses not to shave the pubic area (unless it was to be a minilap operation), a consideration which the Akha women much appreciated.

                                                                                                                              p.175

Akha women do not enjoy having an enema (most have never had one), and tend to offer resistance when the nurses try to give it to them.  This is a procedure which cannot be dropped, however, so we try to get the women to accept it as gracefully as possible.

 

Being told that they must not eat or drink prior to the operation is not contrary to any Akha taboo, but it does mean the last ones operated on get very hungry.  They sometimes complain more about hunger than they do about the pain from the operation.  Those who have had the operation in the morning are given nothing by mouth that day until after surgery.  Those who are to be done in the afternoon receive Ovaltine and some small cakes or cookies early in the morning.  This helps them to put up with the wait much better.  Occasionally a complication of some sort will cause unexpected delays, and a woman will complain of severe hunger and weakness by the time she comes up for surgery.  Everything possible should be done to minimize this period of fasting, which now is a weak point in our program.

 

Akhas are amazingly good at accepting these 'alien rituals,' even though they do not understand them.  They are willing to put up with them, because they are so anxious to have the benefits of tubal ligation.  For the sake of creating the fewest possible barriers to women coming in in the future, however, such 'rituals' need to be kept to a minimum.

                                                                                                                              p.176

                                                               Medication

 

About 10-15 minutes before being taken into the operating room, each woman is given an intravenous injection of dextrose solution, which will continue to drip into her arm throughout the operation.  For most of the women this is the first intravenous injection they have ever had.

 

There are three medications injected into the vein, in dosages given in accordance with the weight of the woman.  They are: 1) valium (5.0-7.5 mg.), 2) pethidine (50-75 mg.), and 3) atropine (1/200-1/150 grain).  These drugs are given to make the woman sleepy.  Many of the women fall asleep, and indeed sleep right through the operation.  There are others who fight the idea of going to sleep in the middle of the day.  Their lives have been structured around struggle and hard work.  The idea of relaxing in the daytime like this is a new concept for Akha women, and tends to bother them somewhat.

 

There is another weakness in our program at this point.  All women should receive enough medication to truly sedate them.  There are too many who are concious enough to move about on the table, thus causing the doctor a great deal of difficulty, and making the chance of complications much more likely.

                                                                                                                              p.177

                                                                  The Operation

 

                                                                Operating Room

 

The emotional state of the Akha women as they are taken to the operating room varies widely.  Some seem not worried at all, while a few are obviously very frightened. 

 

It is good if the woman is asleep when she comes into the operating room.  If she is awake and finds there is no one who can speak her language, she may panic.  A translator must be present or available on call, because almost none of the Akha women can speak Thai well enough to be useful.

 

                                                                Operating Table

 

Akhas are accustomed to sleeping on the floor with full freedom of movement.  When the Akha woman is brought into the operating room, she is helped onto a narrow table high above the floor, where she is strapped down.  This is not pleasant.  Moreover, she is told to spread her legs so that the private area can be cleansed, and a uterine elevator can be inserted.  For an Akha woman to spread her legs in this way goes against all the teachings she has received regarding modesty.

 

One Akha woman was so revolted by the experience that she declared after the operation that she was going to warn every woman in her village against the operation, since "they made us do something we have always been taught not to do."  Other women in her group tried to talk her out of it, since they felt that the value received was much more than the temporary embarrassment they had had to undergo.  If the woman is asleep when she enters the room this problem is obviated.

                                                                                                                              p.178

Inserting the uterine elevator must be done very carefully, so as not to rupture the uterus.  Also, if the woman should happen to be pregnant, the action of the elevator may cause an abortion, or what is even more serious for tribal women, an incomplete abortion, which means they will continue to bleed until medical help is given.

 

                                                               Tubal Ligation

 

The operation itself usually takes about fifteen minutes if it is laparoscopic, and about twenty minutes if it is a minilaparotomy (Kamheang 1976).  Complications can add up to another fifteen minutes or so.  The complications Dr. Arunee has had so far include: adhesions (from internal infections or former operations), enlarged spleen (from repeated attacks of malaria), and ovarian tumor.  Such complications call for the minilap operation.  Otherwise she will perform the one-incision, three-burn laparoscopy.

                                                                                                                              p.179

Occasionally complications develop during the operation, the main one being bleeding from a small blood vessel.  Dr. Arunee uses the laparoscope to halt such bleeding by cauterization, often successfully.  If she cannot stop the flow of blood, however, she must withdraw the laparoscope, close the incision, and then make a new incision for a minilap operation.  There are sometimes other reasons why a second incision is required.

 

Another type of complication that occurs rarely during th operation is a patient who goes into shock from allergy to a medicine used.  One patient turned out to be allergic to valium, for example, so oxygen had to be administered.  Other patients have had problems which necessitated special attention on the part of the doctors and nurses.

 

For those patients who are not fully asleep during the operation, there are two time when they will feel some pain: 1) when the syringe with novocaine (xylocaine) is first inserted for the local anaesthetic, and 2) when electricity is used to cauterize the Fallopian tubes (they feel the heat).  The women often need special attention at these two times.  Simply to tell them what is taking place, in a calm, assured voice, is often enough.  Some of them become very apprehensive, and make me promise over and over again that I will not leave them.

 

There are some women who become very talkative under the influence of valium.  Almost invariably when this happens, they talk about their children--their hopes for them, their problems in raising them, etc.  Through it all they reflect a beautiful love for their children and family.  The women who have come from Burma often talk about the hard time they have in getting food, medicine, and clothing for their children.  There is no word of complaint over what they personally must put up with.  Their thoughts and hopes are directed to their children.

                                                                                                                              p.180

                                                        Post-operation

 

                                                        Recovery Room

 

In most cases the woman can be taken back to the ward immediately following surgery.  If there has been any complication, however, the doctor may have her kept just outside the operating room, where her condition can be periodically checked.  For the most part this works very well.  There have been a few cases (less than 0.5%) where we have had to take the woman back from the ward to the operating theater again to take an extra stitch, or repair something which is not quite right.  Sometimes it can be done right in the ward.

 

                                                          Return to the Ward

 

When the woman gets back to the ward, she only wants to sleep for awhile, which is the best thing for her.  If she has a nursing infant with her, the child can nurse any time after the mother returns to the ward, but special care needs to be given to see that the infant does not fall on the floor, since the mother is not fully conscious.

                                                                                                                              p.181

                                                              Food

 

Usually the food brought for the recuperating patient is rice gruel, the Thai version of a "soft diet," which the Akhas hardly consider to be food.  Only when they get steamed rice with some kind of curry do they consider that they have really eaten.  If the hospital does not have this, we sometimes have to purchase it outside for them.

 

                                                          Instructions

 

Each patient is given four packets of pills to take with her when she returns home.  Thes pills are: APC (for pain), tetracycline (to prevent infection), multivitamins, and iron (to help build her up after the operation).  The dosage instructions are printed in Thai, which the tribal women cannot read; and therefore careful verbal instructions must be given them.  They must also be told when they can go back to work, what foods they can eat, how they should protect their bandage, when they should take it off, etc.

 

They also have questions to ask, and we try to answer them as well as possible.  One question they want to ask, but are often too shy to do so, is when they can start sleeping with their husbands again.  A rumor got out that they must refrain from intercourse following sterilization for at least six months, so it is important to tell them that any time the woman feels up to it is fine.

 

                                                        Return Home

 

Two or three hours after surgery, many of the wome are ready to leave.  They are anxious to get back home--sometimes too anxious, since they will have a two-hour bus ride, and then a walk, depending on where they live, or where they will stay that night.  A few women who have been done late in the afternoon stay overnight in the hospital and leave the next morning.

 

If the couple has an infant with them, and they are following Akha customs, before they get on the bus to go back home, they will pick up a small stone somewhere in the hospital compound or near the road and hand it to the infant.  They will also pluck a small sprig of some plant and stick it into some part of the infant's clothing.  Doing this insures that the soul of the infant will return with them to the village.  If they did not do this, the infant's soul might be tempted to stay there in Phayao, and thus the child would later get sick and perhaps die.

 

They are thrilled to get back home and the people in the village are happy to see them again.  No doubt the women on their return feel very much like the astronauts on returning from the moon.

                                                                                                                              p.183

                                                        Conclusion

 

When projecting the ordeal that confronts the Akha woman in tubal ligation against the mores of Akha life, it is striking that any of them consent to the operation.  If she knew in detail beforehand what she might have to undergo, many a woman might be discouraged from facing the experience.  Fortunately, she encounters each single aspect in turn, rather than all together, and she does so in company with other Akha women so that she is sustained.