[PDF] Plant Use in Ante- and Postpartum Health Care in Lao PDR

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Plant Use in Ante- and Postpartum

Health Care in Lao PDR

Degree project in biology, 2007

Examensarbete i biologi 20 p, 2007

Biology Education Centre and Department of Systematic Botany Uppsala University

Supervisors: Lars Björk and Hugo de Boer

Emma C. S. Lundh

Plant Use in Ante- and Postpartum

Health Care in Lao PDR

Master of Science thesis by

Emma C.S. Lundh

Under supervision of

Lars Björk & Hugo de Boer

Department of Systematic Botany

Uppsala University, Sweden

September, 2007

ABSTRACT

An ethnobotanical study, combining systematic botany, pharmacology and anthropology was carried out December 2005 to Mars 2006 in Central and Northern Lao People's Democratic Republic (PDR). The study documents the medicinal use of plants in an important and complicated passage of

life, childbirth. Semi-structured interviews were conducted in five rural villages among four ethnic

groups on the plants employed during the birth process as well as their associated beliefs. Fifty-four

different plant species were found to treat 15 conditions occurring during pregnancy, birth and the postpartum stages. The most common uses of plants were to promote maternal health and postpartum recovery of strength, healing and contraction of uterus, and to promote lactation. Other common reports included reduce postpartum haemorrhage, alleviate postpartum abdominal pain and protect or cure the newborn from infections. An ethnobotanical plant collection including 93 genera

in 59 families was made from species with medicinal uses in the five villages. In addition 18 species

used in traditional steam saunas as a postpartum health procedure for lowland Lao in urban areas are

presented and compared to the plants used in the villages.

As a result of the study six species used in postpartum health care, representing four Zingiberaceae

genera (Zingiber, Amomum, Alpinia, Elettariopsis) as well as two common steam sauna species (Adenosma

bracteosum and Cymbopogon nardus) were selected for Gas Chromatography combined with a Mass Spectrometry (GC-MS) analysis. Identified compounds are presented and their potential effects in comparison to western medicine are discussed. Few studies have been made on plant use in ante-and postpartum health care. The knowledge of medicinal plants presented in this study may provide an important resource for improving maternal and infant health among upland and highland populations, as well as a rich source of further phytochemical, pharmacological and clinical studies on medicinally applied species in Lao PDR. ii

PREFACE

In your hand you have the outcome of an ethnobotanical study performed in Lao People's Democratic Republic (PDR) and financed as a Minor Field Study (MFS) by the Swedish International Development cooperation Agency (SIDA). For those who are not familiar with the word

ethnobotany, it refers to the study of the interaction between people and plants, and covers a broad

range of different fields and techniques. This study principally encompasses systematic botany, pharmacology and anthropology. Performing an MFS in one of the poorest and least developed countries in the world is a great

challenge. Except for the daily complications with language barriers, health, transport and equipment

issues, it requires you to become acquainted with cultural worldviews that in many aspects collide with your own worldview, and it makes social skills as fundamental as academic skills. I believe that a combined study of this kind would be favoured if performed in cooperation with

specialists from the different fields and on a longer time-span. However, this is rarely the reality, and

unfortunately impossible for a Master thesis project/MFS that is greatly restrained concerning the time aspect. Nevertheless, except for educational purposes, an ethnobotanical MFS can be of great value for the local people and for potential future research project.

The original aim for the study was to investigate the use of the plant family Zingiberaceae in local

health care in rural villages in the National Biodiversity Conservation Area (NBCA) Nakai Nam- Theun (NNT). Pointed out as a biodiversity hotspot and the largest and most well preserved NBCA

in Laos, we saw this as an exceptionally interesting area for the study. We also had the opportunity to

cooperate with a Lao Ph.D. student, Mr Vichith Lamxay, who was doing research on Zingiberaceae genera. The villages situated in the NNT Conservation Area are highly dependent on Non Timber Forest Products (NTFPs) for survival. This also applies in health care where plants in the remote villages serve as medicine due to the inaccessibility or high cost of modern pharmaceuticals.

The project was interview based and it was essential to find a good interpreter, yet this was a difficult

task. The most important quality of an interpreter is the accuracy of the information he/she relays,

and it is difficult to know in beforehand. The project's tight budget and the fact that we preferred a

female interpreter complicated it further. A female interpreter was preferred as women in earlier studies have been noted to give different answers in the presence of men then those they give when they are alone or in presence of other women. It can also happen that a male interpreter relays

different information than a female informant expresses and for example neglect, substitute or fill in

answers during interviews in the belief that he has a greater knowledge. We also intended to interview men and women separately because knowledge, gathering and the use of the plants can differ greatly between the genders. Other consideration on working with interpreters is the time aspect, because more time-consuming interviews are tiring for the informants. After two weeks research in the NNT Conservation Area our project took an abrupt turn. Our

female interpreter could not longer assist us and we had to return to Vientiane capital in search of a

new interpreter. In the mean time regulations concerning the access to the Nakai Nam-Theun NBCA were made more stringent and impeded us to return. We found ourselves forced to change the location of the project. Through contact with the aid organizations ADRA and GTZ we were able to

arrange access to some interesting villages in northern Laos. The change of location also required us

to change the focus of the study, from Zingiberaceae to a more general view of plants in health care

and use during pregnancy, birth and convalescence. My choice of focus on plants connected with childbirth was partly because many of the Zingiberaceae species in Nakai Nam-Theun were used in postpartum health care, and the interesting subject had been given little attention in previous research. Unfortunately the change of focus and study area after our start in Nakai Nam-Theun iii caused some species mentioned from these villages to be classified as having an undefined postpartum use in this report. Also included in the project were interviews performed with steam sauna owners. The idea of making steam sauna interviews arose after our visit to the villages in Nakai-Nam Theun NBCA. Our Swedish

supervisor Lars Björk had in his earlier visit to Laos got in contact with a steam sauna manager in

Vientiane interested in steam distillation for the production of oils that could substitute the fresh

plant material for species not available all year around. Steam baths were found to be an important and common postpartum procedure in the villages visited in Nakai-Nam Theun NBCA. Due to the resemblance of steam sauna to steam bath I believed it also could play an important role in

postpartum health care and be an interesting area of investigation. When the project later needed to

change location and widen its focus from Zingiberaceae, including steam sauna interviews gave an interesting insight in the postpartum care for lowland Lao.

During the interviews the plants' vernacular names were written in Swedish phonetics since it made it

possible to re-read the names with greater accuracy. We chose not to further translate the Swedish

phonetic to English because accuracy loss would be inevitable. All local plant names in this report are

thus expressed in Swedish phonetics. Swedish contains three more vowels, å, ä and ö which are well

represented by to the Lao letters Âx, Áx, Àxó respectively, where x stand for a consonant. In English

the Swedish å represent the sound of "a" in ca ll, "o" in "fore" or "ou" in four. The Swedish "ä" is the sound of "a" in ba ck, "ai" in fair or "e" in best, and the "ö" represent the English "e" in her, the "u" in fu r, or short "a" in about. The Swedish pronunciation of "j" resembles the English "y" in

many words. However the Lao sound xõ does not exist in Swedish or English and is represented with

the symbol ü in this report. It is a nasal sound that lies between the Swedish "u" and "y". Further

guidance in pronunciation of Swedish letters can be found on the web page for Stockholm school of economics (2007). Finally I would like to comment that this ethnobotanical study followed the rules of the Convention on Biological Diversity (CBD) and aims to share experience and knowledge. Although a short study

like this might give only limited possibilities, some basic ethnobotanical methods like making plant

collections were introduced to the villagers and our interpreters. Voucher duplicates were deposited

at the herbarium of the National University of Laos (NUOL). At NUOL some technical equipment

was also introduced and left for educational purpose. The contacts established and the interchange of

culture and language were also to be considered of great value. iv v

CONTENTS

ABSTRACT........................................................................ ...................................................................................i PREFACE........................................................................ .....................................................................................ii

ACRONYMS AND DEFINITION OF MEDICAL TERMS..................................................................vi

1. INTRODUCTION........................................................................ .................................................................1

1.1 Ethnobotany........................................................................

................................................... 1

1.2 Background........................................................................

.................................................... 1

1.3 Objectives........................................................................

.......................................................5

1.4 History and cultural believes of ethnic groups in Lao PDR..................................................... 5

2. METHODS........................................................................ ............................................................................19

2.1 Field work........................................................................

.................................................... 19

2.2 Steam sauna interviews........................................................................

................................. 22

2.3 Extraction of essential oil and chemical analysis.................................................................... 22

3. RESULTS.................................................................. ......................................................................................23

3.1 Ban Kaoy and Ban Mak Feuang........................................................................

.................... 23

3.2 Lao Khao village........................................................................

........................................... 30

3.3 Ban Nam Vang........................................................................

............................................. 30

3.4 Ban Nam Lue........................................................................

............................................... 31

3.5 Steam sauna results........................................................................

....................................... 33

3.6 Summary of results........................................................................

....................................... 37

3.7 GC-MS results........................................................................

.............................................. 38 4. DISCUSSION........................................................................ ........................................................................41

4.1 Reflection upon some genera and species in APP health care................................................ 41

4.2 Steam sauna........................................................................

.................................................. 43

4.3 Informants and gender specific knowledge........................................................................

... 44

4.4 Voucher collections........................................................................

...................................... 44

4.5 GC-MS analysis........................................................................

............................................ 44

4.6 Reflections on future medicinal plant use and research in Laos............................................. 46

ACKNOWLEDGEMENTS........................................................................ ...................................................47 REFERENCES........................................................................ ..........................................................................48

APPENDICES

Appendix A - Translation of local plant words Appendix B - Plant family abbrevations Appendix C - Use and preparation of plant species in health care in Lao PDR Appendix D - List of species used in health care in Lao PDR, sorted by vernacular name Appendix E - Vernacular plant names in Lao PDR written in French phonetics vi

ACRONYMS AND DEFINITION OF MEDICAL TERMS

Acronym Definition

ADRA Adventist Development and Relief Agency

APP Ante- and Postpartum

COX Cyclogenase enzyme

GC-MS Gas Chromatography combined with Mass Spectrometry GTZ Deutsche Gesellschaft für Technische Zusammenarbeit

MFS Minor Field Study

NBCA National Biodiversity Conservation Area

NNT Nakai Nam-Theun

NSAID Non-Steroid Anti-Inflammatory Drug

NTFP Non Timber Forest Product

NUOL National University of Laos

PDR People's Democratic Republic

PPH Primary Postpartum Haemorrhage

SIDA Swedish International Development cooperation Agency

UPS Herbarium of Uppsala University

UXO Unexploded Ordnance

WHO World Health Organization

Term Definition

Primary Postpartum

Heamorrhage (PPH) Excessive vaginal bleeding (>500ml) within the first 24 hours after delivery.

Secondary Postpartum

Heamorrhage Excessive vaginal bleeding after the first 24 hours postpartum. Uterine atony Uterus fails to contract properly after delivery. Prolapse (uterus) Displacement of the organ or structure from its normal position. The uterus can drop into the vagina (first-degree prolapse) or be seen outside the vulva (third-degree prolapse). Antepartum period The period before labour starts in pregnancy.

Postpartum period See puerperium.

Puerperium The period that elapses after the birth until the mother is again restored to her ordinary health. It is generally regarded as lasting for 6 weeks.

Postpartum abdominal

pains or afterpains Pains similar to but feebler than those of labour, occurring commonly in the two or three days following childbirth.

Lactagoge A substance that promote lactation.

Abortifacient A drug or other agent used to cause abortion (terminate pregnancy). 1

1. INTRODUCTION

1.1 Ethnobotany

The word ethnobotany refers to the study of the interaction between people and plants (Martin

2004). Interactions can take many forms. Plants can provide food, shelter, cloth, fuel and are for a

large percentage of the world's population the only preventives, cures and relief against disease and

health problems. The medical use of plants has won great attention in literature, mainly in the search

of new drugs, where ethnobotanical inquiry provides a valuable short-cut for locating biologically active compounds. Some examples of important pharmaceuticals derived from plants are aspirin, quinine, morphine and several HIV-blockers (Balandrin & Klocke 1985, Akerele 1993, Lewis & Elvin-Lewis 2003). Another motivation behind ethnobotanical research is to document knowledge

that is threatened to disappear, and that may be of great value for future generations but are lost with

the old practitioners/healers. Such study could be made for the purpose and aim of sharing experience and knowledge.

In general ethnoobotanical studies cover a broad range of different fields and techniques. This study

principally encompasses systematic botany, pharmacology and anthropology. It examines the use of

plants in one of the most important and complicated passage of life, childbirth. Included in this study

is also the period of convalescence known as postpartum period or puerperium. The study is interview based and performed among five ethnic groups in the diverse country of Lao People's

Democratic Republic (PDR).

1.2 Background

1.2.1 Laos, geography and climate

Lao PDR is a landlocked country in the heart of the Indochinese Peninsula in Southeast Asia (Fig. 1).

In the land area of 236,800 km

2 , about the size of Great Britain, approximately six million people

reside that representing a wide range of ethnic diversity (The World Factbook 2007). With a relative

high forest cover and low population density compared to neighbouring countries (Wikramanayake et al. 2001), Lao PDR is a unique country and has been pointed out as one of the world's global biodiversity hotspots (Conservation International 2007). The climate of Laos is tropical to sub-tropical, with a pronounced wet and dry season. A wide

variation in temperature and rainfall due to topography create a great number of forest habitats. The

principal categories of forest formations are: Evergreen Mountain forest, Evergreen and Semi- Evergreen Lowland Forests, and Deciduous forests (Rundel 1999). Human impact and exploitation of forest resources have accelerated dramatically in the past few decades (Rundel 1999). Forest cover was reduced from 70% of the total land area in the 1940s to

41% in 1999 (Southavilay & Castern 1999). Forest degradation is largely attributed to inappropriate

forest management, uncontrolled logging, and changes in shifting cultivation methods due to increased population pressure. Other threats include road and dam construction, and also hunting

and illegal trade in flora and fauna (Chanthirath 1999). In an effort to protect the dwindling forest

resources 12.5 % of land area has been allocated as reserves, known as National Biodiversity Conservation Areas (NBCAs) (Berkmuller 1995). The largest of the NBCAs is Nakai-Nam Theun in the Annamite mountains bordering on Vietnam. For villages in the area Non-Timber Forest Products (NTFP) account for up to 80% of the cash income (Foppes & Ketphanh 1997, 2000;

Robichaud et al. 2001).

2

1.2.2 Ethnic Diversity

The biodiversity of Lao PDR is matched only by its ethnic diversity. Administratively, the Lao people

are divided into three major groups. Lao Loum (lowland Lao), account for 68% of the population and are mainly ethnic Lao and Thai groups living on the plains along the Mekong river. Lao Theung (upland Lao) comprises 22% of the population, essentially Mon-Khmer and Austroneisian groups that are living on the plateaus and middle slopes, and Lao Soung (mountain/highland Lao) that reside in the remote mountainous area and comprising 10% of the population. Lao Soung incorporates Tibeto-Burman and Hmong-Yao (Milloy & Payne 1997, Evans 1999, Douangsavanh et

al. 2003). Within these three major groups the ethnic make-up is extremely diverse. Around 47 ethnic

groups and numerous subgroups are recognized, differing in religious beliefs, custom, and language (Chazée 1999). The diversity and isolation of the numerous ethnic groups in Laos have made the realization of true

cultural and political unity difficult. Today Laos is one of the poorest countries in the world, with an

ever-increasing gap between the comparably fast economically growing lowlands and the poorer highlands. Fig. 1. Map of the Lao People's Democratic Republic. 3

1.2.3 History

The territory of modern day Lao PDR has throughout history been the victim of foreign nation's interest and wars. As a nation it won independence in 1953 after six decades of French rule and Japanese occupation during World War II, and a constitutional monarchy was established. A conflict though persisted in the country between the US-backed Royal Vientiane government and the communist Pathet Lao (Land of Lao). Amid continued internal fighting, Laos was drawn into the Vietnam War 1964 when the United States began bombing North Vietnamese forces operating inside Laos. The Pathet Lao finally seized power in 1975 (Stuart-Fox 1997). Lao PDR emerged from the war as the per capita most heavily bombed country in the world (Rumpf & Chagnon 2006). Still today unexploded ordnances (UXOs) constrain the amount of land available for agriculture and logging and cause affliction to the upland and highland people practising swidden agriculture (Bounthong et al. 2003, Douangsavanh et al. 2003). After the war the country closed its border to outsiders, and it was almost impossible for Western academics to conduct research inside Laos. In the 1990s however the country came into economic crisis and started to open up to foreign aid and investors (Milloy & Payne 1997). In Laos today the internal change quickens, pressure on natural resources and the influence of foreign culture and goods increases, along with agricultural regimes and resettlement of highland population (Evans 1999). It now becomes increasingly important to document the dynamics of culture and botanical knowledge before the invasion of exotic plants and western ideas diminish its identity.

1.2.4 Traditional Medicine

It has been estimated by World Health Organization (WHO 2002) that 80% of the world's

population relies on traditional medicine (TM) to meet their daily health requirements. In Laos TM is

widely used, and perceived as effective by a fairly large proportion of the population (Sydara et al.

2005). The reliance on TM is partly owing to the inaccessibility and high cost of modern

pharmaceuticals and to inadequate health care facilities. The Laotian government encourages the use

of medicinal plants and traditional medicine, particularly in rural areas where modern treatment is not

affordable or regularly accessible (Libman et al. 2006). Until recently, research on the important resource of medicinal plants has been limited and it

appears, based on scrutiny of literature, that no ethnobotaical research has been carried out in Lao

PDR focusing on the use of plants in ante- and postpartum (APP) health care. Although some literature comprises childbearing and birth among various ethnic groups these are purely anthropological and lack in-depth knowledge on the plant species connected to this vital process.

1.2.5 Childbirth

Birth is a natural process that involves great physical stress and consequently can cause serious health

complications. Most cultures of the world consider postpartum a period of transition and

vulnerability, and more than one-half of all maternal deaths occur during this period. The definition

of postpartum period in medical terms is typically 6 weeks after delivery of the infant. Postpartum haemorrhage is one of the most common causes of maternal mortality and morbidity worldwide and accounts for about 25% of maternal deaths. Nevertheless the rates vary greatly between and within countries and for some developing countries it doubles (Gilbert et al. 1987, Drife 1997, Tsu et al.

2004).

Other health consequences of pregnancy and childbirth are abdominal or perineal pain, infections,

prolapse, fatigue, nausea, depression, and lactation complications (Goodburn et al. 1995, Kline et al.

1998, Ransjo-Arvidson et al. 1998, McGovern et al. 2006). Plants serve as preventives, cures or relief

for these symptoms in many developing countries where access to modern health care facilities is inadequate and birth commonly takes place at home. In these countries plants are also important in 4

family planning and have been shown to serve as fertility enhancers, abortifacient and contraceptives

(Bourdy & Walter 1992, Jain et al. 2004, Ticktin & Dalle 2004).

1.2.6 Are plants and plant derivatives compatible to synthetic pharmaceuticals?

To find out the most common health issues and their cures in western medicine an interview was conducted with Annicka Stridh, who is employed as a midwife at the Swedish hospital Falu Lasarett. She stated that the most common health issue during puerperium was abdominal pain due to contraction of uterus. Analgesics like paracetamol and NSAIDs (non-steroid anti-inflammatory drugs) were prescribed to alleviate this pain. NSAIDs inhibit cyclogenase enzymes (COXs) leading to a decrease in prostaglandin production, which reduces pain and also inflammation (Fox 1999). A

literature search was done on plants and plant compounds used in traditional medicine to see if they

may exhibit similar analgesic activity. In a study by McGaw et al. (1997) several plant extracts

traditionally used to relieve pain and inflammation exhibited high inhibitory activity on prostaglandin

synthesis. Psychotria (Rubiaceae), a common genus in Southeast Asia, has attracted a considerable amount of pharmacological investigation. Both extracts and compounds found in Psychotria species

showed analgesic activity (Elisabetsky et al. 1995, Amador 1996, Both et al. 2002). Plants in the family

Solanaceae also proved to contain numerous species with analgesic effects, for example Mandragora officinarum and Solanum melongena (Vohora et al. 1984, Markovits & Gilhar 1997, Lewis & Elvin-Lewis

2003). Some plant compounds have gained an important position in western medicine. One well-

known analgesic in clinical practice is morphine derived from opium poppy, Papaver somniferum, a species widely used in traditional medicine against pain and stomach problems. Another known

compound traditionally found in Salix spp. is salicin, the precursor of acetyl salicylic acid found in

Aspirin (Vane & Botting 1992, Calixto et al. 2001, Lewis & Elvin-Lewis 2003). Primary Postpartum Haemorrhage (PPH), defined as excessive bleeding within the first 24 h. after

delivery, can be caused by uterine atony (the uterus fails to contract properly after delivery), retained

placenta, inverted or ruptured uterus and genital tract tears. Uterine atony is the most important cause of PPH and in developing countries prolonged labour is one of the main risk factors. Secondary postpartum haemorrhage (haemorrhage after the first 24 h postpartum) is mainly caused

by retained portions of placenta and infections (Drife 1997, Pelage et al.1998, 1999, Tsu et al. 2004).

The pharmaceutical Syntocinon is given on a routine basis to women in Sweden before delivery. Syntocinon have shown to lower the incidents of postpartum haemorrhage. It contains a synthetic

version of the naturally-occurring hormone oxytocin, released by the pituitary gland. Oxytocin causes

the muscle of the uterus to contract and by that help start or continue labour and to control bleeding

after delivery (A. Stridh, personal communication). A number of articles have been published on

plants and plant extracts possessing an oxytocin-like effect. Piyachaturawat et al. (1985) examined the

antifertility activity of Citrus hystrix, containing the essential oil menthol, and found that extracts form

the species caused abortion and could hasten labour time in pregnant rats. Extracts form Melastoma candidum tested on guinea pigs also gave an increased contraction frequency of uterus (Chou & Liao

1982)

The use of plants as contraceptives and abortifacient may be difficult to investigate as these preparations are sometimes outlawed or cultures taboos, and informants are commonly reluctant to relay their knowledge. In the Hmong culture for example women's most important task is to give birth and they are promoted to have more children than there mothers (Symonds 2004). Some examples on plants used in family planning are Mimosa pudica (Mimosaceae) and Mussaenda pubescens (Rubiaceae). A decoction of the widespread M. pudica is used traditionally as a contraceptive in Northeastern India and has shown by Valsala & Karpagaganapathy (2002) to alter the oestrous cycle in rats. Extracts of M. pubescens has also been tested on rats and exhibit significant effects on terminating early pregnancy (Qin & Xu 1998). 5 Plant use during the childbirth and convalescence is important worldwide and refers to a large number of plants and substances, which further have a wide spectrum of biological properties beneficial in APP health care.

1.3 Objectives

The primary objective of the project was to document the medicinal use of plants during pregnancy, birth and puerperium, as well as some of the associated beliefs in Lao PDR. The project included interviews and collection of botanical specimens in five rural villages in the Central and Northern Laos. In total fifteen informants from the ethnic groups Akha, Brou, Hmong and Lanten participated. The various groups' history, cultural belief and language are presented in section 1.4.

Plant use in traditional steam saunas was also included as a postpartum health procedure for lowland

Lao in urban areas. The steam sauna procedure, greatly resembling the steam bath practiced in the

Brou villages, has been given surprisingly little attention in literature in spite of its' importance in Lao

health care.

Furthermore essential oils from selected species (Adenosma bracteosum, Alpinia cf. oblongifolia, Amomum

cf. microcarpum, Cymbopogon nardus, Elettariopsis cf. and Zingiber sp.) were extracted and analyzed through Gas Chromatograph combined with Mass Spectrometer (GC-MS). The analyses were performed in Sweden and aimed to determine bioactive compounds in these species and indicate their potential effect in comparison to western medicine.

Collection of botanical specimens was carried out both with the purpose of identifying useful health

care species and contributing to the currently limited knowledge on floral biodiversity in Lao PDR.

1.4 History and cultural believes of ethnic groups in Lao PDR

1.4.1 Hmong

In Laos the Hmong can be divided into the Hmong Khao, or White Hmong and Hmong Lay, or Striped/Colored or Green Hmong (also commonly called Blue Hmong). Dialect divergences and minor variations in dress, traditions, handicraft and house arrangements mark the differences between these groups (Chazée 1999). They are further subdivided into clans and lineages, and

marriages are arranged between members of different clans, or subclans. Slight variations in healing

methods and taboos can exist between the clans. The extended family household constitutes the

basic cultural and political unit. The oldest male has virtually unlimited authority over its members

and he is responsible for settling disputes between family members and make the final decisions (Symonds 2004). Hmong belong to the Miao-Yao language group of the Sino-Tibetan family (Ovensen 2004). Of the Lao Soung, the Hmong are clearly the most numerous. In 1995 they amounted to about 315.000 persons, or 6.9 percent of the population, while none of the other groups made up more than 0.8 percent (Lao Census 1995, Lemoine 2005).

History

Hmong, means "free people", and they have been seeking their freedom and independence throughout history. The exact origin of Hmong, or Miao/Yao speaking people, is unclear but they lived in the highlands of south-western China for centuries. The Chinese government attempts to

subjugate and settle the Hmong led to periods of protracted conflicts, and in the nineteenth century

many Hmong migrated to Laos, into Burma (Myanmar) and Vietnam, and eventually also to Thailand (Anderson 1993, Tapp et al. 2004). In their new homelands Hmong descendants, like their ancestors 6 Fig. 2. Nam Vang, a Hmong village in Luang Namtha, Lao PDR. The houses are built directly on the ground and each has two doors, the entrance door and the spirit door. settled in high altitudes and continued the practice of swidden agriculture and opium (Papaver somniferum) cultivation. During the Vietnam War many Hmong were recruited and trained by the United States Central Intelligence Agency (CIA) to fight against the North Vietnamese forces and the communist Pathet Lao (Reineke 2001, Moua 2003). In 1975 when United States withdrew and further Lao came under communist regime thousands of Hmong (soldiers with their families) fled to Thailand fearing for their lives. Many of these Hmong were placed in refugee camps, and some were later resettled in Australia, Canada, France, French Guyana and the United States (Tapp 1986, 1988, Anderson 1993,

Reineke 2001). The Hmong are still today struggling for their rights in Laos and challenged not only

by resettlements and opium eradication but also by poor access to education, unemployment, and lack of land for cultivation.

Village structure

Hmong villages can vary greatly in size, partly depending on land available for cultivation. There is no

fence around the village and it does not have gates like Akha villages. The construction and the

location of the house is important and often village-wide social event. Both the location of the village

and houses within it are chosen with great care, as it is important that the site is acceptable to the

ancestors. The houses are always built on the ground (Fig. 2), usually on a slope and in no straight

line to each other, because the good spirits enter the house in a straight line and nothing must obstruct their path (Lewis & Lewis 1984). Every Hmong Khao house has two doors, one regular door for entering and leaving the house and one spirit door used during rituals like the naming

ceremony when a child's third spirit is called upon. The doors are never opposite to each other, and a

spirit altar is on the wall facing the front door (Khao Toh, personal communication).

Gender and division of labour

Gender roles are pronounced in the traditional Hmong family. Women are responsible for the domestic work including cleaning, feeding animals, cooking and childcare. Hunting animals is restricted to the men; women are only allowed to kill chickens. Both men and women work with slashing and burning the fields and harvesting of the rice (Moua 2003). Patrilineality is the framework of Hmong society. Or as a Hmong man expressed in Tapp (1989): "The important part of a Hmong family is the men... Women are important, but women change...

Wives and daughters are like leaves

and flowers, but men are the branches and trunk of the tree, always strong and never changing". This is consistent with the idea that men make up the structure of the society on which all else is built. Hmong women conform to this view and give less prestige to themselves than to men. Symonds (2004) points out that both men and women, stress that "men are more important" and that "Hmong is maleness". They believe that men have better judgment than women and men are both more intelligent and more capable. For that reason, men have the power to make formal and final decisions in most areas of Hmong society. 7 Although women can become shamans, they are not allowed to participate in rituals like calling the souls of newborns or guide the dead back to the otherworld (land of darkness), feed ancestors at

New Year or visit gravesites, as this concern the patriline. First in the afterlives the souls of men and

women become equal, and in the next life the woman's returning soul may be reborn in a male form, carry the patriline along and have a public voice (Symonds 2004). Religious believes: The natural and supernatural world

Hmong are animists and believe that the physical and spiritual worlds coexist. Spirits are involved in

every aspect of their life. The wild spirits of the outside can cause trouble and sickness. These are the

spirits of the forests, fields, rivers, hills, valleys, trees, rocks and even wind currents. The tame and

cared for spirits are ancestor and households' spirits that live inside and in the walls of the house

(Livo & Cha 1991). They offer protection from the wild spirits of the outside, but can also cause illness or even death if they are not cared for and treated with honour and respect (Symonds 2004). The Hmong believe that the body contains various souls, the number of souls can vary between different Hmong groups but the concept of souls and soul loss remains similar across groups. Three

different types of souls are generally recognized. The first soul enters the body as soon as the bone

structure starts to form and will always reside in the body, even after death it stays with the bones in

the grave to guard them. The second soul is brought by the wind at the moment the child takes its

first breath. It is unstable and easily frightened or stolen away by wild spirits. At death this soul

makes the journey back to the land of darkness to join the ancestors, and is fed and remembered by

its descendants. The last soul, the "returning vital soul" enters the body on the third day after birth

during the name calling ceremony. It reincarnates or wanders between the land of darkness and light with the shifting stages between life and death in a never-ending cycle (Symonds 2004, Sperstad &

Werner 2005).

Illness, Spiritual Healers and Shamans

In Hmong culture; society, religion and medicine are connected and cannot be separated easily into

categories. Beliefs and practices about childbearing, birth and childcare are closely inter-convened in

the cultural beliefs of the natural and supernatural world. In health care both worlds are important as illnesses are considered to be sent by the spirits, or a result of being out of balance. Both neglecting the good spirits of ancestors or of the household, as well as catching the attention of wild spirits can be reasons for illness. A person can also easily lose a soul if frightened by a loud noise, a fall, or an animal, which can lead to serious illness or death if it is not restored by a shaman (Symonds 2004). Every village has at least one shaman. A Shaman is a man or a women that been chosen by the spirits, this often reveals in a long illness, which is cured only when the person consents to become a shaman. Each shaman has "teacher spirits", whom he/she calls upon during trance when making the journey to the spiritual world (Fig. 3). Usually a shaman is consulted when the illness is very serious and cannot be cured by the soul calling rituals made by the family or by the sole use of medicinal plants (Plotnikoff et al. 2002, Sperstad & Werner

2005).

Fig. 3. A Shaman (sitting) making the journey to the spiritual world to negociate about a childs soul. Nam

Vang village, Lao PDR.

8

If specific restrictions are not respected it can impoverish health. For example if a woman does not

follow a special diet and obey the restrictions in behaviour during the postpartum month she may experience physical problems like headaches, joint/back pain, excessive haemorrhage or a prolapsed uterus (Kao Tho, personal communication, Symonds 2004). Due to the vulnerable state after

childbirth as well as during pregnancy it is also important to avoid streams and other bodies of water

because of the presence of malevolent spirits (Tsia hua moa, personal communication).

Midwives

Midwives are respected and known in the village for their knowledge about pregnancy and birth. They can deal with complications during birth like turning a breech baby to the right position and

can recommend herbs for fertility and birth. A shaman might also assist if complications arise during

birth, he will perform rituals seeking the answers for the complications in the spiritual world (Symonds 2004).

Fertility

Fertility is important both to Hmong women and men, as it provides the opportunity of rebirth.

Many children are appreciated as the infant-mortality rate is high and children are a good help in the

fields. In addition children are needed to care for their parents when they get older and to make the

funerary rites and feed their souls when they die and wander to the ancestors' village. If a couple

stays childless, the woman is often seen as the responsible for the couple's inability to conceive. She

can then seek help from an herbalist that possesses knowledge about fertility-enhancing herbs.

Nevertheless the first child is believed to seal the marital union and if the wife remains childless the

husband may seek divorce (Symonds 2004). A Hmong woman's power and value are located in the realm of reproduction and many Hmong women are reluctant to use any form of abortifacient or birth prevention. Preventing conception

might deny a soul its opportunity for rebirth. Another reason why contraception is avoided is that a

woman who expresses her wish of not having more children might fear that the husband take a junior wife. Women are also enjoined by their families to have as many children as possible. It is

believed (but not taken very seriously today) that a women must give birth to more children than did

her own mother or mother-in-law if she is to fulfil her destiny (Symonds 2004). Sons are highly appreciated as they carry the clan name along, but a great value is also placed on having an equal number of sons and daughters because of the bride price a family receives in exchange for its daughters (Moua 2003).

Childbirth

Birth consists of two parts, the actual physiological event, and the soul calling ceremony on the third

day after birth, when the baby is given a name and its last soul enters the body. However before birth

a number of preparations have to be done. A supply of chicken for the new mother has to be arranged, and herbs have to be picked to serve as pain relief and to make decoctions to wash the newborn. In Ban Nam Vang, a Hmong village included in this study the plant "Qaub dej" (Begonia

handellii) was picked to relieve pain after delivery. The delivery took place in a sitting position where

the husband normally was supporting the woman from behind. Present was also a midwife and one or two more women from the family. Tough this does not seem to be case for all Hmong. Symonds

(2004) states in her study of a Hmong Lay village in Northern Thailand, that birth is a women's issue

handled only by the women. She says that most births take place alone and point out the importance of privacy.

On the husband responsibility lays recollecting and burying the infant's birth shirt, or placenta. It has

to be done with great care because the child's health may suffer if insects or animals eat any of it. As

in many South Asian cultures the placenta is believed to be collected when the person's soul returns

9 to the land of darkness. All other blood from the delivery also has to be buried with care as the mother and child risk getting sick if the wild spirits finds it (Symonds 2004).

The first three days after delivery is the most dangerous period for a newborn. During this time it is

of highest importance that the mother and child are kept warm and a bed is made up next to the fire (Rice 2000, Symonds 2004). The mother should also shower in warm water and eat warm food and drinks up to 30 days after birth. The concept of hot and cold foods and body temperatures connected with a woman's postpartum vulnerability has been documented for many Southeast Asian countries (Manderson & Mathews 1981, Steinberg 1996, Symonds 2004). It is believed that the woman is in a cold and weak stage after giving birth. In order to return her body to balance and

regain strength and weight she eats a special postpartum diet, usually a combination of herbal teas,

boiled chicken with herbs, rice and eggs (Potter & Whiren 1982, Lewis & Lewis 1984, Symonds

2004).

Chicken is believed to be an excellent food in many South Asian countries, and promotes the recovery of heat and strength. According to the informants in both Nam Vang (Hmong) and Nam Lue (Lanten) village, and also mentioned in Hmong folktales (due to a bargain struck between men and women about who would give birth) one chicken should be slaughtered and prepared by the husband every day during one month. However due to food shortage, nowadays one chicken usually has to last for 2-3 days (Laolee and Kao tho, personal communication). In Nam Vang village the shaman Tsia hua moa reported a number of recipes of chicken boiled with curative herbs to recover health and strength postpartum. Symonds (2004) reports that herbs are boiled with the chicken to remove any residues of stale blood from the body and cleanse the uterus. From the third day after delivery and for a month a decoction of Schizomussaenda dehiscens (Rubiaceae) is also drunk by the mother to promote lactation and quick recovery of strength (Kao tho, personal communication). During this resting period the mother is not permitted to visit other households as her state may harm other people. Warning signs made from bamboo are put up outside the house to warn people that are ill, as well as pregnant women not to enter, because they can diminish a new mother's milk supply (Lewis & Lewis 1984, Symonds 2004). After one month the woman can usually start to do work in the field and resume sleeping together with her husband (Kha tho, personal communication).

1.4.2 Akha

History

In Lao PDR the Akha (also named Kho, Ikor and Kha) live along the Chinese border, and are the second largest Lao Soung after the Hmong (Fig. 4). Akha originated from the Yunnan and the Tibetan region. They have migrated through Burma to their current position in Northeast Laos, Northern Thailand and Vietnam. The Akha first entered Laos in the 1850s, but the majority came from Yunnan and Burma in the 1900s (Lewis & Lewis 1984, Chazée 1999). Akha represent with a population of approximately 66,000 about 50% of the Tibeto-Burman family in Laos (Lao Census 1995), the majority is living in Phongsaly and Luang Namtha provinces. The Akha language falls within the Yi (Lolo) branch of the Tibeto-Burman family, and is only a spoken language, lacking written characters. This makes research on their history and origins difficult. The period of emergence of the Akha as an ethnic group occurred over 55 generations

Fig. 4. Akha woman in Lao Khao village, Sing

district, Lao PDR. 10

ago according to the elder of Akha villages in Long district, Luang Namtha province (Chazée 1999).

Although no written history exists, a rich heritage of legends, proverbs, and rituals, verbally transmitted through the generations gives the Akha a sense to who they are and what being an Akha means. Their strong concerns about continuity and ancestral beliefs make them able to recite the names of all ancestors in the male line back to the "beginning", including more than 60 names, and astonishingly the Akha from China, Burma, Thailand and Laos agree in their repetition of genealogy and migration routs (Lewis & Lewis 1984). The Akha explain the last part of their migration to Laos as a retreat to escape from political

rebellions and Chinese bandits who stole their livestock and pillaged the village. Laos also offered

abundant natural resources and had favourable land for shifting cultivation (Chazée 1999).

The Akha Way

Akha often refers to themselves as those who "carry the Akha Way" (Aka zah taw-eu). The Akha

Way includes their beliefs, traditions and ceremonies. It determines how they cultivate their fields and

hunt animals, and also how they view and treat illness (Lewis & Lewis 1984). Rice cultivation, preparation and consumption are given special attention in the Akha Way, and a number of ceremonies are connected to it. Akha believe that by diligently following the Akha Way they will

maintain good health and have good luck in life as well as behaving in contradiction to the Akha Way

will bring sickness and death to the family. Great respect is shown to the ancestors, through offerings

at the ancestral altar, this keeps the ancestor happy and in turn they care for the family by providing

abundant rice, wealth and good health (Lewis & Lewis 1984).

Spirits and Souls

Although formal aspects of the Akha Way are based primarily on the Akha relationship with the ancestors, in everyday life, perhaps more than among any other ethnic groups in Laos, they are

constantly concerned about spirits. Spirit affliction can cause serious illness and need a traditional

healer or shaman to be summoned and usually a ceremony to be held. The most harmful kind of spirits are those who possess people and can cause epilepsy or death if not driven out by punching

the body of the victim with a fang of a wild animal (Lewis & Lewis 1984). Nevertheless not all spirits

are harmful, the sun and the moon spirit that according to the Akha legend are husband and wife, are

two great powers that can be asked to cure the sick person during healing ceremonies. Other spirits

asked for help are the owner spirits, which are in charge of the fields, the livestock, and the people

themselves (Anderson 1993).

According to Chazée 1999 each person has three souls. Soul loss as well as spirit affliction can cause

illness. Symptoms of soul loss are depression, sense of lassitude, weakness, lack of apatite and all-

over aches. Treatments for ordinary ailments such as wounds and cuts, aches or stomach problems are somewhat more common knowledge and a number of herbal cures are passed on from parents to their children.

The village

The Akha traditionally prefer to locate their villages over 800 meters altitude and up to 1500 meters.

Through the last decade districts authorities have encouraged the Akha to cultivate the lowland and many villages in the province of Luang Namtha are today situated between 400 to 600 meters (Chazeé 1999). The Akha village is represented by an administrative chief or headmen elected by the family elders and approved by the district. In addition to the village chief/headmen, the community is guided by religious leader and an ethnic representative, whose title is hereditary. Although the headman is

generally the political leader, the village religious leader is usually more powerful. He is responsible

for the sacred sites in and around the village; he performs the most important ceremonies and makes 11 sure that "the Akha way" is well respected. His knowledge will be passed on to his eldest son. An Akha village also has its own traditional healers, which can be both male and female, and whom contact the spirits during healing ceremonies at the family level (Lewis & Lewis 1984).

The village site is chosen at a location on the saddleback of a mountain where there is a good breeze,

a dependable source of drinking water, and adequate arable land in the surrounding area. Trials with

rice grains and egg drops are further made to see if the ancestor spirits and Apoe Miyeh, the creator

of first being, are approving the site for settlement (Lewis & Lewis 1984). The traditional house is

built on stilts, and usually a number of small huts or meeting houses are constructed for the young in

the village "courting" area. The village is entered and left through the village gates. These gates

protect the village from the wild spirits of the jungle, as well as dangerous wild animals, illnesses and

plagues (Chazeé 1999).

Family organisation

The Akha household is ruled by the eldest male member, and the Akha society consists of patrilineal clans (Jaafar & Walker 1975). Polygamy can occur, but is not common. The elder son, according to

the tradition, remains in the parents´ house to help them. The transmission of the Akha history, their

origin and customs are particularly transmitted from the father to the elder son (Chazée 1999).

Pre-Natal precautions

When an Akha woman becomes pregnant she alters her lifestyle to follow a number of taboos and restrictions. Some of the taboos include her diet, as a pregnant women she should not eat white buffalo, duck or wild pig and certain vegetables (Laser, personal communication). According to Yeha, an informant from Lao Khao village, snake should be avoided during pregnancy or after the woman had her first child, as well as the husband should avoid killing snakes because these actions might cause the child to resemble a snake. Other taboos, common in Southeast Asia, are the cutting

and tying of knots as this might magically endanger delivery later on. During the pregnancy period it

is also usually forbidden to speak of pregnancy, as the spirits may easily take the child away if something inappropriate is said (Goodman 1996). During the study and our walks around Lao Khao village we noticed a number of holes dug in the ground (Fig. 5). We asked what animal had made these and got the answer that these were dug by the

villagers themselves, as eating clay soil, especially for women is good for health. Laser, one of our

informants in the village, said "It is good to eat when you feel weak; it makes you strong and brings

you good health". Where to dig for the soil has to be asked the spirit/ghosts and a person in contact with the spirits does this. Both during pregnancy and after childbirth eating clay soil promotes health, but the place you dig it from might have to be different depending on the spirits.

In the past pregnant women were encouraged to

work right up to the time of delivery, but the baby was often weak and sometimes born in the field.

Nowadays the women rest during the last month of

pregnancy. Delivery may take place in a hospital but still it is more common to give birth at home.

In case women have a difficult or prolonged

delivery, magic rites are performed by the village shaman (Yeha, personal communication). Fig. 5. Clay soil has been dug out and eaten by Akha women who believe that it promotes good health, Lao Khao village, Lao PDR. In picture also Soyae, local interpreter. 12

A child is born

The newborn must not be picked up until it has cried three times. These cries are to Apoe Miyeh, begging him for a blessing, a soul and a long life (Lewis & Lewis 1984). Then the baby is picked up and given a name usually by the mother-in-law or grandparents. Even if this name only is temporary

it protects the child against wild spirits/ghosts that otherwise can assume that the child is unwanted

and take its soul away (Laser, personal communication). The formal name, linked to the father's, is

given during the naming ceremony that takes place when it is evident that the baby is healthy and will

survive (Lewis & Lewis 1984). The umbilical cord is buried with great care under the house. Other customs and ceremonies are performed to ensure the baby's link with the parents' spirits and the house spirit (Chazée 1999). During the post-natal period certain food are forbidden, like pig, white buffalo, fish and certain vegetables, varying between villages (Lewis & Lewis 1984, Chazeé 1999). In Lao Khao village the

post-natal diet is restricted to rice and salt for the first week, except for the ceremonial chicken and

egg that are prepared and eaten the day of birth. The second week it is acceptable to eat vegetables

and chicken and the third week also pig and fish (Yeha & Soyae, personal communication).

The mother rests indoors for one week after delivery. During this time she shall avoid drinking cold

water as it impoverishes her health and can make her sick. A decoction made from the root of "Kö- sö" is drunk instead of water to promote healing of the mother inside after given birth (Laser,

personal communication). It also increases appetite, which in turn promotes recovery of strength and

health (Yeha, personal communication). A bed made from a carpet and covered with fresh herbs is arranged for the mother close to the fire. The fire ensures that she keeps warm and the herbs promote healing of uterus and prevent postpartum haemorrhage. The woman should rest for 1-2 weeks before she can do easier housework. After approximate 2 month she can start working in the

fields, and the childcare is divided between the husband and wife, and older sisters and brothers. It

takes 2-5 month before she will regain sleeping with her husband (Laser, Yeha & Soyae, personal communication) The child is normally breastfed until the next baby comes. In the past the girls married young and had many children. Up to about two generations ago giving birth to 10 or more children was not uncommon, but nowadays only 4-5 children are desirable and marriage take place around the age of

18 (Laser, Yeha & Soyae, personal communication).

Unusual birth

Giving birth to twins or a deformed child (harelip, too many fingers or webbed fingers) was considered the worst thing that could happen to the family and a tragedy for the Akha village as a whole. Such children were commonly killed and the parents had to leave the village in absolut poverty, their house and belonings were burned. However due to the government's effort and outside interference these actions of the Akha Way are uncommon today, and may only exist in isolated villages (Chazeé 1999).

1.4.3 Lanten

History

Lanten, like the Hmong belong to the Miao-Yao speaking family. Only two subgroups of the Yao

live in Laos, the Mien and Lanten (also called Lao Huay). These groups are closely related in history

and seem to have migrated from southern China to Vietnam, where some communities are still

settled today. They further entered Laos in the early twentieth century and established themselves in

the provinces of Luang Namtha, Phongsali, Udomsai and Bokeo (Chazée 1999, Schliesinger 2003a) (Fig. 1). 13 The Chinese origin can be found in their traditions, beliefs and calendar. Before 1975 Mien and Lanten occupied the same regions and though both groups speak their own dialect today, they can understand each other quite easily. Lanten is the smaller subgroup of Yao and make up around 20% of the Yao population in Laos. According to Chazée (1999) around 4500 Lanten resided in Laos

1995.

Society and religion

Lanten, like the Hmong society is strongly patriarchal in its organization. The husband is the

commander of the family. Membership of the clan is inherited patrilineally for life, and all members

are considered descendants from a common ancestor. The children belong to the father's lineage and even adopted children from other ethnic groups are integrated into the household head's linage (Chazée

1999).

The Lanten practice an ancient form of Taoism

combined with the beliefs in spirits and ancestor worship. They recognize an array of spirits that can either provide protection or cause illness. Worshipped spirits in the Lanten society are the village-, house-, family- and father spirit; other important spirits are those of the natural surroundings, the sky-, forest-, land-, water- and big fig tree spirit (Chazée 1999, Schliesinger 2003a). Lanten villages can have several shamans. They connect to the ancestral and village spirits during rituals and ceremonies. Lanten have strong believes and willingness to preserve their ethnic identity. Men and women still wear traditional clothes made of home woven indigo-dyed cotton, from which also their name Lanten, or more correctly Làn Tien comes, meaning people wearing blue (Fig. 7).

Souls and soul loss

The Lanten believe that each individual possesses several souls; generally the woman has twenty-four

souls, and the man twenty-three. If one of the souls parts from the body the person falls ill and a family healing ceremony should be organized to catch the erring soul. The loss of souls can be

caused by a number of reasons and in case of serious illness the intervention of a healer or shaman is

needed. A healer learns healing rituals by inheritance from the elders, whereas a shaman is appointed by

calling from the spirits. In the most complicated cases, like those related to the father, mother or

ancestral spirits, extensive ceremonies are held. These include animal sacrifices and courier dispatches

on bamboo paper to the spirits (Schliesinger 2003a).

Language and Script

Lanten have their own spoken language and unlike the Hmong have "preserved" the tradition of writing with Chinese characters. Documents and ancient books written on handmade bamboo paper can be found in Lanten villages (Fig. 8). These books concern ancestors, marriage and healing methods, and are consulted during ceremonies. However, the culture and beliefs preserved in these documents are threatened, both due to village's fires and the lack of knowledge about Chinese characters in the younger generations (Chazée 1999). Fig. 7. Lanten woman wearing traditional clothes,

Ban Nam Lue, Luang Namtha, Lao PDR.

14

Village structure

Lanten villages are generally situated in a valley along a river. Villages were traditionally located in mountain valleys between 700-1000 meters altitude. However nowadays many villages settle in the lowland, as the presence of water and availability of land for paddy cultivation are the most important concerns. The river is used for domestic needs, production of bamboo paper, fishing and cultivation of vegetables and corn on the riverbanks. A village ritualist who first ensures that the forest spirit is well disposed to leave the chosen site decides the settlement. Wood and bamboo houses are built on the ground in no defined arrangement (Chazée

1999).

Cultivation

The traditional Lanten production system relies on shifting cultivation (of ordinary rice and corn), small livestock husbandry, hunting, gathering, weaving and production of bamboo paper. Lantén as Hmong and

Akha are well-known for cultivating opium poppy.

Maize and poppies are often grown together in the same field. Rice as their staple crop is grown separately.

They also commonly grow vegetables, cotton, and

tobacco (Chazée 1999). Nam Lue, the village visited in this study base their production syste