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Cambodian Perinatal Culture-Bound Syndromes: Providing Care to Cambodian Women with Toas

Author(s): Julie Tea
Reviewer(s): J. Carey Jackson, MD, MPH, MA; Jeniffer Huong, Caseworker / Cultural Mediator, Harborview Medical Center’s Community House Calls Program, Seattle, WA
Date Authored: December 01, 2010

Methods

Interviews were conducted in 2008 with six Seattle-area physicians who provide care to Cambodian patients and four Cambodian medical interpreters who work in three different healthcare facilities. A focus group about postpartum practices in the Cambodia and the U.S. was conducted with Cambodian women of varying ages. Information from published literature was incorporated.

Introduction

Cambodians call the postpartum period sor sai kchey, which alludes to a period of fragile health lasting from one to three months after childbirth. Many traditional postpartum practices are followed during sor sai kchey. There are strong beliefs about the importance of adhering to these practices and that failure to do so may lead to chronic symptoms called toas that can be temporary or lifelong.

Many Cambodian women who immigrated to the U. S. in the 1980’s are known to have experienced toas and may continue to do so (Goldstein, 1988). Cambodians continue to emigrate to the U.S. and these women are likely to adhere to these practices or have strong beliefs about their importance, though practices and terminology may vary by region. First- and second-generation Cambodian women may follow a modified version of the traditions and are less likely to manifest toas.

Women who immigrated to the U.S. in the 1980’s may be particularly vulnerable to toas because the Khmer Rouge would only allow women to stay home for 3 days to 2 weeks post-partum.

Toas is a culture-bound syndrome. In medicine and medical anthropology, a culture-specific syndrome or culture-bound syndrome is a combination of psychiatric and somatic symptoms that are considered to be a recognizable disease only within a specific society or culture. There are no objective biochemical or structural changes in the body, and the disease is not recognized in other cultures. The term culture-bound syndrome was included in the fourth version of the Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association, 1994)(Wikipedia, 2010).

Failure to follow postpartum traditions may result in chronic symptoms that can be temporary or lifelong.  Toa, roughly translated, means conflict or clash. There are five different types of toas that can result, depending on which postpartum tradition is not adhered to during sor sai kchey (Kulig, 1989).

Knowledge about Cambodian postpartum practices and toas will help medical providers better understand the folk categories of illness faced by some Cambodian American women.  Clarifying toas will assist the provider with taking a better history of the patient, treating the patient, and providing culturally sensitive care.

Background

Cambodian Concepts of Medicine

One of 5 towers at Angkor Wat
Photo by Diem Nguyen. One of 5 towers at Angkor Wat, Cambodia.

Cambodians traditionally view the human body as being in a constant state of balance between hot and cold.  This hot-cold theory evolved as a result of influence over time from Ayruvedic, Galenic, and Chinese medical theory.  An imbalance of these forces can lead to illness (Hourn, 1999).  A pregnant woman is considered to be in a hot state, but after giving birth, she is considered to be in a cold state (White, 2004) and needs to restore balance between hot and cold.

Western medicines are generally considered hot and herbal remedies cool.  Foods also have varying properties.

The older generation may complement Western medicine with traditional healing methods such as herbal remedies, dermal techniques, and maintenance of hot-cold balance.  Cupping, pinching, and coining are still currently practiced.  For some, Western medicines may be used as a last resort because they can be confusing and have side-effects that are not understood by the patient.

Postpartum Beliefs and Practices in Cambodia

Beliefs

Cambodian Mother and Child
Photo by Diem Nguyen. Cambodian mother and child.

The postpartum period called sor sai kchey (sometimes spelled sor sai kjey or saw sai kachai) is considered to be the most important time in life for a woman. Sor sai kchey lasts from one to three months after childbirth when a woman is considered to be in fragile health. The idea of childbirth as a both dangerous and important time in the woman’s life is emphasized in Khmer culture and language. The idiomatic Khmer expression used to describe delivery is schlong tonle, which means “to cross the river.”  As described by a Cambodian interpreter, “A postpartum woman is considered a queen, because she has survived childbirth, which was not always assured due to lack of healthcare resources in Cambodia.”

To restore balance in the body, it is believed that the old, hot blood that was shed during childbirth must be replaced with new blood produced by the mother.  In addition, the growth of new blood vessels and restoration of heat lost during childbirth is required. The pregnant woman is seen as being in a hot state, but after giving birth, she is seen as being in a cold state (White, 2004).  Part of this cold state is attributed to the obstruction of blood flow due to damage to blood vessels or nerves (sor sai) during childbirth, resulting in the term sor sai kchey (kchey means young or fragile), which literally translates as “young or raw blood vessels" (Hourn, 1999).

Postpartum Practices during Sor Sai Kchey

Bed Rest

The woman is confined to bed rest for thirty days.

Mother Warming – Ang Pleung

During bed rest, the woman lies on a bamboo bed under which a fire fueled by charcoal or wood is lit (White, 2004).  This is known as ang pleung or mother-warming. Ang pleung is practiced because “The belief is that it will help the mother heal faster, made the body stronger, and look and stay young by tightening muscles” (Cambodian Focus Group, 2008). Additionally, she is kept warm by layering clothing while avoiding air conditioning, drafts from air or wind, and ice (White, 2004). 

This roasting lasts a minimum of three days but is prolonged as long as firewood or charcoal can be afforded.  Socioeconomic status plays a role in the length of roasting.  Poor women sometimes only roast for one day; these women typically have had several children previously.  Roasting for longer periods is seen as more important for young women who have just given birth to their first child (Sody, 1998). Roasting is thought to increase blood flow in the uterus, thereby preventing blood clots and is seen as essential to the overall recovery of postpartum women.

Hot rocks are sometimes heated, wrapped in cloth and then placed over the woman’s abdomen to help with the swelling and stop the bleeding (Cambodian Focus Group, 2008).  In addition, while the woman is roasting, traditional healers known as krou khmers will often recite incantations from Buddhist writings to ward off any lurking evil spirits and protect the weak mother (White, 2004).

Food Restrictions

Cold foods such as green peas, bean sprouts, fish, pig head, pineapple, and jackfruit are avoided. Also, raw and sour foods are avoided at this time.  Instead, hot foods such as khaw (a traditional dish of beef, pork, or fish braised with salt, pepper, and palm sugar), borbor (rice porridge), pork, and salty foods are consumed to restore heat to the body during this critical period (White, 2004).  The woman will drink only hot water, homemade wine, or herbal tea.

Physical Activity Restrictions

Heavy lifting and standing for long periods is forbidden (Sody, 1998). Some women do not have sexual intercourse for six months to one year following birth, as they believe it is best to avoid this to allow their bodies to recover and heal from pregnancy.

Restrictions on Bathing and Exposure to Rain/Dew

Women are barred from bathing and instead use herbs in a practice called schpoong, in which women will breathe in vapors from a boiling pot of water filled with herbs to clear the skin daily. Women are prohibited from exposure to rain and dew because of the risk of cooling the body and to prevent “wind” from entering the body.

Emotional Health

Women must be relaxed and free from emotional distress and worry.

Post Partum Practices in the United States: Generational Change and Acculturation

Focus group participants who emigrated from Cambodia to the U.S. in the 1980’s expressed a strong belief in the existence of toas. Younger Cambodian women who spent a majority of their adolescence in the U.S. stated that they practiced sor sai kchey to varying degrees, mainly to appease their mothers and mothers-in-law. According to focus group participants, in the U.S. many of the traditional post-partum practices are modified based on available resources. To replace fire-roasting, women fill hot water bottles with boiling water and place the bottle on top of the lower abdomen to warm it. Another method of heating the lower abdomen is to heat a large rock directly on the stove until the rock heats all the way through, wrap a towel around the heated rock and place the rock on the lower abdomen.  Another modification is to add sea salt to boiling water, soak up the water in a towel and then use the towel to heat the uterus. Women are barred from bathing and instead use herbs to practice schpoong, in which women breathe in vapors from a boiling pot of water filled with herbs to clear the skin daily. Most women are unable to rest for an entire month as they must return to work, school, or taking care of the home and family much sooner than they would in Cambodia. Most younger women felt this was not harmful because Western doctors offered supplements and antibiotics to ward off infections they could contract in Cambodia. However, a young woman who immigrates more recently to the U.S. will likely adhere to traditions.

Failure to Follow Postpartum Traditions May Result in Toas

Failure to follow these steps to restore balance in the postpartum mother can lead to a potentially lifelong, incurable sickness known as toas. Chronic symptoms of toas can manifest decades later. The commonly presented symptoms are abdominal pain, weakness, headache, diarrhea, palpitations, weight loss, and poor appetite (Douglas, 1994).

There are five different types of toas that can result, depending on which postpartum tradition is not adhered to during the period of sor sai kchey (Kulig, 1989).  Toas can result from:

1) eating the wrong types of food – toas chamney
2) resuming intercourse earlier than three months postpartum - toas damnek
3) Exposure to rain/dew or bathing – toas tek pleany
4) heavy lifting or hard work -  toas sor sai
5) experiencing emotional distress – toas pruey cet

Complexities of Interpretation

Medical interpreters often have difficulty translating the meaning of toas to physicians due to the complexity of the translation, which magnifies the potential for miscommunication with providers. One medical interpreter explained, “If men use the word toas, they use it to mean allergy.  It is commonly used to mean vomiting or diarrhea.  If food is poisonous, this leads to vomiting.  Toas is to not agree with your body.  For women, regarding food, toas is used too.  For women with babies, toas refers to postpartum wrongdoing.”  A medical interpreter explained, “In the Cambodian language, there are not enough terms to describe Western language.  For example, if there is an allergy to a medication, you use the word toas because the medicine does not agree with your body. If you don’t explain it, the patient will think you’re referring to postpartum toas.”  Toas can mean allergies as well as a chronic disease due to wrongdoing postpartum.  This can lead to confusion between the physician, the interpreter, and the patient.

Another medical interpreter finds that it is hard to explain the concept to the provider: “I would explain toas to a healthcare provider as one of those traditional pregnancy experiences that occur because of what they did or ate after pregnancy. I translate the patient’s exact words and main complaints, and then explain the traditions to the provider and why the patient thinks the two are related.”  In explaining, the interpreter takes into account what region the patient came from, the practices they have encountered, the way they were raised, and any background knowledge the interpreter knows.

Of the four medical interpreters interviewed, all acknowledged mistranslating toas to the physician to both shorten the visit and avoid confusing the physician.  Two interpreters mentioned that they would gauge the level of interest of the physician and explain the beliefs of the patients to the physician, but only if the physician wanted to learn more. Dr. J. Carey Jackson, a physician with 25 years of experience in refugee and immigrant health finds that “As a provider, if I mention toas and show that I know something about Khmer life, even if the topic is far afield from toas, both the interpreter and the patient are assured that I know something and that I am interested and capable of learning more. So knowledge of these folk categories of illness becomes a device for expressing interest, capacity, growing familiarity, and a fund of knowledge they can build on to teach me.”

Physician Knowledge of Toas

The concept of sor sai kchey and postpartum fragility is well-known, widely accepted, and widely practiced among the Cambodian community but most of the physicians interviewed for this article were either unaware of the syndrome or unable to define it. This illustrates the cultural barrier that may exist between female Cambodian patients and their primary care physicians. Belief in postpartum plasticity explains the sequelae of toas as a chronic illness.  Toas may overlap with postpartum depression but is seen much more as a physiologic issue. Misdiagnosis of toas or disregard of this belief can lead to long-term consequences such as panic attacks, sleeplessness, depression, and possibly alcoholism as an escape. This emphasizes the importance of understanding this syndrome.  Furthermore, not recognizing the patient’s belief in toas and not acknowledging the patient’s suffering can appear to undermine the patient’s complaint and deem them as unimportant. Clearly, background knowledge about the beliefs of other cultures is essential to providing culturally competent care. This background knowledge can be used to legitimize the complaints from the patient and illustrate empathy for the patient’s perspective.

Recommendations for Providers

  • Effectively engage patients in their own health care: Establish a long-term relationship by listening to the patient’s whole story, including regularly asking the patient what she thinks is causing the symptoms. Encourage the patient to invest in her own health.
  • Communication is the key to providing culturally competent care: Communication is the key to improved quality of care for all patients.  Culturally competent care is often difficult to deliver but it can greatly impact the patient’s well-being.  Providers should explain the importance of taking medications as prescribed, as well as the reasons for not giving medications if none are given.  Patients are often confused about dosages and may not know to continue taking the medication even if their symptoms improve.  One solution to assuring the correct dosage is to ask patients to always bring all of their medications to their appointments and have them show exactly how many pills of each medication they take and how often.
  • Use open-ended questions:  Keep questions open-ended with patients to avoid making any assumptions.
  • Pay attention to the experience of illness: In cross-cultural settings, a partnership with medical interpreters is needed to pay close attention to the experience of illness and social context of the translation. Legitimize the patient’s beliefs by accepting their explanations for symptoms and offer a biomedical explanation as a parallel model. Give a thorough exam according to the patient’s complaints. Negotiate and compromise with patient about dual usage of Western and traditional medicine.
  • Evaluate patient for PTSD and depression:  Do not say depression or PTSD but ask about their specific symptoms.
  • Ask for specific information about post-pregnancy experience and presence of toas.
  • Link symptoms where possible to treatments for medical problems known to you. Explain what the root issues might be for a cluster of symptoms with no known etiology.  For example, headache, back pain, and sleeplessness are somatic expressions of depression.
  • Assure patient that her illness is not fatal and that she will be OK. This will help relieve angst and build rapport.
  • Be aware that Cambodians often use home remedies or alternative forms of healthcare along with Western medicine: Offer to assist patients as they try to address traditional options for toas.
  • Use interpreters as cultural guides:  Medical interpreters become highly specialized translators with some medical background and knowledge and familiarity with Western clinics.  They are an essential resource.  Instruct interpreters to translate conversations accurately, but also explain everything to the patient at the patient’s level so they have a better understanding of the results.  For example, explaining feared procedures such as blood draws, X-rays and surgery to patients may alleviate anxiety and encourage increased use of Western medicine among Cambodian immigrants.

References

Douglas, L. B. (1994). Antenatal and birthing beliefs and practices of Cambodian women. P. L. Rice (Ed.), Asian mothers, Australian birth (pp. 33–46). Melbourne, Australia: Ausmed Publications.

Goldstein, Erika A. “Meaning in medicine: abdominal pain in Khmer women.” Thesis- University of Washington, 1988.

Healy, G., & Chandoravann, D. (1994). Situational analysis of health service delivery at commune and village-level: Oudong District, Kompong Speu Province, Cambodia. Phnom Penh, Cambodia: Australian Red Cross & Oudong District Health Center Planning Team.

Hourn, Kru Kim. Post Partum Heating Practices in Cambodia. Are they harmful? Royal University of Phnom Penh, Cambodia. February 1999.

Peripartum and Infant Care Issues and Practices Among Refugee Groups in Seattle: Southeast Asian. Dr. Elinor Graham and staff of Community House Calls Program, Harborview Medical Center. August 1996 .

Kulig, J. C. (1989). Childbearing beliefs among Cambodian refugee women. Western Journal of Nursing Research, 12(1), 108–118.

Sody, Ang.  A Descriptive Study of Cultural Presentation of Postpartum Psychiatric Disoder: “Toas” in Cambodia. Phnom-Penh, Cambodia. February 1998.

The Cambodian Women’s Health Project. Outreach Worker Manual. January 1998.

White, Patrice M. (2004) ‘HEAT, BALANCE, HUMORS, AND GHOSTS: POSTPARTUM IN CAMBODIA’, Health Care for Women International, 25: 2, 179-194.

White, Patrice M. “Crossing the River: Khmer Women’s Perceptions of Pregnancy and Postpartum.” Journal of Midwifery & Women’s Health, volume 47. July/August 2002.

Wikipedia (2010) Culture-bound syndrome. Accessed on November 24, 2010 from http://en.wikipedia.org/wiki/Culture-bound_syndrome