Birth in Thailand

This article documents traditional and some modern childbirth practices in Thailand. Traditional principles are largely influenced by the folk beliefs in Central and North Thailand, and modern practices by the western medical model.

Background

History

Thailand kingdom was established in the mid-14th century, and converted to a constitutional monarchy in 1932.^[1] A military coup in September 2006 succeeded in expelling then Prime Minister Thaksin Chinnawat, but his party - People's Power Party (PPP) – became the head of the coalition and took office in February 2008. In the May 2008, there were massive demonstrations by the anti-Thaksin People's Alliance for Democracy (PAD; yellow-shirts).^[1] After the dissolution of the PPP by the court ruling, Abhisit Wetchachiwa took the office of the Prime Minister. Since then, United Front for Democracy Against Dictatorship (UDD; red-shirts), a pro-Thaksin movement was formed, and organized protests in March through May 2010.^[1] Confrontations between the authorities and armed protesters resulted in “at least 92 deaths and an estimated $1.5 billion in arson-related property losses.” ^[1]

Social Structure and Organization

Thailand has a population of 66,720,153, 34% of whom live in an urban setting, and 9.6% of whom live below the poverty line.^[1] Three quarters identify themselves as Thai (75%), 14% as Chinese, and 11% as other nationalities.^[1] The main language is Thai, but there are regional dialects, and most educated people know English.^[1] A large majority (92.6%) of the population is considered literate.^[1] Depending on the status of the person (determined by age, occupation, wage, education, and social connections), different greeting wai and language is used, that would mirror the superior-inferior rankings between the two.^[2]

The demography of Thailand has changed since the 1970s, mostly because of the promotion of small family sizes with the help of family planning outreach programs such as the Population and Community Development Association and efforts of Mechai Viravaidya.^[2] The current fertility rate is 1.66 children born per woman, which is low compared to the rest of Asia.^[1][3]

Political and Economic system

King Bhumibol Adulyadej (or Phumiphon Adunyadet) is the chief of state, and has been on the throne since June 9, 1946.^[1] He and the rest of the Royal Family are deeply revered by the Thai people.^[2] The current Prime Minister and the chief of government is Abhisit Wechachiwa.^[1] These two are parts of the executive branch, which also includes three Deputy Prime Ministers and the Council of Ministers. There are also the Legislative and the Judicious branches.^[1] Thailand’s major industries include: tourism, textiles and garments, agricultural processing, beverages, tobacco, cement, jewelry and electric appliances, computers and parts, integrated circuits, furniture, plastics, automobiles and automotive parts, tungsten, and tin.^[1] The major agricultural products include: rice, cassava (tapioca), rubber, corn, sugarcane, coconuts, and soybeans.^[1]

Religion

A large majority of the population (94.6%) identifies themselves as Buddhist, 4.6% as Muslims, 0.7% as Christian, and 0.1% as other.^[1] There are also many folk beliefs that involve spirits, myths, use of charms and spells, days for doing certain things, and many others.^[2] Religious merit is sought after to improve one’s karma.^[2]

Physical Environment

Thailand is located in the South-East Asia, and shares borders with Myanmar (Burma) on the west, Laos on the east, and Malaysia in the south. The climate is tropical: rainy, warm, and cloudy mid-May to September, and dry and cool November to mid-March); it is always hot and humid on the southern isthmus.^[1]

Health and Illness Theories

Traditional Thai Medicine is based on the mixed indigenous traditions of Indian, Chinese, and Khmer influences. Historically, Jivaka Kumar Bhaccha is considered the “Father Doctor” of Thai medicine.^[4] The “Circle of Life” is a central concept in Thai medicine philosophy, which involves the three essences of the human body that must be kept in balance to maintain health. The three essences are: (1) Energy (holds mind, body, and heart together, similar to qi/chi/prana), (2) Body (physical substance), and (3) Citta (mind/heart, non-physical being that holds all thoughts, emotions, spirit; inner self).^[4] Thai Traditional Medicine has three branches that correspond to the three essences: Thai massage, herbalism (including dietary regimen), and spiritual or religious healing.^[4] The three branches are used to balance each of the essences. For example, there are ten tastes of foods and herbs that are recognized by the Thai medicine, and taste opposite of the disease process would be used to treat it.^[4] Similarly, the four elements of the body (Fire, Water, Air, and Earth) must be kept in balance by eating certain foods.^[4]

Women’s Health Statistics

Women’s life expectancy at birth in Thailand is 76.08 years (as compared to 71.24 years for men).^[1] Two percent of Thai women smoke.^[5] The current (2011) birth rate is estimated to be 12.95 births per 1,000 population.^[1] The maternal mortality ratio is 20.63 per 100,000 live births, and the major causes of maternal death are hemorrhage (27.8%), sepsis (8.73%), toxemia (16.7%), amniotic fluid embolism (11.9%), and other causes (8.73%) (2003).^[6]

A high percentage of laboring women (97%) are attended by skilled health personnel, which is much higher than the regional average (49%) (2008).^[5] Women in Thailand are also much more likely to attend 4 or more antenatal visits (74%) compared to women in other countries in South-East Asia (43%) and use contraception (81% compared to 58%) (2008).^[5]

The under-5 mortality rate (per 1000 live births) has decreased to 14 (2008) ^[5] from 28 (2002).^[6] Infant mortality has also decreased from 20 (2002)^[6] to 16.39 deaths per 1000 births (2011).^[1]

Pregnancy Behaviors and Beliefs

There are many traditional beliefs associated with the way pregnancy should be carried out. According to the Central Thai beliefs, conception occurs when a khwan (soul) flies into the womb during a sexual encounter.^[7] A woman whose period stops and who starts craving sour foods is thought to be pregnant.^[8] Once a woman finds out she is pregnant, she is to tell her partner first, followed by her mother and her mother in law.^[9] Infertility is seen as imbalance in one of the essences. Certain acupressure points, however, could be utilized to resolve the issue.^[10] Abortions are seen by Buddhists as “as impeding an individual's rebirth and disobeying a religious prohibition on taking life,” ^[7] and they are currently illegal in Thailand. Only in the following three cases it is allowed: (1) if mother’s life is in danger, (2) if mother’s physical or mental health is at risk, and (3) if the pregnancy is a result of an offense or seduction of a girl under 15.^[11] However, about two thirds of women seek help outside of the main healthcare system to terminate the unplanned pregnancy, and 12% attempt to do it themselves.^[6]

In Thai folklore there is a ghost known as Krasue (กระสือ) haunting pregnant women in their homes just before or after the childbirth.^[12] Village legends say that it hovers around the house of the pregnant woman uttering sharp cries to instill fear. It uses an elongated proboscis-like tongue^[13][14] to reach the fetus or its placenta within the womb. This habit, among other unmentionable things that this spirit does, is believed to be the cause of many diseases affecting mainly rural women during their pregnancy.

Diet During Pregnancy

Since pregnancy is considered to be a ‘hot’ condition in Thai Medicine, foods to maintain warmth are preferred, such as ginger tea, coconut milk, young coconut meat, salty foods, tamarind, fish, garlic, onion, and warm liquids.^[9] Those who consume pak plang, a slippery vine-like green vegetable, would have an easy birth, since it will make the baby’s body slippery.^[8] Ya tom herbal medicine could be prepared as tea and would make the baby strong and easy to deliver if the pregnant woman drinks the tea three times a day for three consecutive days.^[8] However, khong salaeng (allergic foodstuff) must be avoided by pregnant women, since it may cause unwanted problems during labor or for the unborn child. Khong salaeng foods include papaya salad, pickled food, spicy hot food (baby may be born hairless), coffee and tea (baby will be not intelligent), shellfish (prevents perineum from drying after delivery), and Thai eggplants (may cause anal pain after delivery).^[8] Women are also advised to eat only half a banana, since birth may become obstructed if she eats a whole banana.^[8]

Behavior During Pregnancy

According to traditional beliefs, strenuous activities, such as heavy lifting, farm work, and even driving a car may lead to a miscarriage or stillbirth, however this may sometimes be unavoidable by the rural poor.^[8] Regular activity, however, would promote easy birth by making the abdomen ‘loose’ (tong klon) and therefore aiding in the downward head rotation of the baby. Idleness and frequent resting, on the other hand, would complicate birth.^[8] There is no available information on the importance of sleep in pregnancy.

There are accounts that sexual activity was promoted during pregnancy in Central Thailand since sperm would make the baby strong,^[7] however, in the Northern parts of Thailand it is seen as a form of vigorous activity that may result in miscarriage.^[8] Although pregnant women are prohibited from attending a funeral, wearing a brooch on the abdomen would counteract any negative effects on the fetus. Women should also not make any advanced preparations, such as buying or making baby clothes, as this may result the death of the baby.^[8] Other pregnancy-related beliefs include not sitting in the stairway (causes obstructed birth), not burying anything in the soil (difficult birth),^[8] and having magical showers (to promote easy delivery and emotional calmness). These showers should be “blessed with sacred words known as ‘nam mon’ by mor mon (a magical healer, or even a monk); they are usually done in an open-aired space from eighth to ninth month of pregnancy.^[8] During the last weeks of normal pregnancy, a woman may choose to go to a masseuse for “lifting of a uterus (yok thong) to increase comfort.” ^[15]

Modern Pregnancy

Today, pregnancy test kits are available at most pharmacies; pregnancy could also be confirmed at a gynecologist’s office using blood and urine tests.^[11] Currently, pregnant women are required to attend at least four antenatal care visits.^[8] Normal pregnancies would be managed by gynecological nurses or midwives, while high-risk pregnancies must be monitored by obstetricians.^[8] Ideally, a woman would attend antenatal check-ups “every month until 28 weeks of gestation, then every fortnight from 28–32 weeks and every week after 32 weeks,” ^[8] however, the number of visits will depend on the woman and her healthcare providers. In Thailand, antenatal care is free in the public health services sector. There is a private and public sector in healthcare, the latter provided by the Ministry of Public Health and teaching hospitals.^[8] In the 2005 study by Liamputtong et al., women of Chiang Mai (Northern Thailand) revealed that they “only incorporate cultural knowledge when it is practicable and suitable to their daily living situations.” ^[8]

Labor and Birth

Setting

In 1960’s, 99% of the women in villages delivered at home.^[16] Today the number is much lower, as most Thai women give birth in hospitals and clinics, generally where they go for antenatal care.^[8] However, nowadays homebirths are becoming popular, but they may not be fully covered by insurance policies.^[11] Traditionally, Thai women would give birth at home, either in the bedroom ^[15] or the kitchen.^[8] The delivery room at home is usually decorated with Yant Trinisinghé, “small flags inscribed with sacred numbers from one to nine” or with letters and sings; each flag is a “symbol of a long mantra passage, believed to have power to ward off evil spirits.” Buffalo leather could be used instead of the flags.^[16]

Birth Assistant and Attendants

According to the WHO’s 2008 Thailand health profile, 99% of urban, 97% or rural, and 93% of the poorest 20% of women have their children delivered by skilled health persons, which is a much better compared to the regional average of 49%.^[5] As a part of the four-year curriculum, all nurses go through half a year of midwifery training, and may later choose to specialize. However, an obstetrician carries most responsibility during a birth in the hospitals ^[11] It is unclear how the traditional delivery assistants are trained, but most likely through observational experiences.

The traditional delivery assistant, who is usually a woman, is called 'Mo Tamaye' in the Central Thailand ^[16] and Mae Jang in the North.^[8] It is generally accepted that the labor starts when the waters break.^[8] If the family cannot get to the nearest medical facility, or does not want to, Mo Tamaye is called. Usually, the husband and Mo Tamaye are present during deliver, but relatives and children may attend as well; however, the woman in labor must be covered from the waist to knee.^[15]

Birth Positions

There are variations in the traditional birthing positions. In one, a folded mattress would be supporting a woman’s back while her husband would provide support sitting behind her and letting grab onto his thighs. There would be feet supports made out of bamboo that a woman can push on during contractions.^[8] In another position, a woman would be sitting, with Mo Tamaye supporting her from behind, and would pull on a rope that is hanging from the ceiling to alleviate some pain. The woman must take an active role in the process by breathing and pushing with contractions, with the help of Mo Tamaye.^[15] In a medical setting, a woman would most likely have limited options for positions and would be laid flat on the bed to deliver. Culturally, there is no need to keep silent during the birthing process, but pain management is available in most clinics.^[9] There is no data regarding the use of fetal monitoring; however, it is likely used in the westernized hospital settings, which would limit woman’s mobility during labor. Samitiyei Hospital is currently the only hospital is the country that offers natural and water birth.^[11]

Traditions During Labor

In case of birth complications, the traditional birth assistant would give the woman some holy water or press on her belly.^[16] There were no specific foods mentioned to eat during labor. To promote an easy delivery, all windows and doors must be open and the woman must be facing East to symbolize the emergence of new life.^[8] The husband should also pile logs outside facing East.^[16] Any fastened nails must be undone,^[16] and no one should be punching nails to avoid stalled birth.^[8] To be born with an umbilical (holy) cord wrapped abound neck was considered a sign of fortune.^[17] Nothing in particular was mentioned about sleep and wakefulness, abnormalities, rest, emotional behavior, or sexual activity as pertaining to labor or birth.

Caesarean Section

In the medical model of pregnancy, Caesarean section is performed should the complications arise. However, the rate of C-sections has been increasing globally, which may be due to financial incentives.^[18] Thailand is no exception, with rates rising from 15.2% (1990) to 22.4% (1996) ^[19] to 34% (2007).^[18] A study in 2000 concluded that “private cases have a 5.83 higher chance of primary cesarean section than non-private cases” because “physicians feel obliged to provide personal delivery services, when triggered by leisure and time conflict, [which] leads to higher and possibly unnecessary cesarean procedures.” ^[19]

Traditionally, it would be the woman who would be choosing the provider and working closely with her to carry out the birth in a desired manner.^[15] It is not always possible today, especially in the modernized hospitals, where a woman would be subject to the system regulations.

Postpartum

The postpartum period begins right after the birth of the child, but it is not specified when it ends. It takes place at home following home birth, or in the hospital for 2–3 days and then at home following hospital birth.^[11]

The Cord and Placenta

Following a traditional delivery, Mo Tamaye would milk the umbilical cord three times away from the baby “to remove dirt,” then push it back, tie the cord in two places with a special cotton string, and cut the cord in between the two fastened places.^[7] The cut cord is then burned, and placenta is buried, usually by the father.

Woman’s Rite of Passage

After a woman gives birth to her first child, she is considered an adult. She then undergoes the Jufaj when she must lie near fire for an odd number of days, usually around 11 days, so that her uterus will shrink back to the normal size. After each following births, the number of days spent near fire may be decreased.^[20] Also, a wooden box with a fire pot may be placed on the woman’s stomach to serve the same purpose.^[7] Fire is also said to scare off evil spirits, especially combined with the lemongrass aroma.^[9] After a Jufaj, a woman is allowed to move out of her parents’ residence, where she would live before and during the pregnancy, since she is now a mature adult.^[20]

Postpartum Diet and Behavior

As with the pregnancy diet, warm foods are encouraged, such as hot curries.^[7] A woman’s diet must consist of rice and vegetables in the first few months after pregnancy; meat, with exception of fish, must be avoided.^[9] From a Traditional Thai Medicine perspective, “sour tastes [do] not dry out the body, but built up water; egg [is] too cooling; jackfruit [brings] in wind [air]; glutinous rice and the sugar of sweets wet the uterus; fruits [do] not give strength and [are] excessively cooling.” ^[7] Teas out of herbs (naam puu loey) should be consumed, and showers with herbal water (naam puu loeyand naam bai paw) should be taken daily without washing hair the first two weeks.^[15]

Postnatal Care and Maternal Leave

Woman’s household duties would be taken care by the husband, female relatives, and older children.^[15] Traditionally, the female relatives would also check on the new mother; now in 4 to 8 weeks a woman must attend a health clinic for a check-up and to register her child’s birth.^[11] Labour Protection Act of 1998 guarantees women to have three months of maternity leave, to retain the job a woman had prior to pregnancy, and to temporary change duties with a doctor’s letter.^[11] Nothing in particular was mentioned about sleep and wakefulness, rest, emotional behavior, or sexual activity as pertaining to the postpartum period.

Newborn

Traditional Rituals

There are many variations in traditions across Thailand. Central Thai people say the baby is tog fag (falls on bamboo) when he or she is born. After Mo Tamaye cuts the umbilical cord, she washes and beautifies the baby with yellow and white powder.^[16] On the third day after birth, Lon Dek Nai Kadon rite (translates to “rock the cradle in which a new born baby is sleeping”) ^[20] is carried out. A baby is placed into a basket with a pencil and a notebook (for brightness), and money (for richness); girls are also given knives (to cut and comb hair) (Attagara 1968, p. 103) and cooking utensils.^[9] The basket with the baby and instruments is then handed over to “a respectable man in the village. This means that the baby became his adopted child temporarily, which reflects that the parents expect their baby to be rich and respectable like the adoptive.”^[20]

Another tradition includes making offerings at a temple (wat) on the third day after the baby is born to obtain a blessing from a monk.^[9] Fire-Shaving ceremony takes place when the child reaches the age of one month and one day, which involves cutting of the baby’s hair. As a precaution, babies must be kept away from the rain.^[9] Circumcision is not very prevalent in Thailand; only 13% of Thai male population are circumcised.^[21]

It is not specified when the newborn period ends. There is also no information on the significance of vernix, the baby’s rest, activity, and movement, as well as meconium and handling of the urine and feces.

Care for the Baby

For the first month of the baby’s life, the mother must stay very close and “breastfeed the newborn on its slightest demand.” ^[15] Babies are also sometimes given a mixture of banana, honey, and water to prevent diarrhea.^[7] If the baby cries too much and cannot sleep, it is believed that the baby’s guardian spirit, Mae Sue, is teasing the newborn too much. Usual interaction with Mae Sue is normal, during which the baby will play and laugh by itself.^[16]

Naming

Traditionally, a name is given to the child on the fourth or fifth day after birth by the father,^[20] however, there could be variations in this practice across Thailand. Today, both the mother and father can take part in deciding on a name. A child may not hold the same name as Royalty.^[11]

Twins

There is a variation in the view of twins. While some view twins as needing more resources and being too demanding on a family, others see having twins as lucky, since it is convenient to take care of them at the same time.^[7]

Modern Newborn Care

An infant is examined in the first week of life followed by six examinations in the first year. There are three examinations during the second year, and six examinations every other year until the child turns six. Vaccines coincide with the exams, but are not obligatory except for the BCG for tuberculosis prevention.^[11]

References