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Kristin Harris, CNM, MSN
ABSTRACT A factor-searching study was designed to explore the beliefs and practices of Haitian American women in relation to childbearing. The sample was composed of 11 Haitian women currently residing in the United States who had had children. Data collection was by means of nonstructured interviews, conducted in Haitian Creole by the researcher. Data analysis examined distinct beliefs and practices relating to childbearing in Haiti and cultural conflicts associated with childbearing in the United States. The Haitians’ cultural adaptation to the American obstetric system was revealed by their expressions of solutions to cultural conflicts. An unanticipated finding was that the crucial period of childbearing for Haitian women is after the baby has been born. It is a time of elaborate and well-defined beliefs and practices. Conversely, pregnancy, labor, and birth are seen as inevitable courses. Limitations of the study, implications for research and practice are presented.
The philosophy of the American College of Nurse-Midwives (ACNM) states: “Every individual has the
right to safe, satisfying health care with respect for human dignity and cultural variations.“’ The inclusion of respect for “cultural variations” in the first sentence of the philosophy is significant. Very little is known about the beliefs and practices relating to childbearing of different cultures.2-5 Less is known about how women of other cultures adapt when encountering the American obstetric system. The resulting clinical problem is that American nurse-midwives may be inadequately prepared to work with childbearing women from other cul-
This publication is based on the Masters thesis, Beliefs and Practices Relating to Childbearing of Haitian American Women, by Kristin Harris at Yale University, New Haven, Connecticut, 1986. Address correspondence to: Kristin Harris, CNM,MSN, 114 Medford Street, Arlington, MA 02174.
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tures because of a lack of cross-cultural research on childbearing. REVIEW OF LITERATURE Researchers who have witnessed and -studied the events surrounding birth in several cultures portray childbearing as an interweaving of biological, social, and cultural elements.5-7 Brigitte Jordan5 attended and analyzed dozens of births in each of four places: Yucatan, Holland, Sweden, and the United States. She introduces the word “biosocial” to describe the birth event to illuminate “the universal biological function and the culture-specific social matrix within which human biology is embedded.” Shiela KitzingeP opens her comparison of childbirth in Jamaica and Britain stating “all analyses of physiological states should focus on the dynamic interaction between meaning systems, social behavior
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Copyright 0 1987 by the AmericanCollege of Nurse-Midwives
and physiological function.” The editor of Ethnogrcfphy of Human Fertility and Birth, Carol P. MacCormack,7 insists “the profound human reality (as distinct from the animal reality) is a synthesis of biological function, cultural definitions and rules, and social action.” Consequently, definitions of the childbearing experience vary depending on the culture.3v5*8Jordan5 gives examples of definitions of birth as “a medical procedure (in the United States), or as a stressful but normal part of family life (as in Yucatan), or as a natural process (as in Holland), or as an intensely personal, fulfilling achievement (as is the case in Sweden).” Of particular interest to work in a cross-cultural setting is what Jordan5 has experienced as “the extraordinary extent to which practitioners buy into their own system’s moral and technical superiority.” Me&d3 is more forgiving in her expression of 149 0091-2182/87/$03.50
the same phenomenon, calling it “blindness induced by habituation within our own cultural pattern.” American obstetrics, perhaps because of its extensive contact with other cultures in the United States and abroad, is particularly criticized for its resistance to recognizing other cultural models of the birth experience.3-6 Several researchers who have observed women of different cultures enter into a Western obstetric system describe the women’s anxiety, severe embarassment, and overt conflict.s-7Tg Much of the women’s discomfort results from the ignorance on the part of the caregivers of the specific culture’s beliefs and practices surrounding birth. A widely proposed solution to this problem of discomfort caused by is caregivers’ cultural ignorance cross-cultural research.3,4,6,10,11 Kitzingefi suggests “a multidimensional approach is required in which birth is seen as operating within a specific social context and particular value system.” Scottl* has documented that people of one culture who enter into another culture’s health system, in this case the American system, become “bicultural” to varying degrees. That is, they adapt to incorporate aspects of both cultures. McClain,* in her review of the literature, extends this observation, stating “many childbearing strategies represent women’s attempts to preserve
CMN, MSN, received
a BA
from Middlebu y College, Vermont, and an MSN from Yale University School of Nursing. She was a Peace Corps Volunteer in West Africa and has tmveled extensively in rum/ Haiti. She is fluent in French, two West African languages (Mandinka, WoJof), and Haitian Creole. She is currently practicing as a nurse-midwife in Boston, Massachusetts. in American
and French
valued traditional beliefs and practices even as they accept innovations in birth location and management.” Several studiesl*-‘* provide a general understanding of Haitian Americans’ beliefs and practices related to health and the use of American and ethnic healing systems. These studies develop the cultural context but do not address childbearing. In the one study of Haitian American childbearing, the authors, Dempsey and Gesse,15 collect detailed information using a standard 54-question interview schedule. While identifying “the need to support the culture-specific beliefs, values, and practices of their Haitian clients,” they conclude that Haitians perceive childbearing and its needs in the same way as their American counterparts. The classic anthropological works about the island of Haiti contain little information about beliefs and practices related to childbearing of Haitian women.16-18 One recent source that, though limited in scope, contains useful detail is Wiese’s “Maternal Nutrition and Traditional Food Behavior in Haiti.“lg During a 12-month period in Haiti, the author spoke with ten rural midwife/herbalists in their native language, Haitian Creole. Wiese documents a Haitian belief system of hot/cold classification of life-states and foods that has never been reported in the available literature on Haiti. This knowledge is important because it severely restricts what a woman can eat, especially in the postpartal period. The purpose of this study was to identify the beliefs and practices relating to childbearing of Haitian American women, and ways they adapt these beliefs and practices within the American obstetric system. The resulting knowledge and understanding will promote a better working relationship, involving more cooperation and understanding, between the Haitian woman and her American nurse-midwife.
The author interviewed 11 Haitian women currently residing in the United States, who had given birth in Haiti, in the United States, or in both places. The interviews were conducted in the Haitians’ homes or in their community centers. Local Haitian community leaders identified and contacted possible informants, and arranged times for the interviews. Interviews lasted 1 to 3 hours, averaging 1% hours. The interviews were conducted in Haitian Creole, a language spoken by all the people of Haiti that has evolved out of a combination of French and West African languages. The author is conversationally fluent in Haitian Creole, and is aided by her fluency in French and two West African languages. The data was collected by means of an informal interview approach, allowing the Haitian American women to present the information in a way most closely reflecting their own understanding of childbirth. Often, the author would describe the study and its goals, and the informant would proceed to talk about her birth experiences for an uninterrupted hour or so. Subsequently, the author would return to the interview schedule to ask about areas not covered in the initial offering of information. The Haitian American women in the study had lived in the United States an average of 3.8 years, the range being 1 to 10 years. Of the 11 women, three had given birth in Haiti and the United States. Six women had given birth only in Haiti, and two women had given birth only in the United States. The number of children the women had ranged from 1 to 5, with an average of 3.2 children per women. RESULTS The major discovery of this study was that, for Haitian women, the
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crucial period of childbearing is after the baby has been born. The areas of interest to the Haitian American women are the postpartum and the newborn periods. The postpartal penod for the Haitian woman is a time of many prescriptions and proscriptions. It is a time when she and the women attending her take active roles in her care. There exist clear ideas of what should happen to a woman and her baby after the birth. This is not a time when Haitians talk about individual variation among women. During the postpartal period, 6 of the 11 women talked about the practice of baths, teas, vapor baths, and dressing warmly during the postpartal period as a good way to become healthy and clean again after the birth. All of these women described a practice referred to as the “three baths.” The woman caring for the new mother goes to the fields to find special leaves or buys the leaves necessary for the care of the new mother. For the first 3 days, the mother bathes in hot water boiled with the leaves. She drinks tea boiled with these leaves. For the next 3 days, the mother takes her second bath, which is prepared with leaves in water warmed in the sun. Now the mother drinks only water warmed in the sun, or tea made with leaves and water warmed in the sun. During the first few days after the birth, the mother also takes “vapor baths.” She sits above a pot of steaming water with leaves in it, especially orange tree leaves, and drapes a cloth over her head and shoulders. At this time a mother takes special care to keep her body warm. She stays in the house for at least 3 days after the birth. She keeps the doors and windows shut tight to keep out the cold. She wears long sleeves, keeps her head covered, and wears heavy socks and shoes. At the end of 2 weeks or 1 month, the new mother takes the third bath, the cold bath. She may wash her Journal of Nurse-Midwifery
body with cold water, or jump into an icy stream. She may take a purge to clean her insides. Now she has finished the baths and may drink cold water again, and resume her normal activities. She is considered clean. Five women prescribed bedrest during the first 2 or 3 days postpartum. One woman explained that a woman’s bones are “open” after the birth, and she must stay in bed to allow them to close up. Seven women discussed the use of an abdominal binder for the mother during the postpartal period. They all believed that the abdominal binder is necessary to aid the abdomen in returning to its flatter, nonpregnant state. Two women also referred to the concept that after the birth a woman’s bones are “open.” A woman must bind her abdomen to help close up the bones. One woman noted that the abdominal binder is used after a miscarriage as well as after a term birth. Two of the women described and demonstrated a kind of massage consisting of patting the new mother’s body to help it regain its shape. Five women volunteered information about foods a woman should eat after the baby is born. These foods include cornmeal porridge with bean sauce, rice and beans, and plantains. They also discussed foods a new mother should not eat. There is some variation in the list, but it includes lima beans, tomatoes, black mushrooms, white beans, okra, lobsters, and certain kinds of fish prepared in specific ways. According to these five women, there is a prohibition on new mothers eating foods that are white. Three of the women said, however, that it is permissible for a new mother to eat white foods if they are colored with another food, for instance by adding a little coffee to white milk. One woman linked eating white foods with increased vaginal discharge. She offered the rationale that “if you eat white foods after the baby is born, you will make too much of a white secretion.” An-
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other woman stated that the food prohibitions are kept “because you have a certain kind of pus inside of you for 2 months” after the baby is born. Three women discussed the possible presence of air trapped in the abdomen or the body of the mother after the baby is born. They talked about this condition as undesirable and gave concrete instructions for ways to avoid the condition. These methods depend upon preventing air from entering the vagina or the ears. Along with the well-defined ways to care for a new mother are the equally defined ways to care for the new baby. Six women volunteered the details of the immediate care of the newborn. All of them were familiar with the doctor or midwife cutting the umbilical cord, and the tasks of drying the baby, putting a band on the umbilical stump, dressing the baby, putting little socks and shoes on the baby, and laying him down. In response to a question about caring for the newborn, one woman replied, “You take care of him the way one takes care of babies.” Her response demonstrates the attitude, held also by the other women, that the immediate care of the newborn is familiar, and that there is a prescribed set of practices. Nine women prescribed tying a band of cloth around the baby’s abdomen for the first 2 or 3 months of life. The reported purpose of the band is to help the baby to develop a nice form, a strong body, and a sense of balance. Four women stated that one of the first things you do for the newborn is to give him a purgative “to clean his insides.” Three of these women specified that you make the purgative with a base of the red oil that comes from a plant called “maskreti” in Haitian Creole. They suggested adding various things to the base of “maskreti” oil, including boiled water, sugar, salt, and nutmeg. Four women prescribed keeping 151
the baby warm. Two of these women brought up a traditional custom of keeping the baby and the mother inside the house for 3 days after the birth. One of the women was more precise stating that after 3 days you could take the baby outside to let him see the sun, then after 8 days you could take him on an outing. The other two women talked about the importance of keeping the baby’s head warm. One woman discussed the importance of a cotton bonnet and blueing powder (ordinarily used to brighten laundry) put on the baby’s head to keep it warm while the other woman discussed the tradition of placing several orange tree leaves in the baby’s bonnet to keep the baby’s head warm when it is baptized.
strong contrast emerges between the attitudes toward the period after the birth and the period up through the birth. Pregnancy, labor, and birth are seen as inevitable courses. Once a woman conceives, the baby grows, the labor begins, and the birth happens regardless of what the woman does. In contrast to the active role the woman takes after the birth, the woman is passive up through the birth with the doctor or midwife assuming the active role. During the pregnancy, the doctor may prescribe medicine. At the birth, the doctor or midwife cuts the cord, dries, and dresses the baby. Haitian women acknowledge great individual variation regarding women’s responses to pregnancy, labor, and birth. In pregnancy, the woman eats whatever she can tolerate depending, it is said, upon the desires of the baby. In pregnancy, some women feel fine and others are sick the whole time. Some labors last several hours and some last for days. There is very little prescription or proscription for pregnancy or labor. When women talk about their 152
births, it is with the same understanding of the event taking its inevitable course. “Just at the end of 9 months, you go to the hospital.” “I went to the hospital at noon and had my baby. ” “Then it’s the birth.” It is not out of modesty that women do not discuss the details of the birth. At other times, for instance while discussing postpartum, they talk about vaginal discharge or air entering the vagina. Of the 11 Haitian women interviewed, four stated that they never sought any health care until the time of the delivery. Two other women said that they themselves sought prenatal care late in their pregnancies, but that most pregnant women in Haiti never go to see a doctor or midwife until they deliver. Of these six women who talked about prenatal care, five offered the rationale that if you don’t have any “problems” during the pregnancy, you don’t need to see a doctor or midwife. One woman mentioned that most women know to go see a doctor during the pregnancy if “they don’t feel the baby jump in their abdomen.” Four women referred to the role of the doctor or midwife during pregnancy in Haiti. Three of these women described a primary role of the doctor as dispensing medicine while two identified the role of midwife as giving ongoing care and surveillance during the pregnancy. In response to a very open question about what happens in pregnancy, four women immediately talked about nausea and vomiting. Two of these women discussed how pregnancy vanes with each woman and that some feel very sick while others feel fine. Five of the 11 women discussed eating during pregnancy. All of them stated that a woman can eat whatever she likes during her pregnancy, depending upon the individualized preferences of the mother and baby. The women reported no prescriptions or proscriptions on food consumed during the pregnancy. Varia-
tion among pregnant women in their cravings was reported to be expected and supported. Of these five women, three talked about pica as common and considered harmless in Haiti. Some of the reported substances include starch, ashes, dirt, little rocks, rum, and gasoline. The absence of restrictions on food seems to extend to include permitting consumption of almost any substance during pregnancy. In response to an open question about what a woman does or avoids when she is pregnant, only three women talked about work. Two women stated that there are no specific prohibitions on activities during pregnancy, but strongly advised against working too hard and getting too tired. Two women further volunteered that individual women respond very differently to pregnancy, that some can continue to work without a problem and others must stay in bed. These responses supported variation among individuals. Four of the 11 women volunteered information about the danger of werewolves (“loup garous”) during pregnancy and immediate postpartal period. The werewolves are reported to consume babies before they are born as well as small children. Two of these women offered responses reflecting prescription and proscription to protect children against werewolves. One woman stated, “you must guard your children.” The other warned against pregnant women attending funerals. Five women brought up the subject of labor. Two women stated that in labor a woman walks and two other women discussed the great variation in the lengths of labors. Another woman volunteered that the sex of the baby determines the kind of labor pain. Four of the 11 women talked about the actual birth. All four described a scene involving a midwife in a birth at home. Two women brought up the possibility of death during childbirth. One woman,
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awhose’mother was a midwife in Haiti, discussed the fact that midwives encourage the mothers to push the baby out, and doctors cut episiotomies. Reportedly, there are midwives in the countryside who also “know how to make a passage for the baby,” which presumably means cutting an episiotomy. Four of the 11 women made reference to the difference between normal, natural, speedy birth and birth by cesarean or birth with an episiotomy. On the general level, how Haitian women perceive their childbearing experience within the American obstetric system reveals the great extent to which Haitian American women have adapted. These women have evolved several avenues to achieve effective cultural adaptation. One way of adaptation is to accept the new system as equally valid as the old. It is remarkable the extent to which the Haitian women can accept both systems. “Every country has its own rituals. ” “In the United States you have pills and in Haiti we have leaves. ” The women are incredibly tolerant and accepting. In this way they are bicultural. This is consistent with Scott’sl* main thesis that people of one culture who enter into another culture’s health care system become bicultural to varying degrees. It is impossible to know from this limited study the origins of this form of adaptation. It is possible that Haitians are naturally accepting of other ways. It is possible that the more adventurous and flexible Haitians are those who emigrated to the United States. It is also possible that the experience of living day-to-day in another culture has made them more adaptable. A second avenue towards cultural adaptation expressed by the informants is to create clever solutions that permit maintaining the old values within the new setting: for instance, delaying a practice until discharge from the hospital, as in the case of the baby’s abdominal band Journal of Nurse-Midwifery
or purgative. McClain4 reflects findings of this study by observing that “many childbearing strategies represent women’s attempts to preserve valued traditional beliefs and practices even as they accept innovations in birth location and management.” A third approach to cultural adaptation is to link practices with their geographic location. For example, it is fine to drink ice water in the hospital (an American practice), but when a new mother returns home she avoids cold water and drinks warm tea (the Haitian postpartum practice). All of the six women who talked about the Haitian practice of postpartum baths and teas suggested solutions or ways to live with the two different systems. The women acknowledged that both systems exist, and accept different practices tied to different geographic realities. A woman can benefit from both systems of practice-medicine in the hospital, and then leaves at home. One woman expressed that rest is better for a woman during postpartum, but said that if she needs to work she should. This illustrates one way of resolving a conflict by stating what is best, but that other avenues are acceptable. Four of the seven women who discussed the use of maternal abdominal binders report that in the United States there are alternatives to abdominal binders that serve the same purpose. Two women reported that the American method to restore the abdominal shape and tone is to wear a girdle while two other women stated that in the United States abdominal exercises are advocated to restore the abdominal shape. The Haitian women’s solution is to be open to all the alternative methods as possible treatments. However, binding with a girdle is reported to be preferable to exercises. One woman mentioned that if you’ve bound your abdomen with your first child, then that preserves your shape after subsequent pregnancies.
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In response to the different approaches to postpartal nutrition, one woman expressed an acceptance of both systems, and tied the practices to a geographic location. In the hospital it is okay to eat the hospital food, but when returning home a new mother resumes traditional food proscriptions. Descriptions of cultural adaptations regarding newborn care were similar to the adaptations relating to maternal postpartum care. Six of the nine women who discussed abdominal bands for the babies expressed solutions to the conflict of different practices in the two countries. Four women advocated maintaining the Haitian practice while in this country. One woman reported that her mother who is in Haiti sent her bands for her two babies born in the United States. Another woman declared that Pampers are the American alternative to the abdominal band, and function as well in maintaining the child’s form. She stated that you put on Pampers as soon as the baby’s born, and that supports his waist. One woman expressed a solution to the conflict of wanting to give the newborn a purgative and understanding the purgative is not part of the hospital system. She gave her baby a purgative as soon as she returned home from the hospital. It is noteworthy that the only area of conflict expressed during the period before the birth was over prenatal care. In the United States, prenatal care is considered essential and in Haiti it is considered relatively unimportant. This conflict is consistent with the finding that the crucial time for Haitian women is after the birth of the baby. Haitian American women have made many “leaps of faith” to integrate into the American obstetric system, but they are unable to alter their most fundamental understanding-that the crucial time is after the birth. All of the Haitian American women who mentioned prenatal care confessed to seeking no or very late prenatal care. They 153
understood this to be a conflict in the United States but maintained their Haitian understanding of prenatal care as unimportant. CONCLUSION
This study yielded interesting results on two levels, the specific and the general. On the specific level, much information was obtained about beliefs and practices relating to childbearing of Haitian American women. There was a clear emphasis on the time after the birth rather than before the birth as the important time to Haitian American women. On the more general level, information was obtained about the cultural adaptation of Haitian women in the American setting. This information was consistent with the understandings found in the review of literature. Limitations
of the Study
The major limitation of this study is the small sample size. Another limitation due to the interview format is dependence upon retrospective reporting. Women were asked to recall from memory childbearing events of at least several years previous. Implications
for Further Research
Research on the Haitian American childbearing experience based on participant-observation as well as interviewing might provide new understandings. Further study is required in the area of cultural adaptation, especially adaptation within the American obstetric system. This adaptation moves in two directions. One way is how people of other cultures respond upon entering the American obstetric system. The other, equally important, way is how American nurse-midwives, provided with the findings of cross-cultural research, can incorporate this new knowledge into their practices. As an unanticipated result, this
study points toward further research about the importance of the postpartal period for other cultures and for Americans. Studies about the special needs of new mothers and babies are indicated, including the amount and nature of nurse-midwifery care that would be most beneficial in meeting these needs.
For Practice
There are two areas in which American nurse-midwives and Haitian American childbearing women need to work out their differences in beliefs and practices. One area is where the beliefs and practices of both groups are not mutually exclusive and can coexist. Here there is no conflict. The other area is where the
beliefs and practices of both groups are incompatible necessitating one or both groups to make some changes. Pregnancy management is an example of an area of conflict that requires changes. Haitian Americans consider prenatal care relatively unimportant, while American nursemidwives understand prenatal care to be very valuable in maintaining the health of the mother and the baby. It becomes the obligation of the nurse-midwife to explain her beliefs and practices regarding prenatal care to the Haitian client. She should explain what parameters she is assessing (weight gain, fundal growth, blood pressure, etc) and why they are so essential to the health and welfare of both mother and baby. The Haitian woman may make a change in her beliefs and practices and start seeking regular prenatal care, solving the conflict in this way. Alternatively, the Haitian woman may elect to maintain her Haitian beliefs and practices supporting no prenatal care. When the Haitian woman arrives at the hospital in labor without any prenatal care, it is then the nurse-midwife who must make the change in her beliefs and practices. Relying on the results of
this study, the nurse-midwife can change her belief or understanding that a woman without prenatal care does not care about her baby and recognize that this is not true for a Haitian woman. On a more general level, the fundamental goal of this kind of research on practice is to promote better relationships, involving more trust and cooperation, between women from other cultures and their American nurse-midwives and maternity care teams. REFERENCES 1. American College of Nurse-Midwives. Philosophy. Washington, D.C., 1983. 2. Ford CS: A comparative study of human reproduction. New Haven, CT, Yale University Press, 1945. 3. Mead M, Newton N: Cultural patterning in perinatal behavior, in Richardson SA, Guttmacher AF (eds), Childbearing: Its Social and Psychological Aspects, Baltimore, Williams and Wilkins, 1967. 4. McClain C: Toward a comparative framework for the study of childbirth: A review of the literature, in Kay MA (ed), Anthropology of Human Birth. Philadelphia, F. A. Davis, 1982. 5. Jordan B: Birth in four cultures, 3rd ed. Montreal, Eden Press, 1983. 6. Kitinger S: The social context of birth: Some comparisons between childbirth in Jamaica and Britain, in MacCormack CP (ed), Ethnography of Fertility and Birth. London, Academic Press, 1982. 7. MacCormack CP (ed): Ethnography of fertility and birth. London, Academic Press, 1982. 8. Oakley A: Cross-cultural practices, in Chard T, Richards ME (eds), Benefits and Hazards of the New Obstetrics. Philadelphia, J. B. Lippincott, 1977. 9. Homans H: Pregnancy and birth as rites of passage for two groups of women in Britain, in MacCormack CP (ed), Ethnography of Fertility and Birth. London, Academic Press, 1982. 10. Kay MA (ed): Anthropology of human birth. Philadelphia, F. A. Davis, 1982.
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11. Affonso DD: Framework for cultural assessment, in Clark AL, Affonso DD (eds), Childbearing: A Nursing Perspective, 2nd ed. Philadelphia, F. A. Davis, 1979. 12. Scott CS: Health and healing practices among five ethnic groups in Miami, Florida. Public Health Reports 89(6):525-532, 1974. 13. Scott CS: The theoretical significance of a senSe of well-being for the delivery of gynecological health care, in ??
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Bauwens EE (ed), The Anthropology of Health. St. Louis, C. V. Mosby, 1978. 14. Laguerre MS: Haitian Americans, in Harwood A (ed), [email protected] and Medical Care. Cambridge, Harvard University Press, 1981. 15. Dempsey PA, Gesse T: The childbearing Haitian refugee-cultural applications to clinical nursing. Public Health Reports 98(3):261-267, 1983. 16. Herskovits MJ: Life in a Haitian valley. New York, Alfred A. Knopf, 1937.
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17. Leybum JG: The Haitian people. New Haven, Yale University Press, 1941. 18. Courlander H: The drum and the hoe: Life and lore of the Haitian people. Berkeley, University of California Press, 1960. 19. Wiese HJC: Maternal nutrition and traditional food behavior in Haiti. Human Organization-Journal of the Society of Applied Anthropology 35:193199, 1976.