Romani (Gypsy) culture and social issues.
Gypsy  Mothers and the
Hungarian Health Care System

by Mária Neményi

In this article, based on a study suggested and sponsored by the Hungarian Office of Ethnic and National Minorities, the author argues that perceptions, misperceptions, and cultural differences between health care providers and traditional Roma affect the quality of health care provided by the Hungarian health care system.

In the spring of 1998, we carried out an empirical research on the topic of the health of the Hungarian Gypsy population. Because of the restricted budget of the survey, and even more because of my personal interest and professional background, I chose a social-psychological approach to the topic. We decided to observe the relationship between young pregnant Gypsy women, young mothers with small children, and the representatives of the health care system, focusing on several issues. The problem of this relationship seemed to be relevant for several reasons:
1. Prevention is the most important factor of effective health care. Caretaking of pregnant women, providing adequate conditions for childbirth and the care for young children, and the ability to recognize illnesses as early as possible, are the main items in that process.

2. Care for pregnant women and young mothers is a proper field for our purposes because this field is one of the best documented in Hungarian health care, where each member of the concerned population has contact with health care representatives.

3. Finally, the topics of childbirth, pregnancy, and procreativity of the Gypsy population are very much associated with their poor health conditions, with their short life-expectancy in comparison to the majority population, etc.

Typical explanations of this phenomenon are the higher rates of premature birth, in connection with early, frequent or late deliveries, and consequently, dystrophy, mental and physical disabilities, and sensitivity for several illnesses occuring among Gypsies.

It is a legitimate question why this well-covered field of the health care system where representatives have in every case a personal contact with their patients, is not more effective, why it is not able to intervene in these negative phenomena, and why have not more significant changes occurred in the last few decades.

According to our hypothesis, besides the well-known social, financial, economic and educational disadvantages of the Gypsy population, and the special case of health care (as in education), poor communications between Roma women and health care representatives contributes to the lack of success. Interactions and communications lead to misinterpretations on both sides, which result in deepening mistrust, and consequently, the effectiveness of curative support is weakened. But inadequate communication can have a further consequence in health care. Troubles and misunderstandings occur in an "authority-client" relationship. In an optimal case, uniform care as a universal condition could strengthen equality for everyone, otherwise it may increase segregation and marginalization of Gypsies, instead of helping them to integrate into Hungarian society.

We wanted to analyze the relationship between the two sides. Therefore naturally, we wanted to have information about both sides. The method of our research was interviews, hoping that this would lead us not only to discover facts, but opinions, explanations, and beliefs, as well. We questioned persons in health care who were in everyday contact with Gypsy mothers: district nurses, midwives, gynecologists and family doctors. From the other side, we interviewed 80 mothers of four sub-samples, 20 women in each group. The four groups were selected by ethnic background, choosing the three major Gypsy ethnic groups in Hungary: Vlach, Boyash, Romungro (Hungarian Gypsies or musicians), and as a fourth, so-called control group, the Gypsies of Budapest were selected.

The topics of the conversations were the history of pregnancy, childbirth, the care for the newborn baby at home, and curing their illnesses. Neither representatives of the health care system nor the Gypsy mothers were considered by us to be more objective in any given topic. We assumed that both health care representatives and Gypsy respondents based their experiences, or "knowledge", on personal events, individual experiences constructed by their own wider and narrow communities' values, explanations, and habits (professional in the former case, traditional in the latter). We also assumed that narration of any topic would not be equivalent, communication between the two sides would result in misunderstandings and misinterpretations. But because of the fact that Gypsy mothers are seeking advice, help, and care by health care representatives, who - according to their profession - intervene in order to lead their patients to a required behavior, inaccurate communications hindered the effectiveness of care.

Questions of our research included the following:

1. Whether stagnant and poor morbidity and mortality rates of the Gypsy population can be a result of inadequate communications between health care representatives and Gypsies?

2. What is the relationship between health care representatives and Gypsy communities with different ethnic backgrounds?

3. Is there any conflict between prescriptions of health care representatives concerning life patterns, health conceptions, etc., and that of Gypsies, based on their own traditions?

4. Does the knowledge - facts, beliefs, prejudices - about Roma play any role in the relationship of health care representatives and Gypsy clients?

The main difference in the perception of health care representatives and Gypsy mothers we observed was in the field of procreativity. Medical doctors, nurses, and midwives mostly assumed that the fertility of Gypsy women is due to their lack of family planning, ignorance, poor education, etc. - they are only living their biological life, surrendering to their natural and unconscious destiny. Gypsy mothers in their eyes are so-called "natural human beings", "wild-women", a population in transition from a semi-civilized life to "normal" culture. Elements of that "wild-women-ness" are an early sexual life, easy pregnancy and delivery, prolonged breastfeeding, etc. In their opinion, the obstacle of giving them information and advice originates on one hand from a real communication gap, sometimes because of their different language, sometimes only because of their under-education. On the other hand, they observed Gypsies' theatricality, their over-sensitivity to recognizing prejudice everywhere, etc. They admitted to not having enough knowledge about Gypsies, and some of them also admitted that persons in the health care system have prejudices against different people, especially Gypsies. They have not learned to handle these difficulties, never having learned any communication or conflict-solving techniques.

On the other side, in interviews with Gypsy mothers, we observed a duality of effects behind their family planning processes. This observation was based on the analysis of the whole sample and by comparing the four different sub-samples. This duality of effects, two different vectors sometimes functioning in parallel, sometimes in conflict with each other, is a scale of tradition-modernity, and a scale from spontaneity and ignorance at a high level of consciousness. This duality is present in every case, and it is sometimes difficult to separate this two different kinds of influences on fertility. If we suppose that in Romani communities high numbers of children in families and an acceptance of fertility without any consideration is typical, it is useless to expect a rational choice according to the majority's opinion in family planning. Logically speaking, we may assume that on the one hand a high number of children per family in a traditional community is a rational choice, while in the same community a low family size can happen only by chance, or is a deviant behavior according to tradition. On the other hand, among families without strict traditional customs, a low number of children is a sign that these families followed the norms of the majority, and the high number of children is deviant. Not only traditions, but ignorance, the above mentioned spontaneity, or "primitivism", can influence fertility rates and can hinder the educational work of health care authorities. In these cases individual destiny is relegated to biology, to social influences without the possibility of self-defense.

We do not believe that majority of our respondents live in this way. It is true that women in our sample are different in their fertility habits from the average Hungarian women. This difference is significant only in the case of Boyash and Vlach Gypsies, but in these two sub-samples different causes are working in the background. On the scale of tradition, Vlach Gypsies are more traditional, with large families and higher numbers of children due to their rational choice. In this group family planning and the use of contraception (artificial abortion, as well) is more frequent than in the other groups. The sub-sample of Boyash Gypsies seems to be more dependent on their biological fate. Abortion did not occur in this group, family planning is unknown, or only after several children did they decide to use some contraceptive method, sometimes following the advice of the health care representative. In the group of Romungro Gypsies, like in the Budapest control group, although the average number of children is higher than in the whole population, this number and their attitudes are not different from the similar stratum of Hungarian families characterized by the same level of education, working situation, and social situation. The Budapest group showed the highest level of consciousness in family planning, although they started to plan their fertility after the first or second child, usually giving birth at a very young age. Members of this group had a very mixed ethnic background and many of them came from unstable, broken families, sometimes spending their childhood in state-run institutions. Their fertility habits are mostly influenced by non-traditional mediators such as age-group, neighborhood, school, media, and following the norms of the majority in the field of family planning.

We were aware of being only able to give a non-representative report about the contact between Gypsy mothers and representatives of the health care system. Our first statement is that these two sides are from two different environments. The two kinds of narration about the same life-experiences of these mothers seemed to happen in different universes. According to the interviews made among health care representatives, the Gypsy population is something very different from the whole society, they are in between primitivism and civilization. Interviews with Gypsy mothers convinced us that the sample is very mixed but does not deviate much from the social stratum which has the same social characteristics. What is different, is that these women suffer by the simultaneous claim of the broader and the narrower community to follow their norms, and these two sometimes contradictory effects can result in a conflicting perception of their procreativity. We also observed that the myth of "wild-women" influenced the self-perception of Romani women negatively.

Ignorance, spontaneity assumed by health care representatives seem to be true only in one part of the sample. In the majority of cases when we observed fertility habits different from the majority, it was due to the traditional values. Only in the smaller part of the sample did we experience that ignorance or subversion to biological destiny was the reason for early childbearing or for the high number of children per family.

A third element of the health care authority observed was prejudice in Romani client relationships. Our interviews with health care representatives expressed this prejudice only in a few cases, but in their discourse, in their expressions, we discovered a kind of prejudice which appeared toward the image of "wild-women", under-civilized people. But they also accused their clients with such characteristics as aggression, over-consciousness of their differences, and that they assumed prejudice even where there was only an expectation of "normal" behavior. Interviews with Gypsy mothers convinced us that their everyday experiences with health care representatives is that they feel perceived through the prism of prejudice, instead as individual beings with their own behaviors, problems, that they are only members of a discriminated group.

Neither the group of health care representatives, nor the group of Gypsy mothers was homogenous. Even the small group of health care representatives justified that the higher the contact with Gypsies, the more personal and adequate was their perception of Gypsies. The seldom and low-rate contact of health care workers with Gypsy clients leads to a mythical perception of that population, full of prejudices and misunderstandings. That means, district nurses had the most empathetic and understanding relationships with their clients, and only this group seemed to be able to adapt themselves to Gypsies' traditional or community-based habits. Gynecologists, medical doctors in hospitals had the greatest distance from their Gypsy clients and their false views led them to construct a wall of prejudices.

Inconsistency of Gypsy attitudes was due to our method, choosing four groups of different ethnic backgrounds. In comparison to the uniform image of health care authorities, we observed four widely differing groups when considering habits in choosing partners, family planning, fertility customs and child rearing, from the point of view of spontaneity-consciousness or tradition-modernity. Differences in these groups and the similarity of behavior of health care representatives called our attention to the fact that a universal-rational approach of experts and the prejudicial view of Gypsies results in inadequate communications in the majority of cases.

Finally, we suggest considering one more point. We did not seek to analyze Gypsies' perceptions of health care workers, our purpose was only the comparison of two points of view of the same events: pregnancy and childbirth by Gypsy mothers, and their child-rearing habits. We assumed that adequate communications and effective advisory work is only possible if the two images created by the two different sides overlap each other, in other words, if the expert knows his or her patient in an objective way. We did not intend to analyze the Romani's "doctor-image". However, several experiences mentioned in the Gypsy interviews called our attention to one danger, that advice, instructions and directions of health care representatives can only be effective if the person giving them is trustworthy and genuine. The Gypsy experience of a thoughtless, negligent, or inept medical doctor, working only for extra money, can only lead to a false over-generalization of health care representatives, hindering effective medical advice and treatment, damaging efficient doctor-client relationships.

Mária Neményi is a researcher at the Institute of Sociology of the Hungarian Academy of Sciences.

Copyright © by Mária Neményi, e-mail
This article is reproduced by the Patrin Web Journal with permission of the author.
Posted 06 January 1999.

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