CHAPTER 5

TRANSCULTURAL NURSING ACROSS THE LIFE SPAN

TRANSCULTURAL PERSPECTIVES IN CHILDBEARING
 LEARNING OBJECTIVES
1. Analyze how culture influences the beliefs and behaviors of the
childbearing woman and her family during pregnancy.
2. Recognize the childbearing beliefs and practices of diverse
cultures.
3. Examine the needs of women making alternative lifestyle choices
regarding childbirth and child rearing.
4. Explore how cultural ideologies of childbearing populations can
impact pregnancy outcomes.
 OVERVIEW OF CULTURAL BELIEF SYSTEMS
AND PRACTICES RELATED TO CHILDBEARING
Pregnancy and childbirth practices in contemporary Western
society have seen dramatic changes over the past three decades. As
global populations become increasingly mobile, we are seeing
cultures converge, which calls for a reorientation of our nursing skills
and nursing behaviors. In light of global population shifts that are
likely to continue for years to come, cultural beliefs regarding
childbearing and childrearing need to be examined to enable nurses
to offer our patients culturally congruent care throughout their
pregnancy, birth, and the early postpartum.
 One aspect does remain static: Childbearing is universal and, as
Chalmers (2013) notes, is a great leveler, as all women who give
birth do so in one of two ways. This is also a time of transition and
social celebration of central importance in any society, signaling a
realignment of existing cultural roles and responsibilities,
psychological and physiologic states, and social relationships.
The differences in how women experience this transition lie in the
cultural values and beliefs surrounding pregnancy, the birthing
process, and postpartum practices.The dominant cultural practices or
rituals include formal prenatal care (including childbirth classes),
ultrasonography to view the fetus, and hospital delivery.
 Hospital deliveries routinely involve a highly specialized group of
nurses, obstetricians, perinatologists, and pediatricians who actively
monitor the mother’s physiologic status and the fetal status, deliver
the infant, and provide postpartum and newborn care. Routine
hospital care can also include inducing labor, providing anesthesia
for labor and delivery, and performing a cesarean section. There is
not total cultural agreement about the value of these dominant
practices, however, and some health care providers elect to offer their
pregnant clients alternative health care services. These alternatives
include in-hospital and freestanding birth centers and care by nurse
practitioners and nurse midwives who promote family-centered care
and emphasize pregnancy as a normal process requiring minimal
technological intervention.
 It is a known fact that the United States spends more money than
any other country on health care and more on maternal health than
any other type of hospital care; however, women in the United States
have a higher risk of dying of pregnancy-related complications than
those in 40 other countries. Health disparities in the United States
also play a role in increased maternal morbidity and maternal
mortality, although it is unclear to what extent. For example, African
American women are nearly four times more likely to die of
pregnancy-related complications than White women. These rates and
disparities have not improved in more than 20 years (Amnesty
International, USA, 2010).
 Subcultures within the United States have very different practices,
values, and beliefs about childbirth and the roles of women, men,
social support networks, and health care practitioners. One such
subculture includes proponents of the “back to nature” movement,
who are often vegetarian, use lay midwives for home deliveries, and
practice herbal or naturopathic medicine. Other groups that might
have distinct cultural practices include African Americans, American
Indians, Hispanics, Middle Eastern groups, Orthodox Jewish groups,
Asians, and recent immigrants, among others. Additionally, religious
background, regional variations, age, urban or rural background,
sexual preference, and other individual characteristics all might
contribute to cultural differences in the experience of childbirth.
 Despite the great variations that can exist in relation to the social
class, ethnic origin, family structure, and social support networks of
women in the United States, many health care providers mistakenly
assume that pregnancy and childbirth are experienced similarly by all
people. In addition, some professional nurses view some traditional
cultural beliefs, values, and practices related to childbirth as “old-
fashioned,” “back in the day,” or “old wives’ tales.” Although some
of these customs are changing rapidly, particularly for immigrants in
the United States, many women and families are attempting to
preserve their own valued patterns of experiencing childbirth.
 FERTILITY CONTROL AND CULTURE

The professional literature lacks information specific to cultural

beliefs and practices related to the control of fertility. A woman’s
fertility depends on several factors, including the likelihood of
sterility, the probability of conceiving, and of intrauterine mortality.
In addition, the duration of a postpartum period, during which a
woman is unlikely to ovulate or conceive, influences fertility.
 These variables are further modified by cultural and social
variables, including marriage and residence patterns, diet, religion,
the availability of abortion, the incidence of venereal disease, and the
regulation of birth intervals by cultural or artificial means, all of
which are influenced by cultural norms, values, and traditions. This
section focuses on those societal factors that influence reproductive
rights and population control.
 UNINTENDED PREGNANCY
In the United States, according to Finer and Zolna’s (2011)
combined data study, 49% of pregnancies in 2006 were unintended—
a slight increase from 48% in 2001. Among women aged 19 years
and younger, more than four out of five pregnancies were
unintended. The proportion of pregnancies that were unintended was
highest among teens younger than age 15 years, at 98%. The largest
increases in unintended pregnancy rates were among women with
low education, low income, and cohabiting women. Mosher, Jones,
and Abma (2012) reported similar findings in data from the National
Survey of Family Growth, which indicated no significant decline in
the overall proportion of unintended births between the 1982 and the
2006 to 2010 surveys.
 The proportion of births that were unintended did decline during
these years among married, non-Hispanic White women. Women
more likely to experience unintended births included unmarried
women, black women, women who are socioeconomically
disadvantaged, and those with less education. The public cost of
births resulting from unintended pregnancies has been reported to be
$8 billion; for teens, the average cost was even higher, topping out at
$9.1 billion (Sonfield, Kost, & Gold, 2011).
 Women’s attitudes related to pregnancy, contraception, fertility,
and childbearing have had limited exploration. Rocca and Harper
(2012) used 2009 data from the National Survey of Reproductive and
Contraceptive Knowledge to specifically investigate if contraceptive
attitudes and knowledge explain disparities in method used. Using
mediation analysis and regression models, they reported that Blacks
and Latinas believe the government encourages contraceptive use to
limit minority population growth. They also indicated that although
Blacks and Latinas used less effective methods than Whites, their
attitudes did not explain the disparities in method used. For example,
lower contraceptive knowledge only partially explained Latinas’ use
of less effective methods. The investigators concluded that “other”
variables needed study, including provider behavior and health
system features.
 Unintended pregnancy can have numerous negative effects on the
mother and the fetus, including a delay in prenatal care, continued or
increased tobacco and other drug use, as well as increased physical
abuse during pregnancy; any of these factors can lead to preterm
labor or low-birth-weight (LBW) infants (Finer & Zolna, 2011).
Consideration must also be given to what is influencing unintended
pregnancy, which includes changes in social mores sanctioning
motherhood outside of marriage, contraception availability including
abortion, earlier sexual activity, and multiple partners.
 In addition to increasing access to contraception and targeting
high-risk groups, programs aimed at reducing or preventing
unintended pregnancy must build on the cultural meaning of the
problem and focus on the processes women and their partners use to
make fertility decisions. The United States has established family
planning goals in Healthy People 2020 aimed at improving
pregnancy planning, spacing, and preventing unintended pregnancy.
An objective is to increase the proportion of pregnancies that are
intended to 56%. Family planning efforts that can help reduce
unintended pregnancy include increasing access to contraception,
particularly to the more effective and longer-acting reversible forms,
and increasing correct and consistent use of contraceptive methods
overall (U.S. Department of Health and Human Services, 2014). As
of this printing, this goal has yet to be achieved.
 CONTRACEPTIVE METHODS
Commonly used methods of contraception in the United States
include hormonal methods, intrauterine devices (IUDs), permanent
sterilization, and, to a lesser degree, barrier and “natural” methods.
Natural methods of family planning are based on the recognition of
fertility through signs and symptoms and abstinence during periods
of fertility. The religious beliefs of some cultural groups might affect
their use of fertility controls such as abortion or artificial regulation
of conception; for example, Roman Catholics might follow church
edicts against artificial control of conception, and Mormon families
might follow their church’s teaching regarding the spiritual
responsibility to have large families and promote church growth
(Andrews & Hanson, 2012).
 Negative outcomes of religious family planning teachings have
recently been studied. Pritchard, Roberts, and Pritchard (2013)
analyzed WHO data from two continents sharing religious–cultural
views on suicide and family planning those being Western European
Catholic and Latin American Catholic countries. He reported that in
Latin American female youth (15 to 24 years of age), less access to
contraception contributed to unintended pregnancies and higher
suicide rates.
The ability to control fertility successfully also requires an
understanding of the menstrual cycle and the times and conditions
under which pregnancy is more or less likely to occur—in essence,
an understanding of bodily functions.
 When these functions change, the woman might perceive the
changes as abnormal or unhealthy. Because the use of artificial
methods of fertility control might alter the body’s usual cycles,
women who use them might become anxious, consider themselves
ill, and discontinue the method. American Indian women monitor
their monthly bleeding cycles closely and believe in the importance
of monthly menstruation for maintaining harmony and physical well-
being. Contraceptives such as the IUD are generally better accepted
by American Indian women than hormonal methods because of the
normal or increased flow associated with the IUD. Because the
mechanism of action of an IUD might include the expulsion of a
fertilized ovum, some women in this group oppose the use of the
IUD for religious reasons.
 REFUGEES AND
REPRODUCTIVE HEALTH

Since the Rwandan crisis in 1994, an estimated 26 million

individuals have been displaced across international borders (as of
mid-2013) as part of a mass exodus from their homes due to war,
ethnic and civil unrest, and political instability (UNHCR, 2013).
Women and children account for approximately 80% of the world’s
refugees, and displaced women are extremely vulnerable to poor
reproductive illness and outcomes (CDC, Division of Reproductive
Health, National Center for Chronic Disease Prevention and Health
Promotion, 2014).
 The CDC has developed a refugee program with a focus on
refugee reproductive health. Women living in refugee situations
encounter many barriers to contraceptive use, and even with the
development of programs that target refugee women in the United
States, sponsored refugee women continue to experience barriers to
reproductive health. For example, Somali Bantu women relocated to
Hartford, CT, reported that a major barrier to unmet health needs was
the ethnic distinction/language barrier (Gurnah, Khoshnood, Bradley,
& Yuan , 2011). The authors attributed this finding to the interpreter
translation being conducted in a Somali language that the Somali
Bantu did not understand.
 RELIGION AND FERTILITY CONTROL

The influence of religious beliefs on birth control choices varies

within and between groups, and adherence to these beliefs may
change over time. Cultural practices tend to arise from religious
beliefs, which can influence birth control choices. For example, the
Hindu religion teaches that the right hand is clean and the left is dirty.
The right hand is for holding religious books and eating utensils, and
the left hand is used for dirty things, such as touching the genitals.
This belief complicates the use of contraceptives requiring the use of
both hands, such as a diaphragm (Bromwich & Parsons, 1990).
 In many cases, birth control is seen as an act of God. Purnell and
Selekman (2008) describe the Muslim belief that abortion is “haram”
unless the mother’s life is in danger; consequently, unintended
pregnancies are dealt with by praying a miscarriage will occur. A fact
that is perhaps of greater significance to fertility in Muslim women is
that a woman’s sterility can be reason for abandoning or divorcing
her. The authors go on to say that Islamic law forbids adoption;
infertility treatment is allowed, but is limited to artificial
insemination using the couple’s own sperm and eggs.
 According to Orthodox Jewish beliefs, infertility counseling and
intervention such as sperm and egg donation (from the couple) meet
with religious approval; adoption is viewed as a last resort
(Washofsky, 2000). The use of condoms and birth control pills are
acceptable; abortion and sterilization are the least-supported birth
control methods. However, in cases where the mother’s life is in
jeopardy, abortion is not opposed (Kolatch, 2000).In some African
cultures, there are strongly held beliefs and practices related to birth
spacing. Because postpartum sexual activity has traditionally been
taboo, some women leave their home for as long as 2 years to avoid
preg_x0002_nancy (Miller, 1992).
 CULTURAL INFLUENCES ON FERTILITY CONTROL

It is common for health professionals to have misconceptions

about contraception and the prevention of pregnancy in cultures
different from their own. A qualitative study by Eckhardt and
Lauderdale (2013) sought to identify and describe the barriers to
family planning in North Kamagambo, Kenya, to understand the
cultural context in which they exist. Since the Lwala Community
Hospital’s opening in the North Kamagambo region of Kenya in
2007, the number of patients seeking contraceptives and family
planning counseling has increased. However, maternal mortality
remains high and the culture expects women to bear many children.
 Although this places a large burden on women’s health and
increases a lifetime risk of maternal mortality, cultural and religious
hesitance toward family planning persists.Nurses providing family
planning services must take care to be culturally sensitive so that
women can be assisted in examining their own attitudes, beliefs, and
sense of gynecologic wellbeing regarding fertility control.
 PREGNANCY AND CULTURE

All cultures recognize pregnancy as a special transition period,

and many have particular customs and beliefs that dictate activity and
behavior during pregnancy. Recent reports of childbirth customs in
the United States have focused on accounts of differing beliefs and
practices relative to pregnancy among various ethnic and cultural
groups. This section describes some of the biologic and cultural
variations that might influence nursing care during pregnancy
 BIOLOGIC VARIATIONS
Knowledge of certain biologic variations resulting from genetic
and environmental backgrounds is important for nurses who care for
childbearing families. For example, pregnant women who have the
sickle cell trait and are heterozygous for the sickle cell gene are at
increased risk for asymptomatic bacterial and urinary tract infections
such as pyelonephritis. This places them at greater-than normal risk
for premature labor as well. Although heterozygotes are found most
commonly among African Americans (8% to 14%), individuals living
in the United States and Canada who are of Mediterranean ancestry,
as well as those of Germanic and Native North American descent,
might also carry the trait (Overfield, 1985; Perry, 2000). If both
parents are heterozygous, there is a one-in-four chance that the infant
will be born with sickle cell disease.
 Another important biologic variation relative to pregnancy is
diabetes mellitus. The incidence of non–insulin-dependent and
gestational diabetes is much higher than normal among some
American Indian groups—a problem that increases maternal and
infant morbidity. Illnesses that are common among European
Americans might manifest themselves differently in American Indian
clients. For example, an American Indian woman might have a high
blood sugar level but be asymptomatic for diabetes mellitus. The
mortality rate in pregnant American Indian women with diabetes is
higher than in White European American women.
 Diabetes during pregnancy, particularly with uncontrolled
hyperglycemia, is associated with an increased risk of congenital
anomalies, stillbirth, macrosomia, birth injury, cesarean section,
neonatal hypoglycemia, and other problems.
Because long-term studies have been conducted among the Pima
Indians of Arizona, we know that, for the last 40 years or so, they
have a very high incidence of gestational diabetes and other health
problems during pregnancy (Pettitt, Baird, Aleck, Bennett, &
Knowler, 1983).
 Because some of the children born to Pima mothers after the
studies began are now 30 to 40 years old, we can see how a mother’s
diabetes can influence her child’s health in adulthood. Researchers
have found that the children of women with diabetes during
pregnancy have a higher risk of becoming obese and getting diabetes
earlier in life than those born to mothers who had normal blood sugar
(Chamberlain, n.d.; The Pima Indians: Obesity and Diabetes, 2010).
Pregnant American Indians and Alaskan Native women with type
2 diabetes are at an increased risk of having babies born with birth
defects. Gestational diabetes increases the baby’s risk for problems
such as macrosomia (large body size) and neonatal hypoglycemia
(low blood sugar).
 Although the blood glucoses of American Indian and Alaskan
Native women usually return to normal after childbirth, these women
have an increased risk of developing gestational diabetes in future
pregnancies. In addition, studies show that many women with
gestational diabetes will develop type 2 diabetes later in life (The
Diabetes Monitor, 2011).
 CULTURAL VARIATIONS
INFLUENCING PREGNANCY
Several cultural variations may influence pregnancy. Those
highlighted in this section include alternative lifestyle choices,
nontraditional support systems, cultural beliefs related to parental
activity during pregnancy, and food taboos and cravings. Nurses must
be able to differentiate among beliefs and practices that are harmful
and those that are benign. Few cultural customs related to pregnancy
are dangerous and many are health promoting. However, one practice
that is dangerous is female excision. This cultural practice occurs in
approximately 28 African countries and affects 100 to 140 million
girls and women (WHO, 2008).
 The emotional and psychological impact of this practice on
childbirth is important to recognize when providing childbearing care
for women having undergone this procedure. See d’Entremont,
Smythe, McAra-Couper’s (2014)
 ALTERNATIVE LIFESTYLE CHOICES
Although the dominant cultural expectation for North American
women remains motherhood within the context of the nuclear family,
recent cultural changes have made it more acceptable for women to
have careers and pursue alternative lifestyles. Changing of cultural
expectations has influenced many middle-class North American
women and couples to delay childbearing until their late 20s and
early 30s and to have small families. Many of today’s women are
career oriented, and they may delay childbirth until after they have
finished college and established their career. Some women are
making choices regarding childbearing that might not involve the
conventional method of conception and childrearing.
 Lesbian childbearing couples are a distinct subculture of pregnant
women with special needs. Randi (2012) reports that the way intake
forms are completed needs to be re-evaluated in light of these social
changes. How the patient became pregnant is one such example.
Instead of assuming she became pregnant via intercourse, Randi
suggests asking the patient to tell you “the story” of how she became
pregnant, thus keeping the interview less threatening and
nonjudgmental. The author underscores the need to be aware of the
language used in the first encounter with a pregnant woman in order
to set the tone for future provider–patient encounters.
 Lesbian childbearing couples are a distinct subculture of pregnant
women with special needs. Randi (2012) reports that the way intake
forms are completed needs to be re-evaluated in light of these social
changes. How the patient became pregnant is one such example.
Instead of assuming she became pregnant via intercourse, Randi
suggests asking the patient to tell you “the story” of how she became
pregnant, thus keeping the interview less threatening and
nonjudgmental. The author underscores the need to be aware of the
language used in the first encounter with a pregnant woman in order
to set the tone for future provider–patient encounters.
 The most common fear reported by lesbian mothers is the fear of
unsafe and inadequate care from the practitioner once the mother’s
sexual orientation is revealed. Reluctance to disclose sexual
orientation to one’s health care provider can act as a barrier to a
woman receiving appropriate services and referrals (Snowden, 2011).
 In their review of the literature, McManus, Hunter, and Rennus
(2006) found four areas that are significant in regard to lesbians
considering parenting:
(1) sexual orientation disclosure to providers and finding sensitive
caregivers,
(2) conception options,
(3) assurance of partner involvement, and
(4) how to legally protect both the parents and the child.
 Lesbian and heterosexual pregnancies have many similarities.
Issues of sexual activity, psychosocial changes related to attaining the
traditionally defined maternal tasks of pregnancy (Rubin, 1984), and
birth education all need to be addressed with lesbian couples.
Special needs of the lesbian couple requiring assessment include
social discrimination, family and social support networks, obstacles
in becoming pregnant (i.e., coitus versus artificial insemination),
maternal role development, legal issues of adoption by the partner,
and coparenting roles (Spidsberg, 2007).
 The nursing staff conveyed support by using comforting gestures,
checking with the couple frequently, answering questions, and just
“being there” for them (Buchholz, 2000).
Buchholz’s study identified two major concerns of lesbian
couples. The first centered on legal issues, such as power of attorney,
visiting restrictions for the partner, and birth certificate information
(father identification). Thesecond concern dealt with the couple’s
attention to nurses’ behavioral cues and questioning whether
“busyness” on the part of the nurses might somehow equate to
discomfort with the situation.
 MATERNAL ROLE ATTAINMENT

Maternal role attainment is often taken for granted in Western

culture. If you give birth and become a mother, the assumption is that
you automatically become “maternal” and successfully care for and
nurture your infant. However, many factors can affect maternal role
attainment, including separation of mother and infant in cases such as
illness, incarceration, or adoption, to name only a few.
 An example of successful maternal role attainment superimposed
with a chronic illness is described in a phenomenological study that
explored factors affecting maternal role attainment in HIV-positive
Thai mothers selected for their successful adaptation to the maternal
role. The results indicated six internal and external factors used to
assist in attainment:
(1) setting a purpose of raising their babies;
(2) keeping their HIV status secret;
(3) maintaining feelings of autonomy and optimism by living as if
nothing were wrong, that is, normalization;
(4) belief of quality versus quantity of support from
hus_x0002_bands, mothers, or sisters;
(5) hope for a cure; and
(6) belief that their secret is safe with their health care providers.
 NONTRADITIONAL SUPPORT SYSTEMS
A cultural variation that has important implications is a woman’s
perception of the need for formalized assistance from health care
providers during the antepartum period. Western medicine is
generally perceived as having a curative rather than a preventive
focus. Indeed, many health care providers view pregnancy as a
physiologic state that at any moment will become pathologic.
Because many cultural groups perceive pregnancy as a normal
physiologic process, not seeing pregnant women as ill or in need of
the curative services of a doctor, women in these diverse groups often
delay seeking, or even choose not to seek, prenatal care.
 Pregnant women and their partners have been placing increased
emphasis on the quality of pregnancy and childbirth for some time,
with many childbearing women relying on nontraditional support
systems. For couples who are married, white, middle class, and
infrequent users of their extended family for advice and support in
childbirth-related matters, this kind of support might not be crucial.
However, for other, more traditional cultural groups, including
African Americans, Hispanics, Filipinos, Asians, and Native
Americans, the family and social network (especially the
grandmother or other maternal relatives) may be of primary
importance in advising and supporting the pregnant woman.
 CULTURAL BELIEFS RELATED TO
ACTIVITY DURING PREGNANCY
Cultural variations also involve beliefs about activities during
pregnancy. A belief is something held to be actual or true on the basis
of a specific rationale or explanatory model. Prescriptive beliefs,
which are phrased positively, describe what should be done to have a
healthy baby; the more common restrictive beliefs, which are phrased
negatively, limit choices and behaviors and are practices/behaviors
that the mother should not do in order to have a healthy baby.
Taboos, or restrictions with serious supernatural consequences, are
practices believed to harm the baby or the mother. Many people
believe that the activities of the mother—and to a lesser extent of the
father—influence newborn outcome.
 PRESCRIPTIVE BELIEFS
●Remain active during pregnancy to aid the baby’s circulation
(Crow Indian)
● Keep active during pregnancy to ensure a small baby and an
easy delivery (Mexican and Cambodian)
● Remain happy to bring the baby joy and good fortune (Pueblo
and Navajo Indian, Mexican, Japanese)
● Sleep flat on your back to protect the baby (Mexican)
● Continue sexual intercourse to lubricate the birth canal and
prevent a dry labor (Haitian, Mexican)
● Continue daily baths and frequent shampoos during pregnancy
to produce a clean baby (Filipino)
 RESTRICTIVE BELIEFS
●Avoid cold air during pregnancy to prevent physical harm to the
fetus (Mexican, Haitian, Asian)
● Do not reach over your head or the cord will wrap around the
baby’s neck (African American, Hispanic, White, Asian)
● Avoid weddings and funerals or you will bring bad fortune to
the baby (Vietnamese)
● Do not continue sexual intercourse or harm will come to you
and baby (Vietnamese, Filipino, Samoan)
● Do not tie knots or braid or allow the baby’s father to do so
because it will cause difficult labor (Navajo Indian)
● Do not sew (Pueblo Indian, Asian)
 TABOOS
● Avoid lunar eclipses and moonlight or the baby might be born
with a deformity (Mexican)
● Do not walk on the streets at noon or 5 o’clock because this
might make the spirits angry (Vietnamese)
● Do not join in traditional ceremonies like Yei or Squaw dances
or spirits will harm the baby (Navajo Indian)
● Do not get involved with persons who cast spells or the baby
will be eaten in the womb (Haitian)
● Do not say the baby’s name before the naming ceremony or
harm might come to the baby (Orthodox Jewish)
 ● Do not have your picture taken because it might cause stillbirth
(African American)
● During the postpartum period, avoid visits from widows,
women who have lost children, and people in mourning because
they will bring bad fortune to the baby (South Asian Canadian)
 FOOD TABOOS AND CRAVINGS
Many cultures traditionally believed that the mother had little
control over the outcome of pregnancy except through the avoidance
of certain foods. Another traditional belief in many cultures is that a
pregnant woman must be given the food that she smells to eat;
otherwise, the fetus will move inside of her and a miscarriage will
result (Spector, 2008). Spicy, cold, and sour foods are often believed
to be foods that a pregnant woman should avoid during pregnancy.
Some pregnant women experience pica: the craving for and
ingestion of nonfood substances, such as clay, laundry starch, or
cornstarch. Some Hispanic women prefer the solid milk of magnesia
that can be purchased in Mexico, whereas other women eat the ice or
frost that forms inside refrigerator units.
 CULTURAL PREPARATION
FOR CHILDBIRTH

Women from diverse cultural backgrounds often se culturally

appropriate ways of preparing for labor and delivery. These methods
might include assisting with childbirth from the time of adolescence,
listening to birth and baby stories told by respected elderly women,
or following special dietary and activity prescriptions during the
antepartal period. Most commonly in American culture, pregnant
women and their significant others attend childbirth classes/or get
pregnancy information from the Internet.
 Preparation for childbirth can be developed through programs that
allow for cultural variations, including classes during and after the
usual clinic hours in busy urban settings, teen-only classes, single-
mother classes, group classes combined with prenatal checkups at
home, classes on rural reservations, and presentations that
incorporate the older “wise women” of the community. In addition,
nurses can organize classes in languages other than English and
conduct these classes in community settings that are culturally
appropriate and welcoming to women.
 BIRTH AND CULTURE

Beliefs and customs surrounding the experience of labor and

delivery can vary, despite the fact that the physiologic processes are
basically the same in all cultures. Factors such as cultural attitudes
toward the achievement of birth, methods of dealing with the pain of
labor, recommended positions during delivery, the preferred location
for the birth, the role of the father and the family, and expectations of
the health care practitioner might vary according to the degree of
acculturation to Western childbirth customs, geographic location,
religious beliefs, and individual preference
 Traditionally, cultures have viewed the birth of a child in one of
two very different ways. For example, the birth of the first son may
be considered a great achievement worthy of celebration, or the birth
may be viewed as a state of defilement or pollution requiring various
purification ceremonies. Western culture generally views birth as an
achievement. This achievement is not always attributed solely to the
mother, but extends to the medical staff as well. Gifts and
celebrations are often centered on the newborn rather than the
mother.
 TRADITIONAL HOME BIRTH

All cultures have an approach to birth rooted in a tradition of

home birth, being within the province of women. For generations,
traditions among the oor included the use of “granny” midwives by
rural Appalachian Whites and southern African Americans and
parteras by Mexican Americans. A dependence on self-management,
a belief in the normality of labor and birth, and a tradition of delivery
at home might influence some women to arrive at the hospital in
advanced labor. The need to travel a long distance to the closest
hospital might also be a factor contributing to arrival during late
labor or to out-of-hospital delivery for many American Indian women
living on rural, isolated reservations.
 CULTURAL EXPRESSION OF LABOR PAIN
Although the pain threshold is remarkably similar in all persons,
regardless of gender or social, ethnic, or cultural differences, these
differences play a definite role in a person’s perception and
expression of pain. Pain is a highly personal experience,
depen_x0002_dent on cultural learning, the context of the
situ_x0002_ation, and other factors unique to the individual
(Ludwig-Beymer, 2008). In the past, it was commonly believed that
because women from Asian and Native American cultures were stoic,
they did not feel pain in labor (Bachman, 2000). In addition to the
physiologic processes involved, cultural atti_x0002_tudes toward the
normalcy and conduct of birth, expectations of how a woman should
act in labor, and the role of significant others influence how a woman
 CULTURE AND THE
POSTPARTUM PERIOD

Western medicine considers pregnancy and birth the most

dangerous and vulnerable time for the childbearing woman.
However, other cultures place much more emphasis on the
postpartum period. Many cultures have developed special practices
during this time of vulnerability for the mother and the infant in order
to mobilize support and strengthen the new mother for her new role
(Lee, Yang, & Yang, 2013)
 POSTPARTUM DEPRESSION
Postpartum depression (PPD) is reported worldwide. However,
identifying and reporting of PPD in non-Western cultures may be
delayed by culturally unacceptable labeling of the disorder, varying
symptoms, or differences in treatments from culture to culture
(American Psychiatric Association, 2013; Committee on Cultural
Psychiatry, 2002; Yoshida, Yamashita, Ueda, & Tashiro, 2001).
Insights provided by the literature suggest nurses should assess new
mothers for culture-specific signs of PPD with the understanding that
not all cultures recognize PPD as a medical disorder. Symptoms we
associate with PPD are viewed differently in other cultures, for
example, as a sign of “spirit possession,” as in some traditional
Muslim cultures.
 HOT/COLD THEORY
Central to the belief of perceived imbalance in the mother’s
physical state is adherence to the hot/cold theories of disease
causation. Pregnancy is considered a “hot” state. Because a great deal
of the heat of pregnancy is thought to be lost during the birth process,
postpartum practices focus on restoring the balance between the hot
and cold, or yin and yang. Common components of this theory focus
on the avoidance of cold, in the form of air, water, or food. This real
fear of the detrimental effects of cold air and water in the postpartum
period can cause cultural conflict when the woman and infant are
hospitalized. In order to avoid conflict, some women may pretend to
fol_x0002_low the activities suggested by nurses, for example,
pretending to shower. Nurses must assess the woman’s beliefs
regarding bathing and other selfcare practices in a nonjudgmental
 POSTPARTUM RITUALS
Placental burial rituals are part of the traditional Hmong culture,
and with the continued growth in the number of Hmong Americans
emigrating from California to different areas of the United States,
cultural conflicts are common, especially in the areas of reproductive
health (Clemings, 2001). In an effort to assimilate, many Hmong
have continued to use animistic ceremonies and herbal remedies in
addition to using Western medicine. Helsel and Mochel’s (2002)
study explored Hmong Americans’ attitudes regarding placental
disposition, cultural values affecting those attitudes, and perceptions
of the willingness of Western providers to accommodate Hmong
patients’ wishes regarding placental disposal.
 The Hmong believe the placenta is the baby’s “first clothing” and
must be buried at the family’s home, in a place where the soul can
find the afterlife garment once the person is deceased. If the soul is
unable to find the placental “jacket,” it will not be able to reunite
with its ancestors and will spend eternity wandering. Helsel and
Mochel’s study (2002) suggests that even though Hmong immigrants
have embraced Western culture, traditional Hmong beliefs about
placental burial remain an important cultural belief. These beliefs
should be respected and the staff should make every effort to
accommodate their request.
 CULTURAL ISSUES RELATED TO INTIMATE
PARTNER VIOLENCE DURING PREGNANCY
Domestic violence has emerged as one of the most significant
health care threats for women and their unborn children. Numerous
transcultural factors influence the prevalence of and response to
domestic violence, including a history of family violence, sexual
abuse experienced as a child, alcohol and drug abuse by the mother
or significant other, shame associated with abuse, fear of retaliation
by the abuser, or fear of financial implications if the mother leaves
the abuser, to cite a few. Outcomes of abuse shared by abused women
of all cultures include stress (physical and emotional), poor lifestyle
health practices, delayed prenatal care, and lack of support
 CULTURAL INFLUENCES ON BREAST-FEEDING
AND WEANING PRACTICES
Culturally, breast-feeding and weaning can be affected by a
variety of values and beliefs related to societal trends, religious
beliefs, the mother’s work activities, ethnic cultural beliefs, social
support, access to information on breast-feeding, and the health care
provider’s personal beliefs and experiences regarding breast-feeding
and/or weaning practices, to name a few. The World Health
Organization and UNICEF (2010) recommend children worldwide be
breast-fed exclusively for the first 6 months of life followed by the
addition of nutritional foods, as they continue to breast-feed for up to
2 years, with no defined upper limit on the duration. Physiologically,
children can successfully breast-feed for the first several years of life.
 HISPANIC PREGNANT WOMEN
Although there are many different Hispanic groups, most share
some important commonalities, for example, religion, customs, and
language. As with any cultural group, differences do exist among the
members. The incidence of spouse abuse among pregnant Hispanic
women is not clear in the literature. Access to health care for
pregnant Hispanic women is problematic. Barriers to prenatal health
care include lack of health care insurance, language barriers, and low
levels of education, all of which may encourage the use of traditional
healers and remedies and might foster mistrust of health care
professionals, leading to noncompliance.
 Many Hispanic women tend to be in low-paying jobs whose
annual earnings are considerably less than those of non-Hispanic
women. They may also have less education than White women and
live in large, extended households, often made up of several children
and extended family members. The literature concurs, reporting the
health status of Hispanic pregnant women may be affected by their
economic level as economic status has been shown to limit access to
care (Center for American Progress Action Fund, 2010; Suarez &
Ramirez, 1999).
 AFRICAN AMERICAN PREGNANT WOMEN
Many cultural values of African Americans emphasize the larger
Black society rather than focusing on individuals, making “all”
collectively responsible for one another (Hine & Thompson, 1998).
Therefore, many African American women exist in a social context
supported by social connectedness versus that of autonomy
It is difficult to understand the specific factors related to IPV
(intimate partner violence) among African American women because
of the lack of information. However, poor economic conditions might
be a primary reason why violence occurs in African American
families; domestic violence is often related to social and economic
resources.
 REVIEW QUESTIONS
1. How will the biologic variations discussed impact the nursing
care of the childbearing woman and her family?
2. Describe the special needs of lesbian couples during the
childbearing process. What are common prejudgments about
lesbian mothers and how can they affect care?
3. Compare traditional Western medical support for pregnant
women with nontraditional support, and describe why both might be
critical for successful pregnancy outcomes in women from diverse
backgrounds.
 REVIEW QUESTIONS
4. Why is it important to understand the differences between
prescriptive and restrictive beliefs of a mother’s behavior during
pregnancy?
5. How can nursing interventions for the pregnant American
Indian woman presenting for IPV care be made more culturally
congruent?