Study Guide 6- TRANSCULTURAL PERSPECTIVES IN

CHILDBEARING
Topic Outline
1. Chapters 5 through 8 use a developmental framework to discuss transcultural concepts across the
lifespan. The care of childbearing women and their families, children, adolescents, middle-aged adults,
and the elderly is examined, and information about cultural groups is used to illustrate common
transcultural nursing issues, trends, and concerns
A. Overview of Cultural Belief Systems and Practices related to Childbearing
B. Fertility control and culture
1. Unintended Pregnancy
2. Contraceptive Methods
3. Refugees and Reproductive Health
4. Religion and Fertility Control
5. Cultural Influences on Fertility Control
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C. Pregnancy and Culture
1. Biologic Variations
2. Cultural Variations Influencing Pregnancy
3. Alternative Lifestyle Choices
4. Maternal Role Attainment
5. Nontraditional Support Systems
D. Cultural Beliefs Related to Activity During Pregnany
1. Food Taboos and Cravings
E. Cultural Issues Impacting Prenatal Care
F. Cultural Interpretation of Obstetric Testing
G. Cultural Preparation for Childbirth
H. Cultural Expression of Labor Pain
I. Cultural Meaning Attached to Infant Gender
J. Culture and Postpartum period
k. Cultural Influences on Breast-Feeding and Weaning Practices
l. Cultural Issues Related to Intimate Partner Violence During Pregnancy

Learning Objectives
After studying this module, you as FUTURE NURSES will be able to:

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

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Introduction
This chapter discusses how cultural diversity influences the experience of childbearing. The experiences of
the woman and those of her significant other during pregnancy, birth, and the postpartum period are
examined. Recommendations for practice are provided in each section for nurses caring for childbearing
women and their families. Also presented for the reader’s consideration are discussions related to
culturally specific circumstances and behaviors of the childbearing woman and her family. O

Activating Prior Knowledge

Before you proceed to the study guide, I would like to know your insights about the different perspective
about childbearing of the different cultures globally.

1.1 Discussion of Key Concepts

Overview of Cultural Belief Systems and Practices related to Childbearing

Pregnancy and childbirth practices in contemporary Western society have seen

Course Codedramatic
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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 behaviours.
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 (see Figure 5-1),
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.
Health disparities in the United States also play a role in increased maternal morbidity and maternal
mortality, although it is unclear to what extent
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 w

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

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.

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Women more likely to experience unintended births included unmarried women, black women, women
who are socioeconomically disadvantaged, and those with less education.

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
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;

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 abortio

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
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longer-acting reversible forms, and increasing correct and consistent use Code and Title
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 Method
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 Figure 5-3.of fertility controls such as
abortion or artificial regulation of conception; for example,
Roman Catholics might follow church edicts against artificial control of conception,
Mormon families might follow their church’s teaching regarding the spiritual responsibility to have large
families and promote church growth (Andrews & Hanson, 2012)
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.

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

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).

CDC Refugee Reproductive Health Activities Goals

1. Initiate epidemiologic studies to evaluate the reproductive health status of women in refugee and IDP
settings to better provide information to improve service, quality, and accessibility.
2. Design, implement, and evaluate reproductive health rapid assessment tools and behavioral and
epidemiologic surveillance systems appropriate to refugee settings.

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3. Design, recommend, and evaluate interventions and “best practices” identified through epidemiologic
research, rapid assessment, and surveillance.
4. Strengthen the capacity of the refugee/IDP community, as well as the agencies providing health
services, to collect and use data to improve reproductive health status and services.
5. Translate and communicate study findings and best practices to refugees and supporting agencies.
CDC, Division of Reproductive Health, National Center for Chronic Disease Prevention and Health
Promotion, Atlanta, G

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)

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 Course Code and Title
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 pregnancy (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. H

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

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-thannormal 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).
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.

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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.

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;
A. alternative lifestyle choices Course Code and Title
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.
Lesbian childbearing couples are a distinct subculture of pregnant women with special needs (see
Figure 5-6).
Randi (2012) reports that the way intake forms are completed needs to be re-evaluated in light of
these social changes. Randi suggests asking the patient to tell you “the story” of how she became
pregnant, thus keeping the interview less threatening and nonjudgmental
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).

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. L
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).
Buchholz’s (2000) qualitative study was one of the first to examine the childbirth experiences of
lesbian couples.
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).
To further illustrate the issues surrounding nursing care and lesbian childbearing needs, a study by
Spidsberg (2007) used a phenomenological hermeneutical approach to describe the meaning given
to the maternity care experience by lesbian couples

B. Nontraditional support systems

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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.
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.

Approximately 41% of Filipino births are supported by indigenous attendants called hilots. The
attendants act as a consultant throughout the pregnancy. During the postpartum period, the hilot
performs a ritualistic sponge bath with oils and herbs, which is believed to have both physical and
psychological benefits.
Breast-feeding is encouraged and hot soups are encouraged to increase milk production (Pacquiao,
2008).
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Arab countries, labor and delivery is considered the business of women. Traditionally, dayahs and
midwives presided over home deliveries. The dayahs provide support during the pregnancy and labor and
are considered by traditional Arab women to be most knowledgeable due to their experience in caring for
other pregnant women.
Hospital births are on the rise in most Arab countries, with a decrease in the number of traditional
home births (Purnell, 2012). A thorough cultural assess

A thorough cultural assessment to ascertain a pregnant woman’s use of nontraditional support systems
and/or Western health care during her pregnancy is essential.
Once this assessment is complete and a trusting relationship has been established, the woman’s
pregnancy can be managed with consideration given to all the components that both she and the nurse
believe are important for a successful outcome.
Support during labor is known to have positive effects, such as reduced labor pain, reduced stress,
shorter duration of labor, less medication need, increased maternal satisfaction, and a positive attitude
going into motherhood (Chalmers & Wolman, 1993; Gordon et al., 1999). The decision for the type of
support desired by a woman often has cultural underpinnings and must be explored in order to make
appropriate cultural accommodations in care when possible.

C. Cultural beliefs related to parental 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

Cultural Beliefs Regarding Activity and Pregnancy

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

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● 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)
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● 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 Asia

Cultural Issues Impacting Prenatal Care

Mexican American childbearing women seem to represent a healthy model for preventing LBW infants.
However, acculturation to US lifestyle may put them at an increased risk for poor birth outcomes,
according to a study conducted by Martin et al. (2004)
An ethnographic study in California examined the influence of acculturation on pregnancy beliefs and
practices of Mexican American childbearing women. Lagana (2003) reported that “selective biculturalism”
emerged as a protective approach to stress reduction and health promotion.
Mexican practices such practices include a low-fat, high-protein, natural diet (eat right—come bien);
exercise for well-being (walk—camina); and avoidance of worry or stress, which could have a negative
effect on the pregnancy outcome (don’t worry— no se preocupe).

Cultural Interpretation of Obstetric Testing

Many women do not understand the emphasis that Western prenatal care places on urinalysis, blood
pressure readings, and abdominal measurements. For traditional Islamic women from the Middle East, the
vaginal examination can be so intrusive and embarrassing that they avoid prenatal visits or request a
female physician or midwife.
For women of other cultural groups, common discomforts of pregnancy might be managed with folk,
herbal, home, or over-the-counter remedies on the advice of a relative (generally the maternal
grandmother) or friends (Spector, 2008).

Cultural Preparation for Childbirth

Women from diverse cultural backgrounds often use 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.

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.
Traditional Home Birth

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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 poor 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.
Liberian women are reluctant to share information about pregnancy and childbirth as these subjects are
taboo to talk about with others. Husbands or male elders are the ones who make decisions about allowing
a woman to seek care at a clinic or hospital when she is experiencing a difficult and arduous labor.

Women are reluctant to seek professional health care at clinics or hospitals because they are more
comfortable in their own homes with traditional (but untrained) birth attendants (Lori & Boyle, 2011).
These findings highlight that the influence of culture on childbirth extends beyond the birth experience
itself, often affecting the outcome.

Support During Childbirth

Despite the traditional emphasis on female support and guidance during labor, women from diverse
cultures report a desire to have husbands or partners present for the birth. Spouses or partners are now
encouraged and even expected to make important contributions in supporting pregnant women during
labor. Course Code and Title
For reasons of modesty, an Orthodox Jewish woman in labor may choose a woman from the community as
a labor support person (Noble et al., 2009)

The culturally sensitive nurse will make every effort to cover or drape the woman appropriately and to
provide the husband with the opportunity to excuse himself during the delivery without fear of being
viewed as being insensitive (Purnell & Selekman, 2008)
Orthodox men are not allowed contact with adult women other than their spouses (Noble et
al., 2009).

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, dependent on cultural learning, the context of the situation, and
other factors unique to the individual (Ludwig-Beymer, 2008).

It was commonly believed that because women from Asian and Native American cultures were stoic, they
did not feel pain in labor (Bachman, 2000).

Callister and Vega (1998) reported that Guatemalan women in labor tend to vocalize their pain. Coping
strategies include moaning or breathing rhythmically and massaging the thighs and abdomen. Japanese,
Chinese, Vietnamese, Laotian, and other women of Asian descent maintain that screaming or crying out
during labor or birth is shameful; birth is believed to be painful but something to be endured ( Bachman,
2000).

Birth Positions
Numerous anecdotal reports in the literature describe “typical” birth positions for women of diverse
cultures, from the seated position in a birth chair favored by Mexican American women to the squatting
position chosen by Laotian Hmong women. The choice of positions is influenced by many factors other
than culture, and the socialization that occurs when a woman arrives in a labor and delivery unit might
prevent her from stating her preference

Cultural Meaning Attached to Infant Gender

The meaning that parents attach to having a son or daughter varies from culture to culture. Historically in
the United States, families saw males as being the preferred gender of the firstborn child for reasons
including male dominated inheritance patterns, carrying on the family name, and becoming the “man” of
the family should the need arise.
Arnold (1997) found a high persistence of son preference even in the face of rapid modernization in
developing countries.

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In undeveloped countries, depending on the population and the cultural belief system in place, sons
continue to be desired as the firstborn. As a long tradition in Asian culture, the pre

Pham and Hardie (2013) completed a study whose aim was to evaluate the association of a commonly
reported cultural belief that there is a relationship between a mother’s mood and the gender of an Asian
woman’s firstborn child.

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)

In a study by Igarashi, Horiuchi, and Porter (2013), the researchers investigated what influenced
Japanese women’s postpartum experience either positively or negatively. Interestingly, the research
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revealed that lack of Japanese health literacy was more likely to obstruct positive communication between
the patient and health care providers while in the hospital setting, leading to loneliness.

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).

“Jinn” possession, as reported in a study conducted in the United Kingdom by Hanely and Brown
(2014), includes possession by an evil spirit that has a negative power over the mind and the body.
Symptoms include anxiety, crying, mood swings, and emotional instability, all of which are symptoms of
PPD.
Culturally appropriate care may instead include support through family and community (Hanely &
Brown, 2014). Clinical implications include the importance of nurses acknowledging the illness and the
feelings the woman expresses and allowing her to choose the treatment that she feels is right for her.

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.

Postpartum Dietary Prescriptions and Activity Levels

Dietary prescriptions are also common in this period. The nurse might note that a woman eats little
“hospital” food and relies on family and friends to bring food to her while she is in the hospital. If there are
no dietary restrictions for health reasons, this practice should be respected.
Regulation of activity in relation to the concept of disharmony or imbalance includes the avoidance of
air, cold, and evil spirits. Hispanic women are encouraged to stay indoors and avoid strenuous work. Since
pregnancy and birth are believed to cause a “hot” state, the woman should avoid “hot” activities such as
excessive exercise, including sex, strenuous household chores, quarrelling, or crying (Sein, 2013) in
order to achieve the balance between hot and cold. S

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).

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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.
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.

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 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 Course Code and Title
Dettwyler’s work (2004) in this area reports segments of the country where relatively large groups of
women nurse longer than 3 years. These areas include Seattle, WA; Salt Lake City, UT; College Station,
TX; and Wilmington, DE.
Cartagena et al. (2014) support this view reporting that Hispanic mothers are more likely to practice
nonexclusive breast-feeding, initiate early introduction of solid foods including ethnic foods, and perceive
plumper infants as healthy infants. Cultural norms driving family influences and socioeconomic factors do
play a role in the feeding practices of this population.

Wambach and Cohen’s (2009) qualitative study examined breast-feeding experiences of urban
adolescent mothers. is problematic.
McKee, Zayas, and Jankowski (2004) examined predictors of successful breast-feeding initiation and
persistence in a sample of low-income African American and Hispanic women in the urban Northeast. T
Reported influences included perceptions of breast-feeding benefits (bonding, baby’s health), perceptions
of the problems with breast-feeding (pain, embarrassment, no experience with the act of breastfeeding),
and respected, influential people (Hannon, Willis, Bishop-Townsend, Martinez, & Scrimshaw, 2000).
Banks (2003) describes how breast-feeding is being successfully promoted among the Kanesatake, a
rural Mohawk community in Quebec, Canada, using culturally competent community-based interventions

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.
A study by Shadigian and Bauer (2005) identified homicide as a leading cause of pregnancyassociated
death and suicide also as an important cause of death among pregnant and recently pregnant women.
Health care providers must acknowledge and understand that homicide is a leading cause of pregnancy-
associated death and commonly is a result of intimate partner violence (IPV). Screening for both partner
violence and suicidal ideation is an essential component of comprehensive health and nursing care for
women during and after pregnancy. It has been well documented (Bewley & Gibbs, 1994) that physical
abuse during pregnancy is often focused on the abdomen, breasts, and/or genitals, which puts both the
mother and her unborn child at risk.

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.

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).

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transmitting in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise of any part of this document, without the prior written permission of UCU, is strictly prohibited.
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American Indian Pregnant Women
Violence within families has not always been part of American Indian society. Traditionally, American
Indian cultures were based on harmony and respect. Many activities Western culture has ascribed to one
sex were shared in American Indian society, including the roles of warrior and hunter.
As Indian communities strive to maintain their cultural heritage, the concepts of spirituality (balance,
harmony, oneness), passive forbearance (humility, respect, circularity, connection, honor), and behaviors
that promote harmonious living are reinforced in daily living (Nichols, 2004).

In a study by Bohn (2002), the complicating factor of lifetime abuse events was shown to be a significant
contributor to preterm birth and LBW infants.

Activity (can also be Critical Thinking and Review Questions)

1: Define the following.

Abortion Course Code and Title

Childbearing
Contraception
Fertility controls
Imbalance
Intimate partner violence
Intrauterine device (IUD)
Maternal morbidity
Maternal mortality
Postpartum depression
Pregnancy
Prescriptive beliefs
Restrictive beliefs
Taboos

2. Case Scenario
Critically analyze and describe the culturally competent nursing interventions for a Hispanic woman after
fetal demise from a cord accident.

2. Discuss the responses the culturally competent postpartum nurse should initiate when an Asian woman
refuses to get out from under her bedding.

3. Discuss and compare the cultural differences in the expression of labor pain. Critically analyze how you
would respond to your Hispanic labor patient’s expression of pain versus your Native American labor
patient’s manifestation of pain. Why the different approaches?

All information contained in this module are property of UCU and provided solely for educational purposes. Reproduction, storing in a retrieval system, distributing, uploading or posting online, or
transmitting in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise of any part of this document, without the prior written permission of UCU, is strictly prohibited.
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4. Describe and analyze how the nurse might alter her care approach to an Orthodox Jewish husband who
has followed his cultural traditions and refuses to accept his newborn from a female nurse.

Interactive Link
Reference: Benza, S., & Liamputtong, P. (2014). Pregnancy, childbirth and motherhood: A meta-synthesis
of the lived experiences of immigrant women. Midwifery, 30, 575–58
CDC, Division of Reproductive Health, National Center for Chronic Disease Prevention and Health
Promotion, Atlanta, GA. (2006). Retrieved from http://www.cdc.gov
Information on Cambodian Canadian, Asian, Iranian Canadian, Japanese, South Asian Canadian,
Vietnamese, and Haitian cultures from Waxler-Morrison, N., Andrews, J., & Richardson, E. (1990). Cross-
cultural caring: A handbook for health professionals. Vancouver, BC: University of British Columbia Press.

Everyday Connection
Synchronous and asynchronous via gmeet

Course Code and Title

Summary
Culture, as it relates to pregnancy and childbirth, was discussed from many vantage points. As the United
States becomes home to immigrants and refugees from around the world, and as once considered
traditional societal norms are changing, so too must nurses adapt their care in ways that consider and are
respectful of beliefs different from their own.
These cultural and biologic variations have created opportunities for health care providers to learn about
and incorporate evidence and traditional beliefs into current health care practices, improving pregnancy
and birth experiences for all women of differing backgrounds.
Cultural beliefs and practices are continuously evolving, making it necessary for the nurse to acknowledge
and explore the meaning of childbearing with each family with whom he/she has contact. It is also
important to remember that behavior must be evaluated from within each person’s cultural context and
based on evidence, when

Readings and References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.,
text revision). Washington, DC: Author. Amnesty International, USA. (2010). Deadly delivery: The
maternal health care crises in the USA. AMR 51/007/2010. Andrews, J.M., & Hanson, P.A. (2008).
Religion, culture and nursing. In M.M. Andrews, & J.S. Boyle (Eds.)\
Gunger, I., & Beji, N. K. (2007). Effects of fathers’ attendance to labor and delivery on the experience of
childbirth in Turkey. Western Journal of Nursing Research, 29, 213–231.
Taggart, L., & Mattson, S. (1996). Delay in prenatal care as a result of battering in pregnancy:
Crosscultural implications. Health Care for Women International, 17, 25–34.

All information contained in this module are property of UCU and provided solely for educational purposes. Reproduction, storing in a retrieval system, distributing, uploading or posting online, or
transmitting in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise of any part of this document, without the prior written permission of UCU, is strictly prohibited.
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