CHAPTER 5

TRANSCULTURAL PERSPECTIVE 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.

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 post-partum
period are examined. Also presented for consideration are discussions related to culturally specific
circumstances and behaviors of the childbearing woman and her family.
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.

TOPIC 1: FERTILITY CONTROL AND CULTURE

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.

A. Unintended Pregnancy
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%
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.
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.
 B. Contraceptive Methods
The religious beliefs of some cultural groups might affect their fertility controls such as
abortion or artificial regulation of conception;

EXAMPLE:
1. Roman Catholics might follow church edicts against artificial control of conception.
2. Mormon families might follow their church’s teaching regarding the spiritual responsibility to
have large families and promote church growth.
3. American Indian women monitor their monthly bleeding cycles closely and believe in the
importance of monthly menstruation for maintaining harmony and physical well-being.

C. 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.
EXAMPLE:
1. 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.
2. 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

D. Cultural Influences on Fertility Control

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 well-
being regarding fertility control.

TOPIC 2: 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.

A. Cultural Variations Influencing Pregnancy

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.

1. Alternative Lifestyle Choices

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.
EXAMPLE:
Lesbian childbearing couples are a distinct subculture of pregnant women with special needs

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.

Clinical Implications:
● Understand that being pregnant and living in a lesbian relationship increase visibility, thus
enhancing vulnerability.
● Couples may take responsibility for acts of caring as they are accustomed to health care
providers being uncertain and anxious regarding their relationship.
● Lesbian pregnant couples prefer that health care providers not focus on their sexuality, but
rather treat them as any other laboring couple.
● The need to be accepted, cared for, and communicated with are essential with this group
of women.
● Not using words such as “lesbian” or “partner” can be viewed as discriminating and
reinforce a feeling of invisibility.
● Comprehend the responsibility of ethical caring for patients different than themselves.

2. Maternal Role Attainment

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.
EXAMPLE:
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 husbands, mothers, or sisters;
(5) hope for a cure; and
(6) belief that their secret is safe with their health care providers.
 3. Nontraditional Support Systems
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.

EXAMPLE:
A. 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.
The extended family is involved in the care of the baby, mother, and the household.
Breast-feeding is encouraged and hot soups are encouraged to increase milk production.

B. In 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.

4. 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.
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 Belief
● 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

TOPIC 3: BIRTH AND CULTURE

Traditionally, cultures have viewed the birth of a child in one of two very different ways.
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.
A. 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 poor included the use of “granny” midwives by rural
Appalachian Whites and southern African Americans and parteras by Mexican Americans.
B. 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.
Many women also wish to have their mother or some other female relative or friend present
during labor and birth. Because many hospitals have rules limiting the number of persons present, the
mother-to-be might be forced to make a difficult choice among the persons close to her.
EXAMPLE:
For reasons of modesty, an Orthodox Jewish woman in labor may choose a woman from the
community as a labor support person. The spouse may elect to stay in the labor room, provided the
mother’s private parts are covered. Similar findings are reported from women of Islamic, Chinese, and
Asian Indian backgrounds.
C. 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.
EXAMPLE:
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

D. 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.

E. 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.
A study was conducted that a mother does not have the preferred firstborn sex, does this increase
the likelihood of postpartum depression (PPD) or negatively impact mother–infant bonding.
Note: The practical implications, to provide care to detect symptoms of PPD in all women, remain
the “pillar of care”
 TOPIC 4: CULTURE AND THE POST PARTUM 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.

A. Postpartum Depression
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.

EXAMPLE:

“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. However in this particular culture, the symptoms are not
associated with PPD but are believed to be caused by the Jinn’s influence.

B. 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.

EXAMPLE:
In order to avoid conflict, some women may pretend to follow the activities suggested by
nurses, for example, pretending to shower.

NOTE:
Nurses must assess the woman’s beliefs regarding bathing and other selfcare practices in
a nonjudgmental manner.

C. Postpartum Dietary Prescriptions and Activity Levels

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. Fruits and vegetables and certainly cold
drinks might be avoided because they are considered “cold” foods. Indeed, the nurse should
assess what types of food are being eaten by the woman and document them as appropriate
to ensure the foods are nutritious and not harmful.
 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.

D. Cultural Influences on Breast-Feeding and Weaning Practices

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.

EXAMPLE:
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.

NOTE:
For breast-feeding women from traditional backgrounds, it is important for nurses to
be aware of factors that have been shown to affect the quality and duration of the breast-
feeding experience, along with factors impacting weaning practices.

E. 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.

NOTE:

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.

EXAMPLE:

1. Hispanic Pregnant Women

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.
- all of which may encourage the use of traditional healers and remedies
and might foster mistrust of health care professionals, leading to noncompliance.
2. African American Pregnant Women
One of the most difficult barriers confronting African American abused
women who attempt to get help from police or from the legal system is the
stereotypical view that violence among African Americans is normal. This view
could cause African American victims’ claims of abuse to be dismissed or ignored.

Note:
The nurse might need to rely heavily on her assessment and history-
taking skills, being particularly alert to instances of trauma and problems with
past pregnancies. Patient education must stress that although a woman may see
her man as a “victim,” that does not mean she must tolerate abuse. The nurse
can identify shelter facilities in the woman’s neighborhood and other areas

3. American Indian Pregnant Women

Historically, cruelty to women and children resulted in public humiliation
and loss of honor. Cultural disintegration, poverty, isolation, racism, and
alcoholism are just a few of the problems that have fostered violence in American
Indian cultures. Nevertheless, cruelty to women and children continues to be
viewed by American Indians as a social disgrace.

Note:
The nurse should not only assess for current abuse by the spouse or
significant other but also evaluate the other types of abuse inflicted over the
mother’s lifetime, such as alcohol or drug abuse.

Since the 1970s, American Indian tribes have made an effort to develop
programs to meet the many needs of their communities. However, violence
against women has not been addressed adequately because of the male-
dominated leadership, other needs of the tribes, and the shame associated with
abuse.