Strategies for Incorporating Cultural Competence Into Childbirth Education Curriculum

Abstract

Cultural competence affects all interactions with prospective parents and families. Childbirth educators need to assess their own cultural competence, beginning with an understanding of their own background and how it affects interactions with families. The purpose of this article is to enhance the incorporation of cultural competency, cultural awareness, and cultural sensitivity into the childbirth education curricula. Methods for enhancing cultural competence in a multicultural global society are discussed. Strategies are also presented to address the challenges of assessing parents and families of diverse cultures and their beliefs, traditions, and special needs in the plan of care.

The experience of childbirth is a common thread among all cultures, and the process of giving birth may be viewed as a universal experience among all women. Each woman's experience is unique and different, however, having been determined by the culture with which that woman identifies and the culture in which she gives birth (Ottani, 2002). Culture is defined as a particular group of people's beliefs, norms, values, rules of behavior, and lifestyle practices that are learned and shared and guide decisions and actions in a patterned manner (Leininger & McFarland, 2005). Culture plays a major role in the way a woman perceives and prepares for her birthing experience. Each culture has its own attitudes, values, and beliefs surrounding pregnancy and birth (Ottani, 2002).

Culture is defined as a particular group of people's beliefs, norms, values, rules of behavior, and lifestyle practices that are learned and shared and guide decisions and actions in a patterned manner.

Cultural competence relies on a strong foundation of knowledge about other cultures. It allows the practitioner to appreciate, understand, and empathize with that culture and, as a result, deliver appropriate and effective health care through changes in both approach and technique (Sobralske & Katz, 2005). Childbirth educators need to assess and be aware of the cultural, ethnic, and socioeconomic factors that influence the experience of pregnancy, birth, and parenting (Starn, 1991). For health-care professionals, particularly childbirth educators, cultural competence is an important aspect that needs to be addressed when interacting with clients.

REVIEW OF LITERATURE

A review of recent literature shows that research in the area of childbirth and culture has been conducted. However, much of the research on the cultural experience of childbirth has focused on specific rituals among specific cultures rather than on the experience of birth in several cultures in a setting that is unfamiliar and has traditions different from those of the laboring woman (Ottani, 2002). For example, in the last few decades, the United States has experienced a large influx of immigrants from countries that have norms and traditions surrounding pregnancy and childbirth that are different from those usually practiced in Western, traditional medicine. Unfortunately, many childbirth educators may assume that the current childbirth preparation techniques and knowledge offered to women and their families are adequate across many diverse populations (Ottani, 2002). In her article, “When Childbirth Preparation Isn't a Cultural Norm,” Patricia Ottani (2002) points out that women from diverse cultures may not have the ability to follow their traditional birth practices because their practices are unknown to those caring for them. Ottani focused on Cambodian women and their cultural practices. Based on her findings, Ottani made several recommendations for health-care practitioners, enabling them to be culturally competent with this population, particularly in the areas of diet, finances, weight gain, and language.

In another article, Judy O'Connor (2002) examined the Arab American culture in regard to childbirth and pregnancy. In this particular culture, preventative health practices are uncommon. As a result, many women do not receive adequate prenatal care because they do not see a need for prenatal care unless a complication arises. Arab men do not usually partake in the birthing process or in childbirth education classes. O'Connor recommended that childbirth educators provide culturally appropriate care to these diverse patients by remaining sensitive to their cultural and spiritual needs.

The information on specific childbirth practices in different cultures in the literature can be generalized to include all cultures. Childbirth educators have the opportunity to set the stage for change in the health-care community. A survey completed by the Maternity Center Association (now Childbirth Connection) found that 70% of first-time mothers attend some type of childbirth education class (Declercq, Sakala, Corry, Applebaum, & Risher, 2002). This shows that there is a large, captive audience of women who are eager to learn. It is possible that these women are from various cultural, religious, and economic backgrounds. As a result, it is important for the childbirth educator to be culturally competent and tailor the curriculum to meet the needs of women from different cultures. In keeping with the mission of Lamaze International (2005b), the culturally competent childbirth educator can promote, support, and protect normal birth for women of all cultures through education and advocacy that is adapted to meet a cultural group's specific needs and expectations.

The culturally competent childbirth educator can promote, support, and protect normal birth for women of all cultures through education and advocacy that is adapted to meet a cultural group's specific needs and expectations.

EDUCATIONAL STRATEGIES

Awareness of and Comfort With Cultural Diversity

The educator should examine the current and emergent demographic and economic trends for the geographic area served to determine the needs of the expectant mother. The educator will discover information regarding culture, religion, and socioeconomic status, which need to be respected in order to develop cultural awareness and sensitivity. Prior to the first class session, it is critical for the childbirth educator to assess the demographic profile of the incoming students. The instructor must determine the need for interpretation and translator services. If needed, the instructor should make arrangements to have these services available. Educators should also prearrange to distribute lists of community resources, Web sites, and other literature appropriate to the cultural diversity of the class. The educator will be more prepared to teach clients from various cultures if the curriculum is tailored to address pregnancy and childbearing practices in our culturally diverse population.

Childbirth education classes usually begin with general introductions (names, number of pregnancies, and ages of children) without a discussion of cultural beliefs and traditions regarding the experience of birth. The first class provides an excellent opportunity for the childbirth educator to create an environment of open communication, one in which people can feel comfortable discussing (or, if they prefer, not discussing) their cultural beliefs and practices. Chairs arranged in a circle create a welcoming atmosphere. Therapeutic communication skills such as eye contact, attentive listening, and touch are crucial (Wright, 2005), but they must be used appropriately with individuals of different cultures. For example, some may find eye contact threatening or touching offensive.

The instructor may set the tone by including information about her or his own culture, traditions and experiences with prescriptive, restrictive, and taboo practices relating to pregnancy, birthing, and the postpartum period. Celebrating differences by learning what one can do for the cultural participants and sharing unique aspects about oneself can be enlightening to the group (Mallak, 2000). This may serve as a means to break the ice and get to know each individual. It also fosters the formation of trust between the instructor and members of the group. When health-care professionals incorporate a client's culture with respect to health-care practices, rituals, and beliefs about health care, they establish rapport and gain the client's trust. This trusting relationship is the foundation from which to encourage behaviors necessary to promote health and well-being throughout pregnancy. The instructor should not be afraid to question participants about their culture, religion, or ethnicity. By engaging them in such dialogue, they are given the opportunity to comfortably share personal information that helps build rapport (Mallak, 2000).

The Importance of Childbirth Education and Labor Support

Childbirth education and labor support are often discussed in detail during class sessions. The benefits of education, the role of the labor-support person, communication skills, and coping strategies are presented.

One of the biggest obstacles for most expectant mothers is the fear of the unknown. Education is a key factor in decreasing this fear (Moran & Kallam, 1997). The instructor may ask members of the group to share stories or experiences and to talk about what frightens them about the birth process. When participants are provided with discussion time, they have more opportunity to talk freely about things they have heard or are wondering about (Hotelling, 2005a, 2005b). For mothers who identify with a culture that is resistant to childbirth education and prenatal care, this provides an excellent opportunity for the educator to discuss the importance of childbirth education. Childbirth educators may incorporate the concept of protection for the mothers and their babies. Educators may discuss how the knowledge participants share and gain during such a course can help protect them and their babies (Ottani, 2002). By decreasing fear and increasing knowledge, the educator eases anxiety and tension.

When discussing the role of the labor-support person, the educator must not assume the husband will always be present. For example, in Orthodox Jewish culture, the husband is typically not present in the room with his laboring wife because she is considered “unclean” at this time. Similarly, in Arab cultures, men often do not accompany their wives during the birth of their child; rather, the husband's mother or sister usually accompanies the laboring woman. Hispanic and Asian women typically prefer that their mothers attend to them in labor (Galanti, 2004). Discussing with class participants the role of the support person and how both men and women may perform this role will be helpful when working with a culturally diverse group.

Diet and Nutrition

Prenatal diet and nutrition provide another opportunity for incorporating cultural concepts in these critical areas. For example, Asian and Hispanic cultures practice a system of cold/hot body balance. Pregnancy is believed to be a hot condition and, therefore, foods that are considered hot are restricted. They believe the body is already out of balance and do not want to exacerbate the condition (Galanti, 2004). From a health-care perspective and based on dietary recommendations, this belief can present a dilemma. Many foods that are high in protein are considered to be hot and are avoided by clients from these cultures. It is important for the childbirth educator to carefully assess culturally diverse diets to ensure that the mothers receive adequate nutrition. For example, the educator can suggest foods that are rich in protein and not considered hot (Galanti, 2004). Women from hot/cold-balance cultures may also refuse to take prenatal vitamins and iron supplements because they are viewed as hot. The educator may suggest taking the vitamins with a cold drink, such as juice, to balance the hot and cold (Galanti, 2004). Food-guide pyramids from other cultures such as Asian and Hispanic societies may be incorporated into the curriculum to show mothers how to eat properly by selecting nutritious items among the foods to which they are accustomed (Ottani, 2002). On the last day of the class, the educator can have a small party where each couple brings in their favorite ethnic food to share with the group. The participants will be introduced to new foods while learning how to eat right and ensure proper nutrition for the mother and baby.

The Topic of Pain in Childbirth

Pain and pain management throughout the course of labor is another major topic of discussion at childbirth education classes and another area where cultural awareness of the interpretation of the pain experience across cultures must be included in the curriculum. The educator needs to be aware of her or his personal beliefs regarding pain and pain management. The idea of pain and pain management can be a source of confusion among health-care providers who are not aware of cultural differences and cultural practices in response to pain. For example, Filipinos value stoicism. They believe that a woman must experience pain and discomfort as part of the childbirth experience. In contrast, Mexican women are known for being very loud and expressive during labor (Galanti, 2004). It is very important for the childbirth educator to emphasize the fact that there is no one right way to deal with the pain of labor and that pain is a personal experience.

Just as important as the expression of pain are the cultural differences and attitudes toward the use of pain-relief strategies. Childbirth educators can ask class participants how they handle pain and if, instead of traditional medications, they use specific rituals, treatments, or methods when in pain. They may choose to share with the group how their culture views pain management and how they plan on dealing with their pain. For example, the Chinese are taught self-restraint and, oftentimes, may refuse pain medication the first time they are asked. They consider it impolite to accept something the first time it is offered (Galanti, 2004). Encouraging this type of discussion promotes cultural sensitivity and understanding among the entire group. The participants may learn a new technique to which they have never before been exposed. Additionally, the discussion promotes an understanding of cultural differences among the class participants. Meanwhile, the educator is responsible for presenting the class with evidence-based information on pain-management strategies without personal bias.

Breastfeeding and Postpartum Care

The postpartum period is often discussed in detail during childbirth education classes and, again, presents a unique opportunity to appreciate the cultural diversity of the class. It is crucial for the educator to be aware of common assumptions and beliefs with regard to the postpartum period. Breastfeeding is a practice where cultural differences become apparent. For example, many Mexican women believe they do not have milk until their breasts enlarge and they can actually see it. They perceive colostrum, the early milk, to be bad or spoiled. Yet, despite their custom of waiting for the appearance of the “true milk,” many Hispanic women nurse their children longer than is the custom in American culture (Galanti, 2004). Some women from modest cultures may be embarrassed to expose their breasts while still in the hospital and may choose to wait until they arrive home before breastfeeding. The educator must provide all of the facts to expectant parents about the importance of proper nutrition for the newborn and explain the benefits, as well as the challenges, of breastfeeding. Stressing the importance of personal choice when provided with all necessary information allows for women of all cultures to make an informed, personal decision. Open discussion about the topic will again provide the chance for women of various cultures to speak about their beliefs and preferences.

BIRTH—THE UNIFYING FACTOR IN CULTURAL DIVERSITY

The recommendations presented in this article can be traced back to a common theme: open communication, knowledge, and respect. In a classroom filled with culturally diverse women, giving birth is the unifying factor. These women will approach pregnancy, birth, and the postpartum period differently, respecting their customs and heritage (Mallak, 2000). This must be encouraged and nurtured by educators who prepare clients for childbirth so that it is a safe and memorable experience for the family. By listening, respecting preferences, recognizing differences, and supporting choices, educators remain professional and responsible. Educators must remember their role is to educate, nurture, and protect a couple and their vision of birth. The educator must not force her or his own vision or that of the medical establishment (Mallak, 2000). Offering all of the pertinent, evidence-based information to prospective parents to support their individual decision-making provides couples with a sense of empowerment.

The competencies of a Lamaze Certified Childbirth Educator (Lamaze, 2005a) must be viewed with cultural proficiency in mind. Educators must promote the childbearing experience as a normal, natural, healthy process that profoundly affects women and their families of all cultures. They must assist women and families from diverse backgrounds to discover and use strategies that facilitate normal, natural, healthy pregnancy, birth, breastfeeding, and early parenting. They must help women and their families from various populations to understand how interventions and complications influence the normal course of pregnancy, birth, breastfeeding, and parenting. They must provide culturally sensitive information and support that encourages the attachment between babies and their families. They must assist women from diverse cultural backgrounds to make informed decisions about childbearing. They must advocate normal, natural, healthy, and fulfilling childbirth experiences for all women and their families, regardless of ethnic, cultural, or socioeconomic background. Lastly, they must design, teach, and evaluate a culturally competent course in Lamaze preparation that increases a woman's confidence and ability to give birth.

Cultural diversity makes our world interesting and unique. However, birth is the unifying factor among all people of this earth. Jan Mallak (2000) describes it best in her article when she claims that by being “humanly” sensitive and providing equal care for all, we are as politically correct as we can be. Childbirth educators have the wonderful opportunity to promote change and acceptance through education and advocacy. By incorporating cultural awareness and sensitivity into the curriculum, childbirth educators assist all women and families to have a positive and beautiful birth experience. By simply being open, knowledgeable, and respectful, the goal of cultural competence in childbirth education can be easily achieved.

By being “humanly” sensitive and providing equal care for all, we are as politically correct as we can be.