NCM 120:

Decent Work Employment & Transcultural

Nursing

Chapter 5

Transcultural Perspectives in
Childbearing

Chapter 5
Transcultural Perspectives in Childbearing
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.

Specific Objectives
At the end of the lesson, the students should 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 pregnancy
outcomes.

Duration

Chapter 5: Transcultural Perspectives in Childbearing 5 hour lecture, 1 hour

assessment

Lesson Proper

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.

Fertility Control and Culture

A. 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 that
women more likely to experience unintended births included unmarried women, black women,
women who are socioeconomically disadvantaged, and those with less education.
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.
B. 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).
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.
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. 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. Islamic law forbids adoption; but 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; and adoption is viewed
as a last resort (Washofsky, 2000). The use of condoms and birth control pills are acceptable; and
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 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. Excision has been described
by the WHO (2010) as a complete or partial removal of the clitoris and the labia minora, with or
without the labia majora. Although communal advantages and some personal benefits have been
cited in the literature for female excision, deleterious outcomes have been noted to occur, including
psychological stress, adverse obstetric and perinatal outcomes such as postpartum hemorrhage,
and newborn risks of stillbirth, death, need for resuscitation at birth, and LBW (United Nations
Children’s Fund, 2005; WHO, 2008).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.
A. 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. How the patient became pregnant is one such example. Instead of assuming she became
pregnant via intercourse, ask the patient to tell you “the story” of how she became pregnant, thus
keeping the interview less threatening and nonjudgmental. 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, and birth education all
need to be addressed with lesbian couples.
B. 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 husbands, mothers, or sisters; (5) hope for a cure; and (6) belief that their
secret is safe with their health care providers. The study results indicated that while the diagnosis
of HIV created challenges in attaining the mothering role, the women’s feelings of shame of
infection (seen as a disease of prostitutes in Thai culture) were buffered by their will to live and
their love of and hope for a future with their children. The researcher notes that in Thai society,
women are the major agents of socialization in a child’s life. As such, the knowledge gained by
studying how HIV-positive Thai mothers managed the dual demands of survival and the attainment
of the maternal role will help health care providers as they work to care for and provide support to
women in similar circumstances (Jirapaet, 2001).
C. Nontraditional Support Systems
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.
A number of factors influence childbearing practices for Filipino women including cultural
beliefs, socioeconomic factors, and, in recent years, Western medicine. 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. 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 (Pacquiao,
2008).
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. 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 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. 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.
D. 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.
1. 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)

2. 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)

3. 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 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)
E. 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. The causes of pica are poorly understood, but there are some cultural
implications because women from certain ethnic or cultural groups experience this disorder more
frequently than others. In the United States, pica is common in African American women raised
in the rural South and in women from lower socioeconomic levels. It is not uncommon to see small
balls of clay in plastic bags sold in country stores in the rural South. The phenomenon of pica has
also been described in other countries including Kenya, Uganda, and Saudi Arabia.
F. 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.
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 attitudes 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 expresses and experiences labor pain. 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).
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Activity Sheet
ACTIVITY 5

Name: ____________________Course/Year/Section:___________Score: ____________

Direction: In your own words, answer the following questions.

1. How will the biologic variations discussed impact the nursing care of the childbearing
woman and her family?

2. Why is it important to understand the differences between prescriptive and restrictive

beliefs of a mother’s behavior during pregnancy?