Cultural Competence:
An Essential Journey
for Perinatal Nurses
Mary Lou Moore, PhD, RN, FAAN
Merry-K Moos, MPH, RN, FNP, FAAN
Lynn Clark Callister, PhD, RN, FAAN
© 2010 March of Dimes Foundation
The Need for Cultural Competence
in the 21st Century
• High rates of immigration in the late-19th and
throughout the 20th centuries contributes to
cultural diversity in the United States.
• Differences, including language, ethnicity and
religion, exist within population groups.
• Nurses cannot make assumptions about an
individual based on the person’s race or
ethnicity.
© 2010 March of Dimes Foundation
The Need for Cultural Competence
in the 21st Century (Continued)
• Race is defined in biological terms, based on
characteristics such as skin color and hair.
• Ethnicity refers to a group of people who share
certain cultural characteristics. For example, the
terms Hispanic and Latino refer to ethnicity.
• Immigrants choose to migrate to a country and
can bring money and belongings.
• Refugees commonly are fleeing from their
country of origin, often with little or no
preparation.
© 2010 March of Dimes Foundation
Percent of U.S. Population by Race and
Ethnicity
Race and Ethnicity
2000
Census
2008
Estimate
White
75.1
79.7
Black or African-American
12.3
12.8
American Indian/Alaska Native
0.9
10.1
Asian
3.6
4.4
Native Hawaiian and Other Pacific
Islander
0.1
0.2
Hispanic/Latino
12.5
15.4
Two or more races
2.4
1.7
U.S. Census Bureau, 2000, 2009a
© 2010 March of Dimes Foundation
Racial classifications in the 2000 U.S.
Census
•
•
•
•
•
•
•
White
Black or African-American
American Indian/Alaska Native
Asian
Native Hawaiian and other Pacific Islander
Some other race
Two or more races
U.S. Census Bureau, 2009b
© 2010 March of Dimes Foundation
Health Disparities
• Health disparities are differences that occur in the
incidence or prevalence of disease, or in morbidity
or mortality. The term also refers to differences in
the way patients are treated.
• Disparities occur in race, ethnicity, gender, age,
economic status, religion and sexual preference.
• Among the greatest reproductive disparities in the
United States are preterm birth, infant mortality
and maternal mortality.
© 2010 March of Dimes Foundation
Preterm Birth and LBW by Race and
Ethnicity, 2006
Race/Ethnicity
Preterm Birth
LBW
Non-Hispanic white
11.8 percent
7.2 percent
Non-Hispanic black
18.1 percent
13.6 percent
Hispanic
12.2 percent
7.0 percent
Asian/Pacific Islander
10.9 percent
8.1 percent
American
Indian/Alaska Native
14.2 percent
7.5 percent
Kaiser Family Foundation, 2009; Martin et al., 2009
© 2010 March of Dimes Foundation
Disparities in Infant & Maternal
Mortality, United States, 2006
NonHispanic
white
NonHispanic
black
Hispanic
Total
Infant
mortality*
5.56
16.06
5.52
6.69
Maternal
mortality**
9.50
32.70
10.20
13.30
* Infant mortality is deaths in the first year of life per 1,000 births.
**Maternal mortality is deaths up to 42 days after the end of pregnancy
per 100,000 pregnancies. Maternal mortality measures deaths related to
or aggravated by pregnancy or pregnancy management. It does not
include deaths after 42 days of birth or those related to external causes.
MacDorman et al., 2009
© 2010 March of Dimes Foundation
Cultural Health Disparities
• Failure of nurses and other providers to
understand the importance of beliefs about health
and illness
• Unwillingness to coordinate care with traditional
healers, when appropriate
• Lack of minority staff members
• Inadequate interpreter services
© 2010 March of Dimes Foundation
Strategies for Decreasing Disparities in
Health Care
• Ensuring equality in access to care
• Using educational approaches that serve the
needs of diverse populations
• Ensuring cultural competence among health care
institutions and professionals
• Using evidence-based care
• Maintaining diversity within the health care team
• Conducting research to better understand the
needs of patients from various cultural groups
© 2010 March of Dimes Foundation
Health Literacy
• Health literacy is person’s ability to obtain and
use health information. It is an important
predictor of health outcomes (DeWalt et al., 2004).
• Pregnancy may be the first time a woman with
low or marginal health literacy skills encounters
the health care system.
• Barriers to health literacy
o Language
o Cultural traditions and beliefs
© 2010 March of Dimes Foundation
Definitions of Culture
• Culture is a distinctive way of life that
characterizes a particular community of people.
• Culture encompasses beliefs about health and
illness, including prevention of illness and care of
persons who are ill.
© 2010 March of Dimes Foundation
Dimensions of Culture:
Decision-making
Childbearing decisions may be made by:
• The woman
• The woman and her partner
• The woman’s extended family, including several
generations
• Males or male elders
• Spiritual leaders
© 2010 March of Dimes Foundation
Dimensions of Culture:
Concept of Time
• Much of the world has a relaxed attitude toward
time. Women and families may not understand
the need for specific time commitments,
especially for prenatal care appointments.
• Cultures may be past-, present- or futureoriented. The dominant U.S. culture is futureoriented, which means people act today with
expectations for future rewards. Cultures not
future-oriented may not see the need for
preventive care.
© 2010 March of Dimes Foundation
Dimensions of Culture:
Naming
• Nothing is more personal than a person’s name.
• Societies follow different patterns of naming that
may cause nurses difficulty in record-keeping and
completing birth certificates.
© 2010 March of Dimes Foundation
Dimensions of Culture: Communication
Communication characteristics of the dominant
culture in the United States
• Well-developed verbal skills
• Willingness to disclose personal information
• Direct eye contact
• Relatively large personal space
• Moderate use of gestures
• Expressive faces with smiles representing positive
or encouraging emotions
© 2010 March of Dimes Foundation
Dimensions of Culture:
Religion
Religion
Percent of U.S. Adult Population
Protestant
51.3
Catholic
23.9
Jewish
1.7
Buddhist
0.7
Muslim
0.6
Hindu
0.4
Pew Forum on Religion and Public Life, 2008
© 2010 March of Dimes Foundation
Dimensions of Culture:
World View
• World view is the understanding of how human
life fits into the bigger picture. It allows people to
make sense of what seems unknowable, including
evil, disease and death (Farnes, Callister, Beckstrand &
Carlton, in press).
• Disease etiology is the part of a person’s world
view that explains illness. It may include
ancestral displeasure, body imbalance (yin/yang
or cold/hot), breach of taboo, evil eye, fright,
germ theory, object intrusion, soul loss and spirit
obsession.
© 2010 March of Dimes Foundation
Dimensions of Culture:
Modesty and Gender
• Modesty (exposure of the human body): Some
cultures accept public nudity under specific
circumstances. In others, women must cover
almost all of their bodies.
• Gender roles: For many societies, the norms for
interaction between men and women are much
more restrictive than they are in the United
States.
© 2010 March of Dimes Foundation
Key Concepts in Working Toward
Cultural Competence
• Ethnocentrism: When people think their beliefs
and practices are superior to the beliefs and
practices of other groups
• Cultural relativism: The concept that a person’s
beliefs and behaviors should be understood in the
context of their culture
• Acculturation: The process for adopting the
practices of another group
• Stereotyping: An oversimplification that reduces
the possibility of knowing people as individuals
© 2010 March of Dimes Foundation
Key Concepts in Working Toward
Cultural Competence (Continued)
• Emic perspective: An individual describing her
own culture
• Etic perspective: An individual describing another
culture
• Health practices
o Functional traditions can enhance health.
o Neutral traditions neither harm or help health.
o Nonfunctional traditions are potentially harmful.
© 2010 March of Dimes Foundation
Preconception Care
The main goals of preconception care are to provide
health promotion, screening and interventions to
women of reproductive age to reduce risk factors
that could affect a future pregnancy.
© 2010 March of Dimes Foundation
Preconception Care:
Issues Across Cultures
•
•
•
•
•
•
•
•
Ideal age for a woman to first become a mother
Preferred number of offspring
Preferred interval between pregnancies
Appropriateness of preconception testing for
genetic and other disease risks
Use and suitability of contraception
Appropriateness of induced abortion
Desired gender of children
Appropriateness of fertility treatments
© 2010 March of Dimes Foundation
Preconception Care:
Genetic Counseling
Competent preconception care includes assessment
of genetic risks so that parents can make informed
decisions about reproductive options, including:
• Prenatal diagnosis after conception
• Artificial insemination or oocyte donation
• Preimplantation diagnosis
• Attempting conception and pregnancy, regardless
of potential outcome
Moos, in revision
© 2010 March of Dimes Foundation
Prenatal Care
• In many cultures, prenatal care is not rooted in
interactions with health care providers. Instead,
family members and the community as a whole
provide special attention and care for the pregnant
woman.
• The United States spends more for prenatal care
than any other nation (Strong, 2000); yet in 2005, the
nation ranked 30th in infant mortality compared to
the rest of the world (NCHS, 2008a).
© 2010 March of Dimes Foundation
Prenatal Care (Continued)
• Most prenatal care occurs in an examining room.
The woman is required to adapt to clinic
processes and the authority of the provider and
other staff.
• If a woman or her support persons leave any
prenatal visit feeling disrespected, unwelcome or
marginalized, they may avoid future visits or
disregard the information they received.
© 2010 March of Dimes Foundation
Reasons Women Disengage from or
Do Not Attend Prenatal Care
• Difficulty accepting the pregnancy
• Depression
• Discomfort with the specifics of prenatal care,
such as waiting times and payment requirements
• Perceived judgments by staff
• Inability to keep appointments because of work
or transportation issues
• Belief that the care lacks meaning
• Lack of social support
© 2010 March of Dimes Foundation
Prenatal Care Approaches
• CenteringPregnancy® is a program that provides
prenatal care in a group setting. It purposefully
empowers women to become active participants
in their own assessments and education.
• Taking care out of the examining room can
eliminate barriers between health care providers
and patients.
• Home visitation is an important feature of many
enhanced models of prenatal care.
© 2010 March of Dimes Foundation
Prenatal Education Topics
• Weight
• Exercise
• Postpartum
contraception
• Domestic violence
• Protection against STIs
© 2010 March of Dimes Foundation
• Nutrition
• Breastfeeding
• Avoiding harmful
substances
• Use of seatbelts
• Screening and
diagnostic tests and
test results
Prenatal Testing
• The nurse’s role in prenatal testing is to facilitate
informed choices by the woman and her family.
• Culture mediates reasons for seeking testing,
interpretation of results and decision-making.
• Women and couples may find prenatal testing
confusing, emotionally charged and uncertain.
• Test results can create negative consequences for
women.
© 2010 March of Dimes Foundation
Prenatal Nutrition
• Food has symbolic and health connotations.
• Nutritional counseling can be challenging when
culturally determined practices, such as fasting,
conflict with principles of good and safe prenatal
nutrition.
© 2010 March of Dimes Foundation
Intrapartum Care:
Birthing Environment
The atmosphere and policies of bio-technological
birthing units may present cultural challenges for
women (Lauderdale, 2008).
• They may be anxious and fearful as they are
forced to conform to a medical center’s policies
and procedures.
• They may feel their privacy is being invaded.
• They may find it hard to be far from the support
of extended family members.
• They may face language barriers.
© 2010 March of Dimes Foundation
Intrapartum Care: Support Persons
During Labor and Birth
• Expectations about who accompanies or supports
a laboring woman vary across cultures. Nurses
must know the traditions of the cultural groups
they serve and the specific preferences of each
woman.
• In many cultures childbirth is exclusively a
woman’s experience. The baby’s father is not
present.
© 2010 March of Dimes Foundation
Intrapartum Care:
Cultural Responses to Pain
• A woman’s sense of personal control over pain
management influences the quality of the birth
experience (Carlton, Callister & Stoneman, 2005).
• Perceptions of childbirth pain, pain behaviors and
pain-management preferences are culturally bound
(Callister, 2006b).
o Some view pain as a normal part of childbirth and
coping with pain as a maternal achievement.
o Some view pain as suffering that requires
aggressive pharmacological management.
© 2010 March of Dimes Foundation
Intrapartum Care: Cultural
Responses to Pain (Continued)
• Some women may:
o Prefer to be active during labor
o Use herbs, acupressure, massage, meditation,
hydrotherapy, birthing balls and position changes
to reduce pain
o Prefer to squat to give birth
• Nurses should facilitate the use of safe,
nonpharmacological methods of pain management
and respecting women’s preferences for pain
management.
© 2010 March of Dimes Foundation
Intrapartum Care: Cesarean Birth
and Birth Emergencies
• Nurses should assess how each woman or couple
prefers to make important health care decisions,
including cesarean birth, before a crisis arises.
Ideally this occurs in prenatal care.
• Even when this assessment is available, the labor
and birth nurse revisits preferences and reviews
situational limitations with the woman and her
support persons early in labor.
© 2010 March of Dimes Foundation
Postpartum Care: Restoring
Balance to the Body
• The dominant U.S. culture encourages women to
leave the hospital quickly, resume their normal
diet and participate in activities as they can.
• Other cultures prohibit eating certain foods and
engaging in most activities for several weeks after
giving birth.
• Much of the world believes that health is achieved
by balancing hot and cold. Many believe that giving
birth depletes the woman’s body of the hot
element, which puts her in a cold state.
© 2010 March of Dimes Foundation
Postpartum Care: Activities and
Relationships
• Postpartum practices provide social support, help
the woman adapt to the maternal role, allow for
care of the newborn, and promote the woman’s
physical recovery.
• Some cultures believe that postpartum women
are delicate or vulnerable.
• Who cares for a woman after she leaves the
hospital often is culturally prescribed.
© 2010 March of Dimes Foundation
Postpartum Care: Postpartum
Depression (PPD)
• PPD occurs in most cultures throughout the world,
with similar levels of prevalence (10 percent to 15
percent) (Beck, 2008).
• Culturally specific risk factors for PPD:
• Placing a higher value on having male rather than
female children
• Immigrant or refugee status
• Inability to practice postpartum cultural rituals
• Lack of an effective social support network
© 2010 March of Dimes Foundation
Newborn Care
• Circumcision: Cultural traditions and religious
beliefs may be the basis of whether or not male
infants are circumcised, and when.
• Feeding: Some cultures consider colostrum
essential to establishing nutrition and maternalinfant bonding. Others think colostrum is dirty,
old or unfit for a newborn.
• Names: As hospital stays become shorter,
members of many cultures find it challenging to
follow hospital naming conventions.
© 2010 March of Dimes Foundation
Care of Preterm and High-Risk
Newborns: Family-centered Care
• Family-centered care is an approach to planning,
providing and evaluating health care that is
grounded in collaboration between families,
nurses and other health care providers (Institute for
Family-Centered Care, 2010).
• NICU staff provides ongoing opportunities for
mothers, fathers and babies to be together and
for parents to participate in care.
• Discharge teaching includes discussion of
transportation home and follow-up appointments.
© 2010 March of Dimes Foundation
Fetal and Neonatal Death: Assessing
the Meaning of Loss and Grief
• What are important cultural traditions and rituals
for coping with dying, handling the deceased’s body
and honoring the deceased?
• What does the family believe happens after death?
• What are expected expressions of grief and
acceptance of loss?
• What family roles exist in coping with death?
© 2010 March of Dimes Foundation
Cultural Competence
Culturally competent nurses:
• Acknowledge differences between people as
valuable and enriching
• Seek to understand the perspectives of those who
are different from themselves and modify
practices to accommodate those differences
• Advocate for organizational change
• Continue to develop knowledge and skills about
those for whom they care
© 2010 March of Dimes Foundation
Cultural Competence: Assessing
the Childbearing Woman
• How does the woman’s culture value
childbearing?
• Is childbearing viewed as a normal physiologic
process, a wellness experience, a time of
vulnerability and risk, or a state of illness?
• Is birth a private intimate experience or a
societal event?
• How is childbirth pain managed? What maternal
and paternal behavior is appropriate?
© 2010 March of Dimes Foundation
Cultural Competence: Assessing
the Childbearing Woman (Continued)
• What support is given during pregnancy,
childbirth and beyond? Who gives this support?
• What maternal precautions or restrictions are
necessary during childbearing?
• What does the childbearing experience mean to
the woman?
• How does the culture view newborns? What are
the customs regarding infant care and
relationships within nuclear and extended
families?
© 2010 March of Dimes Foundation
Cultural Competence:
Nursing Education
Diversity in nursing can help achieve culturally
competent care and reduce health disparities (ANA,
2002; Giddens, 2008; IOM, 2003).
Racial Distribution of RNs in the United States, 2008
Race
Percent of all RNs
Non-Hispanic white
83.00
Asian/Pacific Islander
5.87
Non-Hispanic black
5.40
Hispanic/Latino
3.60
U.S. DHHS Bureau of Health Professions, 2009
© 2010 March of Dimes Foundation
Cultural Competence: Health Care
Organizations
• Title VI of the Civil Rights Act of 1964 mandates
that no person shall be subject to discrimination
because of race, color or national origin in any
program receiving federal financial assistance (U.S.
Department of Justice, 1964).
• In 1999, the U.S. DHHS Office of Minority Health
published 14 National Standards for Culturally and
Linguistically Appropriate Services (CLAS).
© 2010 March of Dimes Foundation
Special Topics: Working with an
Interpreter
• The best choice for an interpreter is a trained
medical interpreter. A friend or family member
may not understand terms used by the health
care provider. A woman may be discussing issues
she wants to keep private.
• Many health care agencies rely on phone-based
interpretation services; disadvantages include the
inability to observe nonverbal communications.
© 2010 March of Dimes Foundation
Special Topics: Female Genital
Cutting (FGC)
• FGC is the cutting of the female genitalia for
nonmedical reasons.
• 100 million to 140 million women and girls in the
world have experienced FGC (WHO, 2001).
• The United Nations condemns FGC. It is illegal in
the United States, Canada and most western
European countries.
© 2010 March of Dimes Foundation
Summary
Nurses must understand the role of culture and
cultural competence throughout childbearing, from
the preconception period and care of the newly
born infant through the postpartum period. They
must understand the importance of attitudes,
knowledge and skills in the development of cultural
competence for individual nurses and health care
organizations.
© 2010 March of Dimes Foundation