Breaking Down the Barriers Module 4: Culture and maternity Presentation

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Breaking Down the BarriersModule 4 Culture
and maternity Presentation
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Section 1 Culturally competent maternity care

• 1.1 What is cultural competence?
• To be culturally competent does not mean being
  an expert on every culture. It means

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1.2 Understanding our own cultural assumptions
Two little fish were swimming along when they met
a big fish swimming the other way. Hows the
water? asked the big fish. One of the little
fish turned to the other and asked, Whats
water? Source Traditional

• Most of us are so used to our own familiar
  culture that we are not even aware of it. Unless
  we are of a mixed cultural background, or have
  ourselves experienced migration, it is very
  common to think of the way we do things as
  normal and right. It may not occur to us that
  others do things differently, or if it does, what
  they do may seem by contrast to be abnormal and
  wrong. The starting point of cultural
  competence is to recognise that many of our own
  assumptions about self-care and professional care
  during pregnancy, birth and the postnatal period
  are themselves culturally-specific, not
  universal. It can, however, be very difficult to
  analyse our own assumptions unless we have
  something to contrast them with.

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1.3 Delivering culturally competent care without
stereotypes

• We tend to apply stereotypes rather freely to
  people who are not in our group. Once we know
  something about a group of women who have
  something in common, we frequently use
  stereotypes to save ourselves the time and effort
  of finding things out from the individual. If, in
  our experience, four people from a particular
  group behaved in a particular way, we are likely
  to assume that the fifth person will behave the
  same way. So we might say, or hear

National Childbirth Trust women are such...
Teenagers cant be bothered to...
You know what Polish women are like...
African women never...
Ive cared for lots of Bangladeshi women and they
always...
Well shes a Muslim lady, so she doesnt...
Shes just being a typical Asian lady...
Council estate mums dont...
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• 1.3.1 Stereotypes need not be negative, but...
• We can hold stereotyped views about groups
  without having negative feelings about them.
  Stereotypes are not the same as prejudices. But
  even without negative feelings, stereotypes can
  still have negative consequences if they lead us
  to make false assumptions about individuals from
  that group.
• Why do they assume that all Muslims want to eat
  curry? You ask for a halal meal they will send
  you a curry. Maybe not everybody likes a
  curry...there are Chinese Muslims, Caucasian
  Muslims, you know? Muslims from all over. (1)
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• 1.3.2 The risk of oversimplifying
• Where women come from a different country and/or
  ethnic group from ourselves, we may try to
  improve our care of them by learning about the
  beliefs and practices of their culture, which is
  very positive. However, it is essential to
  remember that cultural background is only one
  influence on a person. Just as we do not define
  ourselves exclusively with reference to our own
  culture, so we must accept that there are many
  other influences on a person and that any
  individual may or may not share the beliefs or
  practices considered normal by her culture.

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1.3.3 Examples of influences on an individual
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1.3.4 Using knowledge with care

• This means that knowing about a particular
  culture does not tell us anything reliable about
  an individual from that culture. What it does is
  help us know what questions to ask the individual
  woman, because we become aware that certain
  things may be an issue for her.
• Knowledge about other cultures can therefore be a
  springboard or a wall.

It is a wall if it obstructs our view of the
individual woman before us.
It is a springboard if we use it as a starting
point to talk to the woman about her needs and
expectations, leading to high quality, truly
woman-centred care.
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Section 2 Cultural difference and maternity

• To deliver culturally competent care, we need to
  ask the individual woman questions about her
  cultural needs and expectations, using our
  knowledge about her culture as a springboard, and
  we need to respond to her identified needs and
  expectations appropriately.

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• 2.1 Asking questions about cultural difference
• There are two basic approaches to asking
  questions about cultural difference

In many situations, a mixture of general and
specific questions may be most appropriate.
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Using knowledge as a springboard, here are some
of the specific questions we might want to ask
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2.2 Responding to cultural difference

• Cultural competence does not mean that we must
  change the way we do everything in the UK to suit
  people from other countries. A woman may have
  expectations we cannot meet (e.g. that someone
  else will look after her baby postnatally), or
  ideas that are medically unfounded (e.g. that
  colostrum is harmful and should be discarded).

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Section 3 Cultural practices around pregnancy,
birth and postnatal care

• In this section, you can read the words of five
  health advocates talking about traditional
  cultural beliefs and practices around pregnancy,
  birth and postnatal care. They work with women
  from five different migrant communities. Their
  words represent personal views and are offered as
  a springboard they are not necessarily
  generalisable.

Photo Jocilyn Pope
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My name is Lakhy. I am an advocate for the
Bangladeshi community

• Our ladies are not used to antenatal care. With
  the first child, they will go for care, but after
  that with later children they stay home until
  20-25 weeks they feel fine and dont want all
  the tumble of so many visits.
• Our ladies dont like the blood tests. They
  wonder, are they selling our blood? there are
  so many bottles. They say They drained my
  blood! You have to explain to them its only a
  teaspoon of blood.
• Ladies want their husband there for antenatal
  care and labour.
• Bangladeshi women express pain loudly in labour
  Ive got so much pain! we are drama queens.
  Some women are very frightened about caesareans.

Photo Steve Evans http//creativecommons.org/lice
nses/by/2.0/
Continued on next slide
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Bangladeshi Continued from previous slide

• We prefer women to give care.
• We are Muslims so the Azaan must be done straight
  away when a baby is born, it can be performed by
  anyone. We put honey or dates in the babys
  mouth. We shave the babys head. Sometimes the
  baby is not named right away the tradition is
  for the parents to ask around for a name.
• Traditionally women squeezed out their colostrum
  and threw it away now we educate women to give
  it to their babies. There is a lot of mixed
  feeding women say I have no milk.
• After giving birth, women do not take a bath for
  40 days. They drink hot water. They dont eat
  meat for the first five days.

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My name is Halie. I am an advocate for the Somali
community

• Our ladies hide from antenatal care, they stay
  away on purpose In case they tell me off for
  having another baby so soon. Also they may be
  criticised by their mother-in-law who says
  Shame! I never went to hospital and we dont
  want to show people our bellies.
• Our ladies dont like blood tests. They never
  accept a test to look for anomalies in the
  babies. Some people are scared of injections.
• Constipation is a big problem. Somali ladies do
  not each much fruit or vegetables even when they
  are not pregnant. They think you must not eat too
  much when you are pregnant or the baby will be
  too fat.
• Continued on next slide

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Somali Continued from previous slide

• Most want their husband to be with them for
  antenatal visits, or if he is working, their
  mother or sister. But traditional women do not
  want their husbands with them in labour that
  should be their sister, mother or friend.
• Women should give care in labour, never men. In
  Somalia, old women deliver the babies in the
  country, a doctor in town.
• Somali women do not make much noise in labour,
  they bite on a cloth. They are worried that if
  they make noise, other people will hear and will
  gossip about them You know when she had her
  baby she shouted a lot. Then why did she sleep
  with a man?
• Many Somali women have caesareans, they think the
  hospitals do too many. No one wants them,
  because the hospitals say you can only have three
  caesareans and then no more babies, but Somali
  women want to have large families.
• Midwives are confused about FGM, and wonder what
  is wrong. A woman who is not circumcised is not
  halal.

Continued on next slide
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Somali Continued from previous slide

• When a Muslim baby is born, we say the Azaan. The
  babys head is shaved and we put honey or dates
  into the babys mouth. The family kill a sheep
  for their neighbours. When the baby is 40 days
  old there is a big party and a strong warrior
  carries the baby boy on his neck.
• For 40 days after birth, the family have to look
  after the woman, feed her, give her nice hot
  soup, wash her. For 40 days she is sitting like
  the queen.
• Back home, women breastfeed for up to two years.
  At around four months they would begin to give
  things like small potatoes to the baby. Here
  there is a lot of mixed feeding women find
  bottles more convenient and the mother-in-law
  expects a woman to work in the house.
• Depression is not a familiar concept to Somali
  people.
• Traditional Somali people do not hand things to
  another person with the left hand, which is
  unclean.

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My name is My Diep. I am an advocate for the
Vietnamese and Chinese communities

• Our Vietnamese women delay going for antenatal
  care because they do not understand the point of
  care or the tests. They wonder why the midwives
  take so much blood, and why they need to have
  tests, for example a woman who has only had one
  partner may say I am a clean woman, I havent
  done anything wrong.
• During pregnancy, Vietnamese women believe spicy
  food is no good it could give the baby a rash,
  and women dont eat crab meat. But otherwise,
  Vietnamese women dont take much care of what
  they eat during pregnancy they dont see strong
  links between food and a healthy pregnancy. They
  need to be educated about healthy eating.

Photo Stasi Albert
Continued on next slide
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Vietnamese/Chinese Continued from previous slide

• Vietnamese women dont mind whether a health
  professional is a man or a woman but prefer to
  have a doctor rather than a midwife for antenatal
  care advocates have to explain the role of a
  midwife in the UK.
• Women may panic when their baby is very big or in
  breech position they dont like caesareans.
• Back home, people think it is bad luck for a man
  to be there during labour. But here, women want
  their husbands with them We want our husbands
  to know how hard the pain is!
• Vietnamese women are very quiet in labour.
• If the baby is a boy, the family cook a sweet and
  sour dish with ginger, eggs and meat and give it
  to their friends and relatives as a birth
  announcement.
• After giving birth, a woman sleeps apart from her
  husband for 100 days. She does not have a bath or
  shower or wash her hair for 100 days she just
  washes her face and down below. She drinks ginger
  water and rice water and doesnt eat green
  vegetables. Failure to observe these customs is
  thought to lead to incontinence in later life.

Continued on next slide
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Vietnamese/Chinese Continued from previous slide

• Traditionally, Vietnamese women discard their
  colostrum. Back home breastfeeding is common but
  here women tend to bottlefeed more than
  breastfeed as it is seen as higher status. Babies
  are given solid food very late, not until 8-9
  months.
• There is no immunisation at home, so women are
  keen on whatever the NHS offers. But often they
  dont know what the injections are for and dont
  understand the side effects.
• Traditional women would not allow people to look
  at or touch their baby, to avoid bad luck. But
  women who have recently come to the UK to join
  husbands are more likely to listen to their
  husband and do what he says.
• Nobody understands about postnatal depression.

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My name is Adela. I am an advocate for the
Afghani community

• Some Afghani ladies have very strong views that
  they dont want to be seen by a male doctor,
  radiographer or interpreter when they are
  pregnant, and may be very reluctant to undress
  where a male health professional is present.
  However it is allowed to be seen by a male doctor
  if it is an emergency, as the womans thoughts
  remain pure.
• It is OK for male relatives to attend during
  antenatal care.
• Traditionally men do not attend at birth a
  sister or other female relative accompanies the
  woman but in the UK many women choose to have
  their husbands with them.

Photo Mira Pavlakovic
Continued on next slide
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Afghani Continued from previous slide

• There is a thriving belief in folk medicine both
  good and bad. In Afghanistan, traditionally
  pregnant women only went to the doctor if they
  were worried about something such as pain or
  breathlessness. There was no routine checking,
  blood tests or scans. In the last decade it has
  become more popular to go to the doctor.
• Women in the UK are sometimes unhappy about their
  blood being taken repeatedly and need reassurance
  about the quantity taken.
• Afghani women expect to get their health
  information from the closest women in their
  family. Often this will be their mother-in-law
  who they live with.
• Literacy is a big problem in Afghanistan, because
  when the Taliban were in power they closed the
  schools for girls above year 5. This means that
  some young women who come to the UK to marry
  cannot read at all and cannot get pregnancy
  information from books they need to get their
  information by talking person to person. It is
  popular for Afghani men in the UK to marry wives
  from back home who cannot read or speak English.

Continued on next slide
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Afghani Continued from previous slide

• In Afghanistan all housework belongs to ladies,
  even if they go out to work. But people believe
  that when a woman is pregnant she should not work
  too much it is better to sit or lie down. After
  delivery a woman should lie in bed for 40 days
  (this is her only opportunity ever to relax),
  although of course this is not practical if she
  has other children. In some families the womans
  mother will come to help cook at this time while
  the mother-in-law sits next to her grandchild.
• Most people dont know about Downs syndrome and
  may accept testing simply because they dont
  understand it. This goes back to the impact of
  the Taliban regime on education as a result of
  poor education, people have never heard of
  chromosomes. They need very detailed
  explanations as an advocate you can spend 5 or
  10 minutes trying to explain the idea in Dari and
  at the end they still dont understand. Its very
  hard to give an uneducated woman this complex
  information.
• People give up asking questions because they may
  be shy, respectful of busy health professionals
  or dont want to admit they dont understand.

Continued on next slide
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Afghani Continued from previous slide

• Women are used to giving birth at home without
  pain relief and with their relatives in the
  house, and some of the relatives do not allow you
  to shout when you are giving birth. (But of
  course some women still do shout). Here in the
  UK, no one wants to choose a home delivery.
• Breastfeeding is normal in Afghanistan, although
  women may mix feed if they return to work outside
  the home. Breastfeeding is popular because
  firstly it is cheaper, secondly other milk could
  be unsafe, as cheaper versions of international
  formula brands are supplied in Afghanistan, and
  thirdly its best for the baby. Women believe
  goats milk is the next best alternative.
• Traditionally in some parts of Afghanistan, only
  the people present at birth could visit a woman
  for the first 40 days. But in the capital Kabul
  people expect visitors right away. New mothers
  would not expect to be visited at home by health
  professionals unless they were paying privately.
• Pregnant women can eat anything, although some
  used to avoid beef. After birth women should have
  a lot of protein, soup, eggs, a soft flour or
  semolina pudding, and should avoid hot chilli,
  fish and aubergine. Women from the Turkmen
  community used to be given only sugar tea and
  bread for 40 days.

Continued on next slide
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Afghani Continued from previous slide

• There is an immunisation programme in Afghanistan
  and women here are keen to have their babies
  immunised.
• People do not understand postnatal depression at
  all. The family thinks You have a child, you
  should be happy, dont you love us? We havent
  done anything to you, so why have you changed?
  They blame the lady. She may keep quiet because
  if she asks them for help they may say She is
  mad, we should find someone else for our son.
  There is very poor understanding of mental health
  generally in Afghanistan.
• Traditionally visitors to an Afghan home take off
  their shoes when they enter the house, but many
  people here do not follow this custom. Its best
  to ask the family.
• Afghanis do accept termination for medical
  reasons. We are not as strict as some Muslim
  cultures, and Somalis sometimes criticise
  Afghanis in the UK for not being Muslim enough.
  But its not that we have changed in the UK we
  had this more moderate life 25 years ago in
  Afghanistan.

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My name is Naima. I am an advocate for the
Moroccan community

• Traditionally women get their health information
  from the extended family. They have little
  knowledge of contraception. Most younger people
  now are literate.
• In Morocco there are government-run hospitals and
  clinics and also private clinics. At private
  clinics you get frequent scans but at the
  government clinics there is only a minimum level
  of care, with fewer tests and only one scan, even
  if there is a big pregnancy problem.
• The role of midwives is different in Morocco
  they are just there at birth.
• A woman is not usually confident to go to
  antenatal care by herself for her first child
  members of her extended family normally go with
  her, and she may be unwilling to go if she hasnt
  got anyone to accompany her.

Photo Angel Velasquez
Continued on next slide
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Moroccan continued from previous slide

• We dont have the habit that men go with women
  for care for pregnancy or gynaecology a woman
  relative is in charge of her. This idea that a
  husband attends labour and delivery is hard for
  both men and women giving birth is just a place
  for women (but this is changing back home for
  young couples).
• When a husband interprets the lady sticks to the
  minimum issues she does not express herself
  fully because she does not want him to know her
  special health problems.
• For some women, the gender of a health
  professional is very important and they expect a
  woman, but more educated women will accept a male
  doctor. Men should not enter the room where a
  woman is giving birth without asking. It is not
  easy to confide in a man, even a professional,
  and women are very modest about their bodies.
  Interpreters should also be women. Gender is a
  bigger issue in the UK than it was at home
  people are becoming more religious here and more
  wear the hijab in the UK.

Continued on next slide
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Moroccan continued from previous slide

• How women express their pain when giving birth
  depends on the family. Young women may find it
  normal to make noise but older women may say,
  Its a shame to her family if she cannot hold
  the pain.
• Not many people go for anomaly tests. They see
  pregnancy outcome as fate, from God, so you
  shouldnt ask. Many are not familiar with Downs
  syndrome.
• There are a lot of fears about caesareans. People
  judge a woman who does not give birth naturally,
  saying Even a cat can give a baby so why you
  cannot? The whole family may be suspicious of a
  caesarean. Back home, private clinics have a
  reputation for doing caesareans right away to get
  more money.
• There is no special food that women should eat
  while they are pregnant but afterwards they
  should have a lot of milk and chicken soup.
• When a woman has just given birth she must cover
  her head for at least 10 days her skin is
  open if she catches cold at this time she will
  never recover. So she is only allowed to have a
  sponge bath (no shower) for the first week, but
  after that she can have a hot bath and a massage.

Continued on next slide
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Moroccan continued from previous slide

• During the first seven days the woman is in bed,
  eats food in her bed, sees visitors in her bed.
  The mother is like the queen for this time, or
  even for 40 days if she has a good family of
  in-laws. It is very hard on her if she has no
  family to look after her.
• Breastfeeding is normal, but women start mixing
  it with bottlefeeding after two months if the
  baby is crying. They give solid food from three
  months some cereal mixed with milk in the
  bottle, and vegetable soup from the bottle at
  four months.
• Women expect immunisation for their babies and
  stick to the schedule, even in rural areas.
• Postnatal depression is not understood and there
  isnt a word for it. The family thinks the woman
  is just not coping with her new baby and the new
  situation, and so she is not a good woman. There
  is no support or help. Mental problems can lead
  to divorce and in the UK there are families who
  will try to hide depression and prevent the woman
  seeking help because it is a shame to the family.
  If they seek advice it is more likely to be from
  the imam (who may recommend reading the Quran)
  medical support is the last thing they think of.

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• This course uses the words of service users from
  the following research reports
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• Ali N Burchett H. Experiences of Maternity
  Services Muslim Womens Perspectives. Maternity
  Alliance, 2004.
• COI Communications. Access to Maternity Services
  Research Report. Department of Health, 2005.
• Gaudion A. Reaching Out to Black, Minority Ethnic
  and Refugee Pregnant Women and New Families. A
  Progress Report. Medact, 2005.
• Kapasi R. Voices of Women in Brent Talking about
  Maternity Services. Brent Community Health
  Council, 1999
• McLeish J. Mothers in exile Maternity
  experiences of asylum seekers in England.
  Maternity Alliance, 2002.
• Richens Y. Exploring the Experiences of Women of
  Pakistani Origin of UK Maternity Services. 2003.
• Serco Consulting. Review of Maternity Services
  Model of Care. Tower Hamlets PCT Barts and The
  London NHS Trust, 2007.
• Ghandi E Bartlett A Life Reduced to Language.
  Everyday experiences of social inclusion in south
  London. St Georges/ West Focus, 2007.
• Sherwood L. Mosaics of Meaning Exploring Asylum
  Seekers Refugees Views on the Stigma Associated
  with Mental Health Problems. Positive Mental
  Attitudes, East Glasgow Community Health and Care
  Partnership, 2008.

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