Cultural Issues in Perinatal Care


  • Beverley Chalmers DSc (Med), PhD

    Adjunct Full Professor
    1. Department of Obstetrics and Gynaecology, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada
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Address correspondence to Beverley Chalmers DSc (Med), PhD, Department of Obstetrics and Gynaecology, Affiliate Investigator, Ottawa Hospital Research Institute, University of Ottawa, PO Box 21091, RPO Princess, Kingston, ON, Canada, K7L 5P5.

The world is increasingly multicultural, exhibiting diversity of ethnicity, religion, culture, and language. Global population movements allow for the intermingling of cultures through migration and refugee relief. Perinatal care must meet the needs of this changing, cultural mosaic.

Cultural Differences and Similarities in Perinatal Care

Childbirth is a universal experience that links physical, psychological, social, cultural, and spiritual components. Childbirth is the greatest leveler we have: we all give birth the same way. Culturally determined childbearing customs do, however, distinguish some women from others. Practices, beliefs, and preferences that differentiate groups worldwide include the following: choice of caregiver as midwife, obstetrician, family physician or traditional birth attendant; birth positions ranging from lithotomy to upright; caregiver gender preferences; birth in hospital, birth unit or home; desirability of a partner/companion during delivery; preference for intervention or nonintervention; mother–infant separation at birth or immediate skin-to-skin contact; nursery or rooming-in neonatal care; and breast or bottle feeding, to name only some. More recently, use of, or in truth, abuse of, technologies like prenatal ultrasound with consequent termination of female fetuses in countries like China and India is prevalent [1]. The resulting gender imbalance may lead to crimes of kidnapping, child brides and sale of (increasingly scarce) women [1].

Is There a “Universally Ideal Birth”?

Many scholars have sought an ideal approach to birth for all women [2]. Implicit in any country's educational system about maternity care, and every caregiver's practice, is the assumption that their way is best. What then is the “right” way to “do” birth? Until recently Eastern Europeans were convinced that their doctor-centered, medicalized approach was the best. Their Northern European counterparts regard midwifery attendance as superior as do traditional birth attendants in rural Africa. Who has the right to say which approach is best and on what grounds? And if there exists such a “right way,” is it universal? Does it apply equally in the rural, bush setting, in the urban home, and in modern tertiary care centers?

Childbirth varies from country to country, from hospital to hospital, and from doctor to doctor within the same hospital. For many there is no doctor at birth and it does not take place in a hospital but at home, attended by a midwife. If we accept that there exists enormous variability in knowledge, attitudes, values, expectations, beliefs, societal conditions, and economic levels globally, then why do we seek a universal childbirth pattern? The birth experience can vary within the same mother from birth to birth: why not then for different mothers with different social, cultural, psychological, and biological backgrounds?

Maslow's Needs Applied to Birth

It may be possible to highlight universal needs of women in childbirth rather than universal means of achieving them [2]. By utilizing Maslow's decades-old framework of need hierarchies [3] one can pinpoint universal needs of women in birth.

Maslow suggests that physiological and safety needs are basic needs. In Africa, these needs may be met by birth in the grandmother's hut, protected by spirits residing in the thatched eaves, assisted by a traditional midwife. In North America and Europe these needs may be met in a hospital assisted by physicians. For others the safest birth place may be at home attended by a midwife.

Emotional needs for love and support, Maslow' next level, are universal, but what is seen as supportive varies from culture to culture and woman to woman. Among some African women the Traditional Birth Attendant is valued while the husband is not; for many Western women the partner is essential, and for women in Eastern Europe the medical professional is idolized, with husbands usually excluded from birth—although this trend is changing.

Needs for self-esteem are also universal. Motherhood confers status and esteem on most women, sometimes being the exclusive means for achieving this status, as in Africa and elsewhere, and at other times being only one of the means of gaining esteem, as in the West. How well women believe they have accomplished pregnancy, birth, and parenthood is partly determined by societal role expectations, for example, giving birth without pharmacological assistance among natural birth advocates, or, alternatively, with a high degree of medication in other circles. Self-esteem is influenced by how closely the woman can approximate the “good mother” image, whatever that may be within her culture. Preserving dignity and privacy in labor are also universal aspects of women's needs for self-esteem. In many parts of the world, exposing intimate bodily parts is shameful and embarrassing. Yet, in hospital, this concern may be discarded under the license of medical care. Exposing women in labor and birth and ignoring privacy needs are commonplace in the former Soviet Union, where many delivery rooms and wards have glass windows and doors so that staff may easily observe women from adjacent passages. Some justify this exposure by claiming that “modern” women are more open about nudity so that exposure is unimportant. There exists, however, a difference between what women choose to say and do with respect to nudity as opposed to what is done to them by others.

Self-actualization—Maslow's highest need—through birth, is recognized in the West by the number of societies, organizations, and websites that are aimed at helping women achieve feelings of accomplishment through birth. These include the International Childbirth Education Association in the United States, the National Childbirth Trust in the United Kingdom, the Association for Childbirth and Parenting of Southern Africa, and the European-based International Society for Psychosomatic Obstetrics and Gynaecology.

International Perinatal Health Consulting: Strengthening Childbirth Care Globally

One challenge when working with childbirth across cultures is the often difficult-to-avoid problem of seeing things through the eyes of one's own culture, and judging all others as inferior instead of as different. Cultures differ significantly in their beliefs with respect to health and illness. Western societies consider biological functioning to be paramount. In contrast, many African cultures regard physiological functioning to be unimportant with spiritual, social, and psychological factors contributing to illness etiology, treatment, and prognosis [4]. Here it is as unacceptable to neglect spiritual rites as it is to omit checking blood pressure in pregnancy in the West. Condemning practices because they are different is inappropriate for while they may not contribute to biological health they might be essential for psychological or spiritual well-being. In African women, for example, it is customary to tie a piece of string, cut from the same ball, around the abdomen of all family members when one of them leaves home, providing spiritual continuity when separated. In pregnancy, ignorant of its role, Western doctors may remove the string as it is “dirty,” causing immense distress. Providing for the spiritual needs of clients, concurrently with physiological needs, is not impossible and might be beneficial. In South Africa, physicians were well advised to encourage traditionally oriented clients who feared surgery to seek the blessing of their sangoma (traditional healer) before entering hospital. Conviction that surgery kills does little to support recovery. Similarly, a survey of women giving birth in Canada with previous female genital mutilation showed that they experienced a 50% cesarean rate when the national rate was half that number [5]. Women from countries where genital cutting is normal practice may be convinced that cesarean section means death as in these countries, admission to hospital only occurred after prolonged labor and did frequently result in death. Particularly supportive emotional care is needed rather than brusque, discounting of fears.

The difficulty is in finding the right balance between encouraging practices that are potentially harmless or beneficial and discouraging those that are truly dangerous. Sensitivity is, however, needed when providing care to women whose cultural practices are regarded as harmful. In the Canadian survey, most of the 432 women with prior female genital mutilation interviewed (87.5%) reported hurtful or offensive comments being made to them [5]. Even in a country that values and encourages cultural differences, ignorance and prejudice may play a disconcertingly large role. Similarly, when encouraging former Soviet Union health care providers to adopt evidence-based perinatal procedures, thereby discounting many long-ensconced obstetric practices, sensitivity was needed in respecting that these caregivers were practicing the best care they could, based on their available knowledge. The physicians were not to “blame” for practicing inappropriate care but their educational system that was lacking up-to-date information.

Assessing which cultural approach is clinically “better” may be difficult. Western evaluations call for “scientific facts” when determining which birth practices are superior. Yet, data with respect to the efficacy of birthing procedures in different countries are not always available. Data collection in, for example, the former Soviet countries is notoriously unreliable as a result of past practices of making data fit expected standards of practice for fear of reprisal, and to obtain funding allocations. Locally, records may be hand written and filed and data aggregation is done manually, slowly, and sometimes inaccurately. Less “hard core” evidence of birth outcomes such as assessments of patient satisfaction are not routinely collected, due partly to the challenges of doing so, but, more often because women's opinions are not valued. In contrast, many of the hitherto “safe” birth practices of Western medicine (e.g., shaving, enemas, continuous fetal heart monitoring, induction, epidurals, multiple ultrasound scanning, cesarean sections, and the lithotomy position), have come under fire from evidence-based studies. What was regarded as good practice is often discarded as harmful in light of available evidence. What current practices are then, truly valuable, and should be used to assess culturally different, appropriate, birth procedures?

A further difficulty arises when sophisticated technology is used inappropriately. Is a “half-baked” application of Western technology at times more harmful than the traditional way? For example, in parts of Eastern Europe routine prenatal ultrasound is now available. Instead of one, or possibly two scans, screening may be done at every prenatal visit. Combined with insufficiently skilled technicians and poor quality equipment, this misapplication may lead to unnecessary, or harmful, interventions. In India and China this technology is used to murder.

On the other hand, some former Soviet practices such as the immensely supportive, systematic, postpartum follow-up of infants was most beneficial. Yet this system—called “patronage”—was dismantled in the 1990s with the rapid overhaul of Soviet health care systems encouraged by the West. Simultaneously, specialist pediatricians were forced to retrain as family doctors—a “missing” category of health care practitioner in Soviet times—resulting in intense dissatisfaction among these now “demoted” caregivers. The “gung-ho” imposition of some of our “superior” models of care on this culture was, at times, breathtakingly rapid and potentially harmful.

In making recommendations for changing international birth practices, local voices must be heard. How often is lip service paid to this call? How easy is it to influence countries in the name of science and with the authority attributed to the “foreign expert” especially if wearing a WHO or other UN hat—and possibly because of local prestige accruing from collaboration with international consultants?

Cross-cultural misunderstandings also occur. Translators vary in quality and do not always understand your perspective. For example, while working with a WHO colleague in St Petersburg, Russia, we entered a teenage health care center. We were met with a print of the famous Leonardo Da Vinci's “Madonna and Child,” the pride of that city. My colleague, Marsden Wagner (then Regional Advisor for Maternal and Child Health in WHO-Euro), was proudly shown this picture and told it had been introduced in response to his earlier suggestion to make the center more attractive to teenagers by decorating it with pictures of “Madonna.” Cross-cultural misunderstandings are not always as harmless or humorous as this misunderstanding.

Health care services need to prepare students for multiculturalism. Yet we do little to encourage medical students to take courses in the humanities or in psycho-social-cultural issues. Few medical schools in North America expect students to take such courses and if they do, these are often regarded as electives, offered by departments outside medical schools. The University of the Witwatersrand, Johannesburg, set an alternative model in the 1970s: medical students, who hitherto scorned such “soft” options, were required to pass the school's own Human Behavioural Science course before progressing to clinical training. This requirement was not only established in principle but it was also implemented.

We have much to learn about how best to work when striving to improve birth globally. The challenge is to satisfy the childbirth needs of women within the woman's own culture—whether this challenge is our own or another's. What “works” in one's own culture may be inappropriate or unacceptable in another. Respectful, sensitive, and honest interactions are the foundation for such multicultural collaborations, both internationally and at home.