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culturally responsive obstetrical and gynecological care

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1 culturally responsive obstetrical and gynecological care
Jean Gilbert, PhD Geri-Ann Galanti, PhD Los Angeles County Department of Health Services Office of Diversity Programs

2 Who Thinks Cultural Competency is a Clinical Skill?
The Accreditation Council for Graduate Education (Residency Programs) The Association of American Medical Colleges (Medical Schools) The American College of Obstetrics and Gynecology The Los Angeles County Department of Health Services: Cultural and Linguistic Competency Standards The American Association of Medical Colleges has just this year published recommendations for integrating cultural skills throughout medical skills and a guide for evaluating medical students on those skills. The American College of Obstetricians and Gynecologists (ACOG) Committee on Health Care for Underserved Women: Culture and Health Care During every healthcare encounter, the culture of the patient, the culture of the provider, and the culture of medicine converge and affect the patterns of healthcare utilization, compliance with recommended medical interventions, and health outcomes. The ACOG has several publications on its website that address cultural issues related to obstetrics and gynecology. In 2003, the Los Angeles County DHS adopted its own Cultural and Linguistic Competency Standards created with the help of a local and national group of experts in the field. These Standards outline the goals, policies, and activities that the county is working on to reflect national and state regulations for quality health care services for diverse patient populations.

3 Why This Recent Emphasis on Culture and Health Care?
Major changes in the composition of the U.S. population: 25% of the California population is foreign born. Many immigrants are from non-Western nations with non-Western health concepts. Increasing emphasis on patient-centered care within medicine. Of the 1.7 million DHS patient visits over the last 6 months, about 779,000 were limited English proficient, preferring services in 88 languages. The U.S. is a nation of immigrants, but up until recently, and excepting African Americans, most of the immigrants came from European nations. There was even immigration legislation designed to keep it that way up until after World War II. Changes in immigration laws in 1965 and refugee resettlements have changed all that. The U.S. is beginning to more completely reflect the global community with all its cultural and linguistic diversity. The emphasis on patient-centered care increases the focus on what the patient brings to the health care encounter in terms of personal context, perspectives and goals in an effort to involve the patient more completely in his/her own prevention and treatment options and goals.

4 If You And Your Patient Hold Very Different Health Beliefs...
This may impact on their trust in you and their evaluation of your abilities. It might impede understanding of your assessment and treatment plan. It may make obtaining consent for procedures very difficult. It might reduce willingness to comply with treatment and follow-up. The clinician workforce and the patient population are becoming more culturally diverse at the same time that medicine is emphasizing patient-centered care. This diversity raises the potential for cultural misunderstandings, particularly in the emotion-laden circumstances of many patient/provider encounters. Finding common ground or common understandings in the midst of cultural diversity is critical in creating the rapport and trust necessary for consenting and follow-up on treatment regimens. Across the world, because of its importance to all cultures, many customs and specialized practices have grown up around the intertwined concerns relating to sexuality, reproduction, and childbirth. Immigrants, socialized by their mothers, aunts and grandmothers, bring with them their belief in the importance of these practices. And beliefs, like many of the important aspects of culture are invisible. What does your patient believe? If you are puzzled by her behavior or attitude, ask gently and non-judgmentally. In cross-cultural situations, it’s important for you to try to determine if your patient and you are seeing the situation differently in important ways.

5 Culture is a Major Force in Shaping an Individual’s:
Expectations of a physician Perceptions of good and bad health Understanding of disease etiology Methods of preventive care Interpretation of symptoms Appropriate treatment Health care self-efficacy Keep in mind that your patient may expect you to behave in preconceived ways, based on her prior experiences here or in their countries of origin. In many countries, a physician is viewed as an authority, not to be questioned, so the idea of bringing or asking questions may need to be empathically encouraged many times. On the other hand, your patient may think you are lacking in some regards if you aren’t familiar with a traditional disease or treatment modality that is familiar to them, though they probably won’t say so! Perceptions of good and bad health and the causes of illness are formed in a cultural and historical context. What may seem a problem to you (plumpness?) may not seem to be a problem to them. Do you think an amulet is an effective preventive strategy? Some of your patients might think so. Do you think that anger and jealousy on the part of a pregnant woman will harm the fetus. This is believed in many Southeast Asian cultures and among some Latin cultures. In Southeast Asia women wear a binder around their midsection and follow a special diet following delivery in order to prevent arthritis when they are older. What do you believe is the like between post-partum diet and arthritis?

6 In Understanding Cultures, a Little Knowledge is Dangerous
Don’t let cultural generalizations become stereotypes. Generalizations are testable probabilities; we couldn’t do science without them. Stereotypes attribute the central tendencies of groups to individuals… ignoring the bell curve! Your patient is an individual, not a culture. In attempting to understand cultures, I’ve found that people want to be given dependable cultural recipes: Vietnamese think this or do this about death; the Hmong believe that most illness involves soul loss, etc. There are, in fact, core cultural beliefs and concepts, but in dealing with individual patients, you need to think of these, like all generalizations as probabilities. Science runs on inductive and deductive thinking, so we all deal with generalizations every day: Mexican American women have a statistically significant higher prevalence of invasive cervical cancer than the general population…but that doesn’t mean that the young Latina in your exam room has cervical cancer. It simply enhances the probability and you need to pay attention to that. In the same way, as you learn about cultural beliefs, you have to see them as possibilities, not predictable individual characteristics.

7 The Importance of Women’s Roles
Norms governing gender roles are critically important in most cultures. Girls’ and women’s behavior reflect on the honor of the entire extended family, and many cultures have strict proscriptions on the social behavior of females. For example, the compassionate and selfless behavior of the Virgin is put forward as the appropriate model for women’s behavior in Latin countries. A proper woman ideally displays motherly qualities, keeps to her home, dresses modestly and show little personal little interest in sex. Upon coming to this country with its radically different notions of appropriate women’s behavior, women and their daughters are caught between confusingly different norms for their behavior. Which one of these women is the model for your patient?

8 Acculturation is a Critical Factor in:
Family dynamics and gender roles Knowledge of and access to public and private helping agencies. Ability to speak and read English. Experience with the U.S. health care system. Acculturation occurs both rapidly and slowly. Learning to use new instrumentalities, such as ATMs, supermarkets, fast food vendors, or even bronchial inhalers can occur in a matter of months; but adopting deeply felt cultural mores such as family and gender roles often happens only across generations and engenders major conflicts within families. The American health care system, its structure, personnel, paths of access and regulations, is especially confusing to immigrants coming from countries whose systems are organized differently and who don’t speak English. It takes a long while and many experiences to understand the workings of both health care and other agencies that are non-existent or different in countries of origin. It is difficult, for example, for patients to follow instructions or directions if they don’t understand the context for the directions or if the labels or signs don’t make them. Having translated materials is very helpful.

9 Video: Lupe’s Dilemma Issues in this video revolve around:
Re-infection with STDs during pregnancy, the vulnerability of an unmarried immigrant woman who lacks her own familial support in this country, and the strategies of a physician assistant who is trying to find a way to get the woman’s partner into the clinic for treatment and advice. The “elephant in the room” is Lupe’s partner’s infidelity, which is never overtly acknowledged. Lupe wisely asks her sister-in-law to intervene, knowing that she will tell her husband and the husband may, in turn, intervene with his younger brother to do the right thing. Video is part of the Multicultural Health Series, a community service project of Kaiser Permanente and The California Endowment.

10 Cultural Resistance to Breast Cancer, PAP and STD Screenings
Lack of orientation to preventive care Fatalistic perspective Fear and embarrassment about pelvic examinations Social shame, invasion of bodily privacy Doctors “push” testing too early, endanger hymen The rates of breast and cervical cancer, as well as STDs are higher for many cultural groups than in the general population and detection occurs much later, raising mortality rates. Research indicates that resistance to testing and screening is attributable to several factors operating separately or together. Many groups have little experience with preventive health care, only seeking care when they are clearly ill (often marked by bleeding or pain). They lack information about the potential efficacy of early treatment. In some cultures that have experience primarily with late diagnosis, a cancer diagnosis is considered a death sentence, and women are fatalistic about the possibility of such a diagnosis. Since they have little experience with preventive screening, they may feel that when a physician orders tests, they are doing so in order to confirm a cancer diagnosis. Education around the reasons for screening tests is clearly needed. Many women have little understanding of their own reproductive systems as there is embarrassment in discussing sex or genitalia. They may feel that their personal privacy is being invaded when their breasts are manipulated or their pelvis is exposed. Young Muslim women especially are concerned that their hymens will be broken, thus their virginity could be called into question. This concern abates significantly after they are married, however. Women may fear that someone will find out that they went for screening, thus indicating that they believe they have a disease. Issues relating to sexual activity or infidelity might be raised, as women’s honor is important to the family group. Finally, many immigrant women believe that testing is going to be expensive or that their illegal status will be discovered. The occurrence and tenacity of these beliefs will be altered by education and acculturation.

11 Video: A Big Baby is Coming
This scenario deals with birth made difficult by the mother’s untreated gestational diabetes, the husband’s unwillingness to attend the birth, and the medical assistant’s obvious criticism of the mother. Video is part of the Multicultural Health Series, a community service project of Kaiser Permanente and The California Endowment.

12 Gestational Diabetes Gestational diabetes is the most common complication of pregnancy among Mexican Americans. Lack of early prenatal care often prevents appropriate treatment. Language issues often make appropriate education and treatment difficult. The prevalence of gestational diabetes (GDM) is three times higher than whites (4.5% vs. 1.5%). A recent study conducted in Aguascalientes, Mexico, using the diagnostic criteria recommended by the American Diabetes Association, found a prevalence of 6.9%. Preterm rupture of the membranes is two times more common among Mexican American women with GDM than it is among white women with GDM. The greater prevalence of macrosomia among babies of Mexican American diabetics often results in difficult childbirth and the need for C sections. For economic or cultural reasons, Mexican American mothers may either delay seeking medical care early in their pregnancies or seek the care of parteras, or untrained lay midwives, of whom there are many in the states bordering Mexico. Many of these midwives are not knowledgeable about GDM and do not refer. Another unfortunate issue is that some of the clinics that conduct prenatal care of Latina MediCaid patients, for economic reasons, fail to refer women with GDM problems to specialists until very late in the pregnancy. Managing the education and treatment of diabetic mothers who can’t speak or read English is not easy. It’s important to have 1) a skilled, empathic interpreter help with one-on-one educational sessions around the issues of diet, glucose testing, and insulin, and 2) having well-illustrated and well translated materials available for each aspect of the pregnancy and GDM treatment. Some health care organizations have had good success with the photonovela comic book format. Dietary education should focus on culturally appropriate foods. It’s helpful to enlist the support of a close kinswoman as early in the pregnancy as possible.

13 Labor Pains Asian women tend to be stoic. African American women may
Individuals respond differently to pain, and cultural norms often dictate how it is expressed. This holds true for the pains of labor. Case Study: Miguela Coronel, a Filipino woman, was delivering her baby. Her contractions were very strong and closely spaced. The baby was positioned a little too high, and there was some discussion of a possible caesarean section. Despite her difficulties, Miguela cooperated with the doctor's instructions and labored in silence. The only signs of pain or discomfort were her look of concentration and her white knuckles. Doris Davis, an African American woman, lay in the delivery room across the hall, moaning and groaning. Although the delivery was progressing normally, her cries increased in intensity. Finally, her bloodcurdling yells resounded through the halls. The hospital personnel compared Doris's behavior to Miguela's and naturally rated it unfavorably. Why was Doris acting like such a baby? Why couldn't she control herself as Miguela did? Cultural differences account for the behavioral differences. Miguela's culture values stoicism; Doris’ culture does not. Filipinos believe that a woman must experience pain and discomfort as a part of childbirth. To express these feelings, however, brings shame upon her. This is true in most Asian cultures. A woman from mainland China once explained, “Any woman, even a queen, would be ashamed to cry out in childbirth”. A nurse who works frequently with Hmong patients noted that it is imperative to monitor their facial expressions very closely to determine if they’ve entered Stage 2 (pushing) because they are very stoic, rarely uttering a word during the process. As Anne Fadiman describes of the mother in The Spirit Catches You and You Fall Down (1997), moaning or screaming is thought to thwart the birth. The culture of African Americans does not place such restrictions upon its women. Varied emotional expression has always been a part of Black culture. Doris was culturally normal in expressing her pain. Another Black woman might have suffered in silence and still have been culturally normal. African American women may be either.

14 Labor Pains Iranian women tend to be expressive.
While some Mexican women labor in silence, many are known for loud behavior during labor and delivery. It is often possible to identify a Mexican woman in labor simply from the aye yie yies emanating from her room. Although this chant can be annoying to health care professionals and patients alike, it can be thought of as a form of "folk Lamaze." To repeat aye yie yie several times in succession requires long, slow, deep breaths. Aye yie yie is not just an expression of pain; it is a culturally appropriate method of relieving pain. However, it is important, as always, not to stereotype. As a third year medical student doing her obstetrics rotation noted, although the two Hispanic women she observed giving birth to their first child were loudly yelling, another Hispanic woman having her fourth child was completely silent during the labor and delivery. It is important to remember that there are always individual differences; it’s just that some cultures allow free expression while others discourage it. Women from some cultures may profit greatly from emphasizing their pain during childbirth. A labor and delivery nurse reported that the most difficult patient she ever attended was an Iranian woman, who yelled and screamed for the entire duration of her labor. After she delivered their child, her husband presented her with a three-karat diamond ring. When her nurse commented on the expensive gift, she responded dramatically, "Of course. He made me suffer so much!" Iranian custom is to compensate a woman for her suffering during childbirth by giving her gifts. The greater the suffering, the more expensive the gifts she will receive, especially if she delivers a boy. Her cries indicate how much she is suffering. A young Iranian doctor recently told me that when his wife has a baby, he will present her with a diamond ring or a watch. Mexican women also tend to be expressive.

15 Preferred Labor Attendants
It is currently standard American practice for a woman's husband to assist her in labor and in the delivery of their child. Husbands are expected to be helpful and to attend to their wives' needs. However, not every culture shares these expectations. Historically, it has been the task of female relatives and comadres to participate in the labor and delivery of their children. The video you just saw demonstrated the discomfort felt by the Mexican woman’s husband, as well as her desire to have her sister attend to her. This may be related to the pronounced modesty of traditional Mexican women. Whatever the reason, a number of cultural traditions dictate that a husband not see his wife or child until the delivery is over and both have been cleaned and dressed. For those who find these cultural practices hard to understand, consider suddenly being forced to watch one's parents have sex. How would we feel? Would we stand there and coach them? Wipe their sweaty brows? Or would we stand in a corner, looking up, down, everywhere but at them? Sexual relations occur in the presence of children in some parts of the world but are taboo in American culture, just as it may be taboo for a Mexican man to watch his wife give birth, though it is a common practice for American men. Younger, more Americanized, and middle class Mexican couples may want to participate in the delivery process together, but it should not be assumed that the husband is the proper person to coach his wife in this situation. The mother should be asked whom she prefers to have in the room with her. Fathers-to-be should be asked about whether they wish to be present. If they do not wish to be, this does not mean that they are any less interested in the child or mother, just that they don’t see themselves as appropriate in the role of coach. One study of Mexican American women’s expectations of their husbands’ participation during labor and delivery indicated that the women hoped that their men would be there to hold their hands and verbally comfort them. They didn’t expect their husbands to actively coach them, help them breathe or rub their backs! Traditional Asian women may also prefer a female relative, although sometimes the mother-in-law is considered more appropriate than the mother. Traditionally, when a Korean or Chinese woman, for example, married, she would live with her husband’s parents and spend much of her married life taking care of the needs of her in-laws. This was reversed during childbirth. Then, a mother-in-law would have to attend to the needs of her daughter-in-law, both during delivery and throughout the month long Iying-in period, which will be discussed shortly. Anglo American: Husband or Domestic Partner Hispanic: Mother or Female Relative Asian: Mother or Mother-in-Law

16 Video: Hmong Birthing Practices
This video deals with an American born Hmong expectant mother trying to inform her obstetrician about the Hmong birthing practices expected by her mother. The obstetrician listens carefully but is puzzled and somewhat put off by the beliefs of the mother and the concerns of the daughter. Video is part of the Multicultural Health Series, a community service project of Kaiser Permanente and The California Endowment.

17 Hmong Prenatal and Birthing Practices
Hmong women may resist napping and invasive prenatal testing; Consent for prenatal and birthing procedures may have to be gotten from parents, husband, and in-laws; At childbirth, both mother and baby are considered especially vulnerable to malevolent spirits. Childbirth is seen by the Hmong as part of a life-death-rebirth cycle shaped by ancestor worship and animism (belief in spirits controlling the natural world). Prenatal procedures, such as blood draws and amniocenteses, are seen to weaken the mother and open her to invasion from evil spirits., particularly if done in a hospital, a place filled with the ghosts of patients who have died there. Contrary to western belief, napping and increased water intake are considered bad for a pregnant woman: napping will weaken her and make childbirth difficult and too much water will distend her stomach and increase her discomfort. While Hmong wife may express herself, she cannot make major decisions without first consulting her elder relatives and husband. Thus, say, a decision to have a C section may require the consent of both sets of parents and the husband before the wife can give her consent. The Hmong consider children to be extremely important, desiring many, and treating them with loving, protective care. If problems develop during pregnancy or childbirth, a shaman may be called to aid the mother with strategies ranging from re-positioning the mother or rituals to call the mother’s spirit back to her body. A woman’s crying out during labor is frowned upon as it may scare the baby from wishing to be born. During labor, a husband’s presence and help is sought. The husband may stroke his wife’s abdomen while calling to the baby to be born. Hmong women are quite small but, with improved nutrition in the U.S., babies are getting larger; cephalopelvic disproportion is increasing, hence a growing need for cesarean section. Strings may immediately be tied around a newborn’s wrist to protect the baby from spirits that may want to whisk the baby away. Similarly, beautiful embroidered caps are made for infants to wear: if seen from above, the spirits will think they are just flowers. Women will be cared for with special food, usually chicken and white rice, no cold drinks and rest for several weeks following the baby’s birth. Many hospitals now routinely keep Hmong placentas refrigerated in zip-loc bags so that they may take them home at discharge. (Kaiser Permanente is an example)

18 Video: Female Circumcision
This video deals with an obstetrician suddenly confronted with her first case of female circumcision in a Somali immigrant women in labor. The patent is accompanied by a concerned and somewhat hostile kinswoman. The obstetrician sees that a c-section will be necessary and is concerned with the vaginal scarring. The situation is made much worse by a self-righteous assistant who preaches to the kinswoman. Video is part of the Multicultural Health Series, a community service project of Kaiser Permanente and The California Endowment.

19 (aka Female Genital Mutilation)
. Female Circumcision (aka Female Genital Mutilation) One of the more controversial traditional practices is that of female circumcision (as it is seen from an emic or insider’s perspective) or female genital mutilation (FGM in the human and women’s rights literature). The origins of this tradition are ancient and largely unknown, and although it is not part of Islamic doctrine, it is consisent with Islamic beliefs regarding sexual desire. As Brooks explains, it is believed that Allah (God) created sexual desire in 10 parts; he gave nine to women and only one to men (hence the title of Brooks’ book cited above), which is why female sexuality must be kept under control. One way it is done is by keeping the woman covered, veiled, and segregated. Another method, used in some remote regions of Egypt, and particularly in other parts of Africa, is through female circumcision. It is believed that the practice reduces women’s sexual desire, and that without it, women might be unable to control their exceptionally strong libido, and family honor might be lost. Circumcised women may be seen are San Diego, Los Angeles, the San Francisco Bay Area, Minnesota, North Dakota, Tennessee, Wisconsin, Rhode Island, Delaware, Alabama, Detroit, Atlanta, New York City and Canad.a Some immigrant families send their daughters to Africa to get circumcised, while others have this procedure illegally performed in the U.S. and Europe. There are several forms of female circumcision. The most minor form involves cutting off the tip of the clitoris. The most severe, known as infibulation, is the removal of the entire clitoris, labia minora, and parts of the labia majora. The outer lips of the vagina are then held together with thorns, sutures, or a paste like material. A small opening is left for urine and menstrual blood. The girl's legs are tied together for several weeks until she heals. As can be imagined, this practice often leads to a myriad of urinary, menstrual, and intrapartum problems, apart from the risk of infection and death at the time. Case study: A twelve-year-old Somalian girl was admitted to the hospital with a temperature of 102 degrees. When the physician examined her, he discovered that her labia minora and labia majora had been sewn together so tightly that he could not insert a foley catheter. He had to call in a urologist to place the foley. The fever resulted from a severe urinary tract infection, likely caused by the infibulation. In another case, an Egyptian woman in labor presented an unusual problem for the nursing staff. Her vagina was severely deformed, and they were unable to find any of the appropriate "landmarks." The entire area appeared to have been badly burned, yet no other parts of her body showed evidence of fire. The doctor and nurses were mystified. They did not realize that the woman had been “circumcised.” The procedure is generally performed when a girl is seven or eight years old, although she may be much younger or a little older. Older women will come in the night, hold her down, and then start cutting. In 1985, a world congress was held in Africa in an effort to reduce or eradicate the practice. Surprisingly, the greatest opposition to the elimination of the custom came not from men but from older women and young girls. The older women wanted to maintain tradition. The young girls were afraid that if they were not circumcised, they would be unable to find husbands. Circumcision is seen as the ultimate proof of purity; why would any man marry a woman without a guarantee of her virginity? In the years since that world congress little, if any, progress has been made toward eradication of the custom. In fact, newspaper and magazine reports indicate that it is spreading, as African women move out of Africa. Anthropologists recognize that it is difficult, if not impossible, to merely eliminate a traditional cultural ritual; efforts would be better aimed at trying to promote the sunna form, which involves cutting only the tip of the clitoris, over infibulation. Complicating the issue is that opposition to the practice has been associated with the Western world, and there is much anti-American feeling in parts of the world where FGM is practiced. For some, continuing the practice is an anti-American statement. Normal Female Anatomy Modified Sunna Illustrations from Prisoners of Ritual, (1989) by Hanny Lightfoot-Klein

20 (aka Female Genital Mutilation)
. Female Circumcision (aka Female Genital Mutilation) Physicians caring for circumcised women should be especially sensitive to their needs and feelings. Female providers should be used whenever possible, and the patient should be kept draped for privacy. Physicians need to know how to handle labor and delivery, since the episiotomy must be done at an earlier stage. Above all, do not express any shock or judgment. You might, however, gently discuss the relationship between their infibulation and any health problems they may have experienced, so that they can make an informed choice for their own daughters. It might also be appropriate to let them know that the practice raises issues of illegality and child abuse in the United States. A nurse from Sierra Leone, where most (if not all) women are circumcised shared something of the experience. She said that the loss of the clitoris was “no big deal”. She explained that they only cut off the clitoris there; they don't do the full infibulation. Her attitude was that sex is for procreation, not fun, and since African men generally do not perform oral sex on the woman, the clitoris was superfluous. She added that women there still have orgasms, since orgasms are more psychological than physiological. She had no negative feelings towards female circumcision, although she did not plan to have her daughter circumcised because it generally isn’t done here. She would not hesitate to do it if they were living in Africa. To help us understand her perspective, she explained that there are a year's worth of festivities associated with the circumcision. It is a very big time in a girl's life. It is followed by an arranged marriage and "virginization" (her term). This is the ceremony in which the girl is "deflowered" by her husband while all the relatives wait outside for the bloody sheet and listen for the appropriate moans of pain. The clinical repercussions of circumcision, especially with infibulation, can include: Infection and/or hemorrhage, cysts and abscesses High risk of vaginal fistula, resulting in incontinence and injury to the rectum, bladder and urethra Childbirth complications often including an anterior episiotomy during childbirth to prevent spontaneous tearing or impeded labor. Frequently, the scar tissue has become so dense that it doesn’t stretch, requiring a cesarean section Debilitating menstrual pain, cysts and keloids along the scar tissue Recurrent urinary tract infections can occur as the urine pools in the vagina. High susceptibility to sexually transmitted disease. Infibulation Infibulation Illustrations from Prisoners of Ritual, (1989) by Hanny Lightfoot-Klein

21 Breastfeeding Colostrum
Breastfeeding is seen as highly desirable by the medical community, although in some cultures, bottle feeding may be preferred, sometimes in part because it is associated with the higher status of the west. Even mothers who are willing to breastfeed, however, may avoid doing so for several days. This is unfortunate because the colostrum that fills a new mother's breasts before her milk comes in is rich in antibodies that fight infections to which newborns might be subject. Case Study: Mexican A Mexican American gave birth to a son. The nurse wheeled the baby into the mother’s room and handed him to her to be nursed. Instead, the mother pointed to her breasts and said, "No leche, no leche" (No milk, no milk). Her husband explained to the nurse that his wife would bottle-feed now and breastfeed when she returned home. Why? Many Mexican women believe they have no milk until their breasts enlarge and they can actually see it. Some perceive colostrum as "bad milk" or "spoiled" and thus not good for a baby. Many do not realize that nursing stimulates milk production. Still others are very modest and are embarrassed to expose their breasts while nursing in the hospital. Some Vietnamese women also believe that colostrum is dirty and often delay nursing until after their milk comes in. The best way to deal with this situation is through education. Explain the importance of colostrum to the baby's health. If the mother's concern is to provide "real" milk for the baby, tell her that nursing on the colostrum will help it to come more quickly. The new mother should also be given privacy while nursing her infant. Colostrum

22 Postpartum Lying-in Traditionally 30 - 42 days
Rest, stay warm, avoid bathing & exercise Eat foods designed to restore warmth Failure to follow custom is thought to result in aches & pains in later years A Iying-in period observed throughout much of Asia and Latin America. For a period of time after a woman gives birth, her body is thought to be weak and especially susceptible to outside forces. The new mother is encouraged to avoid both exercise and bathing, and to eat only certain foods. These traditional practices come into direct conflict with Western health care, which promotes exercise and bathing for new mothers as soon as possible following childbirth. The traditional practice in China is called "doing the month." It is important to keep the room warm, lest cold or wind enter the new mother's joints. Bathing is considered dangerous for similar reasons. No matter how hot the weather, the traditional Chinese woman will want the windows closed and the air conditioning off. In Asia, health is believed to depend upon keeping the body in a state of balance. Pregnancy is generally thought to be a hot condition. Giving birth causes the sudden loss of yang, or heat, which must be restored. The most effective way to do this is to eat yang foods, such as chicken. Cold liquids should be avoided lest the system receive too great a shock. Traditional Asian thought has it that the price for not "doing the month" is aches, pains, arthritis, and other ailments when one is old. Although practical circumstances may prevent a woman from observing the entire month, many want to practice at least a shortened version of it. This explains why patients often refuse ice water in preference for hot, rejected bathing or exercise, insisted upon keeping extremely warm, and ate only certain foods. In Mexico the Iying-in peroid traditionally lastes for six weeks, the time believed necessary for the womb to return to normal. (In fact, forty-two days is generally the amount of time it takes for the uterus to return to its pre-pregnant size.) The customs involved are essentially identical to those of the Asian practice: the woman is to rest, stay very warm, and avoid bathing and exercise. Special foods designed to restore warmth to the body are prescribed. Disregarding these practices is believed to lead to aches and pains in later life. The Postpartum Lying In period is designed to give a woman a period of rest between childbirth and returning to work. The women who practice this custom are usually from cultures where women traditionally did not return to office work, but to physical labor in the fields. Because they usually had large families, it might be the only time they had to rest. Avoidance of bathing may also have practical origins. In many countries the water is impure and filled with harmful bacteria. Bathing could introduce these organisms into the body and cause illness. Although conditions in the United States are different, the custom continues. It should be noted that different generations will adhere to customs differently. Daughters may be less interested in following traditional customs than their mothers, though to avoid a mother's nagging, the daughter may comply with the cultural traditions when the mother is present. When the patient is alone, a nurse may suggest bathing, exercise, and so forth. Compromises can be made. Although it is important for a patient to drink fluids after childbirth, both hot tea and hot water with lemon deliver the same amount of liquid as ice water without violating custom. Using boiled water (cooled down) may make a sponge bath more acceptable. (This was done in China to remove impurities.) The patient should be kept covered and given socks or slippers to walk in. It is important to explain the reason for bathing and exercise and not to assume that the patient will follow orders that violate the traditions and wisdom of her own culture. Sometimes the mother’s reluctance to do much after giving birth is mistakenly interpreted as a warning signal for lack of bonding. If you suspect a problem, ask the woman if she is following a traditional practice.

23 Bonding and Baby Naming Bonding
SERENA: serene Kabira: powerful Taci: washtub Radman: joy Which leads to the issue of bonding. There are a number of other cultural customs which have led healthcare professionals to mistakenly believe that mothers were not bonding with their newborns. This was particularly common in the 1970s, with the large influx of Vietnamese immigrants. Mothers would hold their babies and feed them, but without the overt signs of emotion we’ve come to expect with mothers and their newborn. This behavior was based on the believe that if a child appeared attractive, the spirits would want to “steal” the child -- something accomplished through the child’s death. Thus, mothers showed their deep love for their children by acting as though they weren’t worth caring about. If you observe a look of discomfort on the mother’s face when you fuss over the child, avoid displays of “what an adorable baby!” Another custom that can be misinterpreted as a sign of lack of bonding is failure to name the baby at birth. Case Study: Hindu A Hindu nurse decided to honor her family by following the traditional custom of naming the baby on the 7th day (when umbilical cord stump falls off & life begins). Before choosing a name, they would have to consult an astrologer who would given them a list of auspicious letters, based upon the baby’s time & date of birth. These letters would be given to her husband’s sisters, who would choose a name beginning with one of the letters on the list. When they refused to fill in the baby’s name, the nurse reported her to the head nurse. This resulted in visits from the hospital administrative nurse, the chaplain, and the social worker. They all seemed concerned about Leila’s plans for the baby once they got home. When she asked the social worker why everyone seemed so disturbed, the social worker admitted that they were worried that she wasn’t bonding properly with the baby. Why else would she not have named him? This custom of delaying the name of the baby is found in many Asian cultures. Traditional Chinese will often give the baby an unattractive nickname at birth, such as Little Doggie, or Ugly Pig, to make the child seem less attractive to any spirits who might want to steal the infant. Refusal to name a baby at birth is often considered a warning sign for lack of bonding and potential child abuse. While it is important to be on the lookout for this, it is also essential to be aware that many cultures have customs including delaying the naming of the baby that reflect a history of high infant mortality rates and concern for the health and survival of the infant. Before interpreting a behavior as reflecting a lack of bonding, ask the parents the reason for the behavior. You might learn a lot. CALEB: devotion to God Duranjaya: a heroic son CHAN JUAN: the moon; graceful; ladylike

24 Menopause in Cultural Perspective
Although menopause is universal, the “symptoms” attributed to it are not. Research suggests that the variety of ways menopause is experienced can be termed “local biologies.” Cessation of the menses is looked upon very positively by women in many cultures. Medical models of menopause tend to list hot flashes, night sweats, emotional mood swings, and depression as typical menopausal symptoms, and, indeed they do characterize Western concepts about menopause. While it is widely recognized that individual women experience menopause differently even within the Western paradigm less well know is the fact that research suggests that different cultural groups vary significantly in the more predominant ways menopause is physically and emotionally experienced. For example, hot flashes and depression are much less often reported by Japanese, Thai, and Chinese women than among women in the United States, Canada and the Philippines. Women in Eastern cultures most often report dizziness and shoulder stiffness as physical accompaniment to menopause. In a study of South Asian women, few menopausal symptoms were reported at all. This was also the case in a study of Nigerian women. In some cultures, such as Nigeria, sexual life ends for most women when cessation of the menses occurs. In Western nations, this is certainly not the case. In many Latin cultures, menopause is welcomed because it lifts the burden of childbearing and allows women to avail themselves of more freedom of movement and adoption of some of the masculine privileges such as smoking and alcohol consumption. Older women are not viewed as sex objects and this often relieves them of fear of assault if they leave the home alone. Clearly, cultural norms, attitudes, and exigencies shape the experience of menopause for women across the world.

25 Issues of Language Access in Health Care
DHHS guidance for language access under the Title VI, Civil Rights Act of 1964 MediCal contract regulations DHS Cultural & Linguistic Standards Joint Commission on Accreditation of Healthcare Organizations (JCAHO) includes standards for cultural competence training and language services. Language access is considered a civil right and health care organizations who receive any federal funding, such as MediCal, Medicare, and Healthy Families, are required to provide language services, that is, interpretation and translation, to limited English speakers. The DHHS Office of Civil Rights in 2000 provided extensive guidance as to what health care organizations must do in order to provide such services. The first step organizations need to do is to assess the languages needs of their patients. If an organization cares for Medicaid patients (MediCal), their contract with the state of California states that they must provide culturally and linguistically appropriate services, including clinical and staff training, interpretation and translated materials. In their assessment of health care organizations, JCAHO reviews cultural competence training of staff and the provision of language services in their evaluation and accreditation of the organizations.

26 JCAHO Ruling JCAHO views the provision of linguistically appropriate care as an important quality and safety issue. JCAHO requires the inclusion of language and communication needs in the medical record. Interpretation and translation must be provided for patients who need it.

27 DHHS says: Assess patients’ language needs.
Try not to use family or friends or whoever you can grab. Don’t use minors to interpret. Try to use trained medical interpreters whenever possible. Use telephonic interpreters for rare languages. Each hospital, health plan, or clinic receiving federal funds is bound by the language guidance given by DHHS Office of Civil Rights. Various means of assessment are used: most common is a mandatory field on patient demographic data base. There is currently a California Senate Bill under consideration (Yee) that forbids the use of minors for interpreting elaborating on the federal guidance. County/USC currently has trained over 100 staff persons who do interpreting and plans to train more. It’s impossible to have staff interpreters for every language; telephonic interpreting fills the need for uncommonly encountered languages. If an interpreter is not used, this must be recorded in the patient’s chart. If an interpreter is used, record the interpreter’s name.

28 What Can You Do? Honestly assess your own bilingual skills
Understand the pitfalls in using untrained interpreters Use interpreters effectively Use telephonic interpreters skillfully So you took high school Spanish or even, quite a while back, college Spanish. You can greet your patient and show respect for their language. Good. But probably not enough. You may need to develop facility in effectively using an interpreter.

29 Are your bilingual skills really adequate? Can you:
formulate questions easily? ask a question in more than one way? understand nuance and connotation in the patient’s response to questions? understand regional variations? know terms for anatomy and healthcare concepts? convert biomedical terms into lay terms in the target language? It’s easy to be over-optimistic about your skills in another language, particularly when it takes time to find an interpreter. Dr. Eric Hart of Boston City Hospital who has studied this issue, warns against this strategy. Be sure, for example, that you can differentiate between past, present, and future verb forms. If these aren’t used correctly, it can be confusing to patients in understanding, say, a treatment plan. Best practice: while learning the language, have an interpreter back-up present. Don’t hesitate to ask a patient to slow down if you are only picking up pieces of what s/he is saying.

30 Pitfalls in Using Untrained Interpreters
Studies show that an average of 70% of the interpreted exchanges by ad hoc interpreters contain clinically important errors. Family members, especially, are prone to edit both the clinician’s and patient’s utterances. Children are frightened or intimidated if asked to interpret. There are ethical problems involved. Confidentiality concerns must also be considered. Many of the numerous errors were unintentional: omissions, inaccurate word substitutions, mistranslations of anatomical parts, etc. Intentional editing is more common than you might think: the family or friend interpreter may want to shield the patient or may even have a personal agenda and so edits what the clinician is saying. On the other hand, they may not tell the clinician all of what the patient is saying out of embarrassment or because they don’t want the doctor to know all of what the patient is disclosing. Children who interpret for parents often experience uncomfortable role reversals. If the topic is delicate or serious, they may be too embarrassed or too nervous to interpret well. Recent confidentiality regulations call into question the appropriateness of using casual interpreter substitutes.

31 The Effective Use of Face-to Face Interpreters
Brief the interpreter first, if possible. Introduce the interpreter to the patient. Position the interpreter behind the patient or behind you. Speak and look directly at the patient. Use first person and expect the interpreter to do the same. Avoid interrupting the interpretation. It’s good, if possible, to meet the interpreter outside the room where the patient is. Briefly tell the interpreter what is going on, for example, history-taking, treatment planning, consenting, etc. Usually it’s important to get the patient to agree to the use of the interpreter: “This is Gloria Morales, out interpreter, she’ll help us talk to each other, if this is ok with you. It’s not good to have the interpreter positioned in such a way as you will be attempted to address your remarks to her/him. This makes the patient feel left out. Why first person? It keeps you in control of the conversation and focuses the encounter on your interaction with the patient. It may seem awkward for you and for the interpreter at first, but it results in greater accuracy in the interpretation, for example, fewer additions and omissions.

32 Using Telephonic Interpreters
Use a speaker phone; do not pass a handset back and forth. Remember that the interpreter is blind to visual cues. Let the interpreter know who you are, who else is in the room, and what sort of patient encounter it is. Let the interpreter introduce her/himself. Properly used, a speaker phone works very well in an interpreting situation. Many facilities have a well-maintained speaker phone on a cart that is used only for telephonic interpreting. At County USC hospital, various other technologies are in use at different locations: duel headsets and hands-free telephones. Pet Delgado, the Hospital Administrator, is looking into bringing in VMI: Video Medical Interpreting. One sentence can orient a telephone interpreter: “Hello interpreter,this is Dr. Jameson. I have Mrs. Gupta and her daughter here for Mrs. Gupta’s first visit following her gall bladder surgery.”

33 What You Need to Know to Connect
The language needed Dial 0 for hospital operator Tell operator to connect you with the Language Line. Remember that the telephonic interpreter is bound by confidentiality regulations, just as any other health care personnel. The process of obtaining a telephone interpreter usually takes about 40 seconds. Over time, use of telephone interpreters becomes much easier and seems less impersonal.

34 What Can You Do To Be More Culturally Competent?
Practice ways to build rapport Ask tactful, nonjudgmental questions about their preferences and practices Understand family roles in health care Know something about the cultural beliefs of your patients, but don’t stereotype Use interpreters and use them effectively, don’t “wing it.” It may seem as if we’ve given you a lot of information today. That’s because we have. But it all boils down to a few simple points. Assuming that your primary goal is to help your patients give birth to healthy babies and to take care of their own reproductive health, there are a few things you need to remember. A key point is the importance of building rapport. If your patients trust you and like you, they will be much more likely to follow your recommendations. Learn to ask questions about patients’ preferences and practices. Don’t make the assumption that all women will want the same thing, or do things for the same reasons. Know something about family roles in health care, including appropriate labor partners. How will you find out such information? Again, by asking. Know something about the cultural beliefs of your patient. To that end, we’ve provided a list of resources, including books, articles, films, and websites. We’ve also included information on a number of cultural competency courses you can take for CMEs. But remember not to stereotype; be sure to ask your patient about her beliefs, since they may or may not be consistent with those of her culture. Use interpreters when you are not fluent in your patient’s language, and use them appropriately. In your packet there is a set of Tips on Using Interpreters. In addition, we’re providing you with a special gift for being part of this pilot program to bring cultural competence into the LA County Health Care System. That’s the pocket handbook, Cultural Sensitivity. It’s designed to fit into your pocket, and give you quick access to the common cultural patterns found among nine broad ethnic groups. Consult it before you go on rounds. But remember, your patient is an individual and may not fit the cultural patterns described. Use it to get a sense of some of the possibilities you might consider when treating your patient.

35 Consider: Think back on your “difficult” patients.
May any of the challenges they presented be linked to their cultural beliefs or practices? Would cultural competence skills have made a difference? We hope you’ve all enjoyed and learned from today’s presentation. But more importantly, we hope you will integrate what you learned into your clinical practice. Think back on your “difficult” patients. May any of the challenges they presented be linked to their cultural beliefs or practices? Would cultural competence skills have made a difference? We think the answer is YES.

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