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Cultural competence: implications for childbearing practices.

Childbirth educators should be on a journey to give holistic care to all women regardless of their culture. The childbirth experience is extremely important, and one which most women will go or have gone through. Cultural competence is not an abstract concept or something politically correct to do; it is a process that is necessary to provide holistic care. Cultural competence is a journey, not a destination nor an event; but a process of becoming competent, not being culturally competent (Campinha-Bacote, 2009). Nonetheless, there are cultural, as well as individual differences in each woman's birthing experience. The purpose of this article is to discuss how culture influences birthing practices and the importance of childbirth educators being culturally competent in order to provide effective childbirth programs. Concepts related to culture, and cultural competence will be discussed including definitions, cultural theories, research, and barriers.

Recognizing the need to understand women of diverse cultures rather than requiring them to assimilate is pivotal to providing culturally competent care. Cultural competence begins with an awareness that cultural differences and similarities exist within and between ethnic groups, also different sexual orientations, socioeconomic, geographic, and religious backgrounds (Wilson, 2008). Cultural competence cannot be achieved simply through gaining knowledge; encounters must occur. The best teacher is firsthand experience with a culture, if not immersion in it (Leininger & McFarland, 2002)

As health educators, we must want to become culturally competent to effectively educate. Since each birthing experience is unique and clearly grounded in the parents' own culture, knowledge of and sensitivity to the impact of culture on belief practices must be an integral part of the childbirth educator's role. Perceptions of the childbirth experience vary widely depending on the cultural context. Women and childbearing educators bring their own cultures into the birthing program and ultimately into the educator-client relationship. Subsequently, the quality of a childbearing experience is deeply influenced not only by the woman's experience but also by the cultural understanding that the educator brings to their interaction. All too often, healthcare practitioners assume that all women believe the same about birthing practices. This worldview may prevent women from following their traditional or desired birthing practices, and ultimately not meeting their needs.

Nursing has long considered the value of cultural connection to health and the childbearing process; specifically, transcultural nursing laid the foundations for the concepts of cultural competence. Your own culture plays a significant role in attitudes and potentially determines the way a woman perceives and plans for her birthing experience. Understanding the meaning of culture and its impact on behavior is essential to facilitating a satisfying birthing experience. Although there is a vast amount of literature related to cultural influence on behavior and cultural competence, the gap between culturally competent care and practice application remains a mystery (Monsivais, 2011).

Beliefs and values associated with childbearing cross all cultural boundaries and allow for a commonality for women and their family. The experience and process of giving birth may be viewed differently since each woman brings her lived experience which is influenced by the culture with which she identifies and in which she gives birth (Ottani, 2002). As health care educators, we are expected to respect the rights of all individuals. However, when cultural beliefs and practices are not appropriately assessed and acknowledged, this can lead to cultural incongruence and inefficient childbearing education programs. Effective programs should be geared towards empowering women to make informed health decisions regarding childbearing practices.

Cultural Concepts

In order to provide culturally competent care, there must first be a basic knowledge of terminology such as culture, culturally diverse care, ethnocentrism, and cultural competence.

Culture provides a framework for behaving and is designed for survival in a specific environment. Family roles, childbearing practices and communication are essential attributes that define an individual's culture. Culture influences perceptions, interpretations, decisions, actions, and healthcare practices. Ways of behaving are based on values attributed to group identity, doctrines, and opinions. These values are predicated upon agreed beliefs or creed which are maintained by culture and transmitted through language (Wilson, 2008).

Culture is a set of learned and shared beliefs and values that include human functions related to political, economic, social, religious, philosophical, educational, and technological activities (Leininger, 1995; Leininger & McFarland, 2002). It is the totality of socially transmitted behavior patterns, art, beliefs, values, customs, life ways, products, and characteristics of a population that guide decision making (Purnell, 2000). Actions and decisions are governed by culture, and this subsequently guides our thinking, feelings, being, and behavior (Wilson, 2008). Perceptions, beliefs and evaluation of lived experiences develop through interactions which are defined by culture.

Consistent with other definitions, Giger and Davidhizar (2004) stated that culture is transmitted from generation to generation and serves as a support for survival in a specific environment. Values, knowledge, customs, emotions, rituals, traditions, and norms, are embedded in behaviors predisposed to by culture. The textbox below defines key terms about cultural competence.

Cultural Competence

Competence refers to having adequate means and ability to meet one's needs. The concept of cultural competence is based on assumptions that we all represent a culture and have the capacity to work toward responding effectively to meet the needs of others within the framework of their own culture. Developing cultural competence is an ongoing process, one which includes continuous evaluation, adapting and reevaluation. As childbirth educators, cultural competence is a test of ability to truly care for women as individuals and as a community. According to Morgan (2002), cultural competence is a conscious process, not an endpoint in which nurses continuously strive to work efficiently within the cultural context of an individual/community from a background that is different from their own.

Impact of Cultural Competence on Childbirth Education Programs

Cultural competence allows childbirth educators the opportunity to promote holistic care. They can be an advocate for program-based cultural competence, adapting to meet a woman's needs and expectations. Actions should promote, support, and protect a woman's beliefs and cultural practices. The basis of a culturally competent program is a willingness to develop interventions predicated on knowledge of and encounters with diverse cultures. Holistic programs include academic and interpersonal skills that allow for increased understanding and appreciation of cultural differences and similarities within, among and between groups.

Cultural competence decreases the potential for assumed similarity, which implies all people share the same beliefs. Through self-awareness, insightful interpretation of others' behaviors and attitudes can be facilitated. Without self-awareness, childbearing educators can have a false sense of security about individuals unlike themselves. Therefore, the need to assess your own cultural competence, beginning with an understanding of self is paramount to a successful childbirth education program.

Cultural competence is fundamental to bridging the gap between inadequate and optimal holistic programs. When cultural differences are ignored, barriers to effective programs can emerge. Cultural competence enables childbirth educators to work effectively in cross cultural situations by obtaining cultural information and then applying that knowledge which would allow one to see the entire picture in order to promote quality outcomes.

Despite the increased emphasis placed on cultural competence, many programs continue to be ethnocentric and practice from the belief that theirs is best, correct, moral, and the only acceptable way. Often this belief is unconscious and pervasive but imposed on every aspect of daily interactions and practices in childbearing education programs. For example, birthing classes frequently emphasize foods that are high in protein. In Asian and Hispanic cultures, a system of cold/hot body balance is practiced to maintain balance. Educators should consider this when encouraging foods to eat.


Knowledge of all cultures is impractical and superficial cultural knowledge can be perilous. Therefore, it is vital to have a willingness to learn about, respect, and work with persons from different backgrounds in order to provide care that is compatible with their values and traditions. Cultural competence can only be achieved through extensive awareness, knowledge, respect, and encounters with individuals from diverse cultures.

Cultural Competence Theories

Several assessment tools and cultural theories have been developed and revised over the past 40 years, including Leininger's Transcultural Model, Campinha-Bacote's Culturally Competent Model of Care/Process of Cultural Competence in the Delivery of Healthcare Services, Geiger and Davidhizer's Transcultural Assessment Model, Purnell and Paulanka's cultural model, and Andrew and Boyle's Transcultural Concepts in Nursing Care.

One model in particular, the Process of Cultural Competence in the Delivery of Healthcare Services, by Campinha-Bacote (1998; 2002; 2009) has frequently been used to promote cultural competence in practice settings.

The integration of five constructs form the foundation of the practice model by Campinha-Bacote: cultural desire, cultural awareness, cultural knowledge, cultural skill, and cultural encounters. This model asserts that health care professionals commence their journey toward becoming culturally competent by addressing overt and covert barriers to care; assessing the level of awareness and sensitivity toward culturally diverse persons; conducting a cultural assessment; obtaining knowledge about this cultural group; and maintaining effective clinical encounters Campinha-Bacote (1998, 2002, 2009).

Cultural Desire

Campinha-Bacote (2002) asserts that cultural desire includes a "want" to be involved in providing culturally competent care, not a "requirement" to do so. It is the cornerstone of cultural competence which allows for authenticity, and a true desire to learn about others. Humility, respect, dignity, justice, commitment, motivation, compassion, and truthfulness are terms associated with cultural desire.

Cultural Awareness

Cultural awareness is the next step towards being culturally competent. It involves self-awareness and self-examination of one's own beliefs and biases toward other cultures; an understanding of how one's own culture influences thinking and acting is vital. It is a deliberate process of becoming cognizant of self through in-depth exploration, while being sensitive to the perspectives of others. Self-awareness allows for conscious awakening. The importance of this construct is to prevent engaging in cultural imposition, which is the tendency to impose one's values on another from a different culture (Leininger, 1991). Cultural awareness allows for understanding and determination of where one is along the continuum from unconscious to conscious competence.

Cultural Knowledge

Cultural knowledge is an educational process that allows one to obtain information about diverse worldviews. Cultural knowledge prevents the assumption that all individuals are the same within a specific group. Individuals often misjudge other's actions based on learned expectations and culturally prescribed patterns. Without cultural knowledge, misinterpretations may emerge. A conscious effort is required to become knowledgeable about cultural differences.

Cultural Skill

Cultural skill is the process of learning how to provide culturally appropriate care. It allows for collection of culturally relevant data through a culturally sensitive approach. According to Campinha-Bacote (2002; 2009) the goal of a cultural assessment is to determine how an experience is defined. Assessment is vital to skillfully implementing culturally competent care.

Cultural Encounters

Cultural encounters promote "doing" and being involved, encouraging purposeful cultural interactions. Campinha-Bacote (1998; 2002) further asserts that all encounters are cultural when they allow existing knowledge to be validated, refined, and modified to reduce and or prevent stereotyping. Thus, intercultural "face-to-face" interactions are necessary to allow for mindful communications (Campinha-Bacote, 1998; 2002).

Barriers to Cultural Competence

Barriers are defined as real or perceived gaps to providing quality care. According to Campinha-Bacote (2009) cultural competence requires an egalitarian relationship. Traditionally, childbirth educators, specifically nurses, have been socialized in the "equal treatment" model, where all clients are treated the same, regardless of cultural differences. This model emerges from a perspective that is unidirectional and power oriented, often leading to a paternalistic, patronizing, Western view of the culturally diverse woman (Covington-Wilson, 2004). Childbirth educators who function from a patronizing worldview, frequently assume the right to make decisions for women. When this happens, miscommunication may lead to conflict and possible distrust, eventually leading to inadequate outcomes for the culturally diverse woman.

Childbirth programs can be a culture in and of themselves. When a woman from a different culture enters the program, she becomes part of a structure with its own rules, values, and language and can be predisposed to potential cultural incongruence. As stated earlier, Asian and Hispanic cultures practice a system of cold/hot body balance. Pregnancy is believed to be a hot condition. Therefore, foods considered to be "hot" are restricted since it is believed that the body is already out of balance and the condition should not be exacerbated (Giger & Davidhizar, 2004). Traditions such as cold/hot balance, exemplify the significance for childbirth educators to carefully assess women's behavioral patterns. High proteins are oftentimes encouraged to promote adequate nutrition. For that reason, childbirth educators can suggest foods high in protein, yet not considered to be hot for women of Asian and Hispanic cultures, in order to prevent body imbalance.

O'Connor (2002) recommends that childbirth educators provide culturally appropriate care to women by remaining sensitive to their cultural and spiritual needs. She stated that preventative measures are uncommon among Arab Americans in regards to childbirth practices. Consequently, some women do not receive adequate prenatal care because they do not see a need, unless complications occur. In addition, Arabian men traditionally do not participate in the birthing process or in childbirth education classes. Hence, these practices should be considered when working with Arab Americans in order to reduce the risk of cultural discord.

Cultural Influences on Practices

Childbirth educators should be knowledgeable about cultural rituals related to prenatal, delivery, and postpartum periods. The lack of knowledge can interfere with communication and prevent positive outcomes. Beliefs and practices vary within subcultures of every culture; therefore, this information reflects shared characteristics of a group and is not meant to stereotype. (see chart at right)

Factors to Consider When Planning and Implementing a Childbirth Program

Factors such as language and communication, cultural norms, and concepts of personal space are important variables to consider when encountering women from a different cultural background.


Communication is a critical factor in achieving culturally competent care. Culture is passed on through communication and influences the way information is processed and perceived by groups. Oral and written languages, gestures, and body movements all transmit culture. Issues associated with cultural variations in communication styles have been well documented; nevertheless, healthcare providers tend to relate to all clients from an ethnocentric perspective (Covington-Wilson, 2004). Communication elements that could pose problems such as dialect, grammatical structure, and pronunciations intensify when interactions include those who speak different languages. Conflicts in verbal communication can increase discord and hinder relationships (Giger & Davidhizar, 2004). Problems that occur due to patterns of communication relate to the linear, sequential, and compartmentalized process that occurs in educational programs. Statements like "You must do this first, then next" can be perceived as unidirectional, uncaring, and offensive.

Nonverbal communication patterns such as facial expressions vary greatly between cultures. Particularly, some cultures such as African Americans tend to use facial gestures to convey feelings. Use of eyes, hands, and body movements are common and may be misinterpreted and can negatively impact the relationship. Patterns of interaction such as appropriateness of touch, space, time, and social structures are influenced by culture and can also interfere with communication (Giger & Davidhizar, 2004). Meanwhile, some western culture behaviors such as eye contact is considered confrontational and adversarial in Japanese culture. In some Hispanic cultures, sustained eye contact is considered a source of evil, while avoiding direct eye contact with superiors is a sign of respect.

Space and Time

Cultural groups differ in their need for space, which is a concept that encompasses the individual, body, and surroundings. Some cultural groups are more relational and tactile oriented than others. Touch and sitting or standing close to another is reported to be acceptable in the African American culture, whereas, it is less accepted in European cultures (Giger & Davidhizar, 2004). Behaviors correlated to space and time also influence locus of control.

Time is viewed as circular rather than linear in some cultures. During encounters, childbirth educators may need to consider that being present is more important than being on time (Giger & Davidhizar, 2004). This pattern can pose problems when scheduling follow-up appointments.

For many American Indians, limited planning occurs since the "future" is considered to be outside of the person's control. Navajo language does not include future tense verbs (Purnell, 2000; Purnell, & Paulanka, 1998). Life relates to the environment without time boundaries. The Chinese concept of time is relative to life, not something to control. Time relates to the cyclical seasons of birth, life, and death. Without awareness of the different meanings of "time," conflicts are inevitable as more ethnic minorities participate in childbirth programs.

Literature Review on the Impact of Culture on Childbirth Practices

Studies on birthing support the shared belief that childbirth is a natural process, therefore, little medical intervention is required (Johansen, 2006). Other studies have focused on the meaning of the childbirth experience from the woman's perspective. In a descriptive, phenomenological study by Callister, Semenic, and Foster (1999) the cultural and spiritual meanings of the childbirth experience were articulated as a bittersweet paradox, often accompanied by a sense of empowerment. The findings were from the lived experience of Canadian Orthodox Jewish and American Mormon women. The authors confirmed and noted that religion helped define the meaning of childbirth, while providing coping mechanisms for giving birth. Therefore it is necessity to value and acknowledge cultural and spiritual dimensions of the childbirth experience.

In 2009, Noble, Rom, Wicks, Englehardt, and Wruble concluded that health care professionals should tailor their practice by integrating knowledge of specific cultures into their management plan. They asserted that it is important to include religious observances, specific laws, customs, and traditionally Jewish practices in order to provide culturally sensitive management of labor, delivery, and postpartum.

Greene (2007) asserts that when discussing the role of support system, it is important for the educator to understand how this differs depending on the culture of the participant. For example, the husband is typically not present in the room during the birth of their child in Orthodox Jewish and Arab cultures. Similarly, Hispanic and Asian women typically prefer their mothers to be present at the time of delivery. These patterns are important for educators to be cognizant of, especially when discussing labor support partners or encouraging the use of a hired doula.

In 2006, Johansen found that birthing practices in Norway emphasize the natural process of birth, favoring midwives rather than an obstetrician and medication. Health care professionals have a minimal part in the birthing process, actually, it is considered disrespectful to women in labor. According to Johansen (2006), the problem with this perspective is that it does not allow for options. In Johansen's study of Somali women living in Norway, she found that Norwegian child birthing programs assumed Somali women wanted natural childbirth. Whereas, it was concluded that midwives fail to open up a dialog about possible birthing options. The lack of dialog and cultural understanding of Somali women in Norway contributed to unnecessary pain and complications since they were unaware of options other than natural child birth.

Cambodian women and their cultural practices were the focus of Ottani's (2002a, 2002b) studies. Based on her findings, several recommendations were made for enabling health care professionals to be culturally competent with this population, particularly in the areas of diet, finances, weight gain, and language. Mallak (2000) advised that celebrating differences by learning what one can do for the cultural participants and sharing unique aspects about oneself can be enlightening to the group. She further noted that instructors should attempt to foster a trusting relationship and set the tone by including information about one's own culture, traditions and experiences relating to pregnancy, birthing, and the postpartum period.


A trusting relationship is the basis from which to encourage behaviors necessary to promote positive outcomes during the childbearing period. Cultural awareness and sensitivity are vital to establishing dialogue and promoting a trusting relationship to assist women with making informed decisions about childbearing.

Education is a key factor in increasing cultural competence, thus promoting an opportunity for a positive birthing experience, while cultural incongruence is a major barrier to positive health outcomes. If childbirth educators show an understanding and respect for cultural beliefs, behaviors, and practices, this can be the first step towards cultural competence. Although becoming culturally competent is a complex journey, it offers tremendous reward. The journey starts with learning about self in an honest and engaging manner and gaining knowledge about women of different cultures, who are being served. Cultural competence is not achieved through words alone, but through knowledge, application of that knowledge and cultural encounters in order to improve quality of care and health outcomes.

Culture is a pattern of behavior that is transmitted from generation to generation and embedded in values, knowledge, rituals, traditions and norms (Wilson 2011).

Cultural competence requires a corresponding change in behavior. It refers to "attitudes, knowledge and skills necessary for providing quality care to diverse populations" (AACN, 2008, p1)

Culturally diverse care aims to provide optimal health care that incorporates an individual's cultural values, beliefs, and practices while being sensitive to the environment from which the individual comes and to which the individual may ultimately return (Leininger, 1991).

Ethnocentrism is the perception that one's own way is best when viewing the world. It is the standard by which all other perspectives are measured and held to scrutiny (Giger & Davidhizar, 2004).

Ethnicity is a sense of belonging to, identifying with, and having specific characteristics. Factors such as language, dialect, religion, folklore, food preference, and family geographic background are specific to an ethnic group.

Cultural Practices Related to Childbearing

Native Americans

* Don't braid or tie hair in a knot or tie any knots during labor. This may be perceived as bad luck.

* After birth, the woman attempts to maintain balance. Women should not be given cold liquids to drink or allow exposure to cold drafts.

* The practice for mothers to not buy baby's clothes before birth may be misperceived as not wanting the baby. This is not the case, it is considered to be bad luck by some Native Americans.

African Americans

* Tub baths and shampooing of hair is usually avoided during postpartum.

* Belly bands are sometimes used to reduce the baby's navel protrusion.


* After birth, shower or bathing is prohibited.

* Cold fluids, vegetables, and fruits are avoided until yang or balance returns after giving birth.

* Ambulation is limited or avoided. Therefore when teaching about postpartum practices educators should be aware that Chinese women might not ambulate, want ice in drinking water, or eat fruits and vegetable during postpartum.

* Hot water, warm rooms, and warm clothing are considered good for health. The nurse might not understand or agree with this if the client has a fever. There must be an understanding of how energy is balanced. Health is believed to be a balance between positive and negative energy. An imbalance between the two disrupts normal body functions.

* It is not unusual to delay naming a newborn.


* Mother remains on bed rest for 3 days.

* Breastfeeding starts after the 3rd day because it is believed that colostrums is bad milk until day 3.

* Position legs together soon after birth and protect head and feet from cold air.

* Touch infants while speaking to, about, looking at, or admiring.


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Linda Wilson PhD MSN RN CNS

Dr. Linda Wilson, PhD., MSN, CNS is a Professor of nursing at Middle Tennessee State University. She has almost 40 years of nursing experience in both teaching and clinical practice. She has written many articles and book chapters on topics related to Cultural Diversity and cultural competence. Her presentations have been national, as well as international and she served as a Sigma Theta Tau expert on Cultural diversity.
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Author:Wilson, Linda
Publication:International Journal of Childbirth Education
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Geographic Code:1USA
Date:Jan 1, 2012
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