Enf.º Tito Félix

Maternal and Obstetric Health Specialist Nurse 
Gynecology and Obstetrics Service

Cultural dimensions in pregnancy and childbirth

A multicultural approach to maternal health care

HPA Magazine 20

Culture plays a significant role in preparing women for the experience of motherhood, as it is in culture where the main traits that differentiate us among humans reside. 
Motherhood in general, and specifically pregnancy and childbirth, are not exempt from this rule and are involved and influenced by personal beliefs, cultural values, and practices.
Health professionals are not expected to know the cultural specificities of each client, but it is expected that they use open communication and show respect in their interaction with these women and families.

Therefore, there are important issues underlying the assistance to women with cultural backgrounds that differ from Western and Eastern cultures. This study generally lists some items to be taken into account in a first contact with these clients:

> Where were they born?
> What are their ethnic roots?
> How long have they been in Portugal?
> What is their native language?
> Do they need an interpreter or do they speak a second 
   language?
> What pregnancy, childbirth, and postpartum-related 
   habits or practices should be taken into account?
> What particular dietary habits are respected during 
   this period?
> Is there any particular aspect in the care of the 
   newborn?
> What is the importance of breastfeeding?
> How is pregnancy monitoring carried out?
Additionally, it is pertinent to understand if there is any resistance to a male health professional, how pain is perceived and expressed, what is the importance attributed to the figure of the father as a companion throughout the process (or other relevant family figure), and also how the postpartum period is culturally experienced.
(As a curiosity, in most African countries, in the Middle East, and some Asian countries, the father is relegated to a secondary role, and his presence in the maternity ward or involvement in the process is not required. Another example is that fetal sex determination is illegal in India. 
In Japan, childbirth and pain are seen as natural and physiological, and the use of analgesia is rare. It is also forbidden to take a bath or wash hair after childbirth in Japan for a period of 7 days. In many Asian countries, there are confinement centers where women remain for a certain period after childbirth. There are maternity wards where rooming-in is not a reality, and the newborn is only brought to the mother for feeding.)
The study referred in this article characterizes some ethnic profiles to better understand and respect them regarding communication, health, pregnancy, childbirth, and postpartum care. We selected the Chinese and Indian populations as they coincide with relevant groups in Portugal resulting from large immigration flows, and also because they are geographically distant and culturally diverse.
CHINESE POPULATION

Communication
This population group does not spontaneously talk about their problems because they assume that Westerners allegedly do not understand their culture and habits. Many avoid saying "no" claiming that it is impolite to do so. Open discussions about sexuality are often considered taboo. Most Chinese women prefer to be assisted by female doctors and nurses (by healthcare professionals of the same gender and sex).

Health
Food is commonly classified into two main groups called "hot" and "cold" according to the effects they have on the body. Health is understood as a balance between positive energy (yang) and negative energy (yin). Disease is attributed to an excess of hot and/or cold foods in the body. It can also be due to inheritance from ancestral family errors, the combination of year, day, and month of birth, the influence of evil forces, and a deficiency of Feng Shui* (an ancient practice whose objective is to eliminate negative energies from environments to bring more balance and harmony to spaces). It should be noted that traditional Chinese medicine is based on more holistic treatments, such as acupuncture, among others.

Pregnancy
During this period (as well as in a state of illness), the woman assumes a position of dependence on caregivers. The encouragement of self-care that we often promote can be understood as a lack of care and attention. They believe that pregnancy and childbirth affect the energetic balance necessary for "good" health. Thus, to keep the mother and newborn healthy, the ingestion of chicken broth is encouraged. Lamb is contraindicated because it can cause epilepsy in the baby, and pineapple is an abortive food.

Childbirth
Culturally, Chinese women believe that they should not exhibit exuberant manifestations such as crying or shouting during childbirth. Sitting or squatting positions are traditionally considered the most appropriate. Ideally, the mother or mother-in-law is the most present figure, rather than the husband.

Postpartum
Most postpartum women observe a period of isolation during which they rest (the newborn is separated from the mother in the first 24 hours), wear warm clothes, limit their baths, and consume foods classified as "hot". In certain regions, the postpartum woman does not eat meals with the family because she is considered impure due to the lochia (blood, mucus, and tissues from the inside of the uterus during the postpartum period).

Newborn Care
Traditionally, the newborn is swaddled and completely restrained. They are placed in a prone position. There is a belief that if the newborn wears used clothes, they may assume the characteristics of another individual. 
The Mongolian spot (bluish pigmentation in the sacrococcygeal region) is very common in these babies and can persist until 24 months of age.
Colostrum is considered impure and therefore wasted until the transition to breast milk. Instead, babies are fed with rice water or formula.

INDIAN POPULATION

Communication
Indian patients may always respond "yes" to please healthcare professionals, even if they have not fully understood what has been explained to them. Therefore, it is extremely important to validate the information conveyed with them.

Health
Ayurvedic medicine is based on the basic principle of balancing the elements: Air, Earth, Water, Ether, and Fire in our body. The alteration of this balance (homeostasis) results in disease, and has its origin in certain incorrect dietary habits. Blood is seen as the force of life and something precious.

Pregnancy
In India, pregnancy is considered a normal physiological process that does not require the intervention of healthcare professionals, except in exceptional cases. Women have a fatalistic view in which, like in life, pregnancy and its outcome are beyond their control.
Boys are preferred over girls, and therefore, determining fetal sex is illegal in India, as many women admit to terminating their pregnancy when they believe they have conceived a girl. Some believe in the power of certain medicinal herbs to produce a boy. Twin pregnancy is seen as a curse. "Cold" foods are recommended in the early stages of pregnancy to avoid miscarriage, and "hot" foods are recommended in the later stages of pregnancy as it is believed to facilitate childbirth. The more privileged classes make an effort to respect the pregnant woman's wishes. A baby who cries a lot is an indicator that the mother was not treated well and cared for.

Delivery
The woman in labor is isolated from the family because she is in an "impure" state, and crying and screaming are well accepted. Throughout the process, the woman can choose to lie down, squat, or sit on an appropriate stool. The loss of blood after delivery is seen as a procedure to purify the uterus and the woman.