Learning Objectives:After participating in this continuing professional development activity, the provider should be better able to:

1. Identify stereotypes that may be harmful to the Chinese immigrant patient population.

2. Provide pregnancy and postpartum care recommendations for Chinese immigrant patients.

3. Describe common Chinese traditions related to pregnancy.

According to the United States Census Bureau, the Asian population is now the fastest growing racial group in the United States. From 2000 to 2010, the Asian population grew by 46%.1 Within the Asian population, Chinese is the most common ethnic group with almost 3.7 million Chinese people living in the United States. With Chinese patients present in more communities and in greater numbers, learning to care for this patient population will continue to gain importance. This article focuses on care of Chinese immigrant patients in relation to obstetrics.

Language

The Chinese language is made up of hundreds of different dialects. These dialects are not mutually intelligible, so health care providers must determine the specific dialect spoken by the patient to find the correct language interpreter. In the United States, the 2 most common dialects are Cantonese and Mandarin. Cantonese is the most common dialect spoken in American Chinatowns due to immigration primarily from Guangdong and Guangxi in the late 19th century and early 20th century due to political and economic upheaval in these areas. Mandarin Chinese is the official language of China, and is the language used in schools and government communication. Because of this, many patients who primarily speak another dialect will also know Mandarin. After the Immigration and Naturalization Act of 1965 abolished national immigration quotas, more Chinese-speaking immigrants came to the United States. Many of these immigrants came from Taiwan, where Mandarin is widely spoken, as well as Hong Kong, where Cantonese is most common. Health care workers should ask patients which Chinese dialect they speak, and provide any handouts in the preferred language.

Model Minority Myth

Many people in the United States have an image of Chinese people as being polite, intelligent, and wealthy. They often presume that these individuals and families have excelled in American society through hard work. This stereotype is called the "model minority myth," and reflects the racist ideology that immigrant or other ethnic groups need only work harder to achieve higher social and economic status. This myth is often applied to Black Americans as well, without taking into account the long history and current impact of systemic racism that they and other underprivileged groups face. Believing the model minority myth may result in providers discriminating against Chinese people of low socioeconomic status, sometimes completely unconsciously. For example, providers may not offer Chinese patients the Special Supplementation Nutrition Program for Women, Infants and Children (WIC) if they falsely believe the patient would not qualify for federal benefits. It is important for all providers to appreciate that the Chinese immigrant population is economically diverse and includes many minimum wage workers, particularly those who work and live in Chinatowns.

Traditional Chinese Medicine

Traditional Chinese medicine (TCM) includes multiple facets, such as acupuncture and herbal medication. Chinese patients may concomitantly see Western physicians as well as TCM practitioners. Patients may or may not disclose that they are using TCM. When reviewing medications and medical history, health care workers should explicitly ask patients whether they use TCM. In Chinese culture, Western medicine physicians and TCM practitioners are often respected equally, and providers should be careful not to dismiss TCM methods.

Acupuncture involves stimulating specific points on the body using pressure or thin needles. Research comparing sham acupuncture to real acupuncture has shown similar therapeutic benefits, demonstrating a placebo effect. However, numerous studies have shown that acupuncture is beneficial in patients with back pain, osteoarthritis, and headaches. Acupuncture is generally safe for pregnant patients. Patients should ensure that practitioners use clean, sterile needles and have been certified to perform acupuncture. Incorrect use of acupuncture can result in infection, a collapsed lung, organ, and/or nerve damage.

Herbal medications prescribed by TCM practitioners generally include multiple herbs to be taken together, and patients may not know which herbs are present in the supplements they are taking. For example, a common TCM pill prescribed to prevent miscarriage is simply called the "Antai pill" and contains the herbs dodder, Uncaria, Scutellaria, Atractylodes macrocephala, white peony, Rehmannia, Polygonum multiflorum, Dipsacus, Cistanche deserticola, and mulberry.2 There have been very few studies assessing the safety of Chinese herbal medications in pregnancy, and the safety of these herbs is largely unknown.3 Unfortunately, Chinese herbal medicines have been found to be contaminated with drugs, including warfarin and diclofenac, heavy metals including arsenic, lead, and cadmium, and pesticides and sulfites making this analysis even more difficult. Other undisclosed herbs or contaminants may also be present. Because herbal medications are not regulated by the FDA, patients cannot ascertain the purity of these medications, and providers cannot condone use of these medications.

Delivery Care

The rates of episiotomy and cesarean delivery in China are particularly high, and patients may expect either of these outcomes as a reflection of high-quality care. The American College of Obstetricians and Gynecologists no longer recommends routine episiotomy, but routine episiotomy is still common in clinical practice in China, with rates between 41.2% and 69.7%.4 It is important for the obstetrician to tell the patient explicitly that she has had an intrapartum laceration rather than an episiotomy to ensure that the patient follows the care instructions of the provider rather than presupposed healing methods following episiotomy.

Compared with global rates, the United States and China both have relatively high rates of cesarean delivery. In the United States, the cesarean rate varies from 23% to nearly 40%,5 whereas in China the total cesarean delivery rate was 36.7% in 2018. The Chinese rate also varies widely, and can be as high as 60% in urban areas.6 Given these high cesarean delivery rates, Chinese patients may expect to have a cesarean birth for minor indications. Obstetric providers should prospectively discuss the intrapartum expectations with their Chinese patients. Specifically, they should review indications for episiotomy and cesarean delivery, and should proactively discuss the risks of cesarean delivery for patients who might request this procedure for minor indications.

Postpartum Care

Many Chinese patients follow the tradition of zuoyuezi postpartum, which involves confinement in their homes and rest for 1 month after childbirth. Patients follow certain regulations dictating their diet, hygiene, and physical activity to rebalance their yin and yang. Yin is associated with femininity, darkness, and cold, while yang is associated with masculinity, positivity, light, and heat. According to TCM, pregnancy and childbirth use up large amounts of yang, leaving patients with an imbalance of excess yin. The confinement tradition discourages recovering postpartum patients from performing household chores. Birthing parents following the tradition rest in bed, avoid cold water and bathing, and adhere to a specific diet.7,8

Chinese culture considers different foods and environments inherently "hot" or "cold" regardless of temperature, and patients must reacquire the "heat lost during pregnancy and childbirth" to rebalance their yin and yang. During childbirth, patients lose blood, which they consider "hot." By contrast, water and wind have "cold" energy. Routine recommendations postpartum, such as using ice on the perineum, would exacerbate patients' predominance of yin and "cold." Chinese patients may also decline to shower or brush their teeth postpartum to adhere to the zuoyuezi tradition. Patients may bring in their own food to ensure they are eating "hot" foods. Some common postpartum meals include peanut soup and pig trotters, which are both "hot." Postpartum Chinese patients may shun the raw vegetables, fruit, and ice-cream that hospitals commonly offer because they are "cold" foods.

Conclusion

The Chinese population in the United States is growing and becoming more geographically diverse. Culturally sensitive care of this group requires knowledge of certain customs to provide unbiased and appropriate care. Health care providers should be aware of TCM practices, so they may counsel patients on the complementary use of Western medicine and TCM. Many Chinese patients practice the tradition of zuoyuezi postpartum. Understanding and respecting these traditions allows providers to give the best care to these patients.

REFERENCES