I write this editorial from the Ukraine in Eastern Europe, where my husband and I have been serving a faith-based mission for nearly a year. The experience of being part of an easily identifiable small minority of "others" and being essentially linguistically illiterate has been humbling to say the least. Witnessing the lack of healthcare resources to care for mothers and infants that we take for granted in the United States is sobering and concerning. But those are stories for another day. This experience is providing opportunities for growth. It is increasing my empathy for those who are culturally diverse living in the United States. These women and their families face the challenges of being "other" on a continuing basis in their everyday lives, often with limited English proficiency. So why does culture matter? So why is culture an important consideration in the care of women and newborns? Why should nurses be concerned about increasing their cultural competence?

Factors that contribute to the need for cultural competence include increasing global migration as nearly a million immigrants come to the United States, many of whom are women of childbearing age and their families. We are caring for increasingly multicultural populations. More than 30% of the childbearing women and their families for whom we provide care are from culturally diverse groups. We witness increasing health disparities with concerns about social determinants of health such as poverty and low levels of health literacy.

We practice on healthcare teams with culturally diverse team members. We practice in a competitive healthcare market with concerns about satisfaction with care and an increasing emphasis on patient safety and quality of care issues. This means we have continuing concerns about potential litigation. We face ethical issues related to caring for culturally diverse population who do not speak English, which may compromise quality of care, increase the risk of adverse events, lack of access to healthcare, and lack of informed consent. We practice within the framework of increasingly complex legislative, regulatory, and accreditation requirements associated with caring for diverse populations.1-3

We are facing these overwhelming concerns about caring for culturally diverse childbearing women and their families. Nursing is both an art and a science, and it is important that we balance professional standards of care with the attitudes, knowledge, and skills associated with cultural competence. For perinatal nurses, it is essential that culture competence inform our care.4 Women give birth within their sociocultural context. Culture influences whether or not a woman accesses healthcare and engages in preconception planning. Culture influences the meaning of giving birth and becoming a mother. Culture influences pain-related behavior and desires for pain management during labor and birth. Culture also influences women's behavior during labor and birth, as well as their decision making about interventions. Culture is associated with defined gender roles, communication patterns, how recovery from childbirth is managed, infant care and feeding practices, and perinatal mood disorders.5-7 Culture is inextricably linked to the achievement of the global Millennial Development Goals.

Rosemarie (Susie) Vega, a birthing nurse, shared with me her reflections on caring for culturally diverse childbearing women and their families in her practice in a large birthing center in Utah:

Pacific Islanders are about the happiest and friendliest people we care for in labor and delivery. Every birthing room that houses a Polynesian family is full of people, laughter, and food celebrating the birth of their baby. Hispanic women rely on female family and friends to assist them through labor and birth. They are often stoic and demonstrate humility and gratitude for the care received. Native American women take time to "warm up" and make a connection. Often they don't make eye contact.

But there are also cultures we don't consider as "cultures." We have adolescent mothers who present with their friends and seem to have no clue about the seriousness and magnitude of having a baby. Then we have the mature multigravida who takes her role of childbirth and motherhood seriously. We have women who expect to feel NO PAIN AT ALL and those women who want to feel ALL the PAIN. We have women who just want birth to be a "safe passage" and women who expect birth to be an "enhanced passage." There are husbands who are totally involved in labor support and those who are reluctant observers. All these differences really could be classified as cultural differences.

Caring for culturally diverse women is a challenge that some of us as nurses enjoy. We need to connect with women although our cultures are diverse. We do share the commonality of women giving birth-a celebration of life no matter what the culture!

Susie insights describe the importance of attention to culture in perinatal nursing practice. One noteworthy initiative described in the literature is a new care delivery model based on relationship-based nursing practice.8 This delivery model has been implemented in perinatal units in a California hospital where nurses care for Hispanic women who constitute 41% of their patient population, with white/Caucasian women constituting only 32%. The goals of this model are to shift from task-focused to relationship-focused care, improve patient safety, and actualize the role of nurses within the framework of family-centered care. Cultural considerations are embedded in the model. Documented outcomes have included a significant increase in patient satisfaction, particularly among Hispanic women. I believe this is because Hispanic women value "small talk," that is, speaking on a personal level (personalismo) and establishing a respectful relationship (respecto). Entering the room without a specific task, sitting down at the woman's bedside, looking at the woman, and initiating a conversation beginning with something that is meaningful to the woman are strategies in this care model that contribute to satisfaction with health care.9

It is recommended that nurses include cultural considerations when seeking to improve patient safety and quality care, including the implementation of innovative models of care.8 Qualitative research is indicated to improve the care of childbearing women and their families, including the perceptions of culturally diverse women.9 It is recommended that perinatal nurses balance professional standards of care with attitudes, knowledge, and skills associated with cultural competence. Cultural competency is essential, and caring behaviors can transcend even linguistic barriers, as described by another birthing nurse:

I cared for a Korean first-time mother who came to the hospital fully dilated and gave birth to her son un-medicated. She did not speak any English, and her young husband was obviously uncomfortable and had little understanding about what was going on. As she gave birth, I could see the pain in her face, but she was stoic. I felt powerless because of her language and [other] cultural barriers, but I stayed with her and held her hand and encouraged her. Even though she could not understand my words, I hope she understood that I really cared.2

Culture counts and culturally competent care matters!

-Lynn Clark Callister, PhD, RN, FAAN

Perinatal Guest Editor

College of Nursing

Brigham Young University

Provo, Utah

References