cultural competency for birth-workers and...

CULTURAL

COMPETENCY FOR

BIRTH-WORKERS AND

BREASTFEEDING

COUNSELORS

Dr. Sayida Peprah, PsyD, CD

Luz Chacón, MPH, CLE

Dr. Sayida Peprah, PsyD,

CD

Key Principles and Strategies of Cross-

Cultural Birth-work and Communication

Why Does Cultural Competency

Matter?

Isn’t pregnancy and birth a universal experience?

Shouldn’t a doula be neutral?

Isn’t is prejudice to assume that cultural differences exist?

Why Does Cultural Awareness and

Competency Matter?

Isn’t pregnancy and birthing a universal experience? YES, BUT EXPERIENCE IS SUBJECTIVE.

Shouldn’t a doula be culturally neutral? NOT POSSIBLE!

Isn’t is prejudice to assume that cultural differences exist? NO, IT IS CULTURALLY COMPETENT TO DO SO.

What is Culture?

“A set of behaviors common to a given group”;

like a template shaping behavior and

consciousness.” (LLLI)

Our culture determines our values, our

perspectives, behavior, expectations, and

communication styles.

The Dimensions of Human Differences

PRIMARY DIFFERENCES (inner

circle)

Born with these

We may have little or no control

over them

Immediately obvious

SECONDARY DIFFERENCES (outer

circle)

We may have control over these

Some can be changed

May not be immediately obvious

Six Fundamental Patterns of Cultural

Differences

Cultures Have Different:

Communication Styles (verbal and non-verbal)

Attitudes Towards Conflict

Approaches to Completing Tasks

Decision-Making Styles

Attitudes about Disclosure

Ways of Knowing (Epistemologies)

Ideas about the nature of illness

Examining Our Attitudes Towards

Ourselves and Others

Cultural Lens (Family culture, Educational culture…)

What does your culture say about pregnancy, breastfeeding, about certain groups?

Biases

What do you like and dislike the most about certain group’s approach to pregnancy, birthing, parenting?

Assumptions

What are your beliefs, attitudes and assumptions about mothers, fathers, grandparents… from particular groups?

Cross-Cultural Awareness Exploring

Stereotypes Exercise

Food

Marital Status & Family

Size

Clothing

Religion

Occupation

Physical Features

Educational Level

Economic Status

Language Spoken

Music they listen to

Neighborhood they live in

Key Concepts

Stereotyping

Ethnocentrism

Prejudice

Bigotry

Chauvinism

Cycle of Prejudice

Effect of Past and Present Experiences

Set ourselves up Difficult interaction

Faulty data Negative, judgmental reaction

Cross-Cultural Communication

Communication styles

Communication Styles (verbal and non-verbal)

Eye contact –direct or indirect

Proximity to each other

Interruption on turn taking

Response quick or slow/assertive or passive)

Intonation – affected or low key

Strategies for cross-cultural

communication.

Strategies for Cross-Cultural Communication:

Be culturally informed, but not stuck on any set of ideas

Be willing to learn more from others

Acknowledge your discomfort (internally) and if appropriate verbalize it

Know your own “cultural script”

Develop sensitivity

Listen more, talk less

Have a sense of humor

Acknowledge commonalities as well as differences

References

1. Taylor, S. P., Nicolle, C., & Maguire, M. (2013).

Cross-cultural communication barriers in health care.

Nursing Standard, 27(31).

2. Purnell, L. D. (2012). Transcultural health care: A

culturally competent approach. FA Davis.

3. Huff, R. M., Kline, M. V., & Peterson, D. V. (Eds.).

(2014). Health promotion in multicultural populations:

a handbook for practitioners and students. SAGE

publications.

Luz Chacón, MPH, CLE

Understanding and Approaching Breastfeeding

Support with Latino/Hispanic Families.

Objectives

Describe health beliefs within the Latino culture

Discuss breastfeeding challenges for Latinas/women

of color and low-income families including cultural

myths, societal stigma and institutional barriers

Promoting Breastfeeding is a Public

Health Priority

Health care organizations and professionals around the world universally accept breastfeeding as one of the most important preventative care measures for children’s health.

Given the health disparities, increasing breastfeeding rates among women of color and low-income women is an important intervention that can help close the gap.

Healthy People 2020 Objectives

Increase the proportion of infants who are breastfed:

Goals California 2013 L.A. County

Ever 81.9% 91.6 81.9%

At 6 months 60.6% 71.3 50.5%

At 1 year 34.1% 45.3 30.1%

Exclusively through

3 months

46.2% 56.8 38.6%

Exclusively through

6 months

25.5% 27.4 16.2%

CDC Breastfeeding Report Card, 2013 & CDC National Immunization Survey,

2000-2009

Breastfeeding Initiation Rates

0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

70.00%

80.00%

90.00%

100.00%

White Asian Latina African American

Breastfeeding Rates in California Hospitals, 2013

Any Exclusive

California Department of Public Health Genetic Disease Screening

Program, 2013

Breastfeeding Data

“ … mothers who are less acculturated and demonstrate closer ties with their cultural traditions, beliefs, and practices are most likely to initiate breastfeeding.” (M. Gibson, MD, PhD, et al., “Prevalence of Breastfeeding and Acculturation in Hispanics: Results from NHANES 1999-2000 Study, Birth, Vol. 32, Issue 2, p93, June ’05

Structural Race Inequity

Health & breastfeeding

disparities

Institutional racism (policies,

practices)

Historical and political factors

Interpersonal discrimination

Under-resourced

communities

Structural Barriers for Latinas/Women of

Color and Low-Income Women

Access barriers

Lack of access to quality healthcare

Lack of adequate access to lactation services (lactation consultants, breast pumps, etc.)

Lack of adequate transportation

Lack of childcare

Lack of culturally and linguistically competent care

LAMB Survey Breastfeeding Data,

2010

Latinas reported less encouragement at the time of delivery

Asian/PI (96%)

Whites (93%)

African American (92%)

Latinas (88%)

Certain mothers reported less encouragement from provider at well-baby visits compared to overall population (66%):

Living in SPA 6 (59%)

Latina (60%)

Foreign born (58%)

WKKF State of the Latino Family, 2014

25%

32%

49%

59%

65%

78%

0% 20% 40% 60% 80% 100% 120%

Employer

Counselor/midwife/doula

Nurse/doctor/promotora

Hospital/clinic

Family/friends

Partner/father

When nursing your baby, did you receive support from…?

Yes No

Structural Barriers for Latinas/Women of

Color and Low-Income Women

Hospital practices that interfere with breastfeeding

73% of the lowest-performing hospitals for breastfeeding in 2013 are those that serve predominantly low-income families and women of color.*

Work and school environments that don’t provide lactation accommodation

*California WIC Association and UC Davis Human Lactation Center, 2014

Structural Barriers for Latinas/Women of

Color and Low-Income Women

Formula is aggressively promoted to low-income women (predatory marketing)

Easy access to formula

Lack of adequate paid maternity leave

About half of White women have paid parental leave compared to 43% of Black women and 25% of Latinas

Social Stigma

Mainstream culture does not welcome breastfeeding

Lack of acceptance of breastfeeding in public

The breast is a sexualized object

Men are not always supportive

Misguided campaigns and media portrayals

Who is the Latino Population?

Largest ethnic minority group in the U.S.

54 million in 2013, projected 129 million by 2060

17% of population today, 31% by 2060

Latinos outnumber whites in California

14.92 White vs. 14.99 Latinos

Largest population in L.A. County (4.8 million)

48.4% Latinos, 26.8% non-Latino whites

84% Mexican, 9% Central American, 7% other

subgroups

Who is the Latino Population?

Latinos share many values and perspectives, but are

also very diverse.

Country of origin

Socio-economic status

Skin color

Immigration status

Reason for migration to the U.S.

Assimilation & acculturation: When did they or their

families migrate to the United States?

Spanish Speaking Countries

1. Argentina

2. Bolivia

3. Chile

4. Colombia

5. Costa Rica

6. Cuba

7. Dominican Republic

8. Ecuador

9. El Salvador

10. Equatorial Guinea

11. Guatemala

12. Honduras

13. Mexico

14. Nicaragua

15. Panama

16. Paraguay

17. Peru

18. Puerto Rico*

19. Spain

20. Uruguay

21. Venezuela

* U.S. territory

Understanding Latinos: The Historical and

Cultural Context

Different ancient civilizations (Mayan, Aztec, Incan, Caribbean, etc.) existed before the area was “discovered”/colonized by Europeans.

Conquest by Spain & Portugal led to the “Mestizaje” – the mixture of Indigenous, European and African peoples Fusion of cultures includes

belief systems related to health and spirituality

Latino Values & Health Beliefs

According to the National Alliance for Hispanic

Health there are certain cultural values that affect

the way Latinos approach health care issues:

Family

Spirituality

Respect

“Personalismo”

Importance of Family

Family is very important

including extended family

and kinship networks

(comadres, madrinas,

padrinos, etc.)

Family has strong influence

in decision-making, less

individualistic.

Importance of Religion, Spiritual Forces

and Fatalism

Latino culture tends to view health in a continuum of

body, mind and “espiritu” (spirit).

Prayer is often thought to have profound impact on

health.

Traditional medicine is still very alive, especially

among recent immigrants and there is a resurgence

in “curanderismo” among non-immigrant Latinas

reclaiming this heritage and holistic practices.

Importance of Respeto

Respeto (respect) dictates appropriate deferential

behavior toward others based on age, sex, social

position, economic status and authority.

Health care providers are afforded a high level of

respect as authority figures.

General rules to show respect:

Use “usted” until you are asked otherwise.

Always be more formal with older Latinos.

Formality should not be taken to mean coldness or

distance, but rather politeness.

Encourage clients to ask questions (out of a sense of

respect, many perceive questions to be a form of

disagreement or expressing doubt).

Importance of “Personalismo”

Personal vs. impersonal (institutional) relationships.

Latinos prefer providers to be warm, friendly and

take an active interest in the patient – “confianza”

(building trust)

Continuity of care is preferred.

Common Beliefs in the Latino Culture

“Las dos cosas” may be

viewed as the best of both

worlds

Can be viewed as combining

the traditional (natural) with

the modern (scientific)

Mixed messages from

providers and formula

discharge packs

Misconceptions about the

importance of exclusivity

Common Beliefs in the Latino Culture

Concerns about milk

supply

Perceived insufficient

milk supply

Going outside or

getting cold exposure

to the back

Nipple preference

Lack of confidence

Common Beliefs in the Latino Culture

Big is beautiful/

healthy

Belief in the need to

supplement if baby is

not chubby

Supplementation if

baby is crying

Can result in

overfeeding

Common Beliefs in the Latino Culture

Stress/negative emotions (coraje, susto) and the

impact on quantity or quality of milk

Teas for colic or constipation

Mothers want to breastfeed, but it can be a

struggle (perceived or real) – fatalism

Pain

Dietary restrictions

Common Beliefs in the Latino Culture

Perceived convenience

of bottle/formula

feeding

Baby stays full

longer/sleeps longer

Others can feed baby

Easier to bottle feed in

public (embarrassment,

modesty)

Welcome Baby

Breastfeeding Rates

54%

68%

50%

53%

AfricanAmerican/Black

Latina /Hispanic

California Rate WB Prenatal Rate

Exclusive Breastfeeding Initiation Rate Comparison

Overcoming Barriers through Cultural

Competency

Practice cultural humility – self-awareness, reflection and a respectful attitude toward diversity

Build trust and rapport – “confianza”

Assess and explore individual needs:

Beliefs related to breastfeeding

Past breastfeeding experience, if applicable

Level of interest in breastfeeding/exclusivity

Level of confidence in breastfeeding

Family/partner/social support

Current living situation, employment

Overcoming Barriers through Cultural

Competency

Dispel misinformation and/or misunderstandings related to past experiences, as needed

Explore ambivalence

Provide education and support in a holistic and family-focused approach

Address needs within the context of the family, including others (fathers, grandparents, etc.)

Holistic view of health--mind, body, spirit

Overcoming Barriers through Cultural

Competency

Identify and honor cultural

values and strengths

associated with breastfeeding

and other positive health

behaviors

“La cuarentena”

Motherhood identity

Resilience and hardiness (“somos

luchadoras”)

Overcoming Barriers through Cultural

Competency

Identify and address common barriers

Emphasize the importance of avoiding or at least delaying supplementation – discuss the negative impact of formula on supply and infant gut flora

Emphasize the importance of seeking help if they have concerns about milk supply

Provide anticipatory guidance

Milk supply is based on milk removal and suckling rather than diet or fluids

Normal feeding patterns and growth spurts

Overcoming Barriers through Cultural

Competency

Offer continuity – ongoing support, if possible

The decision to breastfeed is not made just once, but

many times, as mothers confront challenges and barriers

to exclusive and continued breastfeeding.

Collaborate with WIC, peer counseling or other

public health programs that have a culturally

competent approach to support mothers

Overcoming Barriers through Cultural

Competency

Strive toward communicating without introducing

elements of power into the relationship.

Collaborative rather than prescriptive

Empathic, reflective listening

Empowerment

Nonjudgmental

Respectful/honoring of autonomy – embrace the client’s

decision – she is the expert on her child and her

situation

Overcoming Barriers through Cultural

Competency

Practice Spanish skills

Mothers will

appreciate your

efforts and interest in

connecting

Recognize when you

need an interpreter

and use one

In short….

Culture plays a significant role in every individual’s life, but it is not the sole determinant in defining a person’s beliefs and behaviors.

There are many differences within a culture and there will always be individual variations from any cultural norm.

When you work with a client, you are not just helping a person with a condition or problem, but an individual with a history, cultural background and experiences that matter.

References

“State of the Latino Family”, W.K. Kellogg Foundation, 2014

“It’s Official Latinos Now Outnumber whites in California”, Los Angeles Times article, 7/8/15

“Removing Barriers to Breastfeeding: A Structural Race Analysis of First Food,” Center for Social Inclusion, 2015

“Breastfeeding Report Card”, 2013, CDC

“Breastfeeding in Los Angeles County: Exploring Mother’s Barriers to Initiation and Reasons for Stopping”, The Los Angeles Mommy and Baby Project, MCAH Health Programs, 2013

“Bringing Breastfeeding Home: Building Communities of Care”, CWA and the UC Davis Human Lactation Center, 2014

“Association between Acculturation and Breastfeeding among Hispanic Women: Data from the Pregnancy Risk Assessment and Monitoring System”, 2012

“Maternal Child Health and Breastfeeding in the Latino Community”, National Alliance for Hispanic Families, 2012

“Latino Families in the Perinatal Period: Cultural Issues in Dealing with the Health-Care System” Great Plains Research: A Journal of Natural and Social Sciences, 2002

Considerations for

Approaching Pregnancy and

Birth Support with Specific

Cultural Groups

Muslim Women and Families

Common culture-specific values

Common beliefs

Common customs

Common communication styles

West African Women and Families

Common culture-specific values

Common beliefs

Common customs

Common communication styles

Jewish Women and Families

Common culture-specific values

Common beliefs

Common customs

Common communication styles

Share a specific example (in 1 minute) of

effective cross-cultural dynamics or approaches

you have experienced/encountered/utilized

Participant Reflections

Questions and Answers

THANK YOU!!!