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!!!