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Abstract

Target: To wathc behavioural patterns of cultural origin during delivery in inmigrant women which could haverd health assistance.
Material and methods: Qualitative investigation based upon participating observation and twenty semi-structured interviews to inmigrant women.
Results: Cultural sensitivities regarding sense of prudeness and the preference for female obstetric assistance have been found, also in perception of attitude towards labour pain, in company preferences during labour, in their experience and perception (position during third stage, acceptance of medicalised labour, etc.), as well as in patterns of inmediate interaction with the newborn.
Conclusions: The differences found, which can not be generalised towards the whole of women from the same geographical origin, occasionally are misunderstood by the  health profesionals, and may help us understand that our model of performance is not the only one, or the best, or the most "natural", allowing to establish a health assistance sensitive to every woman's needs.

Introduction

     Over the past two decades, a lot of immigrants from developing countries have come to Spain. Immigrant women represent a young population and as a consequence, most of them are of reproductive age¹, so that attendance at birth is a main priority.
     Health assistance/care can be influenced by both cultural and linguistic barriers² because reproduction and maternity are bio-cultural phenomena where values, feelings and beliefs are reflected^3,4.
     There is a great diversity of experiences concerning delivery. In some traditional areas, empirical midwives take part in the delivery process which takes place at home. They have special traditions when assisting the newborn⁵ and the post-natal mother. Nevertheless, in the west, birth takes place in hospital and medication levels are high.
     Even if for immigrant women, Spanish health improvements result in a decrease in maternal and neonatal morbid-mortality rates, socio-cultural differences between both countries may lead to a clash of habits in health assistance during delivery. It is by that, related to the delivery care, that may occurs conflicts between the origin and reception customs.
     Cultural aspects play an important role in the perception and acceptance of the health services and they have been studied in the case of fertility, contraception⁶ and puerperium⁷. It has been considered the reproductive behaviour of immigrant women influenced by socio-cultural and health concepts of their home countries but also by the habits of the countries in which they are living right now. It is not common for people to get used to new rules and values and to forget about their habits, they just try to combine values of both cultures by changing some traditions and holding up some others⁸.
     Whatever the influence of the culture in reproductive behaviour, health professionals do not always understand these differences in the health assistance and from an ethnocentric attitude, we often judge people based on our prejudices and lack of understanding. This may lead to unfairness in the health care. However, cause-effect relation is not always stablished between stereotypes, prejudices and discrimination. Sometimes and because of these differences people are not treated equally and it usually happens in the health field, where prejudices are not normally the cause of discriminatory attitudes because according to professional principles, we should act with fairness9. Nevertheless, we may show subtle¹⁰ signs of prejudice towards them, shown by a minor expression of feelings of affection and warmness in the assistance and a lack of recognizement of the cultural specifities of those women, either because we do not know about their cultural patterns or because of ethnocentric attitudes. This last aspect responds to a defense of traditional or "normal" values when giving birth. We are talking about criteria which determine whether the attitudes are acceptable (adjusted to this values) or not (not adjusted).
     That is the reason why the aim of our research has been to study the behavioural patterns of immigrant women during delivery that can have a cultural origin, and result in some difficulties in the relation, in intercultural clash and in prejudices showed by health professionals assisting them.  

Methodology

     Qualitative investigation based upon participating observation has been carried out. It includes informal conversations and twenty semi-structured interviews. Observations have been carried out between January and May 2002 in the areas of obstetrics and in the delivery room of a public hospital in Andalusia, taking advantage of all the interactions and the professional attention of the investigators with women inmigrants.
     It has been explained the aim of the semi-structured interviews to women and we have promised them not to reveal their names. The selection criteria was their linguistic competence of Spanish and their willingness to collaborate with us. They told us about the way they lived the delivery at the hospital, their preferences for assistance and their attitude towards labour pain, as well as the difficulties concerning assistance. All the information compiled after every observation and interviews were first written in a field journal and it was later codified and analysed qualitatively.
     The sample consisted of immigrant women who have given birth in this hospital, their relatives and all those accompanying them. The hospital is located in an area with a diversified population with a high percentage of immigrants, so that 20% of the deliveries where foreign women deliveries. Most of them came from Africa, followed by eastern European and women from Latin America.

Results and Discussion

     Sense of decency. In our culture, assistance to women is provided by professionals of both sexes, but it does not happen in other countries. We realized that just some women, mainly from Africa, are unwillingly to be examined by a male gynaecologist. It does not happen only with male health professionals but with men in general. In most cases, their husbands prefer to leave their wives alone during examination. This situation has been described in literature with Muslim women¹¹ that consider their body as a symbol of custody of the honour of their family. This attitude also has to do with the sexual segregation of traditional Muslim societies.
     Nevertheless, even if the sense of decency and the preference for female assistance is higher for Muslim women, it is often overestimated. A lot of women are not reluctant to be examined by male doctors. Furthermore, even if cultural factors play an important role, they get over these differences after they are explained the reason for the examination and after they realize that they are being kindly treated.
     Perception and attitude towards labour pain. The perception and expression of pain have a lot to do with socio-cultural^12,13 differences. In some cultures, women are asked to be quiet during delivery, while in some others it is assumed that they shout as a way to express their pain¹⁴. The vast majority of women from East Europe and sub-Saharan Africa have stoical behaviour. African women make grimaces of pain with facial muscles and the body movements are minimum. When they are in great pain, they make guttural sounds of difficult description. Their faces express pain and there are usually problems concerning verbal communication.
     On the contrary and although it is not general to the whole colective, it is common for North African women to have fewer inhibitions, expressing their pain more clearly and they become even exasperated. Sometimes they complain noisily, making active corporal movements even if they are not in the active phase of labour. They usually repeat a litany in their language or they call their mothers.' It is even verified women who ask for epidural, continue to express their pain. Nevertheless, just a few of these women ask for epidural analgesia, in most cases, because they do not know anything about it. On the contrary, South American women or women from Eastern Europe know about this kind of anaesthetic and they often ask for it.
     Apart from cultural aspects, the perception of pain can be influenced by information previous to birth, and psycho-social conditions of immigrant women: finding themselves in a different context makes it possible for them to feel afraid about the delivery. The fact that they feel alone and the lack of emotional support may decrease the tolerance of pain.
     Whatever the reason for the perception of pain, they are not always understood by health professionals participating in the delivery process. We do not want women, whatever their country, to express their pain and we consider negatively those who complain "too much" because they demand more health assistance.
      Company during labour. Cultural aspects also play an important role when talking about company preferences during labour although there are enormous differences between women from the same culture. In general, Muslim men are more reluctant to accompany their wives during delivery. Some of them accompany their wives during dilation but they are physically far from them without stroking or encouraging them, they just go in and out the delivery room. Some health professionals consider this attitude to be "indifferent" to the pain endured by women. Even if sometimes they accompany their wives during dilation with a loving attitude, they prefer not to be with them during third stage. Some men, who have been previously convinced to enter the delivery room have then expressed their gratitude and satisfaction after witnessing the birth of their child.
      But it is not just an attitude typical of men. Some African women express their wish not to be accompanied by their husbands for a number of reasons: linguistic incompetence, occupations or just because "labour is only for women". Here we have an example:
     "A Moroccan woman entered the delivery room. She told me that her husband wanted to be with her during delivery. Her husband, who spoke fluent Spanish, acted as an interpreter to complete the clinical history. The woman complained but her husband did not approach her to support her. When I went to examined her I realized that she did not want to take her clothes off in front of her husband. During delivery she pronounced repeatedly the name of her mother. Suddenly she gestured to her husband to ask him to get out of the room. After the child was born, the woman covered her genital area with green cloths and she did not let us examine the area. When there were just the two of us in the room, she removed the cloths and said to me that I could begin".
     This story suggests that the woman asked her husband to be there just because her insecurity was stronger than her embarrassment. This is a common situation, but it does not always happen. There are also some cases in which husbands express their feelings before and after the birth to their wife and newborn.
     Immigrant women from any country who enjoy social and familiar support sometimes prefer to be accompanied by a friend or a female relative. However, when they do not have relatives, a friend can witness the delivery process. They are usually compatriots who have been living here for a long time and who speak our language and who know the way our health system works, that is why they sometimes act as translators and speak to health professionals. This is a social and gender phenomenon very common for North African and eastern European women; however, it does not happen with sub-Saharan women who very often give birth alone. Sometimes they are accompanied by Spanish women who are their friends or with whom they have a work relationship. Sometimes they are accompanied by women just because their husbands give priority to work or because they prefer to wait in the waiting room.
     When women are not able not speak Spanish, it is very useful for health professionals to count on husbands or friends that come in the dilatation or delivery rooms who act as translators when they ask them about clinical information or just when they want to say something to the woman in labour. Besides, relatives or friends should take care of the woman and the baby during the two hours after the birth, that is why when they are reluctant to do it, health professionals might get angry and say that "they should get used to Spanish habits".
     It is understandable that some foreign men do not feel comfortable when they are asked to take part in the delivery process. In some cultures and traditional societies, the delivery takes place at home and just women take part in it. In Spain, from halfway through the 20th century -when deliveries started to take place in health facilities- families did not take part in the delivery process and they had to wait in the waiting room until the baby was born¹⁵. However, the father's role has been promoted through the last years as a result of new cultural values.
     With the birth rate on the decrease, the concepts of maternity and paternity have been redefined. According to the new cultural concept of paternity, to look after the children is considered to be a very important factor. The father's role¹⁶ starts by supporting the woman and taking care of the newborn. In fact, for most non-immigrant women it is important to be accompanied by their husbands during the delivery process. They do not feel that it is necessary to be accompanied by anyone else¹⁷.  
     However, there are some exceptions to this rule which have to do with cultural differences and historical changes that have taken place in our society over the last decades that are not taken in consideration. It would be necessary for professionals to question the belief that the person who accompanies the woman during childbirth should always be the husband. They should also ask immigrants and non-immigrant women about their preferences, so that husbands only accompany their wives because they are willing to do so but not because that is what most people do¹⁸.
     Experience and perception during labour. In our culture, acceptance of medicalised labour is largely widespread, whereas in some other cultures it is not. We expect women to obey all rules, to accept all care provided and to do as health professionals tell them to do but it is not always the case for women from different geographical origins. Here we have a revealing example:
     "A woman from Ecuador pregnant with her fourth child came to Accident and Emergency on her own. She had arrived in Spain just two months before. After being examined, we realized that she was in her final phase of pregnancy, so we decided to start with the ordinary protocol: to shave the perineum, bedding her, to monitor the heartbeat of the foetus and to find a venous access. As we carried on with all these things, we realized that she did not feel comfortable and that it was all very strange to her. She repeatedly insisted that we removed the "straps". She wanted to walk. We said to her that she could not get out of bed. While artificial amniorrhexis she asked: why are you doing that? Rapidly she reach the complete dilatation. However, even if contractions became more frequent, she did not push. We decided to take her to the delivery room. When we told her to push, she asked: "Let me squat". She squatted and the baby was born".
     This is also a common situation for African women and it gets on the nerves of health professionals, who are used to acting quick and to forcing the delivery. Although most women from different cultures give birth in a vertical position, in Spain as well as in other countries, they give birth lying down because it makes things easier for professionals. However, we know about the advantages of the freedom of movement¹⁹ during labour.
     Interaction with the newborn. Even if the way of expressing feelings differs from one person to another, after the baby is born the mother is expected to remain calmly and peacefully. Sometimes they express their feeling of happiness and affection by kissing or saying lovely words to the newborn²⁰. However they are some women that do not show any interest during immediate postpartum even though they had desirable pregnancies. They do not show their feelings towards the newborn. After childbirth, the baby is placed on the belly of his mother but some women do not touch them or they do not even look at them. The attitude of these women could be defined as "emotionally deprived", which means that they do not express their feelings in a "natural" and "common" way.
      Instead of making an effort to understand the reasons for this attitude, health professionals say things like that: "I don't understand that, they don't love their children", "It would have been better not to have had children.", "What a shame!"  We say that because we only think of our culture and the way mothers express their love to their children when they are born²¹.
     What are the reasons for this attitude? We may think that the personal situation of these women makes them not to express their feelings. However, some authors state that we should make a difference between natural and social affections. They say that we should have in mind that these attitudes, as well as some other attitudes which have to do with feelings, are not natural and depend on the socio-cultural and economic context in which they take place. In some places where perinatal and child birth and mortality rates are high, the bond between the mother and the newborn²² is not immediate. In fact, we have realized that in our postpartum rooms, women that were considered to be "unaffectionate" towards their babies while they were in the delivery room, show their affection some minutes afterwards, so that they express their motherly love but at different times.

Conclusions

     This study highlights difference in behavioural and attitudes patterns of cultural origin during delivery. However, even if some differences have been found between women from different groups, they cannot be generalised: individual variability is an important premise.
     Because of the increasing amount of immigrants, health professionals face a wide range of new cultural situations in health assistance. In order to overcome difficult situations when dealing with these patients, some strategies considering a broad range of socio-cultural and economic contexts should be adopted.
     The differences found in those minorities, which cannot be generalised to all women from the same geographical origin, are occasionally misunderstood by the health professionals, and may help us understand that our model of performance is not the only one, or the best, or the most "natural", allowing to establish a health assistance sensitive to every woman's needs.
     In order to face up to this challenge, a cognitive change in health professionals and a better anthropological education are needed. It should be promoted attitudes of respect to the otherness and differences in behavioural patterns of cultural origins should be relativized provided that they respect human dignity and human rights.
     It is also important for professionals to work on interculturality in order to improve "cultural sensitivity" and mutual respect. The biomedical model is considered as the hegemonic, to be the best one, although there is a lack of reflection about the cultural bias of the system. It is a fact that the ideology of the western biomedical system offers to our professional praxis some rules of behaviour which are not supported by the scientific evidence and that there are a lot of ritual and symbolic aspects concerning health professions and institutions and that the intrahospital space also creates cultural ways of assistance which change through the years²³.
     In order to become sensitive to cultural diversity, it would be really important for professionals to think about it and to become aware of the implicit culture of our health institutions. Adopting a political attitude towards our own praxis, influenced by cultural values, and understanding that expressions and habits concerning health and illness change from one culture to another and even within the same cultural system is the first step to understand the women we deal with, either if they are immigrants or not.

References

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