Pregnancy and childbirth are arguably the most significant periods in the lives of many women across the globe. Whilst the stages of pregnancy and childbirth are consistent biologically worldwide, the traditions surrounding them, the care of both the foetus and the mother, the amount of medical intervention and gender roles all differ substantially between varying cultures. Specific cultures explored in this essay include the Western culture, Indian culture, Chinese culture, Brazilian culture, the culture of the Canadian Inuits and the deaf community. It is important for us as current and future healthcare workers to be familiar with some of these differences in order to become more culturally competent and respect and manage the expectations and needs of a wider range of patients. It is also important to note that whilst certain cultures have a particular custom or belief, an individual of the community may have their own differing viewpoints, therefore it is always important to determine a patients particular needs and wishes.
In modern Western culture, pregnancy and childbirth have become highly medicalised (1). It is thought that the traditions of the past stemming from religion have been replaced by a more individualistic and clinical approach (2). In the past, most pregnancies were not medically monitored and only in cases of severe complications did a woman see her physician prior to giving birth (3). Now, the methods of Cesarean section and use of instruments and medication during delivery are common practice. In the West, pregnancy and childbirth were historically one of the only aspects of healthcare exclusively managed by females. In today’s Western culture there is a much higher number of male midwives and gynaecologists, further emphasising the rise of gender equality in modern times (1). Whilst there are not many traditions associated with childbirth in the Western culture accept for religious customs such as baptism and circumcision, a small amount of women may chose to consume their placenta following birth as it is thought to give them strength (4). The more recent medicalisation of pregnancy and childbirth, specifically advances in infection control, has contributed to a much lower mortality rate for both mothers and newborns (3).
The Indian community has a variety of unique traditions and beliefs surrounding childbirth and pregnancy, mainly stemming from religious customs. Whilst India is the birthplace of four major religions; Sikhism, Buddhism, Jainism and Hinduism (5), the most prominent religious belief is Hinduism (6). Hindus carry out a number of ceremonies and rituals throughout the different stages of marriage and pregnancy, for example ‘Garbadhana’- a foetus-laying ceremony in which a newly-wed couple are prayed for in order to be able to fulfil their parental duties at the consummation of marriage. Other rituals include ‘Punsavana’- the ‘male-making’ rite which is performed to try to predetermine the sex of the foetus as male in order for it to carry on the family name and legacy and ‘Simmanantannaya’ – the wearing of red or green glass bangles on the wrist in order to produce softs sounds that will comfort the foetus from the seventh month of gestation. Simmanantannaya is seen as the mother’s last opportunity to fulfil any last wishes she has such as food cravings, as after this time she has entered a more dangerous period of the pregnancy (7). Rather than an Indian woman staying in her own home in the weeks before and after giving birth, it is customary for her to stay with her mother (8). Many working class Indian women will continue to work and lift heavy loads whilst they are pregnant, and may chose to do so right up until labour (9).
In regards to the childbirth process, it is common that both Hindu and Indian women will prefer to been seen by a woman gynaecologist and midwife in order to preserve their modesty (7). Due to modern medical advances, many middle and upper class women in urban India will use medical intervention for childbirth however many women in rural India will stick to traditional home births with a midwife present (9). However, there are still many more advances that need to take place in regards to maternity in India, as in 2015 it had the second highest rates of maternal death worldwide (10). In Indian culture there are a number of protective customs regarding the baby once it is born, such as removing the baby’s hair a period of time after birth, burying the placenta (although this is not allowed by all hospitals and clinics), performing a sacrificial slaughter and dressing the baby in an amulet. Common customs followed by new mothers include wearing warm socks and shoes to strengthen the womb and wearing flannel around their abdomen following delivery (8).
Although there are major differences in political, social and economic dimensions between mainland China and other areas of Chinese culture, there are many core values and culture traditions shared by Chinese people no matter where they are from (11). Similar to western culture, Chinese women will find out they are pregnant at home using a pregnancy test and will attend some form of clinic or hospital throughout her pregnancy. In Chinese culture there are many restrictions placed on pregnant women in order to avoid complications such as stillbirths, miscarriages and maternal deaths. These restrictions originate from the ‘yin and yang’ (positive and negative forces that counterbalance) concept of traditional Chinese Medicine and entail the pregnant lady following certain dietary and behavioural rules. It is suggested that women avoid eating cold foods as they are thought to decrease blood circulation in the uterus and increase the chances of bleeding or miscarriage. It is also advised not to eat ‘wet-hot foods’ such as shrimp, lychee, mango, pineapple or longan as these are seen as poisonous and allergy-evoking to the baby (12). If a mother is financially well off she can chose to pay to have the baby’s gender determined before birth, or chose to have the baby delivered via Cesarean section. Women sometimes chose this over a natural birth in order to avoid pain and to keep the slimness of their hips and the tightness of their vagina (13). China as a country has the highest rates of Cesarean sections worldwide (14). It is advised that pregnant Chinese women avoid any emotional stress or worry as it is believed this can translate to physical illness and complications (12). An interesting aspect of the Chinese birthing culture was the presence of the now-abolished one child policy that began in 1979 in order to slow down the rapid growth of the population of China (15). A possible detrimental effect of the implementation of this policy on the Chinese culture is the emergence of an abnormal sex ratio at birth, with sex-selective abortions being requested in order to have a son to pass on the family name and legacy (16). It is customary in China for a woman who has just given birth to enter a ‘zuo yuezi’ period in which she is confined to the home for one month postpartum. In this period it is not advised for the new mother to wash her hair or touch cold water but is suggested that she eat hot food (for example eggs and chicken) in order to restore her health and strength. The woman is supported in care for the child by her family and both mother and baby are confined to the home until the end of the zuo yuezi period when they attend a checkup at the hospital (12).
Brazil is a multiracial country that is associated with being one of the most inequitable worldwide. In the 1988 Brazilian Constitution child healthcare was deemed a right universally, however although there was free birth coverage and outreach for immunisations, the accessibility and quality of prenatal care was not greatly increased (17). The typical diet of a pregnant Brazilian lady consist of rice or pasta with beans and/or beef, chicken and eggs along with artificial juice. This is the basis of a typical Brazilian diet, however more wealthy women may adopt a ‘high-risk, high cost’ diet including food that is more expensive but more readily available such as finger foods, whole milk, yogurt and ice cream (18). Gaining admittance to public hospitals in Brazil is difficult and mothers in labour risking being turned away if their cervix is not yet dilated, causing many women to wait until later stages of labour to present to the hospital in order to increase their chances of securing a bed (19). In Brazil the idea of midwifery is rather polemic, and being a midwife is not considered a legitimate profession. Their lack of training and isolation raises concerns about the quality of prenatal care provided to women emphasised by the fact that in a study of 127 female ‘traditional birth attenders’, only 39% had ever used pharmacological drugs on a mother giving birth (20). There is evidence of racism present in the healthcare system in Brazil, and the field of obstetrics is no exception. A study conducted in 1993 found that non-white pregnant ladies had less prenatal visits and were also less likely to receive Cesarean sections, episiotomies or the option of immunisations for their newborn (17).
Another culture group with its own unique approach to childbirth and pregnancy is the African culture, consisting of both North and South Africa. Since North Africa is a developing country with low-income, the quality of its healthcare system is sub-par (21). When South Africa’s first democratic government was elected in 1994 they brought about many changes in order to improve healthcare for all South Africans following many inequalities in services. In 2005 a survey was conducted in which 89% of the study population reviewed the healthcare service in South Africa as good or excellent (22). There are many childbirth traditions associated with African culture, specifically in Western Africa, for example the act of squatting to deliver the child which signifies the mothers connection to the earth. Sometimes a stool would be used during delivery and the woman is surrounded by her female relatives and a midwife, who is only paid if the birth is successful. Since the 19th century the act of burying the placenta has been recorded. It is customary for new West African mothers to complete this ritual in order heal her womb and restore her fertility. It is also tradition for an infertile woman to urinate over the burial site in order to restore her fertility (23). In traditional African culture multiple different herbal remedies were used during pregnancy as antenatal remedies, to encourage foetal growth or to induce or augment labour (24). In South Africa, there is concerning effects on maternal and foetal wellbeing due to the Human Immunodeficiency Virus (HIV), with a reported prevalence of 38.7% in women attending prenatal clinics in the province KwaZulu-Natal (25). Midwives in the African culture have a unique role in their provision of abortion care, as in South Africa abortion is legal on request up to twelve weeks in to gestation (26). Traditionally, men were never present during labour however in urban areas of Africa this practice is now changing and men are now more involved in the birthing process (23).
A Canadian Inuit is an individual from the group of indigenous people living in Arctic Canada (27). Like other cultures, the Canadian Inuits have their own specific pregnancy and childbirth culture. The diet of Canadian Inuits in general has changed drastically in modern times, from a more hunting based culture to now a more modern food-purchasing culture (however there is not a wide variety). It is recommended for pregnant Canadian Inuit women to take vitamin supplements to ensure they are not malnourished and that the baby is receiving enough nutrients, as a recent study on the diet of pregnant and lactating Canadian Inuit women suggested that there were high inadequacies in magnesium, folate and vitamins A,C and E (28). Many Canadian Inuits are unilingual, speaking and reading only in their traditional language of ‘Inuktitut’(29). Therefore it is extremely important that all medical staff, including maternity staff, are able to communicate in a way to patients that they will understand. A study conducted found that many Canadian Inuits were highly dissatisfied with the quality of healthcare they were receiving. It was suggested that increasing the Inuit medical interpreters ability to advocate for their patients would greatly increase the satisfaction in quality of healthcare (30). This further emphasises the significant impact of communication in patient comfort and satisfaction. Traditionally, midwifery was an internal part of the culture of the Canadian Inuits, however the standard of maternity care changed in around 1970 when all pregnant women were transported to hospitals in Canada in order to give birth in an attempt to lower mortality rates. However, Inuits seen this change as part of their culture being taken away and being substituted by a more medical model that split up their families, removed pride and strength from the women and weakened the health, spirit and strength of the community. This resulted in the formation of a community-led maternity service and education program which allowed Canadian Inuits to reclaim their birth, health and culture. Whilst this approach has shown some improved outcomes for Inuit women, midwives under this system have not yet received formal recognition of their graduates under the Quebec Midwifery Act (31). More centres have been adapted in Artic Canada in an attempt to adapt to local requirements and traditions (32). Although Canadian Inuits have their own childbirth culture, they like to view each birth as an individual experience and event rather than collective. In each birthing experience there is particular emphasis placed on courage, stoicism, obedience and virtue. It is advised that a pregnant mother works hard, remains active, is obedient to elders and does not over eat in order to have a quick birth and a small but healthy baby. Crying out in pain is frowned upon as it is seen as the mother not concentrating on pushing hard to achieve a faster and therefore safer labour (33).
Another community which has its own unique culture is the deaf community. Whilst there is disagreement as to whether other disabled communities have their own culture or are no different from the rest of the community, deaf culture is more distinguished due to the use of their own specific means of communication; sign language and lip reading. In 2005 the World Health Organisation (WHO) estimated that approximately 278 million people suffer from deafness worldwide, emphasising the magnitude of the community (34). In maternity services, deaf pregnant women are often neglected due to a lack of understanding on how best to care for them based on their differing communication needs. This is further emphasised by the fact that in a study, 76% of deaf or hard-of-hearing women missed their appointment or had to wait till the waiting room was cleared due to the fact that they could not hear their own name being called out (35). Deaf women are also at a greater risk of experiencing adverse pregnancy outcomes due to the communication barrier, with many women replying on writing down their thoughts in order to communicate (36). Studies show that it is not only maternity care that is sub-par for the deaf community, but their quality of health in general is less than the rest of the population as they are put at a higher risk of ill health due to under diagnosis and under treatment of chronic conditions (37). In all cases of deafness approximately 60% of cases are inherited genetically. Genetic screening is now available for mothers with this form of deafness in order to tell whether their baby will be affected or not. This is mainly frowned upon by the culturally deaf as they are proud to be deaf and are positive about belonging to a community with its own history, language, identity and culture and therefore they are sceptical about what a mother would do with this screening result, for example they would disagree with her considering aborting the perfectly healthy child (38). An example of genetic hearing loss is Usher’s syndrome, which combines hearing loss with visual impairment (39). Usher’s syndrome follows an autosomal recessive inheritance pattern as shown below in Fig.1 (40), therefore two unaffected parents that are carried have a 25% chance of having a child with the genetic disorder. This means that an affected mother will still have a 50% chance of having a child with the condition when crossed with a carrier father, as she will have two faulty alleles.
In conclusion, the inter-relationship between culture and health (specifically pregnancy and childbirth) is very complex. Many aspects of obstetrics remain constant regardless of the culture involved, for example the alteration of diet in order to nutritionally support the child, the obvious need for some kind of medicalisation and the actual process of giving birth, which unites women worldwide. However as I have clarified above, the nature of childbirth and pregnancy and the traditions surrounding them vary greatly between different cultures, only a few of which have been discussed in this essay. The main areas of differences appear to be the ways in which diet is varied, the quality of maternity care and the extent of medicalisation (including the roles of diffferent genders). It is of vital importance that each culture’s ‘norms’ are more understood by our healthcare workers worldwide in order to give each pregnant woman the quality of healthcare that she deserves, and achieve the best foetal outcomes possible.