Pre‐ and Perinatal Care of Hispanic Families: Implications for Nurses

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PRE- AND PERINATAL CARE of HISPANIC FAMILIES Implications for Nurses

Susan B. Darby, RNC, MSN

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The terms Hispanic American or Latino American are broad terms that refer to groups with a cultural and national identity arising from Mexico, the Caribbean, Central and South America, Puerto Rico, Cuba, Spain and other Spanish-speaking communities who now live in the United States (Munoz & Luckmann, 2005; Spector, 2004; U.S. Census Bureau, 2004). In 2004, 35.2 million Hispanics accounted for 12.5 percent of the total U.S. population, representing an increase of 61 percent from 1990, when there were 21.9 million Hispanics living in the United States (U.S. Census Bureau). Within this Hispanic population are many women of childbearing age who utilize health care services during pregnancy and childbirth. In fact, Hispanic women had the highest fertility rate (97.7 births per 1,000) of all ethnic/racial groups and accounted for 23 percent of all births in the United States in 2004 (compared with 15 percent in 1990) (Hoyert, Mathews, Menacker, Strobino, & Guyer, 2006). This article offers general guidelines for providing cultural care to Hispanic American families during the pre- and perinatal period and covers topics such as communication, high-risk health behaviors, maternal-child nutrition, and child-bearing customs and beliefs. These guidelines provide a helpful starting point for working with many Hispanic clients, but it’s still important to bear in mind that some Hispanic individuals do not follow their culture’s traditional values either because they’ve assimilated values of a different culture (e.g., U.S. culture) or because they’ve formulated their own value system. The most important consideration is that each Hispanic woman is first an individual and second a member of a cultural group (Munoz & Luckmann, 2005). Susan B. Darby, RNC, MSN, is an assistant professor of nursing at Wilkes University in Wilkes-Barre, PA, and a doctoral student at Texas Woman’s University in Houston, TX. DOI: 10.1111/j.1751-486X.2007.0131.x

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Effective Communication For those clients who do not speak English as a native language or who do not speak English at all, it’s important to have Spanish-speaking nurses and other health care personnel (e.g., receptionist) available during an appointment (Olds, London, Ladewig, & Davidson, 2004). The Spanish-speaking staff person can be on standby in case communication obstacles arise or can be present in the room during the client’s visit. Box 1 offers additional specific communication strategies. Also of note is that physical touch is perceived differently in Hispanic culture than in American culture and this has implications for nurses conducting physical examinations (see Box 2). Because of their orientation to time, Hispanic clients often arrive late to appointments or miss them altogether. This can become a significant barrier to adequate prenatal care. To Hispanic individuals, time is a relative phenomenon and little attention is given to the exact time of day. Their frame of orientation for time is wide for Hispanic individuals and they are mainly concerned with the issue of whether it’s day or night. To ensure regular prenatal care for Hispanic clients, nurses should explain to women

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HISPANIC WOMEN HAD THE HIGHEST FERTILITY RATE (97.7 BIRTHS PER 1,000) OF ALL ETHNIC/RACIAL GROUPS AND ACCOUNTED FOR 23 PERCENT OF ALL BIRTHS IN THE U.S. IN 2004 that it’s crucial to arrive on time for appointments (Purnell & Paulanka, 2005) and should underscore any office policies related to tardiness (e.g., explain that clients who are more than 30 minutes late to an appointment will not be seen). Explaining the health significance of attending every appointment will help encourage clients’ timely arrival. As an alternative, walk in hours, which Hispanic clients tend to prefer, can be offered (Spector, 2004).

Understanding the Hispanic Family Within Hispanic culture, the family entity is highly valued such that the needs of the family are often placed above those of a single individual. Therefore, decisions regarding health care are often made on behalf of the entire family. A particular family member is commonly designated as the final decision-maker regarding a client’s health care, while the same or a different family member may be designated as the

family spokesperson. Some households are patriarchal, some are matriarchal and some are egalitarian. Regardless of who makes the decision, the man traditionally is expected to be the spokesperson for the family. Further, sons have the responsibility for their protective care of their sisters. When decisions need to be made regarding a client’s health care, the nurse should ask who makes the decisions for the family (Leininger & McFarland, 2002; Purnell & Paulanka, 2005) because every family is different.

High-Risk Health Behaviors A priority health assessment that needs to be made at the first prenatal visit is determining whether the Hispanic woman is a migrant worker. If she is, she will need to be counseled on the importance of protecting herself from pesticides and herbicide poisoning. Because pesticides and herbicides are less commonly used in Mexico, many Hispanic women may not be

Box 1 TIPS FOR EFFECTIVELY COMMUNICATING WITH HISPANIC PATIENTS Using an Interpreter When using an interpreter, address all questions directly to the client, rather to the interpreter. As the client listens and responds to the interpreter, take this opportunity to observe the client’s facial expressions and body language (Kozier, Erb, Berman, & Snyder, 2004). This will provide valuable feedback on the client’s current degree of understanding and emotional state.

Incorporating Spanish-Language Teaching Tools Supplement verbal communication with the use of Spanish-language videos and literature to help increase compliance with health interventions. Ideally, Hispanic individuals will be pictured in these materials to help the clients relate to the messages conveyed (Purnell & Paulanka, 2005).

Addressing Clients with a Formal Greeting Unless told to do otherwise, when greeting Hispanic clients, address individuals formally, using the culture’s common terms of respect: Senor (for men), Senora (for married women), or Senorita (for young or unmarried women). This term may be used alone (e.g., simply Senora) or in conjunction with a client’s name (e.g., “Senora Villagran Perez”). Formal names in the Hispanic culture are often extensive; the nurse should invite the client to indicate her preferred name for conversational purposes as well to specify which name is used for legal purposes (Purnell & Paulanka, 2005).

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Box 2 PHYSICAL TOUCH: WHAT’S APPROPRIATE, WHAT’S NOT • Many Hispanic clients are accustomed to supportive touch or a gentle embrace (such as a hug) from people of the same gender. However, men and women rarely touch in public. Therefore, male nurses should avoid providing supportive touch to female clients and female nurses should refrain from making physical contact with male family members. • Make a point of shaking hands with Hispanic clients and their families when they arrive at and depart from appointments; standing or sitting close to the patient during the appointment will also put the client at ease. • It’s usually acceptable to touch a Hispanic client when paying a compliment, because touch is viewed as a gesture of sincerity. • When talking to a Hispanic child, it’s appropriate to praise and smile at the child while gently touching his or her head or hand (Munoz & Luckmann, 2005). • Other gestures of supportive touch might include placing a hand on the client’s shoulder or forearm when trying to underscore a point of verbal communication or placing a hand on the client’s back as she exits the appointment room alongside of the nurse. • Before touching a private body area during a physical examination, always ask permission of the client and explain the reason for the assessment (Purnell & Paulanka, 2005). • Keep in mind that a Hispanic woman’s modesty might make her hesitant to discuss reproductive or genitourinary concerns with her children present (Munoz & Luckmann, 2005). Therefore, encourage clients to make provisions for private time during the appointment (e.g., bring a family member along to visits who can stay with children in the waiting room) or perhaps even assist them in the process (e.g., take children into a different room for a short period while the health care provider discusses issues with the client).

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aware of their use in the United States or of their potential for negative health consequences for the fetus (Purnell & Paulanka, 2005). Some human studies have associated pesticide exposure during pregnancy with an increased risk of childhood cancer. As with all chemicals, exposure can be minimized by working in a well-ventilated area and using protective equipment, such as clothing, mask and gloves (Organization of Teratology Information Specialists, 2005). Any counsel regarding teratogenic substances should be provided to the entire family to improve chances that a woman will comply with protecting herself (Olds et al., 2004). The Hispanic population is more likely to engage in binge drinking than other cultural groups, and some Hispanic individuals use alcohol to feel more emotionally and socially extroverted (Purnell & Paulanka, 2005). Hispanic clients should therefore be assessed for alcohol use and counseled about the negative effects of alcohol during pregnancy given that such counseling has proven effective in reducing drinking among pregnant women in general (Olds et al., 2004). Finally, Hispanic clients should be assessed for their seat belt use. Many newer Hispanic immigrants may be reluctant to use seat belts in the United States because they’re not accustomed to doing so in their home countries (Purnell & Paulanka, 2005). To increase compliance with seat belt use, nurses should explain the legal requirements of using three-point restraint seat belts (e.g., a lap belt plus shoulder belt) as well as the safety issues risked by those not wearing seat belts (Olds et al., 2004). Clients should be informed that motor vehicle crashes are one of the most common causes of nonobstetric death among pregnant women in the United States (Grossman, 2004).

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Maternal-Child Nutrition The Hispanic diet is generally high in complex carbohydrates and consists mainly of unprocessed foods. Individuals typically consume vegetables as ingredients in soups, rice, pasta, meat and tortilla-based items and eat semitropical and tropical fruits when available. Meals are often vegetarian, but when meats are consumed they include poultry, pork and goat. Cooking techniques may rely heavily on frying and stewing using oil or lard. Nurses can encourage clients to maintain their typical intake of fruits, vegetables and complex carbohydrates, while encouraging clients to use less fat during cooking by substituting canola or olive oil for lard, bacon and margarine (Dudek, 2006). This will play a part in helping clients avoid excessive weight gain during pregnancy. Sufficient calcium and phosphorus intake during pregnancy is essential because it is involved in the mineralization of fetal bones and teeth, energy and cell production, and acid-base buffering (Olds et al., 2004). Common foods in the Hispanic diet that contain calcium (through milk) include arroz con leche (rice with milk), flan (sweetened egg custard topped with caramelized sugar), atole (hot beverage of milk or water and sugar thickened with cornstarch) and café con leche (coffee with milk) (Dudek, 2006) (see

Box 3). Clients can be encouraged to consume these items, as appropriate (e.g., one to two cups of café con leche per day to avoid high caffeine intake). Because dairy products represent a major source of calcium, it’s important to note that many people of Hispanic descent have lactose intolerance and difficulty digesting milk and other dairy products. Nurses should thus assess Hispanic clients for lactose intolerance and provide special counsel, as needed, on how to consume sufficient dietary calcium from nondairy sources. Depending on their type of intolerance, clients can be counseled to ingest dairy products in small amounts at a time or to only consume those dairy products that don’t affect them (National Digestive Diseases Information Clearinghouse, 2006). Nurses may also recommend that clients do the following: drink specially treated (lactose reduced) cow’s milk, which is available in most large grocery stores (Olds et al., 2004); take a calcium supplement; and eat nondairy sources of calcium, such as leafy green vegetables, dates, prunes, canned sardines, salmon with bones, nuts, dried peas and beans, and calcium-fortified orange juice and whole grains (Dudek, 2006). Some Hispanic women don’t believe in feeding their newborn colostrum before the milk supply is estab-

Box 3 TRADITIONAL HISPANIC FOODS THAT CONTAIN CALCIUM Flan and café con leche.

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WHEN ASSESSING A CLIENT’S PAIN, SUCH AS DURING LABOR, NURSES SHOULD NOTE THAT HISPANICS TEND NOT TO VERBALIZE COMPLAINTS OF PAIN.

als or eggs. Once the food is added to the formula, the bottle’s nipple is often enlarged to enable the newborn to consume the food. Hispanic mothers report that it’s important to add these foods to the formula for two reasons. First, mothers believe it will help the baby grow to be large, which is valued in Hispanic culture. Second, they believe that the consumption of traditional foods at a very young age will prepare children to accept their traditional foods and enjoy them when they’re older (Pawloski, 2001). Hispanic mothers should be taught that solid foods before the age of six months is not easily digested by the baby and may lead to food allergies and possibly aspiration.

Childbearing and Health Care Practices

When assessing a client’s pain, such as during labor, nurses should note that Hispanics tend not to verbalize complaints of pain (Munoz & Luckmann, 2005). To help identify a client’s pain level, the nurse should perform a full pain assessment, and visual pain scales should be used for those women who do not read Spanish. If pain relief is deemed necessary or helplished. They have a deep-rooted belief that the infant ful, the woman should be encouraged to accept anneeds formula. Nurses should compromise with the algesics (Purnell & Paulanka, 2005). In one study, mother and encourage them to breastfeed and supepidural analgesia rates were lower for Hispanic plement the newborn’s feedings with formula. Among women (35.3 percent) than for Caucasian women some Hispanic women, language differences can often (59.6 percent), despite the fact that both groups had affect the understanding of proper feeding practices, identical Medicaid insurance (Rust et al., 2004). The so many Hispanic women have reported turning to ultimate decision related to epidural use may come their grandmothers or aunts. The advice from these from the Hispanic woman’s cultural, situational derelatives is often based on beliefs terminant (e.g., waiting longer that, unfortunately, can conto go to the hospital and being flict with advice given from a further along into labor, shortnurse or a physician (Pawloski, ening hospital time when the a major 2001). Nurses should include comprise s ic d n e a epidural might be an option), it p n is U e • H group in th f b the mother’s grandmothers or u s ic n or physicians’ choice related to eth eo knowledg d n a aunts when providing educa, s te is clinical or economical reasons Sta ctices ltural pra tion to the mother regarding specific cu . (Atherton, Feeg, & El-Adham, s e t for nurs newborn nutrition. importan ro 2004). p im e family is th f Adding food to an infant’s o le Many Hispanic individu• The ro include it’s vital to ily formula is a standard practice m fa d e als practice the “hot and cold tant and d n of the exte r. e th with Hispanic women. The o m members w theory,” according to which ne on of the addition of these foods usuin educati fs e li many diseases and illnesses e b n mo many com ally occurs a couple months re a y b re are caused by disruption in e ld h he • T s that are m g to after a child’s birth, but for s re u p c g d the hot and cold balance of an gardin women re some, it can occur as early as w b or n e n d Hispanic the body (Purnell & Paulann a , stpartum two weeks into a newborn’s nancy, po ka, 2005). Diseases and illlife. Foods used might include care. nesses are classified as “hot” coffee, sugar, rice, beans, cereor “cold.” Treatments, food

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and medications are characterized as hot (caliente), cold (frio) and cool (fresco). Cold illnesses are treated with hot remedies; hot illnesses are treated with cold or “cool” remedies. Hot and cold do not always correspond with temperature (Purnell & Paulanka; Spector, 2004). The nurse should assess the Hispanic woman’s use of the hot and cold theory, and nonharmful practices should be incorporated into the plan of care (Purnell & Paulanka). See Box 4 for examples that would be useful to know during the perinatal period.

Common Childbearing Beliefs There are many common beliefs and customs held by Hispanic women regarding pregnancy, postpartum and newborn care. During pregnancy, Hispanic women may believe that walking in the moonlight will cause birth deformities (Purnell & Paulanka, 2005). Similarly, they may believe that viewing an eclipse will cause structural deformities in the fetus, particularly cleft lip (Leininger & McFarland, 2002). As a safety precaution to protect against such deformities, safety pins, metal keys or other metal amulets may be worn under one’s clothes (Leininger & McFarland; Purnell & Paulanka). Nurses need to assure the woman that these activities will not harm the baby (Olds et al., 2004) while nevertheless showing respect for such customs by, for example, not removing amulets (Leininger &

Box 4 EXAMPLES OF APPLICATIONS OF THE “HOT” AND “COLD” THEORY • Iron tablets, penicillin, and vitamins (hot) may not be used to treat pregnancy (hot) (Spector, 2004). Clients should be strongly encouraged to take prenatal vitamins, but if they refuse they can be given a folic acid supplement and strict guidelines for achieving a balanced diet with appropriate vitamin intake. • During the postpartum period (cold), a woman may avoid ice water (cold). • A baby should not be fed a formula (hot), as it may cause rashes; whole milk (cold) is acceptable (Spector, 2004).

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DEER’S EYE AMULET from Mexico is decorated with an image of the Virgin Guadalupe and a red string and pom-pom.

FAJITAS or newborn bands, for umbilical care. Image courtesy of iplay® www.iplaybabywear.com.

McFarland). During the actual birthing process, traditional Hispanic culture dictates that the delivery room is not a place for men. Many believe that allowing the father to see the woman or newborn during the delivery may harm the mother or newborn (Purnell & Paulanka, 2005). Nurses should respect the father’s wishes and encourage a female relative to be in attendance at the birth. After childbirth, Hispanic clients typically choose to dispose of the placenta in one of two ways: the placenta may be placed in a plastic bag and thrown in the trash or it may be buried in one’s yard, sometimes with a religious or folk ceremony (Spector, 2004). Nurses should consult Hispanic families on how they would like to dispose of the placenta, if hospital policy allows for this choice. Otherwise, nurses should take care to explain, ideally in advance of childbirth, the rationale behind hospital policies that require medical staff to dispose of the placenta. During the period of la cuerentena (first 40 days after birth), Hispanic women are thought to be susceptible to harm from cold; consequently, some women avoid taking showers and sitz baths, sitting in a bathtub, washing their hair, being exposed to air

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drafts and consuming iced drinks (Leininger & McFarland, 2002; Purnell & Paulanka, 2005). Nurses should encourage warm compresses instead of sitz baths and offer these women a warm washcloth to increase maternal comfort (Purnell & Paulanka; Olds et al., 2004). Nurses will want to consider the many Hispanic beliefs and customs regarding the newborn. For example, Hispanic women believe that cutting a newborn’s nails in the first three months of life will cause blindness and deafness in the baby. The nurse should therefore ask permission before cutting a neonate’s nails (Purnell & Paulanka, 2005). The deer’s eye and man negro amulet are pinned on a newborn to protect it from the evil eye and the envy of others

appetite, the Hispanic culture attributes these symptoms to an illness termed caida de mollera (fallen fontanel). The symptoms of caida de mollera correlate to the health care provider’s diagnosis of dehydration, but the cultural interpretation of this illness does not include such an understanding. Instead, caida de mollera is thought to have numerous other causes, such as removing a nursing infant too harshly from the nipple, handling an infant too roughly or allowing a nurse or physician to touch the head of the baby (Leininger & McFarland, 2002; Purnell & Paulanka, 2005; Spector, 2004). A baby who experiences a fall is also considered susceptible to caida de mollera (Leininger & McFarland, 2002). The folk cures for caida de mollera are themselves harmless

IN SPITE OF COMMONALITIES ACROSS THE HISPANIC CULTURE, NURSES SHOULD WORK TO FAMILIARIZE THEMSELVES WITH EACH FAMILY AS A UNIQUE ENTITY. (Spector, 2004). The nurse can show respect by not removing such amulets. Hispanic culture dictates several practices for handling umbilical cord care. Mothers may place a key, coin or other metal object on the newborn’s umbilicus to promote healing (Purnell & Paulanka, 2005). In addition, Fajitas, or cloth bands, are applied around the neonate’s abdomen to cover the cord to prevent “air” from entering the infant’s body. The nurse can instruct mothers regarding frequent cord care and changes of the umbilical band to prevent infection. This allows nurses to ensure proper neonate care while showing respect for the cultural practice of using fajitas (Leininger & McFarland, 2002). When certain symptoms develop in newborns, such as depressed fontanels, restlessness and poor

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(hold the infant upside down by the feet or place pressure on the palate), but the application of these practices may delay a family’s decision to take the infant in for professional care, which ultimately could be life-threatening for a newborn suffering from dehydration (Leininger & McFarland, 2002; Purnell & Paulanka). Nurses can help clients avoid this situation by educating them at the time of childbirth on the symptoms of dehydration and the importance of bringing dehydrated infants in for immediate care.

Conclusions Providing culturally sensitive care to Hispanic families during the perinatal period is a challenging experience. It requires nurses first to spend time learning

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about the Hispanic culture and then to s how respect for that culture by flexibly and creatively adapting nursing interventions to conform to clients’ beliefs and needs. A careful balance must be sought, such that nurses respect clients’ cultural norms while also working to ensure maternal and child health and safety. Cultural beliefs and practices should thus be accommodated whenever possible; when they cannot be accommodated, alternate practices should be carefully and respectfully presented and explained. Finally, in spite of commonalities across the Hispanic culture, nurses should work to familiarize themselves with each family as a unique entity since no two families are ever exactly the same. NWH

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Get the Facts Centers for Disease Control and Prevention Office of Minority Health

http://www.cdc.gov/omh/Populations/HL/HL.htm Department of Health and Human Services Office of Minority Health

http://www.omhrc.gov/templates/browse. aspx?lvl=1&lvlID=5 Language and Culture

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Refugee Health/Immigrant Health

Pawloski, L. (2001). Understanding cultural differences when advising mothers about feeding choices. Pediatric Nursing, 27(1), 52–53.

http://www3.baylor.edu/~Charles_Kemp/ hispanic_health.htm

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Transcultural Nursing

http://www.culturediversity.org/hisp.htm

Rust, G., Nembhard, W., Nichols, M., Omole, F., Minor, P., Barosso, G., et al. (2004). Racial and ethnic disparities in the provision of epidural analgesia to Georgia Medicaid beneficiaries during labor and delivery. American Journal of Obstetric & Gynecology, 191(2), 456–62. Spector, R. (2004). Cultural diversity in health and illness (6th ed.). Upper Saddle River, NJ: Pearson Education. U.S. Census Bureau. (2004, December). We the people: Hispanics in the U.S. Census 2000 special report. Retrieved April 13, 2006, from http://www.census.gov/prod/ 2004pubs/censr-18.pdf

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