Maternal-Newborn Cultural Maternal-Newborn Cultural Issues Affecting Intrapartum Issues Affecting Intrapartum

and Neonatal Careand Neonatal CareBy Patricia M. Dillon RN,

MALaGuardia Community

College

Following this module, the health practitioner will have an enhanced Following this module, the health practitioner will have an enhanced competency to work with childbearing families from various cultural competency to work with childbearing families from various cultural backgrounds.backgrounds.

OBJECTIVES:OBJECTIVES:

Recognize the need to assess and validate the cultural beliefs and Recognize the need to assess and validate the cultural beliefs and traditions of patients associated with the different ethnic groups.traditions of patients associated with the different ethnic groups.

Identify the need to examine one’s own beliefs and values in an Identify the need to examine one’s own beliefs and values in an attempt to remain non-judgmental when caring for multicultural attempt to remain non-judgmental when caring for multicultural clients. clients.

Distinguish the difference between the terms generalization and Distinguish the difference between the terms generalization and stereotype.stereotype.

List examples of cultural beliefs and traditions in identified ethnic List examples of cultural beliefs and traditions in identified ethnic groups that could affect maternal health and birthing options. groups that could affect maternal health and birthing options.

List examples of cultural beliefs and traditions in identified ethnic List examples of cultural beliefs and traditions in identified ethnic groups that could negatively affect fetal/neonatal well being.groups that could negatively affect fetal/neonatal well being.

Discuss interventions to promote positive outcomes following the Discuss interventions to promote positive outcomes following the pregnant family's experiences with the childbirth and the health pregnant family's experiences with the childbirth and the health delivery system.delivery system.

ImmigrationImmigration

Immigration and diversity have always been at Immigration and diversity have always been at the core part of American history. These continue the core part of American history. These continue in momentum in the present and will continue to in momentum in the present and will continue to exist into our future. exist into our future.

““To address their patients’ individual needs To address their patients’ individual needs effectively, health care practitioners must effectively, health care practitioners must acknowledge the need for a substantially broader acknowledge the need for a substantially broader base of information and understanding (1998 base of information and understanding (1998 Conference Proceedings –The Growing Diversity Conference Proceedings –The Growing Diversity of American Society).of American Society).

Practitioners have to be prepared for the possible Practitioners have to be prepared for the possible “risk” problems that may occur in immigrants and “risk” problems that may occur in immigrants and their children.their children.

Culture and ChildbirthCulture and Childbirth

The meaning of childbirth is unique to The meaning of childbirth is unique to each culture. each culture.

Cultural beliefs and traditions often play a Cultural beliefs and traditions often play a major role in childbirth.major role in childbirth.

Many of these traditions may be harmless Many of these traditions may be harmless

and some may be beneficial, but others and some may be beneficial, but others can be damaging to both mother and can be damaging to both mother and infant.infant.

Childbirth is experienced very differently by Childbirth is experienced very differently by each woman and man.each woman and man.

It is personal and unique, influenced by:It is personal and unique, influenced by:1) cultural beliefs1) cultural beliefs2) traditional practices2) traditional practices3) age 3) age 4) education4) education5) gender5) gender6) and other variables (stress, 6) and other variables (stress,

personality, parity and spiritual beliefs).personality, parity and spiritual beliefs).

Changing demographics and the continuous Changing demographics and the continuous influx of immigrants has led to a growing influx of immigrants has led to a growing national awareness of differences and rising national awareness of differences and rising issues surrounding culture, ethnicity, race, issues surrounding culture, ethnicity, race, age, gender, and sexual orientation in the age, gender, and sexual orientation in the United States.United States.

Maternal AspectsMaternal Aspects Globally, more than 500 000 maternal deaths Globally, more than 500 000 maternal deaths

take place yearly, with the majority occurring in take place yearly, with the majority occurring in developing countries, but with the arrival of more developing countries, but with the arrival of more and more immigrants, the potential risks increase and more immigrants, the potential risks increase even here in the US. even here in the US.

The major complications that result in most The major complications that result in most maternal deaths everywhere are:maternal deaths everywhere are:1) hemorrhage1) hemorrhage2) sepsis2) sepsis3) pregnancy induced hypertension (PIH) 3) pregnancy induced hypertension (PIH) 4) dysfunctional labor4) dysfunctional labor5) abortion5) abortion

Fetal AspectsFetal Aspects Maternal complications ultimately affect the fetus/neonate Maternal complications ultimately affect the fetus/neonate

as well causing about 8.1 million infants (about as well causing about 8.1 million infants (about 48,700:3,899,599 live births in the US) to die each year, 48,700:3,899,599 live births in the US) to die each year, some during the first days of life, and almost half within some during the first days of life, and almost half within their first monththeir first month . .

Many deaths are related to:Many deaths are related to:1) poorly managed pregnancies and deliveries 1) poorly managed pregnancies and deliveries 2) birth asphyxia2) birth asphyxia3) infections 3) infections 4) trauma 4) trauma

Those that survive have significant amounts of residual Those that survive have significant amounts of residual damage that leave them with lifelong physical or mental damage that leave them with lifelong physical or mental disabilities.disabilities.

How Complications Affect mother and babyHow Complications Affect mother and baby

Problem or complicationProblem or complication Most serious effects on Most serious effects on mother's healthmother's health

Most serious effects on fetus/newbornMost serious effects on fetus/newborn

Severe anemiaSevere anemia Cardiac failureCardiac failure Low birth weight, asphyxia, stillbirthLow birth weight, asphyxia, stillbirth

HemorrhageHemorrhage Shock, cardiac failure, Shock, cardiac failure, infection infection

Asphyxia, stillbirthAsphyxia, stillbirth

Hypertensive disorders of Hypertensive disorders of pregnancypregnancy

Ecclampsia, Ecclampsia, cereberovascular cereberovascular accidentsaccidents

Low birth weight, asphyxia, stillbirthLow birth weight, asphyxia, stillbirth

Puerperal sepsisPuerperal sepsis Septicaemia, shockSepticaemia, shock Neonatal sepsisNeonatal sepsis

Obstructed labourObstructed labour Fistulae, uterine rupture, Fistulae, uterine rupture, prolapse, amnionitis, prolapse, amnionitis, sepsissepsis

Stillbirth, asphyxia, sepsis, birth trauma, Stillbirth, asphyxia, sepsis, birth trauma, handicaphandicap

Infection during Infection during pregnancy, sexually pregnancy, sexually transmitted disease.transmitted disease.

Premature onset of Premature onset of labour, ectopic labour, ectopic pregnancy, pelvic pregnancy, pelvic inflammatory disease, inflammatory disease, infertilityinfertility

Premature delivery, neonatal eye Premature delivery, neonatal eye infection, blindness, pneumonia, infection, blindness, pneumonia, stillbirth, congenital syphilisstillbirth, congenital syphilis

HepatitisHepatitis Postpartum haemorrhage, Postpartum haemorrhage, liver failureliver failure

Hepatitis Hepatitis

MalariaMalaria Severe anaemia, cerebral Severe anaemia, cerebral thrombosisthrombosis

Prematurity, intrauterine growth Prematurity, intrauterine growth retardationretardation

Unwanted pregnancyUnwanted pregnancy Unsafe abortion, Unsafe abortion, infection, pelvic infection, pelvic inflammatory disease, inflammatory disease, haemorrhage, infertilityhaemorrhage, infertility

Increased risk of morbidity, mortality; Increased risk of morbidity, mortality; child abuse, neglect, abandonment.child abuse, neglect, abandonment.

Unclean deliveryUnclean delivery Infection, maternal Infection, maternal tetanustetanus

Neonatal tetanus, sepsisNeonatal tetanus, sepsis

New immigrants may have difficulty acquiring adequate New immigrants may have difficulty acquiring adequate employment which limits funds for health care.employment which limits funds for health care.

Immigrants with limited or no familiarity with the English Immigrants with limited or no familiarity with the English language, may have difficulty accessing adequate health care language, may have difficulty accessing adequate health care services. services.

Low socio-economic status may cause insecurities about lack of Low socio-economic status may cause insecurities about lack of food, clothing, and shelter that often override health concerns.food, clothing, and shelter that often override health concerns.

Deficits in these basic needs lead to nutritional insufficiency Deficits in these basic needs lead to nutritional insufficiency (anemia) and exposure to the elements that increase the risk of (anemia) and exposure to the elements that increase the risk of infections and other illness for both mother and neonate.infections and other illness for both mother and neonate.

Legal and illegal immigrants that are not eligible for Medicaid are Legal and illegal immigrants that are not eligible for Medicaid are covered for emergency services, such as labor and delivery, but covered for emergency services, such as labor and delivery, but often not for preventive services, such as prenatal or well- child often not for preventive services, such as prenatal or well- child care.care.

RISK FACTORSRISK FACTORS

Health CareHealth Care Many conflicts and misunderstandings in patient Many conflicts and misunderstandings in patient

care are a direct result of the division between care are a direct result of the division between the values of the health care culture and those the values of the health care culture and those of the patient. of the patient.

Just as values influence our patient’s reactions Just as values influence our patient’s reactions and behavior, they also influence ours. Therefore, and behavior, they also influence ours. Therefore, it is important to first understand our own culture it is important to first understand our own culture and beliefs.and beliefs.

Acknowledging patient cultural differences and Acknowledging patient cultural differences and utilizing them to individualize health care will utilizing them to individualize health care will positively affect the patient’s experience and positively affect the patient’s experience and response to pregnancy and childbirth.response to pregnancy and childbirth.

StereotypingStereotyping vs. Generalizationsvs. Generalizations

Stereotyping is an end point where no Stereotyping is an end point where no attempt is made to determine if the attempt is made to determine if the individual really fits the criteria.individual really fits the criteria.

Generalization is more of a beginning Generalization is more of a beginning point which indicates common threads, but point which indicates common threads, but suggests the need for further information. suggests the need for further information.

(from Cultural Profiles at (from Cultural Profiles at http://http://www.ggalanti.com/index.comwww.ggalanti.com/index.com//

Specific Cultural Behaviors Affecting Specific Cultural Behaviors Affecting Childbirth Options and the NeonateChildbirth Options and the Neonate AsianAsian

CULTURAL BEHAVIORS:CULTURAL BEHAVIORS: Some groups believe that while the fetus resides in the womb, it Some groups believe that while the fetus resides in the womb, it

absorbs information which develops its personality and physical absorbs information which develops its personality and physical appearance. The expectant mother may fear that if she doesn’t appearance. The expectant mother may fear that if she doesn’t consumes the item that she craves, her baby will take on (physical) consumes the item that she craves, her baby will take on (physical) characteristics of that food.characteristics of that food.

It is not uncommon for primigravidas (first pregnancies) to return to It is not uncommon for primigravidas (first pregnancies) to return to their country of origin to reunite with their parents when it comes time their country of origin to reunite with their parents when it comes time to deliver their baby.to deliver their baby.

INTERVENTIONS:INTERVENTIONS: As long as the food craving is not dangerous to the expectant mother As long as the food craving is not dangerous to the expectant mother

or fetus, the health practitioner should recognize and accept this or fetus, the health practitioner should recognize and accept this cultural belief and allow the mother to satisfy her food craving to cultural belief and allow the mother to satisfy her food craving to appease her fear. appease her fear.

The health practitioner must ensure that the patient has sufficient The health practitioner must ensure that the patient has sufficient health information regarding prenatal care given so that the couple health information regarding prenatal care given so that the couple can more efficiently convey medical history to the new healthcare can more efficiently convey medical history to the new healthcare provider. provider.

Asian CultureAsian Culture

CULTURAL BEHAVIORSCULTURAL BEHAVIORS Traditional Asian men frequently do not attend the delivery of Traditional Asian men frequently do not attend the delivery of

their infants. Expectant fathers may remain outside of labor room their infants. Expectant fathers may remain outside of labor room until the infant is born. As extended family members are until the infant is born. As extended family members are decreasing and nuclear families are becoming more prevalent, decreasing and nuclear families are becoming more prevalent, younger Asians are becoming more acculturated attending younger Asians are becoming more acculturated attending childbirth classes as a couple. More families are choosing this childbirth classes as a couple. More families are choosing this birth option which encourages the father’s participation and birth option which encourages the father’s participation and support of the mother during labor.support of the mother during labor.

INTERVENTIONS:INTERVENTIONS: Health practitioners should assess the family needs, and female Health practitioners should assess the family needs, and female

family members/relatives such as mother, mother-in-law, aunts family members/relatives such as mother, mother-in-law, aunts and sisters should be allowed to provide the needed support and sisters should be allowed to provide the needed support during this time. during this time.

Fathers should be supported and encouraged to attend classes Fathers should be supported and encouraged to attend classes and the birth if they demonstrate this interest.and the birth if they demonstrate this interest.

AsianAsian

CULTURAL BELIEFS/BEHAVIORSCULTURAL BELIEFS/BEHAVIORS Women may eat large meals early in labor to gain energy Women may eat large meals early in labor to gain energy

they believe is needed to get through labor. Western they believe is needed to get through labor. Western cultures discourage eating to prevent nausea/vomiting cultures discourage eating to prevent nausea/vomiting during active labor and in the event that an emergency during active labor and in the event that an emergency cesarean section may be required. This common complaint cesarean section may be required. This common complaint of nausea seen in laboring many Asian women (particularly of nausea seen in laboring many Asian women (particularly Chinese) reflects their misunderstanding regarding this Chinese) reflects their misunderstanding regarding this need. need.

INTERVENTIONSINTERVENTIONS It is essential to educate Asian women pre-natally that eating It is essential to educate Asian women pre-natally that eating

during this time could be detrimental to them and the infant during this time could be detrimental to them and the infant in the event that nausea and vomiting occurs. It may also in the event that nausea and vomiting occurs. It may also limit their birthing options for various types of anesthesia in limit their birthing options for various types of anesthesia in the event that emergency cesarean section is required. the event that emergency cesarean section is required.

AsianAsian

CULTURAL BELIEFS/BEHAVIORS:CULTURAL BELIEFS/BEHAVIORS: If the couple makes arrangements to have “natural childbirth” If the couple makes arrangements to have “natural childbirth”

without the usual restrictive equipment, i.e. intravenous fluids, without the usual restrictive equipment, i.e. intravenous fluids, monitor, etc, then taking clear fluids during labor is essential to monitor, etc, then taking clear fluids during labor is essential to prevent dehydration and exhaustion. This condition would not only prevent dehydration and exhaustion. This condition would not only adversely affect the mother, but the fetus as well. adversely affect the mother, but the fetus as well.

Traditional Chinese medicine is based upon the balance opposite Traditional Chinese medicine is based upon the balance opposite forces, Yin and Yang (hot vs cold), and harmony of nature forces, Yin and Yang (hot vs cold), and harmony of nature associated with Wu-Xing (Five Elements).associated with Wu-Xing (Five Elements). Since Asians believe that Since Asians believe that pregnancy is a hot condition, in order to keep the body in a state pregnancy is a hot condition, in order to keep the body in a state of balance, cold liquids are typically avoided to prevent shock to of balance, cold liquids are typically avoided to prevent shock to the system. Traditional Asians refer to this as "doing the month" the system. Traditional Asians refer to this as "doing the month" which they believe will prevent aches, pains, arthritis, and other which they believe will prevent aches, pains, arthritis, and other ailments which they can develop in old age. ailments which they can develop in old age.

INTERVENTIONINTERVENTION In the event that your patient is traditional in adhearing to her In the event that your patient is traditional in adhearing to her

cultural rituals, offer warm clear fluids during labor along with ice cultural rituals, offer warm clear fluids during labor along with ice water. Offer more than once, since some Asian cultures water. Offer more than once, since some Asian cultures (particularly Vietnamese) may refuse the first time out of respect.(particularly Vietnamese) may refuse the first time out of respect.

AsianAsian

CULTURAL BELIEFS/BEHAVIORS:CULTURAL BELIEFS/BEHAVIORS: Drinking milk will cause one to gain too much weight and make baby fat as well Drinking milk will cause one to gain too much weight and make baby fat as well

as difficult to deliver. This may put them at risk for hypocalcemia.as difficult to deliver. This may put them at risk for hypocalcemia. Colostrum is believed to be "dirty" by some Asian cultures and may be Colostrum is believed to be "dirty" by some Asian cultures and may be

discardeddiscarded..

INTERVENTIONS:INTERVENTIONS: Again, good prenatal teaching regarding importance of nutritional Again, good prenatal teaching regarding importance of nutritional

requirements during antepartum is essential. Neonates can be born anemic, requirements during antepartum is essential. Neonates can be born anemic, placing them at risk if sufficient weight gain between 25 and 30 lbs is not placing them at risk if sufficient weight gain between 25 and 30 lbs is not achieved. achieved.

Mother needs to be informed that taking Mother needs to be informed that taking 1,5001,500 to 2,000 mg of calcium daily to 2,000 mg of calcium daily can lower the risk of pregnancy-induced hypertension by 70% and the risk of can lower the risk of pregnancy-induced hypertension by 70% and the risk of pre-eclampsia by over 60% (as reported in Journal of the American of Medical pre-eclampsia by over 60% (as reported in Journal of the American of Medical Association, JAMA) !Association, JAMA) ! It is also reported to reduce the incidence of related pre- It is also reported to reduce the incidence of related pre-term deliveries, low birth-weight babies and cesarean sections.term deliveries, low birth-weight babies and cesarean sections. Suggest Suggest familiar traditional foods that are high in calcium (tofu, small fish with bones, familiar traditional foods that are high in calcium (tofu, small fish with bones, i.e. sardines). Supplements may be required.i.e. sardines). Supplements may be required.

Parents must also be instructed on the importance of colostrum feedings in the Parents must also be instructed on the importance of colostrum feedings in the transmission of protective immunoglobulins (antibodies) to their newborns . transmission of protective immunoglobulins (antibodies) to their newborns .

African AmericanAfrican American

CULTURAL BEHAVIORSCULTURAL BEHAVIORS Due to past experiences with racial discrimination, African Due to past experiences with racial discrimination, African

American patients may not trust white institutions. They American patients may not trust white institutions. They may also be very sensitive to what they perceive as may also be very sensitive to what they perceive as discrimination. discrimination.

INTERVENTIONSINTERVENTIONS Staff should always address patients and families in a Staff should always address patients and families in a

professional manner as Mr., Mrs. or Ms. Be careful to avoid professional manner as Mr., Mrs. or Ms. Be careful to avoid using “gal” when referring to African-American women or using “gal” when referring to African-American women or “boy” when referring to African-American men because “boy” when referring to African-American men because especially in the south, these have negative connotations.especially in the south, these have negative connotations.

African American African American CultureCulture

CULTURAL BEHAVIORSCULTURAL BEHAVIORS In the south, African American women have been identified as In the south, African American women have been identified as

having frequent cravings for red clay dirt when they become having frequent cravings for red clay dirt when they become pregnant (pica). In other areas, including NY, this craving has pregnant (pica). In other areas, including NY, this craving has sometimes been replaced by cornstarch. sometimes been replaced by cornstarch.

INTERVENTIONSINTERVENTIONS Staff should ask about the use of cornstarch when the African-Staff should ask about the use of cornstarch when the African-

American woman has her first prenatal assessment. Teaching is American woman has her first prenatal assessment. Teaching is essential to inform the patient that in small amounts, eating essential to inform the patient that in small amounts, eating cornstarch may prove to provide comfort, but in large amounts, can cornstarch may prove to provide comfort, but in large amounts, can cause constipation. Since constipation is commonly a problem cause constipation. Since constipation is commonly a problem during any pregnancy due to the effect of hormones and uterine during any pregnancy due to the effect of hormones and uterine growth on gastric motility (growth on gastric motility (), eating cornstarch could accentuate ), eating cornstarch could accentuate this already problematic area. this already problematic area.

African AmericanAfrican American

CULTURAL BEHAVIORSCULTURAL BEHAVIORS Some African Americans may have strong religious beliefs Some African Americans may have strong religious beliefs

regarding illness (punishment from God) or believe in voodoo regarding illness (punishment from God) or believe in voodoo (usually those families originating from the south or rural (usually those families originating from the south or rural areas). Typical gastrointestinal changes (nausea, vomiting, areas). Typical gastrointestinal changes (nausea, vomiting, diarrhea, loss of appetite) in early pregnancy may be diarrhea, loss of appetite) in early pregnancy may be interpreted as a sign of punishment from God or voodoo interpreted as a sign of punishment from God or voodoo poisoning. poisoning.

INTERVENTIONSINTERVENTIONS Clear teaching early in the antepartal period regarding Clear teaching early in the antepartal period regarding

physiological changes common in pregnancy may relieve physiological changes common in pregnancy may relieve some of the fears of these women. Some who believe in some of the fears of these women. Some who believe in voodoo, must be treated by a voodoo practitioner (root voodoo, must be treated by a voodoo practitioner (root doctor) to achieve psychological reliefdoctor) to achieve psychological relief..

African AmericanAfrican American

CULTURAL BEHAVIORSCULTURAL BEHAVIORS Newborn care may include warm baths, massaging with sesame oil Newborn care may include warm baths, massaging with sesame oil

, and passive stretching of the baby's limbs. Patients may practice , and passive stretching of the baby's limbs. Patients may practice a cultural ritual of applying an herb called malmal to the umbilicus a cultural ritual of applying an herb called malmal to the umbilicus for the first 7 days of life. for the first 7 days of life.

INTERVENTIONS:INTERVENTIONS: Families should be instructed that warm baths should be avoided Families should be instructed that warm baths should be avoided

until the umbilical cord (and circumcision in some instances) is until the umbilical cord (and circumcision in some instances) is completely dry and healed (about 7 to 10 days) to prevent completely dry and healed (about 7 to 10 days) to prevent potential infection. They should be taught to watch for possible potential infection. They should be taught to watch for possible signs of infection such as redness, warmth, drainage and odor at signs of infection such as redness, warmth, drainage and odor at the site of the umbilicus.the site of the umbilicus.

If sesame seed oil is utilized by the family, they need to realize If sesame seed oil is utilized by the family, they need to realize that the newborn will still shed the top layer of epidermis, so the that the newborn will still shed the top layer of epidermis, so the oil may delay, but will not prevent the typical flaking off of skin.oil may delay, but will not prevent the typical flaking off of skin.

There is no evidence to show that the application of mamal is There is no evidence to show that the application of mamal is

problematic as long as the solution is handled with clean aseptic problematic as long as the solution is handled with clean aseptic technique. Staff should continue to instruct patients on the apply technique. Staff should continue to instruct patients on the apply alcohol three times a day as well to assist in preventing infection. alcohol three times a day as well to assist in preventing infection. There may be some delay in the drying of the cord with the There may be some delay in the drying of the cord with the application of mamal. (malmal can be found in the U.S. in some application of mamal. (malmal can be found in the U.S. in some Asian markets). Asian markets).

African AmericanAfrican American

CULTURAL BEHAVIORSCULTURAL BEHAVIORS Historically, breastfeeding was the primary form of infant Historically, breastfeeding was the primary form of infant

nutrition. It was not uncommon to breastfeed a child until 2 nutrition. It was not uncommon to breastfeed a child until 2 years of age. African American will most likely breastfeed, years of age. African American will most likely breastfeed, but will typically want to supplement with bottle feedings. but will typically want to supplement with bottle feedings. Traditionally, animal milks such as camel, goat, and cow Traditionally, animal milks such as camel, goat, and cow may be used by these groups especially in the first few may be used by these groups especially in the first few days of life because colostrum is considered unhealthy. days of life because colostrum is considered unhealthy.

INTERVENTIONSINTERVENTIONS As stated previously when dealing with the Asian As stated previously when dealing with the Asian

population, parents must be instructed in antepartum about population, parents must be instructed in antepartum about the importance of colostrum feedings in the transmission of the importance of colostrum feedings in the transmission of

protective imunoglobulins (antibodies) to their newborns .protective imunoglobulins (antibodies) to their newborns .

Native American IndianNative American IndianCULTURAL BEHAVIORS:CULTURAL BEHAVIORS: Berries, highly valued by Native American Indians, are used throughout the

reproductive years for a variety reasons. Indian women believe that during menstruation and pregnancy, that the woman’s body becomes very toxic. They prize wild berries are used traditionally to cleanse the body of impurities. Some are used to help normalize uterine contractions.

Blue Cohosh (Algonquin)Blue Cohosh (Algonquin) and and Partridgeberry Partridgeberry (Cherokee) are uniquely native (Cherokee) are uniquely native American plants that serve as oxytocics used several weeks before childbirth to American plants that serve as oxytocics used several weeks before childbirth to induce uterine contractions,induce uterine contractions, and after delivery as a salve for sore or cracked and after delivery as a salve for sore or cracked nipples. Iroquois medical uses for this vine was as an abortifacient.nipples. Iroquois medical uses for this vine was as an abortifacient. Elderberries, Elderberries, red raspberry and sumacberryred raspberry and sumacberry sprouts are also used for blood-building and sprouts are also used for blood-building and purifying properties. purifying properties. Juniper berryJuniper berry (Navaho) is a diuretic, cleansing tonic used in (Navaho) is a diuretic, cleansing tonic used in adults and newborns (given the juice of the juniper bark skin to vomit the mucus adults and newborns (given the juice of the juniper bark skin to vomit the mucus and amniotic fluid swallowed). May cause uterine contractions and menstrual and amniotic fluid swallowed). May cause uterine contractions and menstrual bleeding. bleeding. Traditional dietary restrictions may be observed which may include not drinking Traditional dietary restrictions may be observed which may include not drinking milk (Navaho), eating meat or salt.milk (Navaho), eating meat or salt.

INTERVENTIONS:INTERVENTIONS: It is important to instruct these women that during pregnancy, the root of the It is important to instruct these women that during pregnancy, the root of the

elderberry elderberry (Sambucus canadensis, L. Caprifoliaceae)(Sambucus canadensis, L. Caprifoliaceae) is toxic. However, it is okay is toxic. However, it is okay to eat the berries themselves if they are cooked. to eat the berries themselves if they are cooked. PartidgeberryPartidgeberry (also referred to as (also referred to as checkerberry, -Mitchella repens) oil is teterogenic when concentrated. Certified checkerberry, -Mitchella repens) oil is teterogenic when concentrated. Certified nurse midwives (CNM) identified nurse midwives (CNM) identified Blue Cohosh Blue Cohosh (caulophyllum thalictroides) with (caulophyllum thalictroides) with complications of nausea, meconium-stained fluid, and transient fetal tachycardiacomplications of nausea, meconium-stained fluid, and transient fetal tachycardia.. Several cases have been associated with post delivery neonatal distress. Several cases have been associated with post delivery neonatal distress. JuniperJuniper (Juniperus communis,(Juniperus communis, Cupressaceae)Cupressaceae) should be avoided in pregnanc because it should be avoided in pregnanc because it may induce uterine contractionsmay induce uterine contractions.. The FDA lists these in their ‘Poisonous Plant The FDA lists these in their ‘Poisonous Plant Database’, Database’, therefore these sources strongly suggest that these plants should only therefore these sources strongly suggest that these plants should only be used under the guidance of a knowledgeable herbalist and ONLY in the last be used under the guidance of a knowledgeable herbalist and ONLY in the last trimester of pregnancy. trimester of pregnancy.

A thorough nutritional assessment should be done to determine if there is A thorough nutritional assessment should be done to determine if there is sufficient protein in the diet. We also need to reinforce that although berry plants sufficient protein in the diet. We also need to reinforce that although berry plants do have nutritional value, they are not enough to supply complete nutritional do have nutritional value, they are not enough to supply complete nutritional requirements. They are only a supplement to enhance diet, which needs to be well-requirements. They are only a supplement to enhance diet, which needs to be well-balanced or the insufficient diet may result in low birth weight infant.balanced or the insufficient diet may result in low birth weight infant.

Native American IndianNative American IndianBerries for nutrition and medicineBerries for nutrition and medicine WILD STRAWBERRYWILD STRAWBERRY (noon tak tek hah kwa) – considered a purifier and (noon tak tek hah kwa) – considered a purifier and

builder of blood that functions as a laxative, diuretic and astringent. The builder of blood that functions as a laxative, diuretic and astringent. The leaves and berries are rich in iron and contain the minerals magnesium,leaves and berries are rich in iron and contain the minerals magnesium,potassium and sodium. Also, old Indian woman say that too many strawberries potassium and sodium. Also, old Indian woman say that too many strawberries during pregnancy will cause the baby to be born with a strawberry birthmark!during pregnancy will cause the baby to be born with a strawberry birthmark!

RED RASPBERRYRED RASPBERRY (oo na joo kwa) – tea made from the leaves has been (oo na joo kwa) – tea made from the leaves has been effective in relieving nausea. It is said to assist uterine contractions to prevent effective in relieving nausea. It is said to assist uterine contractions to prevent hemorrhage during labor and delivery. After delivery, it is said to strengthen hemorrhage during labor and delivery. After delivery, it is said to strengthen and cleanse the system, as well as, enriching the supply of breastmilk. and cleanse the system, as well as, enriching the supply of breastmilk. Raspberry leaf tea is believed to help stimulate and promote normal menstrual Raspberry leaf tea is believed to help stimulate and promote normal menstrual function.function. The berries and leaves are said to be rich in iron; also containing The berries and leaves are said to be rich in iron; also containing minerals-phosphorus, potassium, magnesium.minerals-phosphorus, potassium, magnesium.

PARTRIDGEBERRYPARTRIDGEBERRY (noon kie oo nah) – called ‘Squaw Vine’ which is (noon kie oo nah) – called ‘Squaw Vine’ which is actually a derogatory term that should be avoided. This traditional herb’s actually a derogatory term that should be avoided. This traditional herb’s leaves, oil, fruit are used to regulate hormone imbalance, and facilitate labor.leaves, oil, fruit are used to regulate hormone imbalance, and facilitate labor.

BLUE COHOSHBLUE COHOSH (caulophyllum thalictroides) – the roots have been used (caulophyllum thalictroides) – the roots have been used Native Americans for inducing labor or abortion.Native Americans for inducing labor or abortion. From 1882 to 1905, blue From 1882 to 1905, blue cohosh was listed (for labor induction) in the U.S. Pharmacopoeia. Many cohosh was listed (for labor induction) in the U.S. Pharmacopoeia. Many herbalists advise against its use in early pregnancy and even its avoidance in herbalists advise against its use in early pregnancy and even its avoidance in late pregnancy.late pregnancy.

JUNIPER BERRYJUNIPER BERRY:: (Gad) – (Gad) – Navajo named evergreen shrub used as an emetic Navajo named evergreen shrub used as an emetic (causes vomiting) to purify the system of both adults and newborns. The (causes vomiting) to purify the system of both adults and newborns. The needles are boiled as a teas used to relieve diarrhea and as a postpartum needles are boiled as a teas used to relieve diarrhea and as a postpartum stimulant.stimulant.

Native American IndianNative American IndianCULTURAL BEHAVIORSCULTURAL BEHAVIORS Native American Indians (aboriginal midwifery and traditional Mohawk Native American Indians (aboriginal midwifery and traditional Mohawk

childbearing practices) believe that all breastmilk is contaminated childbearing practices) believe that all breastmilk is contaminated with what the people call the Wahecmah, the bad stuff, with what the people call the Wahecmah, the bad stuff, polychlorinated biphenyls (PCBs). This may result in many choosing polychlorinated biphenyls (PCBs). This may result in many choosing not to breastfeed.not to breastfeed.

INTERVENTIONSINTERVENTIONS Although the fear of PCBs and any level of chemicals in breast milk is Although the fear of PCBs and any level of chemicals in breast milk is

a real potential health concern for mother and neonate, the Natural a real potential health concern for mother and neonate, the Natural Resources Defense Council identifies once specific group of chemicals Resources Defense Council identifies once specific group of chemicals as the most significant pollutant, as the most significant pollutant, persistent organochlorinespersistent organochlorines. Known . Known as persistent organic pollutants (POPs), these chemicals persist in the as persistent organic pollutants (POPs), these chemicals persist in the environment and human body for years. But even with this environment and human body for years. But even with this knowledge, the council supports the fact that health benefits of knowledge, the council supports the fact that health benefits of nursing still far outweigh the potential problems from POPs. They also nursing still far outweigh the potential problems from POPs. They also go on to say that all countries are seeing the potential danger of go on to say that all countries are seeing the potential danger of these chemicals to our mothers and babies and as of May 22, 2001, these chemicals to our mothers and babies and as of May 22, 2001, the United States has join 119 other nations in an agreement to ban the United States has join 119 other nations in an agreement to ban the production or use of many of these chemicals. As practitioners, the production or use of many of these chemicals. As practitioners, we need to ensure that this information is taught to all our patients in we need to ensure that this information is taught to all our patients in the event that they have fears about contaminating their infants by the event that they have fears about contaminating their infants by passing these dangerous chemicals in breastmilk. passing these dangerous chemicals in breastmilk.

Hispanic (primarily Mexican) Hispanic (primarily Mexican) CultureCulture

CULTURAL BEHAVIORS:CULTURAL BEHAVIORS: The family is highly valued in the Hispanic culture both nuclear and The family is highly valued in the Hispanic culture both nuclear and

extended providing a supportive environment for the pregnant extended providing a supportive environment for the pregnant woman.woman. In labor & delivery, the woman's mother may be the In labor & delivery, the woman's mother may be the preferred birthing partner and traditional wives may defer to preferred birthing partner and traditional wives may defer to husbands in decision-making in health matters.husbands in decision-making in health matters. It is not uncommon It is not uncommon for grandmothers to move into the pregnant family homes during for grandmothers to move into the pregnant family homes during the last trimester of pregnancy and remain for weeks after the the last trimester of pregnancy and remain for weeks after the infant’s birth. infant’s birth.

Also may refuse some foods with preference to hot over cold. Also may refuse some foods with preference to hot over cold.

INTERVENTIONS:INTERVENTIONS: Try offering alternative foods or liquids to ice water. Try offering alternative foods or liquids to ice water. Respect familial duties by encouraging members to spend as much Respect familial duties by encouraging members to spend as much

time with the patient as possible to provide non-technical caretime with the patient as possible to provide non-technical care. .

HispanicHispanicCULTURAL BEHAVIORSCULTURAL BEHAVIORS Although there is a high birth rate in the Mexican population, the use of Although there is a high birth rate in the Mexican population, the use of

prenatal care services is very low, most probably due to traditional belief prenatal care services is very low, most probably due to traditional belief that prenatal care should take place in the home, with consultation of a that prenatal care should take place in the home, with consultation of a ‘curandera’ (folk healer). Also fear of separation from the family is also a ‘curandera’ (folk healer). Also fear of separation from the family is also a related factor and lack of financial resources (may be illegal alien).related factor and lack of financial resources (may be illegal alien).

INTERVENTIONSINTERVENTIONS Providers should instruct all their patients regarding the importance of Providers should instruct all their patients regarding the importance of

early prenatal care in a medical facilitiy under the care of a professional early prenatal care in a medical facilitiy under the care of a professional provider. Information and assistance should be obtained from the provider. Information and assistance should be obtained from the Mother-Baby Package:Implementing safe motherhood in countriesMother-Baby Package:Implementing safe motherhood in countries developed by the World Health Organization (WHO) which can be developed by the World Health Organization (WHO) which can be accessed from accessed from

http://www.who.int/reproductive-health/publications/MSM_94_11/MSM_94_11_table_of_contents.en.html

which addresses all these aspects of reproductive health and thus which addresses all these aspects of reproductive health and thus provides an opportunity to develop an integrated approach to service provides an opportunity to develop an integrated approach to service delivery. The Mother-Baby Package is the product of extensive delivery. The Mother-Baby Package is the product of extensive consultation. Input was received from United Nations Development consultation. Input was received from United Nations Development Program (UNDP), United Nations Population Fund (UNFPA), United Nations Program (UNDP), United Nations Population Fund (UNFPA), United Nations Children's FundChildren's Fund (UNICEF) and the World Bank, as well as governments, (UNICEF) and the World Bank, as well as governments, universities, Environmental Networks (NGOs) and bilateral agenciesuniversities, Environmental Networks (NGOs) and bilateral agencies. .

HispanicHispanicCULTURAL BEHAVIORS:CULTURAL BEHAVIORS: Family frequently encourages the pregnant mother to rest Family frequently encourages the pregnant mother to rest

frequently, walk, eat well, and get plenty of sleep. frequently, walk, eat well, and get plenty of sleep. Milk is avoided because of the belief that it results in large babies Milk is avoided because of the belief that it results in large babies

and difficult births. It is also believed that drinking chamomile tea and difficult births. It is also believed that drinking chamomile tea assures the mother of an effective labor. assures the mother of an effective labor.

Similarly to the Native American Indian, some Hispanic cultures Similarly to the Native American Indian, some Hispanic cultures believe that an infant may take on the characteristics of an object believe that an infant may take on the characteristics of an object the mother craves during pregnancy if the craving is not satisfied the mother craves during pregnancy if the craving is not satisfied (eg, strawberry spots if the craving for strawberries is not met). (eg, strawberry spots if the craving for strawberries is not met).

INTERVENTIONS:INTERVENTIONS: Providers should instruct the patients on the importance of Providers should instruct the patients on the importance of

balanced rest and activity. balanced rest and activity. Information should also be provided regarding the development of Information should also be provided regarding the development of

large for gestational age infants (LGA) with alternative foods to mild large for gestational age infants (LGA) with alternative foods to mild that will provide the calcium needed during pregnancy.that will provide the calcium needed during pregnancy.

Tolerance and understanding of cultural fears regarding cravings is Tolerance and understanding of cultural fears regarding cravings is essential as long as safety is not a factor. If the craving puts the essential as long as safety is not a factor. If the craving puts the fetus or mother at risk, intervention utilizing all family members fetus or mother at risk, intervention utilizing all family members should be utilized. Attempting to reach the father or “mother-in-should be utilized. Attempting to reach the father or “mother-in-law” is the best action since they hold authoritative roles in law” is the best action since they hold authoritative roles in Hispanic culture. Hispanic culture.

Muslim CultureMuslim CultureCULTURAL BEHAVIORSCULTURAL BEHAVIORS The custom ofThe custom of ‘TAHNEEK’ ‘TAHNEEK’ - - Before the infant is fed, almost directly Before the infant is fed, almost directly

following birth, a small piece of softened date is gently rubbed into the following birth, a small piece of softened date is gently rubbed into the baby’s upper palate by a respected member of the family, often the baby’s upper palate by a respected member of the family, often the father. The hope is that some of the positive attributes of the person father. The hope is that some of the positive attributes of the person will be transmitted to the newborn and it will enter a sweet world. will be transmitted to the newborn and it will enter a sweet world. Where dates are not easily available, substitutes are often used. Where dates are not easily available, substitutes are often used.

INTERVENTIONSINTERVENTIONS Nurses have to be very observant of what family members give to the Nurses have to be very observant of what family members give to the

infant. Sometimes, if dates are not available, the member may infant. Sometimes, if dates are not available, the member may substitute an easily accessible sweetened item that could be substitute an easily accessible sweetened item that could be dangerous to the infant, such as hard candy which could slip from the dangerous to the infant, such as hard candy which could slip from the hand and choke the infant. The nurse should guide the family to hand and choke the infant. The nurse should guide the family to substitute another item such as glucose water. After good asceptic substitute another item such as glucose water. After good asceptic handwashing, the member can dip his fingers into the water and handwashing, the member can dip his fingers into the water and gently rub it on the palate of the infant which would elicit the same gently rub it on the palate of the infant which would elicit the same desired effect. desired effect.

MuslimsMuslims

CULTURAL BEHAVIORS:CULTURAL BEHAVIORS:

The ‘Taweez’ is a small pouch that hangs from a small piece of string. The The ‘Taweez’ is a small pouch that hangs from a small piece of string. The pouch contains a prayer which is tied around the baby's wrist or neck. This pouch contains a prayer which is tied around the baby's wrist or neck. This practice, particularly seen among Muslims from the Indian subcontinent, practice, particularly seen among Muslims from the Indian subcontinent, protects the baby from ill health.protects the baby from ill health.

For Muslims, as in the Jewish community, religious law requires male For Muslims, as in the Jewish community, religious law requires male circumcision. Muslims consider male circumcision important for hygienic circumcision. Muslims consider male circumcision important for hygienic purposes essential when offering prayers. This decreases the risk of clothing purposes essential when offering prayers. This decreases the risk of clothing becoming soiled from urine that may leak the foreskin. According to the becoming soiled from urine that may leak the foreskin. According to the religion, soiled clothes nullify prayer. It is also believed that circumcision religion, soiled clothes nullify prayer. It is also believed that circumcision decreases the incidence of penal cancer.decreases the incidence of penal cancer.

INTERVENTIONS:INTERVENTIONS:

Strongly suggest that the parents place the ‘Taweez’ around the baby’s wrist Strongly suggest that the parents place the ‘Taweez’ around the baby’s wrist to prevent accidental choking of the infant. to prevent accidental choking of the infant.

Since circumcision is so controversial in the US at present, this once almost Since circumcision is so controversial in the US at present, this once almost routine procedure frequently does not get mentioned until the family brings it routine procedure frequently does not get mentioned until the family brings it up at discharge. This is problematic since the infant has to be watched closely up at discharge. This is problematic since the infant has to be watched closely following the procedure for passage of urine and potential bleeding. Early following the procedure for passage of urine and potential bleeding. Early recognition of the culture and the need for circumcision should be identified recognition of the culture and the need for circumcision should be identified by the practitioner and the family should be presented with this option by the practitioner and the family should be presented with this option shortly after delivery.shortly after delivery.

MuslimsMuslims

CULTURAL BEHAVIORS:CULTURAL BEHAVIORS: Many mothers may wish to breast feed since this is encouraged by religious Many mothers may wish to breast feed since this is encouraged by religious

teaching, but insufficient privacy may pose a barrier. Muslims demand that teaching, but insufficient privacy may pose a barrier. Muslims demand that women not expose certain body parts to anyone but their husbands. This women not expose certain body parts to anyone but their husbands. This may result in the decision to bottle feed in the hospital. may result in the decision to bottle feed in the hospital.

Similarly to some other cultures some sections of the Muslim community Similarly to some other cultures some sections of the Muslim community believe that colostrum is either harmful to the baby, or of poor nutritional believe that colostrum is either harmful to the baby, or of poor nutritional value. Supplements of honey and water may be given in the first few days value. Supplements of honey and water may be given in the first few days of life.of life.

INTERVENTIONS:INTERVENTIONS: Health practitioners should make arrangements for private areas where Health practitioners should make arrangements for private areas where

Moslem women feel comfortable enough to breastfeed that doesn’t conflict Moslem women feel comfortable enough to breastfeed that doesn’t conflict with their religious beliefs. If a woman says that she going to wait until she with their religious beliefs. If a woman says that she going to wait until she gets home to begin breastfeeding, this privacy issue should be explored gets home to begin breastfeeding, this privacy issue should be explored and alternatives suggested that will foster breastfeeding in the hospital. and alternatives suggested that will foster breastfeeding in the hospital. This will prevent difficulty with obtaining adequate mild production that This will prevent difficulty with obtaining adequate mild production that may accompany a delay in breastfeeding. may accompany a delay in breastfeeding.

A new born infant may develop iron deficiency anemia and/or rickets A new born infant may develop iron deficiency anemia and/or rickets (osteomalacia) if nutritionally rich supplements are not being utilized. (osteomalacia) if nutritionally rich supplements are not being utilized. Parents need to be instructed that honey is only delivering empty calories Parents need to be instructed that honey is only delivering empty calories and the practitioner should share literature with the family regarding the and the practitioner should share literature with the family regarding the high protein and immunoglobulins in colostrum, and how very valuable it is. high protein and immunoglobulins in colostrum, and how very valuable it is.

MuslimsMuslims

CULTURAL BEHAVIORS:CULTURAL BEHAVIORS: Breastfeeding for longer than six months is the not out of the Breastfeeding for longer than six months is the not out of the

ordinary and some families switch from infant formula to cow’s ordinary and some families switch from infant formula to cow’s milk from 5 to 6 months. milk from 5 to 6 months.

INTERVENTIONS:INTERVENTIONS: Feeding cow’s milk so early in the infants life is contrary to the Feeding cow’s milk so early in the infants life is contrary to the

Department of Health recommendation that reconstituted infant Department of Health recommendation that reconstituted infant formula should be continued beyond six months to prevent formula should be continued beyond six months to prevent deficiencies of iron and vitamins A, C, and D. Parents should be deficiencies of iron and vitamins A, C, and D. Parents should be encouraged to either maintain breastfeeding while beginning solid encouraged to either maintain breastfeeding while beginning solid foods, or supplement with infant formula.foods, or supplement with infant formula.

BibliographyBibliography American Public Health Association, University of Oregon Center American Public Health Association, University of Oregon Center

for Asian and Pacific Studies.for Asian and Pacific Studies. (2002, Apr. 4). (2002, Apr. 4). Asia: Health culture Asia: Health culture sketch. Maternal and reproductive health beliefs.sketch. Maternal and reproductive health beliefs. [Online]. [Online]. Available: Available: http://www.apha.org/ppp/red/asiabeliefs.htmhttp://www.apha.org/ppp/red/asiabeliefs.htm

Archives of Disease in Childhood, Fetal Neonatal Edition. (2001, Archives of Disease in Childhood, Fetal Neonatal Edition. (2001, January). January). Muslim Birth Customs.Muslim Birth Customs. [Online]. Available: [Online]. Available: http://adc.bmjjournals.com/cgi/content/full/fetalneonatal;84/1/F6?http://adc.bmjjournals.com/cgi/content/full/fetalneonatal;84/1/F6?

Galanti, Geri-Ann. Cultural Diversity in Health Care. (2002). Galanti, Geri-Ann. Cultural Diversity in Health Care. (2002). [Online]. Available: [Online]. Available: http://http://www.ggalanti.com/index.htmlwww.ggalanti.com/index.html

IIewirokwas Program, Pulling the baby out of the Earth.IIewirokwas Program, Pulling the baby out of the Earth. (1999, (1999, March). March). Into our handsInto our hands and and Using the Berry Plants for Women's Using the Berry Plants for Women's Nutrition and Medicine.Nutrition and Medicine. [Online]. Available: [Online]. Available: http://www.nativemidwifery.com/Articles.html#anchor42535http://www.nativemidwifery.com/Articles.html#anchor42535

Natural Resources Defense Council. (2001, May 22). Natural Resources Defense Council. (2001, May 22). Healthy Milk, Healthy Milk, Healthy Baby Chemical Pollution and Mother's Milk.Healthy Baby Chemical Pollution and Mother's Milk. [ [Online].Online]. Available: http://www.nrdc.org/breastmilk/default.aspAvailable: http://www.nrdc.org/breastmilk/default.asp

Bibliography ContinuedBibliography Continued

Nicoles, Francine H., RNC. (Journal of Perinatal Education, 1997. Nov.3). Nicoles, Francine H., RNC. (Journal of Perinatal Education, 1997. Nov.3). The Meaning of the Childbirth Experience: A Review of the Literature The Meaning of the Childbirth Experience: A Review of the Literature [Online]. Available: [Online]. Available: http://www.rosebaby.com/experience.htmlhttp://www.rosebaby.com/experience.html

Pediatrics. (1997, July). Pediatrics. (1997, July). Health Care for Children of Immigrant Families.Health Care for Children of Immigrant Families. [Online]. Available:[Online]. Available: http://www.aap.org/policy/970702.html http://www.aap.org/policy/970702.html

Thomson American Health Consultants: Alternate Therapies in Womens’ Thomson American Health Consultants: Alternate Therapies in Womens’ Health. (1999, October). Health. (1999, October). Blue Cohosh: A Word of Blue Cohosh: A Word of Caution. [Online]. Caution. [Online]. Available:Available: http://www.ahcpub.com/ahc_root_html/hot/archive/atwh1099.htmlhttp://www.ahcpub.com/ahc_root_html/hot/archive/atwh1099.html

University of Michigan Health System. (2002). University of Michigan Health System. (2002). Biweekly Multicultural Biweekly Multicultural Health FactsHealth Facts. [Online]. Available: . [Online]. Available: http://http://www.med.umich.edu/multicultural/ccp/bulletin.htmwww.med.umich.edu/multicultural/ccp/bulletin.htm

World Alliance for Breastfeeding Action Risks. (1996) World Alliance for Breastfeeding Action Risks. (1996) Communicating Communicating

about Risks and Infant Feeding.about Risks and Infant Feeding. [Online]. Available: [Online]. Available:http:///www.waba.org.br/penny6.htmhttp:///www.waba.org.br/penny6.htm

World Health Organization. (1999). World Health Organization. (1999). Mother Baby Package.Mother Baby Package. [Online]. [Online]. Available:Available: http://www.who.int/reproductive-health/publications/MSM_94_11/MSM_94_http://www.who.int/reproductive-health/publications/MSM_94_11/MSM_94_11_table_of_contents.en.html11_table_of_contents.en.html

Childbirth OptionsChildbirth Options

BabyZone. (2001). BabyZone. (2001). Interactive Birth Plan.Interactive Birth Plan. [Online]. [Online]. Available:Available: http://dopey.babyzone.com/pregnancy/interactive/birthplanhttp://dopey.babyzone.com/pregnancy/interactive/birthplan.asp.asp

BabyZone. (2001). BabyZone. (2001). Childbirth Choices.Childbirth Choices. [Online]. Available: [Online]. Available: http://www.babyzone.com/pregnancy/childbirth/naturalbirthhttp://www.babyzone.com/pregnancy/childbirth/naturalbirth.asp.asp

Immergut, Debra Jo. (Parents, 2001). Immergut, Debra Jo. (Parents, 2001). Exploring Your Labor Exploring Your Labor and Birth Options.and Birth Options. [Online]. Available: [Online]. Available: http://www.parents.com/articles/pregnancy/1115.jsphttp://www.parents.com/articles/pregnancy/1115.jsp