One Maternal Ne Born Cultural Issues

7/31/2019 One Maternal Ne Born Cultural Issues

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Maternal-Newborn CulturalIssues Affecting Intrapartum

and Neonatal CareBy Patricia M. Dillon RN, MA

LaGuardia CommunityCollege


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Following this module, the health practitioner will have an enhancedcompetency to work with childbearing families from various culturalbackgrounds.

OBJECTIVES:

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

Identify the need to examine ones own beliefs and values in an attempt toremain non-judgmental when caring for multicultural clients.

Distinguish the difference between the terms generalization andstereotype.

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

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

Discuss interventions to promote positive outcomes following thepregnant family's experiences with the childbirth and the health deliverysystem.


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Immigration

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

To address their patients individual needs effectively,

health care practitioners must acknowledge the need fora substantially broader base of information andunderstanding (1998 Conference ProceedingsTheGrowing Diversity of American Society).

Practitioners have to be prepared for the possible risk

problems that may occur in immigrants and theirchildren.


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Culture and Childbirth

The meaning of childbirth is unique to eachculture.

Cultural beliefs and traditions often play a majorrole in childbirth.

Many of these traditions may be harmless andsome may be beneficial, but others can bedamaging to both mother and infant.


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Childbirth is experienced very differently by eachwoman and man.

It is personal and unique, influenced by:1) cultural beliefs2) traditional practices3) age4) education

5) gender6) and other variables (stress, personality,

parity and spiritual beliefs).

Changing demographics and the continuous influxof immigrants has led to a growing nationalawareness of differences and rising issuessurrounding culture, ethnicity, race, age, gender,and sexual orientation in the United States.


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Maternal Aspects

Globally, more than 500 000 maternal deaths take placeyearly, with the majority occurring in developingcountries, but with the arrival of more and moreimmigrants, the potential risks increase even here in the

US. The major complications that result in most maternal

deaths everywhere are:

1) hemorrhage

2) sepsis3) pregnancy induced hypertension (PIH)

4) dysfunctional labor

5) abortion


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Fetal Aspects

Maternal complications ultimately affect the fetus/neonate as wellcausing about 8.1 million infants (about 48,700:3,899,599 live birthsin the US) to die each year, some during the first days of life, andalmost half within their first month.

Many deaths are related to:1) poorly managed pregnancies and deliveries

2) birth asphyxia3) infections4) trauma

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

C


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How Complications Affect mother and baby

Problem or complication Most serious effects onmother's health

Most serious effects on fetus/newborn

Severe anemia Cardiac failure Low birth weight, asphyxia, stillbirth

Hemorrhage Shock, cardiac failure,infection

Asphyxia, stillbirth

Hypertensive disorders ofpregnancy

Ecclampsia, cereberovascularaccidents

Low birth weight, asphyxia, stillbirth

Puerperal sepsis Septicaemia, shock Neonatal sepsis

Obstructed labour Fistulae, uterine rupture,prolapse, amnionitis, sepsis

Stillbirth, asphyxia, sepsis, birth trauma,handicap

Infection during pregnancy,sexually transmitted disease.

Premature onset of labour,ectopic pregnancy, pelvicinflammatory disease,infertility

Premature delivery, neonatal eye infection,blindness, pneumonia, stillbirth, congenitalsyphilis

Hepatitis Postpartum haemorrhage,liver failure

Hepatitis

Malaria Severe anaemia, cerebralthrombosis

Prematurity, intrauterine growth retardation

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

Increased risk of morbidity, mortality; childabuse, neglect, abandonment.

Unclean delivery Infection, maternal tetanus Neonatal tetanus, sepsis


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

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

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

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

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

RISK FACTORS


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Health Care

Many conflicts and misunderstandings in patient careare a direct result of the division between the valuesof the health care culture and those of the patient.

Just as values influence our patients reactions andbehavior, they also influence ours. Therefore, it isimportant to first understand our own culture andbeliefs.

Acknowledging patient cultural differences and utilizingthem to individualize health care will positively affectthe patients experience and response to pregnancy andchildbirth.


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Asian Culture

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

infants. Expectant fathers may remain outside of labor room until theinfant is born. As extended family members are decreasing and nuclearfamilies are becoming more prevalent, younger Asians are becoming moreacculturated attending childbirth classes as a couple. More families are

choosing this birth option which encourages the fathers participation andsupport of the mother during labor.

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

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

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


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Asian

CULTURAL BELIEFS/BEHAVIORS

Women may eat large meals early in labor to gain energy theybelieve is needed to get through labor. Western cultures discourageeating to prevent nausea/vomiting during active labor and in theevent that an emergency cesarean section may be required. This

common complaint of nausea seen in laboring many Asian women(particularly Chinese) reflects their misunderstanding regarding thisneed.

INTERVENTIONS

It is essential to educate Asian women pre-natally that eating duringthis time could be detrimental to them and the infant in the eventthat nausea and vomiting occurs. It may also limit their birthingoptions for various types of anesthesia in the event that emergencycesarean section is required.


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Asian

CULTURAL BELIEFS/BEHAVIORS: If the couple makes arrangements to have natural childbirth without the

usual restrictive equipment, i.e. intravenous fluids, monitor, etc, thentaking clear fluids during labor is essential to prevent dehydration andexhaustion. This condition would not only adversely affect the mother, butthe fetus as well.

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

INTERVENTION

In the event that your patient is traditional in adhearing to her culturalrituals, offer warm clear fluids during labor along with ice water. Offer morethan once, since some Asian cultures (particularly Vietnamese) may refusethe first time out of respect.


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Asian

CULTURAL BELIEFS/BEHAVIORS: 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.

Colostrum is believed to be "dirty" by some Asian cultures and may be discarded.

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

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

Mother needs to be informed that taking 1,500to 2,000 mg of calcium daily canlower 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

Association, JAMA) ! It is also reported to reduce the incidence of related pre-term

deliveries, low birth-weight babies and cesarean sections.Suggest familiartraditional foods that are high in calcium (tofu, small fish with bones, i.e. sardines).Supplements may be required.

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


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African American

CULTURAL BEHAVIORS

Due to past experiences with racial discrimination, African Americanpatients may not trust white institutions. They may also be verysensitive to what they perceive as discrimination.

INTERVENTIONS

Staff should always address patients and families in a professionalmanner as Mr., Mrs. or Ms. Be careful to avoid using gal when

referring to African-American women or boy when referring toAfrican-American men because especially in the south, these havenegative connotations.


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African American Culture

CULTURAL BEHAVIORS

In the south, African American women have been identified as havingfrequent cravings for red clay dirt when they become pregnant (pica). Inother areas, including NY, this craving has sometimes been replaced bycornstarch.

INTERVENTIONS

Staff should ask about the use of cornstarch when the African-Americanwoman has her first prenatal assessment. Teaching is essential to inform

the patient that in small amounts, eating cornstarch may prove to providecomfort, but in large amounts, can cause constipation. Since constipation iscommonly a problem during any pregnancy due to the effect of hormonesand uterine growth on gastric motility (), eating cornstarch couldaccentuate this already problematic area.


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African American

CULTURAL BEHAVIORS

Some African Americans may have strong religious beliefs regardingillness (punishment from God) or believe in voodoo (usually thosefamilies originating from the south or rural areas). Typicalgastrointestinal changes (nausea, vomiting, diarrhea, loss of

appetite) in early pregnancy may be interpreted as a sign ofpunishment from God or voodoo poisoning.

INTERVENTIONS

Clear teaching early in the antepartal period regarding physiologicalchanges common in pregnancy may relieve some of the fears ofthese women. Some who believe in voodoo, must be treated by a

voodoo practitioner (root doctor) to achieve psychological relief.


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African American

CULTURAL BEHAVIORS Newborn care may include warm baths, massaging with sesame oil , andpassive stretching of the baby's limbs. Patients may practice a culturalritual of applying an herb called malmal to the umbilicus for the first 7 daysof life.

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

umbilical cord (and circumcision in some instances) is completely dry and

healed (about 7 to 10 days) to prevent potential infection. They should betaught to watch for possible signs of infection such as redness, warmth,drainage and odor at the site of the umbilicus.

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

There is no evidence to show that the application of mamal is problematicas long as the solution is handled with clean aseptic technique. Staff shouldcontinue to instruct patients on the apply alcohol three times a day as wellto assist in preventing infection. There may be some delay in the drying ofthe cord with the application of mamal. (malmal can be found in the U.S. insome Asian markets).


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African American

CULTURAL BEHAVIORS Historically, breastfeeding was the primary form of infant nutrition.

It was not uncommon to breastfeed a child until 2 years of age.African American will most likely breastfeed, but will typically wantto supplement with bottle feedings. Traditionally, animal milkssuch as camel, goat, and cow may be used by these groups

especially in the first few days of life because colostrum isconsidered unhealthy.

INTERVENTIONS

As stated previously when dealing with the Asian population,

parents must be instructed in antepartum about the importance ofcolostrum feedings in the transmission of protective imunoglobulins

(antibodies) to their newborns .

N ti A i I di


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

years for a variety reasons. Indian women believe that during menstruation andpregnancy, that the womans body becomes very toxic. They prize wild berries are usedtraditionally to cleanse the body of impurities. Some are used to help normalize uterine

contractions. Blue Cohosh (Algonquin)and Partridgeberry (Cherokee) are uniquely native American

plants that serve as oxytocics used several weeks before childbirth to induce uterinecontractions,and after delivery as a salve for sore or cracked nipples. Iroquois medicaluses for this vine was as an abortifacient.Elderberries, red raspberry and sumacberrysprouts are also used for blood-building and purifying properties. Juniper berry (Navaho)is a diuretic, cleansing tonic used in adults and newborns (given the juice of the juniperbark skin to vomit the mucus and amniotic fluid swallowed). May cause uterinecontractions and menstrual bleeding.

Traditional dietary restrictions may be observed which may include not drinking milk(Navaho), eating meat or salt.

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

(Sambucus canadensis, L. Caprifoliaceae) is toxic. However, it is okay to eat the berriesthemselves if they are cooked. Partidgeberry (also referred to as checkerberry, -Mitchellarepens) oil is teterogenic when concentrated. Certified nurse midwives (CNM) identifiedBlue Cohosh (caulophyllum thalictroides) with complications of nausea, meconium-stainedfluid, and transient fetal tachycardia.Several cases have been associated with postdelivery neonatal distress. Juniper (Juniperus communis,Cupressaceae) should beavoided in pregnanc because it may induce uterine contractions.The FDA lists these intheir Poisonous Plant Database, therefore these sources strongly suggest that theseplants should only be used under the guidance of a knowledgeable herbalist and ONLY inthe last trimester of pregnancy.

A thorough nutritional assessment should be done to determine if there is sufficientprotein in the diet. We also need to reinforce that although berry plants do havenutritional value, they are not enough to supply complete nutritional requirements. They

are only a supplement to enhance diet, which needs to be well-balanced or the insufficientdiet may result in low birth weight infant.


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Native American IndianBerries for nutrition and medicine WILD STRAWBERRY(noon tak tek hah kwa) considered a purifier and builder

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

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

PARTRIDGEBERRY(noon kie oo nah)called Squaw Vine which is actually aderogatory term that should be avoided. This traditional herbs leaves, oil, fruit areused to regulate hormone imbalance, and facilitate labor.

BLUE COHOSH(caulophyllum thalictroides) the roots have been used NativeAmericans for inducing labor or abortion.From 1882 to 1905, blue cohosh was listed

(for labor induction) in the U.S. Pharmacopoeia. Many herbalists advise against itsuse in early pregnancy and even its avoidance in late pregnancy.

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


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Native American Indian

CULTURAL BEHAVIORS

Native American Indians (aboriginal midwifery and traditional Mohawkchildbearing practices) believe that all breastmilk is contaminated withwhat the people call the Wahecmah, the bad stuff, polychlorinatedbiphenyls (PCBs). This may result in many choosing not to breastfeed.

INTERVENTIONS

Although the fear of PCBs and any level of chemicals in breast milk is a realpotential health concern for mother and neonate, the Natural ResourcesDefense Council identifies once specific group of chemicals as the mostsignificant pollutant, persistent organochlorines. Known as persistentorganic pollutants (POPs), these chemicals persist in the environment andhuman body for years. But even with this knowledge, the council supportsthe fact that health benefits of nursing still far outweigh the potential

problems from POPs. They also go on to say that all countries are seeingthe potential danger of these chemicals to our mothers and babies and asof May 22, 2001, the United States has join 119 other nations in anagreement to ban the production or use of many of these chemicals. Aspractitioners, we need to ensure that this information is taught to all ourpatients in the event that they have fears about contaminating their infantsby passing these dangerous chemicals in breastmilk.


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Hispanic (primarily Mexican) Culture

CULTURAL BEHAVIORS:

The family is highly valued in the Hispanic culture both nuclear andextended providing a supportive environment for the pregnant woman.Inlabor & delivery, the woman's mother may be the preferred birthing partnerand traditional wives may defer to husbands in decision-making in healthmatters.It is not uncommon for grandmothers to move into the pregnant

family homes during the last trimester of pregnancy and remain for weeksafter the infants birth.

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

INTERVENTIONS:

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

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


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HispanicCULTURAL BEHAVIORS

Although there is a high birth rate in the Mexican population, the use ofprenatal care services is very low, most probably due to traditional belief thatprenatal care should take place in the home, with consultation of a curandera(folk healer). Also fear of separation from the family is also a related factorand lack of financial resources (may be illegal alien).

INTERVENTIONS Providers should instruct all their patients regarding the importance of early

prenatal care in a medical facilitiy under the care of a professional provider.

Information and assistance should be obtained from the Mother-Baby Package:Implementing safe motherhood in countriesdeveloped by the World HealthOrganization (WHO) which can be 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 provides anopportunity to develop an integrated approach to service delivery. The Mother-Baby Package is the product of extensive consultation. Input was receivedfrom United Nations Development Program (UNDP), United Nations PopulationFund (UNFPA), United Nations Children's Fund(UNICEF) and the World Bank,as well as governments, universities, Environmental Networks (NGOs) andbilateral agencies.
http://www.who.int/reproductive-health/economics/implementing.en.htmlhttp://www.who.int/reproductive-health/economics/implementing.en.htmlhttp://www.who.int/reproductive-health/economics/implementing.en.htmlhttp://www.who.int/reproductive-health/economics/implementing.en.htmlhttp://www.who.int/reproductive-health/publications/MSM_94_11/MSM_94_11_table_of_contents.en.htmlhttp://www.who.int/reproductive-health/publications/MSM_94_11/MSM_94_11_table_of_contents.en.htmlhttp://www.who.int/reproductive-health/publications/MSM_94_11/MSM_94_11_table_of_contents.en.htmlhttp://www.who.int/reproductive-health/publications/MSM_94_11/MSM_94_11_table_of_contents.en.htmlhttp://www.who.int/reproductive-health/publications/MSM_94_11/MSM_94_11_table_of_contents.en.htmlhttp://www.who.int/reproductive-health/economics/implementing.en.htmlhttp://www.who.int/reproductive-health/economics/implementing.en.htmlhttp://www.who.int/reproductive-health/economics/implementing.en.htmlhttp://www.who.int/reproductive-health/economics/implementing.en.htmlhttp://www.who.int/reproductive-health/economics/implementing.en.html


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HispanicCULTURAL BEHAVIORS:

Family frequently encourages the pregnant mother to rest frequently, walk,eat well, and get plenty of sleep. Milk is avoided because of the belief that it results in large babies and

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

Similarly to the Native American Indian, some Hispanic cultures believe thatan infant may take on the characteristics of an object the mother craves

during pregnancy if the craving is not satisfied (eg, strawberry spots if thecraving for strawberries is not met).

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

and activity.

Information should also be provided regarding the development of large forgestational age infants (LGA) with alternative foods to mild that will providethe calcium needed during pregnancy.

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

they hold authoritative roles in Hispanic culture.


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Muslim Culture

CULTURAL BEHAVIORS

The custom ofTAHNEEK- Before the infant is fed, almost directlyfollowing birth, a small piece of softened date is gently rubbed into thebabys upper palate by a respected member of the family, often the father.The hope is that some of the positive attributes of the person will betransmitted to the newborn and it will enter a sweet world. Where dates arenot easily available, substitutes are often used.

INTERVENTIONS

Nurses have to be very observant of what family members give to theinfant. Sometimes, if dates are not available, the member may substitute aneasily accessible sweetened item that could be 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 substitute another item such asglucose water. After good asceptic handwashing, the member can dip hisfingers into the water and gently rub it on the palate of the infant whichwould elicit the same desired effect.


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Muslims

CULTURAL BEHAVIORS:

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

For Muslims, as in the Jewish community, religious law requires male circumcision.Muslims consider male circumcision important for hygienic purposes essential whenoffering prayers. This decreases the risk of clothing becoming soiled from urine that

may leak the foreskin. According to the religion, soiled clothes nullify prayer. It isalso believed that circumcision decreases the incidence of penal cancer.

INTERVENTIONS:

Strongly suggest that the parents place the Taweez around the babys wrist toprevent accidental choking of the infant.

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


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Muslims

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

but insufficient privacy may pose a barrier. Muslims demand that women not exposecertain body parts to anyone but their husbands. This may result in the decision tobottle feed in the hospital.

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

INTERVENTIONS: Health practitioners should make arrangements for private areas where Moslemwomen feel comfortable enough to breastfeed that doesnt conflict with theirreligious beliefs. If a woman says that she going to wait until she gets home to beginbreastfeeding, this privacy issue should be explored and alternatives suggested thatwill foster breastfeeding in the hospital. This will prevent difficulty with obtainingadequate mild production that may accompany a delay in breastfeeding.

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


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Muslims

CULTURAL BEHAVIORS:

Breastfeeding for longer than six months is the not out of the ordinary andsome families switch from infant formula to cows milk from 5 to 6 months.

INTERVENTIONS:

Feeding cows milk so early in the infants life is contrary to the Departmentof Health recommendation that reconstituted infant formula should becontinued beyond six months to prevent deficiencies of iron and vitamins A,C, and D. Parents should be encouraged to either maintain breastfeeding

while beginning solid foods, or supplement with infant formula.


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Bibliography

American Public Health Association, University of Oregon Center for Asianand Pacific Studies.(2002, Apr. 4). Asia: Health culture sketch. Maternal

and reproductive health beliefs. [Online]. Available:http://www.apha.org/ppp/red/asiabeliefs.htm

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

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

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

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

Nicoles, Francine H., RNC. (Journal of Perinatal Education, 1997. Nov.3).The Meaning of the Childbirth Experience: A Review of the Literature

[Online]. Available: http://www.rosebaby.com/experience.html

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

Thomson American Health Consultants: Alternate Therapies in WomensHealth. (1999, October). Blue Cohosh: A Word of Caution. [Online]. Available:

http://www.ahcpub.com/ahc_root_html/hot/archive/atwh1099.html

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

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

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

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

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

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

Immergut, Debra Jo. (Parents, 2001). Exploring Your Labor andBirth Options.[Online]. Available:

http://www.parents.com/articles/pregnancy/1115.jsp
http://interactive%20birth%20plan.htm/http://exploring%20your%20labor%20and%20birth%20options.mht/http://exploring%20your%20labor%20and%20birth%20options.mht/http://interactive%20birth%20plan.htm/http://interactive%20birth%20plan.htm/

One Maternal Ne Born Cultural Issues

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