Traditional family values

In this section, additional information about Asian traditional family structures, family-based decision-making, gender roles, parenting, intergenerational and other cultural expectations are provided. The suggested cultural approaches or considerations are included to expand health providers’ cultural understanding and to enhance engagement with Asian families.

In New Zealand, Asians who have extended family members usually live together as a single-family unit, which includes grandparents, parents, children, as well as the families of parental uncles. With increased mobilization to urban areas, this structure is slowly moving towards that of the nuclear family comprised of parents and their children.

• The grandparent’s role in raising the children is a highly valued link to culture, religion and heritage.
• For traditional Chinese families with multiple sons, the parents or grandparents usually choose to live with the eldest son, while for traditional Indian families the choice usually is to live with the eldest son or the one with more financial capability.
• Asians value family ties and have strong filial love, respect for seniors, loyalty and honour as well as duty to the family.
• It is a traditional Asian belief that children have to give a lot of respect to parents and take care of parents when they get old. Some Asian older people may be more dependent on their children’s care when they are unwell. They may be reluctant to do exercise or help themselves in daily activities. There may be the dilemma of dependence and interdependence. For this reason, the process of and purpose of rehabilitation needs to be carefully explained by health practitioners.
• Because of the close-knit family structure, a family can expect many visitors when a family member is in the hospital.

Suggested approaches:

• Explore family dynamics and relationships.
• Find out who is the primary caregiver for the child.
• Explore the level of acculturation of the family members and their service expectations.
• Ask the client if he/she has family or community who can help in practical ways when he/she returns home.
• Ask how many visitors would be expected to visit the child.

• The father or the husband is usually the decision-maker for bigger family issues. However, mothers are usually the main caregivers of the children and older persons.
• Some Chinese and Korean mothers may have difficulties with taking on the role of making decisions on serious health matters for their children, because their husbands are working in their homeland. While they may have to be the main decision-makers they may still need to discuss decisions with their husband first. This may lead to a lot of stress.
• Because of the value placed on interdependence and privacy in Asian cultures and the desire to “save face”, family issues including healthcare decisions, are frequently discussed within the immediate family before seeking outside help.

Suggested approaches:

• Establish the main decision-maker(s) for healthcare matters (including informed consent).
• For communication, convey information to both (father or the husband or the mother of the children or caregivers of the children or older persons) to avoid communication breakdown.
• Find out if there is anyone overseas that needs to be contacted for healthcare decisions.

The roles of Asian men and women are distinct. Women manage the home by keeping all finances, family, and social issues in order. Women are more passive and men typically are the bread-winners and managers of issues requiring interaction with individuals in the community, eg health care. This type of behaviour implies that men have a dominant and authoritative role because they are the primary point of contact with society. However these roles are beginning to change among educated Asians and among immigrants in progressive or permissive societies.

Suggested approaches:

• Ask who the primary care giver is for the child and who is responsible for decision making.

• In many Asian cultures, parents expect their children to be obedient, well-disciplined and to achieve high academic qualifications. Therefore Asian parents employ a “training” mode of upbringing, organizing children to attend different tutorials or interest groups, even after school and during holidays.
• Failure to meet expectations (eg academic) brings shame and “loss of face” to the child and the family.
• Some parents are concerned about their children losing their native language ability and being unable to maintain traditional values. Children may be stressed by their parents’ traditional expectations and face conflict between eastern and western cultural values and peer group norms.
• In most instances in Asian communities, the whole family is involved in the care of the children. Grandparents play an important role in rearing children.
• For grandparents who do not live with the couple, they will come before the birth and stay to help out for the first few months to several years after the birth of the child.
• Children often sleep with parents from the time of birth to early childhood. If the grandparents are part of care taking, the children may be as attached to the grandparents as to their parents. This may cause some attachment issues between the child and their parents.
• Respect for elders is highly valued and children, including grandparents, older siblings, teachers, and family friends. The discipline of children is thought to come naturally. In some families, a child is responsible for many of the adult tasks, such as finance, legal forms, and interpretation/translation. Children from refugee backgrounds in particular may be responsible for adult tasks including the care of younger children.
• China’s one child policy was introduced in 1979. This has resulted in the development of the 4-2-1 This refers to the first generation of law-enforced only children becoming parents themselves. The adult child has two parents and four grandparents. Consequently, some Chinese parents and grandparents may over-indulge their only child or grandchild resulting in a child who may lack self-discipline and the ability to cooperate with others. The Chinese media refers to these traits as the “little emperor syndrome”. (Wikipedia, 2017). The impact of the one-child policy may result in some Chinese young couples having limited parenting skills. 

Suggested approaches:

• Assess parents’ views about the importance they place on the child’s education and the child’s ability to cope with parental expectations of high achievement.
• Assess the child (if he/she can speak for himself/herself) on their own to determine stressors and issues (eg cultural identity issues, educational expectation, etc). Explain to the parents the importance of assessing the child on their own (if parents are not comfortable to have their child assessed without them).
• During an invasive procedure, ask the child for their choice for support: grandparents or parents – or better, both.
• Advise parents/grandparents against using their children as interpreters.
• Assess the effects on the child of having adult responsibilities.
• Explore the couple’s parenting skills and encourage parenting education or incredible years’ education. (If grandparents are involved as primary care givers, encourage them to attend parenting education programmes together with the parents).

There are increasing interethnic marriages and relationships in New Zealand society (Didham & Callister, 2014). Rates of interethnic marriage are significantly higher in Asian populations in the 1.5 generation and among the New Zealand born than in the overseas born (Didham & Callister, 2014). The term 1.5 generation in this resource refers to people who were born overseas and relocated to New Zealand at a young age.

It is important to remember that maintaining ethnic belonging is central to the identity of many Asian women in interethnic marriages or relationships. Being in a cross-cultural marriage does not preclude the pressure from family and community to observe traditional birthing, postnatal and parenting/grandparenting practices. New Zealand born and 1.5 generation women may be living with mothers or mothers-in-law who have an expectation that their daughter or daughter-in-law will follow their cultures’ traditional child rearing practices.

Traditional practices during birth and the postnatal period are used worldwide in countries and regions such as China (Lau, 2009), Myanmar (Kokanovic, 2011; 2012), Korea (Kim, 2015), India (Goyal, 2006; Wells & Deitsch, 2014) and beyond. When families migrate, traditional birth, postnatal and parenting practices are challenged by western models. Older family members in New Zealand are likely to maintain traditional beliefs and parents may struggle with a lack of decision-making power (Lau & Wong, 2008).

Specific postnatal traditions differ by ethnicity, but they are all generally female-oriented with family-centric support networks aimed at ensuring the mother and baby’s health. Typically, during the first month after birth the woman is under the care of her mother or mother-in-law who helps to restore her health and strength as quickly as possible after birth, for example, by providing her with good nutrition, taking care of the older children, and doing the housework.

Postnatally, the traditional practices of rest, abstaining from housework, having a good diet, and avoiding fatigue and stress are intended to support lactation. In traditional cultures, the first month is of fundamental importance to the survival of the new mother and her baby, therefore the postpartum period is as important as the pregnancy.

Cultural expectations and conflicts

Older family members’ expectations of what constitutes healthy practices in the postnatal period may conflict with the advice women receive from their midwives/Well Child Tamariki Ora (WCTO) nurse and other child health service providers (Guo, 2013).

Older family members who support the woman often experience culture shock as their experiences of pregnancy, childbirth, postpartum and child rearing may not be understood by maternity service providers (Guo, 2013). 

In Guo’s (2013, p.309) study of migrant Chinese mothers in New Zealand, a midwife successfully included older family members by providing the kind of support that was acceptable to the woman and her husband. During a postnatal home visit, the midwife asked the woman and her husband how the woman’s mother would help them during the postpartum period. The couple was worried that the woman’s mother would expect the woman to observe the practice of the ‘sitting month’, and that she would be making decisions about breastfeeding and how they should parent their baby.

To overcome the potential cross-cultural communication barriers between herself and older family members, and to avoid conflict between the grandparents and parents, the midwife recommended that the parents interpret what was being discussed for the grandparents:

I can actually sit here with you guys and baby and your mum and dad and you can translate for me. And sometimes when I have you translate for me they kind of like get to understand a bit more about how things are for you here. Okay?

(Guo, 2013, p.310)

By doing this, the older family members felt included and they had an opportunity to understand the roles and practices of New Zealand maternal and child health services. Most importantly, the older family members felt respected and involved in decision-making rather than being excluded from the communication between the midwife and the couple.

Suggested approaches:

• Recognise that there may be components of traditional practices that migrant women wish to follow or to adapt, and that these practices may be helpful for the woman and her baby.
• Health practitioners can act as cultural mediators. Health practitioners can discuss the need to include extended family members when engaging with parents. Family harmony can be maintained by acknowledging the important role of older family members and the relationship between the care-giver and the extended family, and by including them in decisions about the child’s care. Additionally, health practitioners can act as mediators between older family members and parents. The cultural practices that sound useful can be considered by parents and can be modified to ensure that the older family members feel accommodated.
• Connect women to networks of other women of the same ethnicity. When women are unfamiliar with the New Zealand maternal and child health system, networking with other migrant women is helpful, in particular when women have limited English language skills. For example, Asian communities often access online forums to share ideas and perspectives on childbirth and parenting. For first-time mothers, the role of maternity-care/WCTO service providers is critical in linking women to child health services and supports, for example, some Plunket groups offer ‘coffee groups’ for specific ethnic groups in order to encourage networking and support for new mothers.

China’s preference for sons stretches back for centuries China’s one child policy has exacerbated the problem and produced disparity in the sex ratio at birth. In the past two decades, the advent of ultrasound scans has allowed people to abort female foetuses, although sex-selective abortion is illegal.

In Indian society , there is a similar preference for sons rather than daughters (Branigan, 2011). Gender preference issues may lead to a female infant being neglected.

Suggested approaches:

• Ask the couple about the family’s gender preference and views if there are concerns with the care provided to the female child. If there are neglect issues, make every effort to explain the neglect and abuse concerns and the serious consequences of these to ensure that the couple are aware. Take action if there are signs of child abuse, following DHB protocols.