Cultural assessment tools

The following general questions should be considered when caring for CALD women. Some women, in particular those from a refugee background, may be reluctant to disclose personal information. This may be due to pre-migration experiences and a general mistrust or fear of authority. LMCs, should explain the need for collecting this information and the duty of confidentiality if using an interpreter. The responses to these questions should be recorded in the antenatal care record for future reference.

Cultural assessment tool (A) for CALD women
(Adapted from Queensland Health Multicultural Services, 2009)

1. Where were you born?
2. Which countries have you lived in?
3. What is your ethnic background?
4. How long have you been in New Zealand?
5. Did you come to New Zealand as a migrant or a refugee?
6. What is your preferred language?
7. Do you need an interpreter?
8. Do you prefer a male or female interpreter?
   If relevant, ask
9. Are there any customs/traditional practices that we need to be aware of in caring for you during your pregnancy and birth (eg dealing with Female Genital Mutilation (FGM), birthing position, bathing before labour)?

The following cultural assessment questions will help you identify the woman’s cultural and religious practices and expectations during pregnancy, birth and postnatal care.

Cultural assessment tool (B) for pregnancy, birth and postnatal care
(Adapted from Queensland Health Multicultural Services, 2009)

1. Are you comfortable with both male and female health care providers?
   Explain that wherever possible a female health care practitioner will be provided if preferred, but in an emergency situation this might not be possible.
2. Are there any cultural/religious practices that we need to be aware of in caring for you during your pregnancy, giving birth and the postnatal period?
   For example, requirements with the placenta, female/male circumcision, infant feeding method, praying in baby’s ears or the shaving of baby hair etc.
3. In your culture, do fathers usually attend births? Does your partner want to attend the birth of his child? If not, is there another close family member you would like to be present? Would you like us to speak to them about your care? Do family members who are present during labour/birth have any particular requirements eg a prayer room?
   Ensure that the woman is aware that the policy of the birthing unit is to speak directly to her. However, somebody else can be included if it is culturally important.
4. Are there any foods that are appropriate or inappropriate for you according to your religion or customs during pregnancy, birth and the postpartum period?
5. Are there any beliefs or customs prohibiting physical activity during pregnancy, birth and the postpartum period? Do you plan to observe these?
   For example, a postpartum period.
6. What is the culturally acceptable way for you to express pain during childbirth?
   For example, screaming or trying to keep silent.
7. Are there any precautions with neonatal care?
   For example, Vietnamese and Thai women may believe that the head of the baby is the site of the soul and should not be touched.
8. How many visitors do you expect while you are in the birthing unit?
   Ensure that the woman is aware of visiting hours and any restrictions on the number of people that may be able to visit her.
9. Do you have anyone in your family or community who can help you in practical ways when you get home?
10. What is a culturally appropriate way to disclose bad news to the woman?
    For example, the risk of miscarriage: Discuss this as early as possible in the woman’s antenatal care (although this might cause anxiety).
11. Have you attended antenatal care in New Zealand before?
    Discuss with the woman the role of LMCs and Well Child/Tamariki Ora nurses in their care, and the purpose of home visits (support and care rather than control).
    Ask the woman if she would prefer to attend a women-only childbirth education group.
12. Have you experienced any problems with your antenatal care before?
13. Do you have any concerns or worries about your care?
14. Do you have cultural or religious support with your emotional health during your pregnancy?

During pregnancy, birth and the postnatal period, there may be cultural prescriptions about the kinds of food and the quantities of food that are appropriate for women and their babies to maintain good health.

Cultural Assessment Tool (C)
Nutrition and Physical Activity during pregnancy, birth and postnatal period
(Adapted from Queensland Health Multicultural Services, 2009)

1. Ask the woman:Are there any foods that are appropriate or inappropriate for you according to your religion/culture during pregnancy, birth and the postnatal period?
2. Do you intend to drink traditional homemade or purchased beverages or brews during pregnancy?
   Some homemade traditional drinks may contain alcohol at a concentration that may pose a risk to the unborn baby
3. Are you going to fast during your pregnancy or while in the birthing unit if during festival periods?
4. Do you intend to take any traditional herbal remedies during pregnancy, birth or breastfeeding? Are you taking any now?
5. In your culture, are there any beliefs or customs prohibiting physical activity during pregnancy, birth and the postnatal period? Do you plan to observe these?
6. In your culture/religion, do women have a postpartum period? If so, what does this involve? Do you plan to observe this?

Discuss with the woman:

• Appropriate nutrition during pregnancy, taking into account any food restrictions she wants to observe
• Whether she needs special food (eg halal, vegetarian) during her postnatal stay
• Whether she needs help to understand what is on the menu each day
• Whether she would like chilled, cold, warm or hot meals and drinks
• Whether she would like to arrange her own food if the birthing unit does not cater for her dietary needs.

Cultural assessment tool (D)
Birth and Postnatal Stay
(Adapted from Queensland Health Multicultural Services, 2009)

Ask the woman:

1. Are there are any customs/traditional practices that we need to be aware of in caring for you during birth (eg birthing position, bathing before labour, dealing with FGM, cord cutting, handing baby to specific family members and birthing the placenta)?
2. What are your cultural views about induction of labour or caesarean section? Have an open discussion about the importance of a safe birth. Explain that if the baby has not arrived before 40 weeks of gestation, it is very important that the woman and the LMC keep in close contact? (This is important to avoid women going into hiding at 41 weeks in fear of an induced birth).
3. Is it acceptable in your culture to express pain during birth and/or how do you express pain during labour and birth?
4. Is early bonding or contact with your baby appropriate?
   Some women may not want to have skin to skin contact with the baby immediately after birth, or until the baby has been bathed. They may see the unwashed baby as polluted.
5. Is there anyone who can look after your other children (if any) while you’re in the birthing unit?
6. How many visitors would you expect to have while you are in the birthing unit?
   NB: Ensure that the woman is aware of visiting hours and any restrictions on the number of people who may be able to visit her while she is in the birthing unit?

Cultural assessment tool (E) for postnatal care
(Adapted from Queensland Health Multicultural Services, 2009)

It is essential to provide a qualified female interpreter when assessing women who have limited English proficiency. However a woman’s request to have a family member interpret has to be carefully considered. It would require health providers to respectfully negotiate with the woman and explain the interpreter’s professional duty of confidentially.

NB: Health providers should find out how to access interpreting services and how to use the different types of services available (ie phone, face-to-face, telephone assignment and appointment confirmation services). eCALD® Services offers CALD 4: “How to Work With Interpreters” training. See www.eCALD.com.

Postnatal Care

Ask the woman:

• Do you intend to breastfeed? If yes, do your immediate or extended family support your decision to breastfeed?
• Do you plan to do anything to increase or decrease your breast milk supply?
• Are you happy to express breast milk if your baby is unwell or when there are problems with breastfeeding?
• Will you observe any practices to encourage your recovery?
• How are you feeling emotionally?

Discuss with the woman:

• Are there any practices that you would like me to know about while I am caring for you during the postnatal period? (eg dietary practices, bathing after labour, dealing with FGM requirements, placenta, and requirements with resting).
• In your culture, who cares for you and your baby after the birth? How long will you receive their support? Who will care for you in New Zealand? Talk openly about her cultural and traditional experiences around post natal care and talk about where she can access support in New Zealand.

Care of the Baby

Ask the woman:

• It is common in New Zealand for baby to be roomed in with the mother, that is, to be with the mother all the time, is this acceptable to you?
• Is it acceptable in your culture to compliment a newborn baby?
  Some women may dislike compliments addressed to their babies, believing that an evil eye can cause the baby to fall ill.
• Are there any precautions with holding the baby?
  Some Vietnamese and Thai women may believe that the head of the baby is the site of the soul and should not be touched.
• When would you like your baby to have their first bath?
• Do you plan to practice any type of skin care for your baby?
  Some women may wish to massage the baby with oil
• How would you like your baby’s belly button to be cared for?
  In some cultures, women may make an effort to ensure that the baby has an attractive belly button by placing a coin on the infant’s navel and binding it with a piece of cloth. The woman should be advised to clean the coin with soap and water, place a clean cloth between coin and belly button, then bind firmly but not tightly. Take it off for a few moments each day.
• Do you have any precautions towards baby’s eye, nose or ear care?
• We do expect new mothers to provide care for their own baby, does this match with your expectation of the maternity service?
• How would you like to dress your baby?
  Some women may not wish their baby to wear clothes that have been worn by another baby, for example Chinese people may believe that a baby that wears used clothes will adopt the behaviour of the previous wearer.
• Do you plan for your son to be circumcised and at what age?
  If the woman intends to do this, it is essential to provide information about circumcision.
• Would you like your daughter to be circumcised?
  If the woman indicates an intention, a multi pronged approach should be taken. Firstly, provide education on the physical harms of FGM. Secondly, provide FGM education resources in the clients language. These resources provide clear and detailed information on the physical harms of FGM to children, religious teachings against FGM, and details on why FGM is illegal in NZ. If it appears the woman has significant support for FGM, and a plan to circumcise her daughter, then refer the woman to the FGM Education Programme for support for the family www.fgm.co.nz and to NZ CYFS who will follow up with the family according to the NZ FGM Child Protection Guiding Principles.
• In your culture, who cares for you and your baby after the birth? How long do you receive their support? Talk openly about her cultural and traditional experiences around post natal care and talk about where she can access support in New Zealand.

Breastfeeding

• Do you intend to feed colostrum to your baby?
  Explain what colostrum is and the role of colostrum.
  If the woman wants other options, it is important to discuss with her preferable substitutes for colostrum (eg. water, formula) and to make sure that these substitutes are acceptable.
• Will you follow any cultural practices before breastfeeding?
  For example, Muslim families may put a tiny amount of date paste on baby’s palate before breastfeeding as recommended in Islam. It is known as ‘Tahneek’.
  Some women who have chosen to breastfeed, may not breastfeed their babies until the colostrum is fully expressed? [if this is the case, explain the importance of colostrum as part of breastfeeding].

Discharge planning and home visits

Ask the woman:

• Do you have anyone in your family or community who can help you in practical ways when you get home?
• Is there anyone who can provide you with emotional support during early parenthood?
  Explain to the woman that it is very common for women to feel sad or anxious after birth.

Discuss with the woman:

• The role of LMCs and Well Child/Tamariki Ora nurses in their care, and the purpose of home visits (support and information sharing rather than being told what to do).
• Any cultural/religious practices that need to be observed by the health professional during home visits, including the health professionals’ dress code.
• Contraceptive methods/options.
  During a home visit, discuss contraceptive methods/options that are culturally or religiously acceptable.

Information and Referral:

• Provide the woman (and significant others such as grandparents) with information about family health and the importance of registering with a GP, Well Child/Tamariki Ora services and DHB women’s and children’s services and cultural support if available.
• Ensure referral to a Well Child/Tamariki Ora provider and other services including a referral to the regional public health service for BCG.