culturally responsive
obstetrical and gynecological care
Jean Gilbert, PhD
Geri-Ann Galanti, PhD
Los Angeles County
Department of Health Services
Office of Diversity Programs
Who Thinks Cultural Competency is a
Clinical Skill?

The Accreditation Council for Graduate Education
(Residency Programs)

The Association of American Medical Colleges
(Medical Schools)

The American College of Obstetrics and
Gynecology

The Los Angeles County Department of Health
Services: Cultural and Linguistic Competency
Standards
Why This Recent Emphasis on Culture
and Health Care?

Major changes in the composition of the U.S.
population: 25% of the California population is
foreign born.

Many immigrants are from non-Western nations
with non-Western health concepts.

Increasing emphasis on patient-centered care
within medicine.

Of the 1.7 million DHS patient visits over the last
6 months, about 779,000 were limited English
proficient, preferring services in 88 languages.
If You And Your Patient Hold Very
Different Health Beliefs...

This may impact on their trust in you and their
evaluation of your abilities.

It might impede understanding of your assessment
and treatment plan.

It may make obtaining consent for procedures very
difficult.

It might reduce willingness to comply with
treatment and follow-up.
Culture is a Major Force in Shaping an
Individual’s:

Expectations of a physician

Perceptions of good and bad health

Understanding of disease etiology

Methods of preventive care

Interpretation of symptoms

Appropriate treatment

Health care self-efficacy
In Understanding Cultures, a Little
Knowledge is Dangerous

Don’t let cultural generalizations become
stereotypes.

Generalizations are testable probabilities; we
couldn’t do science without them.

Stereotypes attribute the central tendencies of
groups to individuals… ignoring the bell curve!

Your patient is an individual, not a culture.
The Importance of Women’s Roles
Which one of these women is the model for
your patient?
Acculturation is a Critical Factor in:

Family dynamics and gender roles

Knowledge of and access to public and private
helping agencies.

Ability to speak and read English.

Experience with the U.S. health care system.
Video: Lupe’s Dilemma
QuickTime™ and a
H.263 decompressor
are needed to see this picture.
Video is part of the Multicultural Health Series, a community service project of Kaiser Permanente and The California Endowment.
Cultural Resistance to Breast Cancer,
PAP and STD Screenings

Lack of orientation to preventive care

Fatalistic perspective

Fear and embarrassment about pelvic
examinations

Social shame, invasion of bodily privacy

Doctors “push” testing too early, endanger hymen
Video: A Big Baby is Coming
QuickTime™ and a
H.263 decompressor
are needed to see this picture.
Video is part of the Multicultural Health Series, a community service project of Kaiser Permanente and The California Endowment.
Gestational Diabetes

Gestational diabetes is the most common
complication of pregnancy among Mexican
Americans.

Lack of early prenatal care often prevents
appropriate treatment.

Language issues often make appropriate education
and treatment difficult.
Labor Pains
• Asian women tend to be stoic.
• African American women may
be either.
Labor Pains
• Iranian women tend to be
expressive.
• Mexican women also tend to be
expressive.
Preferred Labor Attendants
Anglo American: Husband or Domestic Partner
Hispanic: Mother or Female Relative
Asian: Mother or Mother-in-Law
Video: Hmong Birthing Practices
QuickTime™ and a
H.263 decompressor
are needed to see this picture.
Video is part of the Multicultural Health Series, a community service project of Kaiser Permanente and The California Endowment.
Hmong Prenatal and Birthing Practices

Hmong women may resist napping and invasive
prenatal testing;

Consent for prenatal and birthing procedures may
have to be gotten from parents, husband, and inlaws;

At childbirth, both mother and baby are considered
especially vulnerable to malevolent spirits.
Video: Female Circumcision
QuickTime™ and a
H.263 decompressor
are needed to see this picture.
Video is part of the Multicultural Health Series, a community service project of Kaiser Permanente and The California Endowment.
Female Circumcision
(aka Female Genital Mutilation)
.
Normal Female Anatomy
Modified Sunna
Illustrations from Prisoners of Ritual, (1989) by Hanny Lightfoot-Klein
Female Circumcision
(aka Female Genital Mutilation)
.
Infibulation
Infibulation
Illustrations from Prisoners of Ritual, (1989) by Hanny Lightfoot-Klein
Breastfeeding
Colostrum
Postpartum Lying-in

Traditionally 30 - 42 days

Rest, stay warm, avoid bathing & exercise

Eat foods designed to restore warmth

Failure to follow custom is thought to result in
aches & pains in later years
Bonding and Baby Naming
SERENA: serene
Kabira: powerful
Taci: washtub
Radman: joy
CALEB: devotion to God
Duranjaya: a heroic son
CHAN JUAN: the moon; graceful; ladylike
Menopause in Cultural Perspective

Although menopause is universal, the “symptoms”
attributed to it are not.

Research suggests that the variety of ways
menopause is experienced can be termed “local
biologies.”

Cessation of the menses is looked upon very
positively by women in many cultures.
Issues of Language Access in Health
Care

DHHS guidance for language access under the
Title VI, Civil Rights Act of 1964

MediCal contract regulations

DHS Cultural & Linguistic Standards

Joint Commission on Accreditation of Healthcare
Organizations (JCAHO) includes standards for
cultural competence training and language services.
JCAHO Ruling

JCAHO views the provision of linguistically
appropriate care as an important quality and safety
issue.

JCAHO requires the inclusion of language and
communication needs in the medical record.

Interpretation and translation must be provided for
patients who need it.
DHHS says:

Assess patients’ language needs.

Try not to use family or friends or whoever you can
grab.

Don’t use minors to interpret.

Try to use trained medical interpreters whenever
possible.

Use telephonic interpreters for rare languages.
What Can You Do?

Honestly assess your own bilingual skills

Understand the pitfalls in using untrained
interpreters

Use interpreters effectively

Use telephonic interpreters skillfully
Are your bilingual skills really adequate?
Can you:

formulate questions easily?

ask a question in more than one way?

understand nuance and connotation in the
patient’s response to questions?

understand regional variations?

know terms for anatomy and healthcare concepts?

convert biomedical terms into lay terms in the
target language?
Pitfalls in Using Untrained Interpreters

Studies show that an average of 70% of the
interpreted exchanges by ad hoc interpreters
contain clinically important errors.

Family members, especially, are prone to edit both
the clinician’s and patient’s utterances.

Children are frightened or intimidated if asked to
interpret. There are ethical problems involved.

Confidentiality concerns must also be considered.
The Effective Use of Face-to Face
Interpreters

Brief the interpreter first, if possible.

Introduce the interpreter to the patient.

Position the interpreter behind the patient or
behind you.

Speak and look directly at the patient.

Use first person and expect the interpreter to do
the same.

Avoid interrupting the interpretation.
Using Telephonic Interpreters

Use a speaker phone; do not pass a handset back
and forth.

Remember that the interpreter is blind to visual
cues.

Let the interpreter know who you are, who else is
in the room, and what sort of patient encounter it is.

Let the interpreter introduce her/himself.
What You Need to Know to Connect

The language needed

Dial 0 for hospital operator

Tell operator to connect you with the Language Line.

Remember that the telephonic interpreter is bound
by confidentiality regulations, just as any other
health care personnel.
What Can You Do To Be More Culturally
Competent?

Practice ways to build rapport

Ask tactful, nonjudgmental questions about their
preferences and practices

Understand family roles in health care

Know something about the cultural beliefs of your
patients, but don’t stereotype

Use interpreters and use them effectively, don’t
“wing it.”
Consider:

Think back on your “difficult” patients.

May any of the challenges they presented be
linked to their cultural beliefs or practices?

Would cultural competence skills have made a
difference?
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