Perinatal Loss and Palliative Care —
A Women’s Health Conference 2008
Multicultural Issues in Perinatal
Grief and Loss
Shannon Mulligan BSW
Social Worker NICU /FAU
St. Boniface General Hospital
Canada is a richly pluralistic society.
1996, 17% of the Canadian population were
Canadian Institute for Health Information, 1999
Many new immigrants consider or settle in
Manitoba based on the ‘point’ system bonuses
within the Canadian Immigration System.
As of 2006, the foreign-born population
numbered 121,300, or 17.7% of the total
population of Winnipeg.
Statistics Canada Census 2006
Manitoba’s immigration rate is relatively
high and ranked third among the
provinces behind Alberta and Ontario.
 According to the 2006 Statistics Canada
report, an estimated 31,200 newcomers
settled in Manitoba, about 2.8% of the
total recent immigrants.
 The foreign-born population in Winnipeg
grew by 10.5% between 2001 and 2006.
About 1 in 5 foreign-born residents of
Winnipeg were recent immigrants,
predominantly born in Asia and the Middle
East. The Philippines was the leading
source country, with nearly 3 out of every
10 newcomers, while India and the
People's Republic of China were also
among the leading source countries of
recent immigrants.
Statistics Canada Census 2006
Manitoba Immigration
Top 10 countries of origin, 2004
Philippines: 1,529
Ethiopia: 305
Germany: 952
China: 290
India: 535
Sudan: 225
South Korea: 398
Ukraine: 213
Israel: 329
England: 170
What is Culture?
Culture may be considered an “invisible
blueprint for living” (Jones, 1999, p.395), the
essence of one’s being.
 Capers (1992) defines culture as the “
pattern of learned behaviors, values,
beliefs and customs which are shared by
members of a group and are usually
transmitted to other group members
through time.
It is essential to recognize that the
term ‘culture’ goes beyond racial,
ethnic, and linguistic differences
Andrews and Boyle, 1999; Castillo, 1996.
Culture evolves and develops when
families immigrate to new places and
become influenced by the dominant
What is Culture?
“You sure look nice tonight Ginger… and what you rolled in
sure does stink!”
Cultural Values
A preferred way of acting or knowing
something that has been reinforced by
ones social structure, and ultimately,
governs one’s actions and decisions.
Leininger, M. Transcultural Care, Diversity and Universality; A Theory of Nursing.
Nursing and Health Care. 1985.6:209-212
Cultural Values
Values can be reflected in a person’s
cultural perception of time, personal
space, communication style, role of
gender and family practices in aspects of
daily living.
Prenatal Neonatal Nursing, June, 1999; 13(1):15-26.
Cultural Values
“This is your side of the family, you realize.”
Cultural Values
Understanding different cultural beliefs as
they pertain to loss and grief is critical
because “lack of cultural understanding,
language barriers, and internal bias or
prejudice creates visible and invisible
barriers for our clients.”
(1999, p. 3) Journal of Cultural Diversity.Vol. 9, No. 3
Cultural Values
It should be noted that every belief system
ranges from the most orthodox to the least
conventional in practice or observance.
Therefore, cultural, professional and spiritual
competency should be considered an evolutionary
A universal theme of almost all cultures is the
creation of rites and rituals around important life
Shah, Mary Ann, ed. Transitional Aspects of Perinatal Care; A Resource Guide. National
Perinatal Association; 2004
All cultures have developed methods for
adaptive coping, grief, and mourning.
Hence, a lack of cultural awareness and
sensitivity may interfere with a family’s
ability to cope effectively with loss and
Developing Core Competencies
Becoming culturally sensitive involves
self awareness and learning to
appreciate the differences of cultural
 It requires the health care provider to
engage in a mutually respectful
relationship with patients/clients and
their families.
Developing Core Competencies
Cultural competence entails a
willingness to allow ourselves to
experience and learn others’
practices and to approach our
patients and their families from a
position of respect and openness.
 We must first recognize our own
cultural beliefs and acknowledge
them as our unique and individual
Developing Core Competencies
While becoming culturally sensitized,
however, it is important to resist
stereotyping people of any particular
national origin or religion, recognizing that
within any group, individuals, families,
communities and other sub groups can
differ substantially from one another in
their beliefs and practices.
Shah, Mary Ann, ed. Transitional Aspects of Perinatal Care; A Resource Guide.
National Perinatal Association; 2004.
4 Core Competencies
Cultural Competence
Linguistic Competence
Professional Competence
Spiritual Competence
Cultural Competence
“ The awareness and respect for cultural/
religious practices, beliefs, and differences,
enabling practitioners to adapt health care
in accordance with ethno cultural/religious
heritage of the individual, family, and
Spector, R. E. Cultural Care: Guidelines to Heritage. Assessment and Health
Traditions, 2nd. Ed. Upper Saddle River, NJ: Prentice Hall Health; 2000
Linguistic Competence
The provision of bilingual staff or
interpretation services for all clients
without English Language proficiency.
US Department of Health and Human Services Office of Minority
Health. Assuring Cultural Competence in Health Care:
Recommendations for National Statistics and an OutcomesFocused Research Agenda. Washington, DC.
Professional Competence
The accrual of scientific knowledge and
skills and the application of the best
evidence available in the rendering of
health care that is congruent with the
traditions and beliefs of members of
diverse ethno cultural/religious groups.
Shah, Mary Ann, ed. Transitional Aspects of Perinatal Care; A Resource Guide.
National Perinatal Association; 2004.
Spiritual Competence
The ability to identify and
understand one’s own values and
spiritual beliefs in the context of a
pluralistic society, recognizing how
interactions with patients and
families may be affected by
religious differences.
Shah, Mary Ann, ed. Transitional Aspects of Perinatal Care; A Resource
Guide. National Perinatal Association; 2004
Culture evolves and develops when families
immigrate to new places and become
influenced by the dominant culture.
Culture is, therefore, not static and is an
ever evolving, individualistic viewpoint or
Culturally sensitive questions should be
asked of patients and families who are
faced with coping with the loss of a loved
Culturally Sensitive Questions
Clements, Vigil et al. in the Journal of
Psychosocial Nursing, identify four sets
of Culturally Sensitive Questions.
Culturally Sensitive Questions
What are the family’s cultural traditions
and rituals for coping with dying, the
deceased’s body, and honoring the
What are the family’s beliefs about what
happens after death?
Culturally Sensitive Questions
What does the family consider to be the
roles for each member in coping with the
What does the family feel to be a normal
expression of grief and acceptance of the
Clements, Paul T., Vigil, Gloria J., et al. Cultural Perspectives of Death, Grief, and
Bereavement. Journal of Psychosocial Nursing, Vol. 41, No. 7; July, 2003.
What can we do as Professionals?
Promote and support the attitudes,
behaviors, knowledge and skills necessary
for staff to work respectfully and
effectively with patients and each other in
a culturally diverse work environment.
 Utilize formal mechanisms for community
and consumer involvement in the design
and execution of service delivery,
including planning, service delivery and
What can we do as professionals?
Require and arrange for ongoing education and
training for all staff in culturally and linguistically
competent service delivery.
Provide all clients, with limited English language
proficiency , access to bilingual staff or
interpretation services.
Undertake ongoing organizational assessments of
cultural and linguistic competence and institute
performance improvement programs.
Shah, Mary Ann, ed. Transitional Aspects of Perinatal Care; A Resource
National Perinatal Association; 2004.
Thank You!

Dealing with Grief and Loss in a Multicultural Society