Analysis of labor epidural analgesia disparities

Childbirth is one of the most important events in a woman’s life however, it is associated with a great deal of pain. The perception of pain is a highly subjective phenomenon and is dependent on the individual. A woman’s attitude toward pain and the decision to use a labor epidural may be influenced by personal, medical, social and, cultural factors. Changing demographics in society are impacting the current healthcare system. Cultural influences of immigrants are challenging traditional Western medical influences and demanding alternative approaches toward healthcare, specifically labor pain management. In 2016, the percentage of women giving birth was higher among immigrants (7. 4%) than among U. S. born (5. 9%). United States born women birthed over 3 million newborns while immigrant women gave birth to more than 750, 000. Epidural analgesia represents one of the most effective pharmacological ways to relieve labor pain. Approximately 60% of laboring women (2. 4 million each year) choose epidural analgesia for pain relief during labor. Labor epidural analgesia use may be on the rise but there is still a need to assess and educate women regarding knowledge of the risks and benefits prior to labor. This information would assist health care providers to support women as they prepare for labor (Stark, 2003). . The expectant mothers’ lack of educational resources, family tradition and language barrier may alter her perception of a labor epidural.

Hispanic Cultures and Beliefs

Hispanics are the nation’s largest ethnic minority reported by US Census bureau reports in 2017, constituting 17. 8 percent of the nation’s total population. According to their projections, the Hispanic population will constitute approximately 119 million people or 28. 6 percent of the nation’s population by 2060. Hispanics are the fastest growing minority in the United States and are facing difficulties within the health care system because of culture disparities, language barriers and lack of health insurance benefits. Though living in a modernized world, many Hispanic people retain the customs and traditions of their country of origin. Religious beliefs are an important aspect of all cultures, some more than others. A majority of Hispanics believe that God is actively involved in the world and seventy five percent claim miracles still occur today. Primarily Catholics, their beliefs and how they practice have an intensity unrivaled to non-Hispanic Catholics. A significant religious figure in Hispanic culture is the Virgin Mary. An intense devotion to the Virgin Mary and belief that she watches over believers, sets Hispanics apart from other Catholics. A study conducted in 2009, by Wiech et al. revealed less pain reported by Catholic participants when observing a picture of the virgin Mary compared to the control group.

Another widespread theme among studies of Hispanic families is the idea of strong commitment to family life. Family needs are generally more important than the concerns of the individuals. Both the individual’s self-esteem and identity are strongly affected by relationships with family members. Men occupy a position of respect and authority. A traditional view of manhood is a belief that a man is strong, brave, honorable and provides for his family. Paternalism within the Hispanic population may exist and as a result women are hesitant to participate in their own health care or decision making. Women are expected to care for children and elderly family members. The concept of Familism is central in the Hispanic community and extends beyond the nuclear family to include grandparents, aunts, uncles, cousins, friends, neighbors, and organizations that are important to the community. Hispanics view all life events as occasions to gather and celebrate.

Hispanic religious and cultural beliefs surrounding childbirth are intertwined with the absence of pain management. Hispanic women tend to believe that labor is a battle to be overcome and pain is part of this process. Devout religious Hispanic women believe a mother’s role is based on sacrifice and denying one’s own needs for those of her child, emulating the Virgin Mary. Natural childbirth and enduring the pain of labor is highly valued by the Hispanic culture. Healthcare professionals often times misunderstand these beliefs and customs and provide medical intervention when culturally sensitive care is preferred.

Muslim Culture and Beliefs

Pew Research Center estimates 3. 45 million Muslims living in the U. S. in 2017, making up 1. 1% of the total U. S. population. The U. S. Muslim population is projected to double by the year 2050.

There are varying practices among Muslims and health providers must be careful not generalize or make assumptions regarding patients’ beliefs. Muslim families, rather than the individual are the core of the community. Unlike Western culture, immediate and extended family members determine acts and behaviors, and bring relatives into all decisions. Muslin beliefs indicate the reward for a woman who bears the pains of childbirth is great, and should ask Allah for their full share of reward. Similar to other customs, Muslims believe the Mothers of The Prophets went through difficulties of childbirth to bear great men. It is believed through physical pain, their children will become assets to the Muslim Ummah. A Muslim woman prepares for the experiences of pain with patience (Sabr) and the hope that Allah will reward her good deed (Ihtisaab). Women believe temporary pain is insignificant in relation to the long term benefits in this world and the hereafter.

Islam holds women in high esteem and the Islamic rules of covering are intended to protect and guard her dignity and honor. The awrah, parts of the body that are not to be exposed, can differ depending on who is present. Observant Muslim women cover up their body when in the company of non-mahram males, those not related by blood or marriage.

Giger and Davidhizar’s Model of Transcultural Nursing

Cultural diversity education had not been successfully integrated into nursing school curriculums until 1988, when Giger and Davidizhar introduced the Transcultural Assessment Model. . Identifying concepts of the Giger and Davidhizar Model include: transcultural nursing, culturally competent care, culturally unique individuals, culturally sensitive environments, and health and health status. Transcultural nursing refers to the recognition and appreciation of cultural differences in healthcare values, beliefs and customs.

Culturally competent care exists when values are known and serve as a foundation to ensure patient satisfaction and positive outcomes. We are all culturally unique individuals in that we all have personal experiences that directly influence behaviors. Culturally sensitive environments produce safe and consistent patient care regardless of the location. Individual health and health status beliefs are personal attitudes manifested by patients and influenced by cultural background.

Giger and Davidhizar’s model identifies each individual as a culturally unique person capable of expressing themselves through six cultural phenomena. These phenomena are the represented in almost every culture. Communication, time, space, social organization, environmental control, and biological variations are the core framework required for the development of culturally competent care. Communication barriers include language differences, poor language translation and misinterpretation of non-verbal cues. The idea of time exists in almost all cultures, but the concept is not universal. Cultures may be more focused on the past as opposed to future, and others focused on the present. Space is defined as the “ distance between individuals when they are interacting”. Social organization is learned from within one’s familial unit and refers to how a family unit functions in relation to their associated cultural group. Environmental controls involve the belief in internal versus external control methods. Does the patient adhere to the belief that they have control over their health, or do they believe that their health outcomes will be determined by external forces? The final phenomena are biological and genetic differences within a cultural group. The model is based on the idea that culture is a patterned behavior developed over time as a result of social and religious manifestations. Assessing and incorporating each of these cultural phenomena to develop a strong knowledge base may improve cultural awareness and patient outcomes.

Integration of Culture, Transcultural Nursing Model & Evidence-Based Practice

The rising number of migrant patients means communication errors between a healthcare practitioner and patient are increasingly likely. Assessment and treatment of pain is based largely on patients’ reports about the location, intensity, and quality of pain, effective provider-patient communication is necessary for effective treatment. Epidural analgesia is most frequently used and recommended by the American College of Obstetricians and Gynecologists. Studies on attitudes of Hispanics towards pain during labor and delivery suggest they have similar pain management expectations as non-minority patients.

Counseling Hispanic women regarding pain management by their obstetrician increased the acceptability of labor epidurals use by 10 %. The initial step in dealing with this issue is to first assess the language and communication needs of the population.

Cultural Communication

One important way to improve communication between providers and limited English proficient (LEP) patients is to use interpreters.

Interpreters do not eliminate language barriers, they facilitate communication between providers, patients, and patients’ families. Previous studies have shown that use of interpreters improves communication between healthcare providers and patients with LEP, and promotes adherence to prescribed treatment regimens and follow-up care. Ad hoc interpreters, including family members, friends, and untrained members of the support staff are commonly used in clinical encounters by healthcare professionals. Such interpreters are unlikely to have training in medical terminology, confidentiality and are more likely than professional interpreters to commit errors that may have clinical consequences. It is especially risky to have children interpret, since they are unlikely to have a full understanding of two languages and frequently make errors in translation. Recent studies have indicated better patient reports of pain control, timely response to pain needs, and perceived helpfulness of healthcare providers to provide pain treatment when professional interpreters are utilized. These findings indicate that providing interpreters for hospitalized patients with language barriers results in higher-rated patient-reported quality of care for pain control. In 1999, the Joint Commission on Accreditation of Healthcare Organizations declared that pain assessment was the fifth vital sign and require documented interventions. Several studies are suggesting that use of interpreters can help to properly implement this mandate for patients with language barriers. Pain control during labor and delivery requires excellent communication between providers and patients. Patients’ expectations and knowledge about different alternatives for pain treatment, specifically labor epidural analgesia can influence the use of these methods. Use of interpreters may be particularly valuable to facilitate communication around pain control with obstetric LEP patients who have lower levels of education, are new to the healthcare system, and have poor knowledge of analgesic alternatives for labor and delivery.

Social Organization within Cultures

Cultural differences between the healthcare practitioner and the patient exist when the same rules, values or behaviors are not shared. Hispanic cultures include a more family-centered decision making model than the more individualistic model embraced by culture in the United States. Hispanic families can play an important role in supporting the patient within the medical setting. In one survey of Mexican American nurses, family support was identified as the most important area to which health care providers should attend while caring for Hispanic patients. Hispanic patients are more likely to permit their physician to take the predominant role in making health decisions in the absence of family members. In some studies, Hispanics of lower socioeconomic status generally preferred to use non-internet sources of health information to make medical decisions and to rely on advice obtained by word of mouth. Hispanics emphasize the role of faith and religion in coping with pain, evidenced with studies conducted by Kueter, 2014. Muslim families play an important role in the patient-provider healthcare decisions. Muslim families and community members provide physical care, emotional and spiritual support, and mediate interactions with the healthcare system. Additionally, within family-centric decision making structure, there may be particular gender-based roles. Muslim women are often portrayed as inferior beings, desperately in need of liberation from the Muslim patriarchal culture. This stereotype, created in the western media leaves much to be desired. Recent studies have shown that Muslim women prefer to make their own health care decisions however, it was “ important” and “ necessary” for their husband to attend the medical evaluation and treatment session with them. Hispanic families are traditionally male-dominated and very family oriented. Often sought for advice, elder family members hold a prominent status due to their life experience. The male and especially the elder male, is seen as the head of the family and often makes important decisions regarding the family. Despite this, all family members are consulted for support and advice when a family member is hospitalized.

Cultural Space Disparities

Clinicians who understand Muslim religious practices are better equipped to provide appropriate, individualized care of Muslim patients. Healthcare professionals interacting with Muslim patients, should follow certain guidelines whenever possible. This includes avoiding eye and physical contact between a patient of the opposite gender when possible. Furthermore, male doctors may have to communicate through a spouse if the patient is female. Muslim patients’ modesty and privacy should be respected, should be cared for by a nurse of the same gender. Simple approaches can be taken to make Muslim patients feel comfortable.

When entering a room of a Muslim patient, obtain permission before entering, allowing a female time to cover herself. Muslim patients’ privacy and modesty must be respected and nursing staff should provide gender specific care when possible. Requesting permission before uncovering any part of the body and performing exams and procedures by exposing as small an area as possible will exhibit cultural acceptance and sensitivity.

Religious & Environmental Influences

Health professionals should inquire about patients’ cultural backgrounds pertaining to their religious and spiritual system. Hispanic and Muslim patients often turn to religion or spirituality when dealing with pain. Spiritual beliefs and practices may influence pain perception and tolerance because psychological states are modulators of the pain experience. There is a known positive relationship between spirituality and well-being, life satisfaction and the quality of life. Muslims believe illness and injury are caused by a higher power (Allah), and attribute their illness, injury, pain and sufferings to Allah. Several studies identified the role of spirituality regarding pain suggesting that spirituality may be an important pain mediator. Results of a pain questionnaire distributed by the American Pain Society to hospitalized patients showed that personal prayer was the most commonly used nondrug method of controlling pain. In this study, prayer as a method of pain management was used more frequently than intravenous pain medication. Health professionals need to be aware of the importance of spirituality and religion when assessing and treating patients with pain and respect various coping mechanisms.

Cultural Biological Variations

Psycho-physiological factors that influence perceived pain difference between ethnic groups have been studied however, few have identified mechanisms that influence pain perception. It is suggested that observed ethnic differences regarding pain are unlikely to be explained by sociocultural influences but varying neuro-biological processes.

Conclusion

Lack of knowledge of Muslim and Hispanic cultural differences can produce barriers toward achieving cultural competence. Each country has its own unique culture that defines the normative values of an individual or a group. This culture determines behavior that outlines all aspects of their lives.

When healthcare providers are knowledgeable of the cultural customs, this enables them to provide better care and help avoid misunderstandings. It is extremely significant that a health care provider is knowledgeable and culturally competent and can effectively interact with people of different cultures.