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Maternal-Newborn Cultural Issues Affecting Intrapartum and Neonatal Care

By Patricia M. Dillon RN, MA LaGuardia Community College

Following this module, the health practitioner will have an enhanced competency to work with childbearing families from various cultural backgrounds.
OBJECTIVES:

Recognize the need to assess and validate the cultural beliefs and traditions of patients associated with the different ethnic groups. Identify the need to examine ones own beliefs and values in an attempt to remain non-judgmental when caring for multicultural clients. Distinguish the difference between the terms generalization and stereotype. List examples of cultural beliefs and traditions in identified ethnic groups that could affect maternal health and birthing options.

List examples of cultural beliefs and traditions in identified ethnic groups that could negatively affect fetal/neonatal well being.
Discuss interventions to promote positive outcomes following the pregnant family's experiences with the childbirth and the health delivery system.

Immigration

Immigration and diversity have always been at the core part of American history. These continue in momentum in the present and will continue to exist into our future. To address their patients individual needs effectively, health care practitioners must acknowledge the need for a substantially broader base of information and understanding (1998 Conference Proceedings The Growing Diversity of American Society). Practitioners have to be prepared for the possible risk problems that may occur in immigrants and their children.

Culture and Childbirth



The meaning of childbirth is unique to each culture. Cultural beliefs and traditions often play a major role in childbirth. Many of these traditions may be harmless and some may be beneficial, but others can be damaging to both mother and infant.

Childbirth is experienced very differently by each woman and man. It is personal and unique, influenced by: 1) cultural beliefs 2) traditional practices 3) age 4) education 5) gender 6) and other variables (stress, personality, parity and spiritual beliefs). Changing demographics and the continuous influx of immigrants has led to a growing national awareness of differences and rising issues surrounding culture, ethnicity, race, age, gender, and sexual orientation in the United States.

Maternal Aspects

Globally, more than 500 000 maternal deaths take place yearly, with the majority occurring in developing countries, but with the arrival of more and more immigrants, the potential risks increase even here in the US. The major complications that result in most maternal deaths everywhere are: 1) hemorrhage 2) sepsis 3) pregnancy induced hypertension (PIH) 4) dysfunctional labor 5) abortion

Fetal Aspects

Maternal complications ultimately affect the fetus/neonate as well causing about 8.1 million infants (about 48,700:3,899,599 live births in the US) to die each year, some during the first days of life, and almost half within their first month . 1) 2) 3) 4) poorly managed pregnancies and deliveries birth asphyxia infections trauma

Many deaths are related to:

Those that survive have significant amounts of residual damage that


leave them with lifelong physical or mental disabilities.

How Complications Affect mother and baby


Problem or complication Severe anemia Hemorrhage Hypertensive disorders of pregnancy Puerperal sepsis Obstructed labour Most serious effects on mother's health Cardiac failure Shock, cardiac failure, infection Ecclampsia, cereberovascular accidents Septicaemia, shock Fistulae, uterine rupture, prolapse, amnionitis, sepsis Premature onset of labour, ectopic pregnancy, pelvic inflammatory disease, infertility Postpartum haemorrhage, liver failure Severe anaemia, cerebral thrombosis Unsafe abortion, infection, pelvic inflammatory disease, haemorrhage, infertility Infection, maternal tetanus Most serious effects on fetus/newborn Low birth weight, asphyxia, stillbirth Asphyxia, stillbirth Low birth weight, asphyxia, stillbirth Neonatal sepsis Stillbirth, asphyxia, sepsis, birth trauma, handicap Premature delivery, neonatal eye infection, blindness, pneumonia, stillbirth, congenital syphilis

Infection during pregnancy, sexually transmitted disease.

Hepatitis Malaria Unwanted pregnancy

Hepatitis Prematurity, intrauterine growth retardation Increased risk of morbidity, mortality; child abuse, neglect, abandonment.

Unclean delivery

Neonatal tetanus, sepsis

RISK FACTORS

New immigrants may have difficulty acquiring adequate employment which limits funds for health care. Immigrants with limited or no familiarity with the English language, may have difficulty accessing adequate health care services. Low socio-economic status may cause insecurities about lack of food, clothing, and shelter that often override health concerns. Deficits in these basic needs lead to nutritional insufficiency (anemia) and exposure to the elements that increase the risk of infections and other illness for both mother and neonate. Legal and illegal immigrants that are not eligible for Medicaid are covered for emergency services, such as labor and delivery, but often not for preventive services, such as prenatal or well- child care.

Health Care

Many conflicts and misunderstandings in patient care are a direct result of the division between the values of the health care culture and those of the patient. Just as values influence our patients reactions and behavior, they also influence ours. Therefore, it is important to first understand our own culture and beliefs. Acknowledging patient cultural differences and utilizing them to individualize health care will positively affect the patients experience and response to pregnancy and childbirth.

Stereotyping vs. Generalizations

Stereotyping is an end point where no attempt is made to determine if the individual really fits the criteria. Generalization is more of a beginning point which indicates common threads, but suggests the need for further information.
(from Cultural Profiles at http://www.ggalanti.com/index.com/

Specific Cultural Behaviors Affecting Childbirth Options and the Neonate


Asian
CULTURAL BEHAVIORS: Some groups believe that while the fetus resides in the womb, it absorbs information which develops its personality and physical appearance. The expectant mother may fear that if she doesnt consumes the item that she craves, her baby will take on (physical) characteristics of that food. It is not uncommon for primigravidas (first pregnancies) to return to their country of origin to reunite with their parents when it comes time to deliver their baby. INTERVENTIONS: As long as the food craving is not dangerous to the expectant mother or fetus, the health practitioner should recognize and accept this cultural belief and allow the mother to satisfy her food craving to appease her fear. The health practitioner must ensure that the patient has sufficient health information regarding prenatal care given so that the couple can more efficiently convey medical history to the new healthcare provider.

Asian Culture
CULTURAL BEHAVIORS
Traditional Asian men frequently do not attend the delivery of their infants. Expectant fathers may remain outside of labor room until the infant is born. As extended family members are decreasing and nuclear families are becoming more prevalent, younger Asians are becoming more acculturated attending childbirth classes as a couple. More families are choosing this birth option which encourages the fathers participation and support of the mother during labor.

INTERVENTIONS:
Health practitioners should assess the family needs, and female family members/relatives such as mother, mother-in-law, aunts and sisters should be allowed to provide the needed support during this time. Fathers should be supported and encouraged to attend classes and the birth if they demonstrate this interest.

Asian
CULTURAL BELIEFS/BEHAVIORS Women may eat large meals early in labor to gain energy they believe is needed to get through labor. Western cultures discourage eating to prevent nausea/vomiting during active labor and in the event that an emergency cesarean section may be required. This common complaint of nausea seen in laboring many Asian women (particularly Chinese) reflects their misunderstanding regarding this need. INTERVENTIONS It is essential to educate Asian women pre-natally that eating during this time could be detrimental to them and the infant in the event that nausea and vomiting occurs. It may also limit their birthing options for various types of anesthesia in the event that emergency cesarean section is required.

Asian
CULTURAL BELIEFS/BEHAVIORS: If the couple makes arrangements to have natural childbirth without the usual restrictive equipment, i.e. intravenous fluids, monitor, etc, then taking clear fluids during labor is essential to prevent dehydration and exhaustion. This condition would not only adversely affect the mother, but the fetus as well. Traditional Chinese medicine is based upon the balance opposite forces, Yin and Yang (hot vs cold), and harmony of nature associated with Wu-Xing (Five Elements). Since Asians believe that pregnancy is a hot condition, in order to keep the body in a state of balance, cold liquids are typically avoided to prevent shock to the system. Traditional Asians refer to this as "doing the month" which they believe will prevent aches, pains, arthritis, and other ailments which they can develop in old age. INTERVENTION In the event that your patient is traditional in adhearing to her cultural rituals, offer warm clear fluids during labor along with ice water. Offer more than once, since some Asian cultures (particularly Vietnamese) may refuse the first time out of respect.

Asian
CULTURAL BELIEFS/BEHAVIORS:

Drinking milk will cause one to gain too much weight and make baby fat as well as difficult to deliver. This may put them at risk for hypocalcemia. Colostrum is believed to be "dirty" by some Asian cultures and may be discarded .

INTERVENTIONS:

Again, good prenatal teaching regarding importance of nutritional requirements during antepartum is essential. Neonates can be born anemic, placing them at risk if sufficient weight gain between 25 and 30 lbs is not achieved. Mother needs to be informed that taking 1,500 to 2,000 mg of calcium daily can lower the risk of pregnancy-induced hypertension by 70% and the risk of preeclampsia by over 60% (as reported in Journal of the American of Medical Association, JAMA) ! It is also reported to reduce the incidence of related pre-term deliveries, low birth-weight babies and cesarean sections. Suggest familiar traditional foods that are high in calcium (tofu, small fish with bones, i.e. sardines). Supplements may be required. Parents must also be instructed on the importance of colostrum feedings in the transmission of protective immunoglobulins (antibodies) to their newborns .

African American
CULTURAL BEHAVIORS Due to past experiences with racial discrimination, African American patients may not trust white institutions. They may also be very sensitive to what they perceive as discrimination.

INTERVENTIONS Staff should always address patients and families in a professional manner as Mr., Mrs. or Ms. Be careful to avoid using gal when referring to African-American women or boy when referring to African-American men because especially in the south, these have negative connotations.

African American Culture


CULTURAL BEHAVIORS In the south, African American women have been identified as having frequent cravings for red clay dirt when they become pregnant (pica). In other areas, including NY, this craving has sometimes been replaced by cornstarch.

INTERVENTIONS Staff should ask about the use of cornstarch when the African-American woman has her first prenatal assessment. Teaching is essential to inform the patient that in small amounts, eating cornstarch may prove to provide comfort, but in large amounts, can cause constipation. Since constipation is commonly a problem during any pregnancy due to the effect of hormones and uterine growth on gastric motility (), eating cornstarch could accentuate this already problematic area.

African American
CULTURAL BEHAVIORS Some African Americans may have strong religious beliefs regarding

illness (punishment from God) or believe in voodoo (usually those families originating from the south or rural areas). Typical gastrointestinal changes (nausea, vomiting, diarrhea, loss of appetite) in early pregnancy may be interpreted as a sign of punishment from God or voodoo poisoning.

INTERVENTIONS

Clear teaching early in the antepartal period regarding physiological changes common in pregnancy may relieve some of the fears of these women. Some who believe in voodoo, must be treated by a voodoo practitioner (root doctor) to achieve psychological relief.

African American
CULTURAL BEHAVIORS Newborn care may include warm baths, massaging with sesame oil , and passive stretching of the baby's limbs. Patients may practice a cultural ritual of applying an herb called malmal to the umbilicus for the first 7 days of life. INTERVENTIONS: Families should be instructed that warm baths should be avoided until the umbilical cord (and circumcision in some instances) is completely dry and healed (about 7 to 10 days) to prevent potential infection. They should be taught to watch for possible signs of infection such as redness, warmth, drainage and odor at the site of the umbilicus.

If sesame seed oil is utilized by the family, they need to realize that the newborn will still shed the top layer of epidermis, so the oil may delay, but will not prevent the typical flaking off of skin. There is no evidence to show that the application of mamal is problematic as long as the solution is handled with clean aseptic technique. Staff should continue to instruct patients on the apply alcohol three times a day as well to assist in preventing infection. There may be some delay in the drying of the cord with the application of mamal. (malmal can be found in the U.S. in some Asian markets).

African American
CULTURAL BEHAVIORS

Historically, breastfeeding was the primary form of infant nutrition. It was not uncommon to breastfeed a child until 2 years of age. African American will most likely breastfeed, but will typically want to supplement with bottle feedings. Traditionally, animal milks such as camel, goat, and cow may be used by these groups especially in the first few days of life because colostrum is considered unhealthy.

INTERVENTIONS

As stated previously when dealing with the Asian population, parents must be instructed in antepartum about the importance of colostrum feedings in the transmission of protective imunoglobulins (antibodies) to their newborns .

Native American Indian


CULTURAL BEHAVIORS: Berries, highly valued by Native American Indians, are used throughout the reproductive years for a variety reasons. Indian women believe that during menstruation and pregnancy, that the womans body becomes very toxic. They prize wild berries are used traditionally to cleanse the body of impurities. Some are used to help normalize uterine contractions. Blue Cohosh (Algonquin) and Partridgeberry (Cherokee) are uniquely native American plants that serve as oxytocics used several weeks before childbirth to induce uterine contractions, and after delivery as a salve for sore or cracked nipples. Iroquois medical uses for this vine was as an abortifacient. Elderberries, red raspberry and sumacberry sprouts are also used for blood-building and purifying properties. Juniper berry (Navaho) is a diuretic, cleansing tonic used in adults and newborns (given the juice of the juniper bark skin to vomit the mucus and amniotic fluid swallowed). May cause uterine contractions and menstrual bleeding. Traditional dietary restrictions may be observed which may include not drinking milk (Navaho), eating meat or salt.
INTERVENTIONS: It is important to instruct these women that during pregnancy, the root of the elderberry (Sambucus canadensis, L. Caprifoliaceae) is toxic. However, it is okay to eat the berries themselves if they are cooked. Partidgeberry (also referred to as checkerberry, -Mitchella repens) oil is teterogenic when concentrated. Certified nurse midwives (CNM) identified Blue Cohosh (caulophyllum thalictroides) with complications of nausea, meconium-stained fluid, and transient fetal tachycardia. Several cases have been associated with post delivery neonatal distress. Juniper (Juniperus communis, Cupressaceae) should be avoided in pregnanc because it may induce uterine contractions. The FDA lists these in their Poisonous Plant Database, therefore these sources strongly suggest that these plants should only be used under the guidance of a knowledgeable herbalist and ONLY in the last trimester of pregnancy. A thorough nutritional assessment should be done to determine if there is sufficient protein in the diet. We also need to reinforce that although berry plants do have nutritional value, they are not enough to supply complete nutritional requirements. They are only a supplement to enhance diet, which needs to be well-balanced or the insufficient diet may result in low birth weight infant.

Native American Indian Berries for nutrition and medicine

WILD STRAWBERRY (noon tak tek hah kwa) considered a purifier and builder
of blood that functions as a laxative, diuretic and astringent. The leaves and berries are rich in iron and contain the minerals magnesium, potassium and sodium. Also, old Indian woman say that too many strawberries during pregnancy will cause the baby to be born with a strawberry birthmark!

RED RASPBERRY (oo na joo kwa) tea made from the leaves has been effective

in relieving nausea. It is said to assist uterine contractions to prevent hemorrhage during labor and delivery. After delivery, it is said to strengthen and cleanse the system, as well as, enriching the supply of breastmilk. Raspberry leaf tea is believed to help stimulate and promote normal menstrual function. The berries and leaves are said to be rich in iron; also containing minerals-phosphorus, potassium, magnesium.

PARTRIDGEBERRY (noon kie oo nah) called Squaw Vine

which is actually a derogatory term that should be avoided. This traditional herbs leaves, oil, fruit are used to regulate hormone imbalance, and facilitate labor.

BLUE COHOSH (caulophyllum thalictroides) the roots have been used Native

Americans for inducing labor or abortion. From 1882 to 1905, blue cohosh was listed (for labor induction) in the U.S. Pharmacopoeia. Many herbalists advise against its use in early pregnancy and even its avoidance in late pregnancy.

JUNIPER BERRY: (Gad)

Navajo named evergreen shrub used as an emetic (causes vomiting) to purify the system of both adults and newborns. The needles are boiled as a teas used to relieve diarrhea and as a postpartum stimulant.

Native American Indian


CULTURAL BEHAVIORS

Native American Indians (aboriginal midwifery and traditional Mohawk childbearing practices) believe that all breastmilk is contaminated with what the people call the Wahecmah, the bad stuff, polychlorinated biphenyls (PCBs). This may result in many choosing not to breastfeed.

INTERVENTIONS

Although the fear of PCBs and any level of chemicals in breast milk is a real potential health concern for mother and neonate, the Natural Resources Defense Council identifies once specific group of chemicals as the most significant pollutant, persistent organochlorines. Known as persistent organic pollutants (POPs), these chemicals persist in the environment and human body for years. But even with this knowledge, the council supports the fact that health benefits of nursing still far outweigh the potential problems from POPs. They also go on to say that all countries are seeing the potential danger of these chemicals to our mothers and babies and as of May 22, 2001, the United States has join 119 other nations in an agreement to ban the production or use of many of these chemicals. As practitioners, we need to ensure that this information is taught to all our patients in the event that they have fears about contaminating their infants by passing these dangerous chemicals in breastmilk.

Hispanic (primarily Mexican) Culture


CULTURAL BEHAVIORS: The family is highly valued in the Hispanic culture both nuclear and extended providing a supportive environment for the pregnant woman. In labor & delivery, the woman's mother may be the preferred birthing partner and traditional wives may defer to husbands in decision-making in health matters. It is not uncommon for grandmothers to move into the pregnant family homes during the last trimester of pregnancy and remain for weeks after the infants birth. Also may refuse some foods with preference to hot over cold. INTERVENTIONS: Try offering alternative foods or liquids to ice water. Respect familial duties by encouraging members to spend as much time with the patient as possible to provide non-technical care.

Hispanic
CULTURAL BEHAVIORS

Although there is a high birth rate in the Mexican population, the use of prenatal care services is very low, most probably due to traditional belief that prenatal care should take place in the home, with consultation of a curandera (folk healer). Also fear of separation from the family is also a related factor and lack of financial resources (may be illegal alien). INTERVENTIONS Providers should instruct all their patients regarding the importance of early prenatal care in a medical facilitiy under the care of a professional provider. Information and assistance should be obtained from the Mother-Baby Package: Implementing safe motherhood in countries developed by the World Health Organization (WHO) which can be accessed from

http://www.who.int/reproductivehealth/publications/MSM_94_11/MSM_94_11_table_of_contents.en.html
which addresses all these aspects of reproductive health and thus provides an opportunity to develop an integrated approach to service delivery. The MotherBaby Package is the product of extensive consultation. Input was received from United Nations Development Program (UNDP), United Nations Population Fund (UNFPA), United Nations Children's Fund (UNICEF) and the World Bank, as well as governments, universities, Environmental Networks (NGOs) and bilateral agencies.

Hispanic
CULTURAL BEHAVIORS:

Family frequently encourages the pregnant mother to rest frequently, walk, eat well, and get plenty of sleep. Milk is avoided because of the belief that it results in large babies and difficult births. It is also believed that drinking chamomile tea assures the mother of an effective labor. Similarly to the Native American Indian, some Hispanic cultures believe that an infant may take on the characteristics of an object the mother craves during pregnancy if the craving is not satisfied (eg, strawberry spots if the craving for strawberries is not met).

INTERVENTIONS: Providers should instruct the patients on the importance of balanced rest and activity. Information should also be provided regarding the development of large for gestational age infants (LGA) with alternative foods to mild that will provide the calcium needed during pregnancy. Tolerance and understanding of cultural fears regarding cravings is essential as long as safety is not a factor. If the craving puts the fetus or mother at risk, intervention utilizing all family members should be utilized. Attempting to reach the father or mother-in-law is the best action since they hold authoritative roles in Hispanic culture.

Muslim Culture
CULTURAL BEHAVIORS

The custom of TAHNEEK - Before the infant is fed, almost directly following birth, a small piece of softened date is gently rubbed into the babys upper palate by a respected member of the family, often the father. The hope is that some of the positive attributes of the person will be transmitted to the newborn and it will enter a sweet world. Where dates are not easily available, substitutes are often used.

INTERVENTIONS Nurses have to be very observant of what family members give to the infant. Sometimes, if dates are not available, the member may substitute an easily accessible sweetened item that could be dangerous to the infant, such as hard candy which could slip from the hand and choke the infant. The nurse should guide the family to substitute another item such as glucose water. After good asceptic handwashing, the member can dip his fingers into the water and gently rub it on the palate of the infant which would elicit the same desired effect.

Muslims
CULTURAL BEHAVIORS:

The Taweez is a small pouch that hangs from a small piece of string. The pouch contains a prayer which is tied around the baby's wrist or neck. This practice, particularly seen among Muslims from the Indian subcontinent, protects the baby from ill health. For Muslims, as in the Jewish community, religious law requires male circumcision. Muslims consider male circumcision important for hygienic purposes essential when offering prayers. This decreases the risk of clothing becoming soiled from urine that may leak the foreskin. According to the religion, soiled clothes nullify prayer. It is also believed that circumcision decreases the incidence of penal cancer.

INTERVENTIONS:

Strongly suggest that the parents place the Taweez around the babys wrist to prevent accidental choking of the infant. Since circumcision is so controversial in the US at present, this once almost routine procedure frequently does not get mentioned until the family brings it up at discharge. This is problematic since the infant has to be watched closely following the procedure for passage of urine and potential bleeding. Early recognition of the culture and the need for circumcision should be identified by the practitioner and the family should be presented with this option shortly after delivery.

Muslims
CULTURAL BEHAVIORS:

Many mothers may wish to breast feed since this is encouraged by religious teaching, but insufficient privacy may pose a barrier. Muslims demand that women not expose certain body parts to anyone but their husbands. This may result in the decision to bottle feed in the hospital. Similarly to some other cultures some sections of the Muslim community believe that colostrum is either harmful to the baby, or of poor nutritional value. Supplements of honey and water may be given in the first few days of life.

INTERVENTIONS:

Health practitioners should make arrangements for private areas where Moslem women feel comfortable enough to breastfeed that doesnt conflict with their religious beliefs. If a woman says that she going to wait until she gets home to begin breastfeeding, this privacy issue should be explored and alternatives suggested that will foster breastfeeding in the hospital. This will prevent difficulty with obtaining adequate mild production that may accompany a delay in breastfeeding. A new born infant may develop iron deficiency anemia and/or rickets (osteomalacia) if nutritionally rich supplements are not being utilized. Parents need to be instructed that honey is only delivering empty calories and the practitioner should share literature with the family regarding the high protein and immunoglobulins in colostrum, and how very valuable it is.

Muslims
CULTURAL BEHAVIORS: Breastfeeding for longer than six months is the not out of the ordinary and some families switch from infant formula to cows milk from 5 to 6 months.

INTERVENTIONS: Feeding cows milk so early in the infants life is contrary to the Department of Health recommendation that reconstituted infant formula should be continued beyond six months to prevent deficiencies of iron and vitamins A, C, and D. Parents should be encouraged to either maintain breastfeeding while beginning solid foods, or supplement with infant formula.

Bibliography

American Public Health Association, University of Oregon Center for Asian and Pacific Studies. (2002, Apr. 4). Asia: Health culture sketch. Maternal and reproductive health beliefs. [Online]. Available: http://www.apha.org/ppp/red/asiabeliefs.htm Archives of Disease in Childhood, Fetal Neonatal Edition. (2001, January). Muslim Birth Customs. [Online]. Available: http://adc.bmjjournals.com/cgi/content/full/fetalneonatal;84/1/F6? Galanti, Geri-Ann. Cultural Diversity in Health Care. (2002). [Online]. Available: http://www.ggalanti.com/index.html IIewirokwas Program, Pulling the baby out of the Earth. (1999, March). Into our hands and Using the Berry Plants for Women's Nutrition and Medicine. [Online]. Available: http://www.nativemidwifery.com/Articles.html#anchor42535 Natural Resources Defense Council. (2001, May 22). Healthy Milk, Healthy Baby Chemical Pollution and Mother's Milk. [Online]. Available: http://www.nrdc.org/breastmilk/default.asp

Bibliography Continued

Nicoles, Francine H., RNC. (Journal of Perinatal Education, 1997. Nov.3). The Meaning of the Childbirth Experience: A Review of the Literature [Online]. Available: http://www.rosebaby.com/experience.html

Pediatrics. (1997, July). Health Care for Children of Immigrant Families. [Online]. Available: http://www.aap.org/policy/970702.html
Thomson American Health Consultants: Alternate Therapies in Womens Health. (1999, October). Blue Cohosh: A Word of Caution. [Online]. Available: http://www.ahcpub.com/ahc_root_html/hot/archive/atwh1099.html University of Michigan Health System. (2002). Biweekly Multicultural Health Facts. [Online]. Available: http://www.med.umich.edu/multicultural/ccp/bulletin.htm World Alliance for Breastfeeding Action Risks. (1996) Communicating about Risks and Infant Feeding. [Online]. Available: http:///www.waba.org.br/penny6.htm World Health Organization. (1999). Mother Baby Package. [Online]. Available: http://www.who.int/reproductivehealth/publications/MSM_94_11/MSM_94_11_table_of_contents.en.html

Childbirth Options

BabyZone. (2001). Interactive Birth Plan. [Online]. Available: http://dopey.babyzone.com/pregnancy/interactive/birthplan.asp BabyZone. (2001). Childbirth Choices. [Online]. Available: http://www.babyzone.com/pregnancy/childbirth/naturalbirth.asp Immergut, Debra Jo. (Parents, 2001). Exploring Your Labor and Birth Options. [Online]. Available: http://www.parents.com/articles/pregnancy/1115.jsp