Markkula Center of Applied Ethics

A Difficult Birth: Navigating Language and Cultural Differences

By Karen Peterson-Iyer

Ana Lopez is 17 years old and works in the U.S. as a farm laborer. Ana speaks no English and very little Spanish; she is an immigrant from Oaxaca, Mexico, and her primary language is Mixteco. She is illiterate. Roughly estimated to be 36 weeks pregnant, she is admitted through the emergency room to East Valley Hospital with cramping and vaginal bleeding. Upon examination, placental abruption is diagnosed, and the medical team recommends a Cesarean section. Ana is also discovered to be severely anemic. Toward the start of these exams, a nurse offers Ana ice chips (a normal procedure for laboring women), which Ana quietly refuses. Although the medical team considers Ana's C-section to be an emergency measure (thus not requiring explicit consent), the hospital staff nevertheless do attempt to obtain Ana's consent before the surgery; she replies "yes" to all questions and appears to acquiesce to everything the medical team suggests. However, since no one on staff speaks Mixteco, they cannot be sure that Ana fully understands her (or her child's) situation. After the C-section, the baby boy's APGAR scores, which measure the vital signs of a newborn, are quite low. He is immediately transferred to the neonatal intensive care unit (NICU) with diagnoses of neonatal encephalopathy, a disease of the brain, and being small for gestational age (SGA).

Ana had arrived at the hospital early in the morning with her mother and sister, neither of whom speaks English or Spanish. She does have a husband, Hugo, but he was not present at the admission or the time of the birth since he feared losing his job if he missed work for the day. Hugo eventually arrives at the hospital later in the afternoon. He speaks no English but is haltingly conversant in Spanish.

A social worker, fluent in Spanish but not Mixteco, meets with Ana and Hugo and discovers (to the best of her abilities) that Ana has no health insurance and had not been able to obtain any regular prenatal care (which would explain why her anemia had gone undiagnosed). She had no money even for vitamins, which (the social worker surmised) Ana may nevertheless have taken intermittently, when she could obtain them from a mobile health clinic. The social worker guesses that Ana had worked in the fields right up until the previous day. She wonders privately about Ana's exposure to harmful pesticides during her pregnancy. She is fairly certain that Ana has no legal immigration papers.

Once Ana is stabilized after the birth she is allowed to go to the NICU to see her baby. Her husband Hugo remains with her in the NICU, along with a Spanish-language translator called for by the social worker. Through this translator, Hugo is able to communicate imperfectly on and off with the medical team.

Throughout this process, Ana shows very little emotion, at least publicly, and the nurses present are bothered by her flat, unemotional affect. The nurse manager of the NICU in particular wonders (aloud, to her co-workers) why Ana "doesn't seem really to care about" her sick baby. Ana's mother and sister, meanwhile, speak quietly but urgently with Hugo whenever they get the chance.

Late that evening, Hugo tentatively interrupts a nurse and asks her (via the translator) whether the baby might be visited by a "curandero," a traditional healer from their community. He suggests (apparently at the insistence of his mother-in-law) that the baby should be "cleaned with an egg." The nurse in charge is clearly uncomfortable with his request (and a treatment unfamiliar to her) and responds that the baby may be too unstable to be subjected to any "alternative" treatments. She reminds Hugo, somewhat sharply, that his baby is very sick but under the care of the best medical experts. When Ana's relatives appear chagrinned and distressed by this response, the nurse's demeanor softens, and she gently asks them if they have had anything to eat recently and suggests that they pay a visit to the hospital cafeteria. Hugo looks at the ground and utters a polite refusal. He does not repeat the request.

After three days, Ana herself is discharged from the hospital, though the baby remains in the NICU. Over the course of the next few weeks, the baby stabilizes. The extent of brain impairment is unclear and, according to the medical team, will only make itself known over time. During these few weeks, Hugo is unable to be present at the hospital much during the day, but Ana is regularly accompanied by her mother and other family members, who bring food and sit with her as much as possible. The social worker pays special attention to Ana and Hugo's situation, particularly making an effort to get them signed up with a Medicaid-sponsored program. While ultimately successful, this move proves challenging, since they initially fear discovery of their undocumented status. Ana and Hugo eventually are able to take their baby boy home, unsure of what long-term complications he may encounter.

Does the staff at East Valley Hospital approach Ana's situation in a manner that is sufficiently respectful of her culture (sometimes called a "culturally competent" manner)?

Reflection by Rebecca J. Hester
Reflection by Nayamin Martinez
Reflection by Marc Tunzi
Reflection by Karen Peterson-Iyer

Introduction to Culturally Competent Care
Introduction to Culturally Competent Care for Latino Patients

Karen Peterson-Iyer is a program specialist in health care ethics at the Markkula Center for Applied Ethics.

The cases here are fictional composites made up from the details of many different real situations.

July 2008