JOGNN. Intercultural Caring From the Perspectives of Immigrant New Mothers Anita Wikberg, Katie Eriksson, and Terese Bondas R ESEARCH

JOGNN Intercultural Caring From the Perspectives of Immigrant New Mothers Anita Wikberg, Katie Eriksson, and Terese Bondas Correspondence Anita Wikberg, MNSc, RM, RN, Department of Caring Science, Åbo Akademi University, PB 311, 65101 Vaasa, Finland. anita.wikberg@abo.fi Keywords intercultural caring maternity immigrant women mother new country Finland ethnography observation ABSTRACT Objective: To describe and interpret the perceptions and experiences of caring of immigrant new mothers from an intercultural perspective in maternity care in Finland. Design: Descriptive interpretive ethnography using Eriksson s theory of caritative caring. Setting: A maternity ward in a medium-sized hospital in western Finland. Participants: Seventeen mothers from 12 countries took part in the study. Methods: Interviews, observations, and field notes were analyzed and interpreted. Results: Most mothers were satisfied with the equal access to high-quality maternity care in Finland, although the stereotypes and the ethnocentric views of some nurses negatively influenced the experiences of maternity care for some mothers. The cultural background of the mother, as well as the Finnish maternity care culture, influenced the caring. Four patterns were found. There were differences between the expectations of the mothers and their Finnish maternity care experience of caring. Caring was related to the changing culture. Finnish maternity care traditions were sometimes imposed on the immigrant new mothers, which likewise influenced caring. However, the female nurse was seen as a professional friend, and the conflicts encountered were resolved, which in turn promoted caring. Conclusion: The influence of Finnish maternity care culture on caring is highlighted from the perspective of the mothers. Intercultural caring was described as universal, cultural, contextual, and unique. Women were not familiar with the Finnish health care system, and many immigrant mothers lacked support networks. The nurse/patient relationship could partly replace their support if the relationship was perceived as caring. The women had multiple vulnerabilities and were prone to isolation and discrimination if they experienced communication problems. JOGNN, 41, 638-649; 2012. DOI: 10.1111/j.1552-6909.2012.01395.x Accepted March 2012 Anita Wikberg MNSc, RM, RN, is a PhD student in the Department of Caring Science, Åbo Akademi University and a senior lecturer at Novia University of Applied Sciences, Vaasa, Finland. (Continued) Disclosure: The authors report no conflict of interest or relevant financial relationships. Introduction Leininger (1998, 2006), the founder of transcultural nursing, studied universal and diverse human care/caring in approximately 58 cultures and found 175 emic care constructs, including love, respect, presence, listening, supporting, assisting, doing for/with, being kind, paying attention, providing comfort, and hope among others. A large Australian study, Mothers in a New Country (Small, Liamputtong, Yelland, & Lumley, 1999), illuminated the experiences of Vietnamese, Turkish, and Filipino women in maternity care in Australia. The women, who were not fluent in English, experienced care less positively. Women who had difficulties understanding English experienced unsympathetic attitudes. Most caregivers did not ask about traditional practices, and most women did not think or were unsure if the caregivers knew anything about their cultures. Many felt they could not practice their traditions in the hospital. All three groups of women preferred female caregivers. In a recent meta-synthesis of 40 studies (Wikberg & Bondas, 2010), the authors highlighted the experiences of the intercultural caring of mothers in maternity care, however, there were also experiences of noncaring. Language and communication problems existed as well as a lack of information and difficulties in making decisions. Acculturation consisted of preserving the original culture and adapting to a new culture. Access to medical and technological care was appreciated, however, some health care professionals (HCPs) were incompetent in cultural care. A professional caring relationship was as important as family and community involvement. Caring was important for well-being and health, whereas conflicts caused interrupted care. In some cases women were 638 C 2012 AWHONN, the Association of Women s Health, Obstetric and Neonatal Nurses http://jognn.awhonn.org

Wikberg, A., Eriksson, K., and Bondas, T. vulnerable due to painful memories, whereas in others racism occurred. The metaphor of Alice in Wonderland was used to explain experiences of mothers in a culture different from their own. Immigrant Somali mothers in Finland (Hassinen- Ali-Azzani, 2002) reported that help from their female relatives was lacking and replaced their support with help from their husbands. They trusted midwives and doctors. Support from and trust in HCPs (Knuuttila, 1996; Tanttu, 1997), communication problems, and the feeling of isolation (Tanttu) were found in other Finnish transcultural maternity care studies. Estonian mothers in Finland described the burden of children mostly as the responsibility of the mother without any extended family support, whereas assistance from antenatal clinics and other support organizations were experienced positively (Hyvönen, 2008, 2009). Most immigrant patients in Finland experience equal access to high-quality health care (Dayib, 2008; Hyvönen, 2008, 2009; Idehen-Imarhiagbe, 2006). However, some immigrants experience a lack of access to health care due to the requirement of having a health insurance card (Adjekughele, 2003), difficult access to doctors (Taavela, 1999), language and communication barriers, and lack of trust and respect for marginal communities, including perceived racism and discrimination (Adjekughele; Dayib). Finnish studies (Abdelhamid, 2004; Ikonen, 1999; Silvennoinen, 2000; Taavela; Tuokko, 2007; Virkki, 1999) showed that HCPs have inadequate skills to provide care for patients from other cultures. We conducted an ethnographic study of intercultural caring from the perspective of immigrant new mothers with different cultural backgrounds. Most previous studies focused on the specific cultures of mothers or some other aspect of maternity care than caring. An enhanced understanding of the views of mothers on intercultural caring may help to improve maternity care internationally and increase the scientific knowledge of intercultural caring that is needed in a multicultural world. Because caring is culturally expressed and understood differently (Leininger, 2006) and may influence the health and well-being outcomes of mothers (Malin & Gissler, 2009), it is important to give voice to immigrant mothers perceptions and experiences of caring from an intercultural perspective. Our aim was to describe and interpret the perceptions and experiences of caring of immigrant new mothers from an intercultural perspective of maternity care in Finland, including prenatal, birth, and postnatal care. This study is part of a larger research project titled Encountering the Unknown in Health Care. Theoretical Perspective The caritative caring theory and caring tradition (Eriksson, 2002; Lindström, Lindholm, & Zetterlund, 2006) was the theoretical perspective for this study. In this caring tradition, the human being is seen as an entity made up of body, soul, and spirit. Humans want to be unique and belong to a community. They want to experience love, hope, and faith through caring, which is described as tending, playing, and learning. The ethos of caring comprises an HCP s respect for the dignity of the patient and a striving for a genuine communion and understanding of the unique human being. Caring is seen as the core of nursing and medical care. Caring serves life by alleviating suffering and promoting health and well-being. The caritative caring theory was the starting point for the development of the model for intercultural caring (Wikberg & Eriksson, 2008). Intercultural caring refers to a genuine relationship between nurse and patient who belong to different cultures. The relationship is asymmetric because the nurse has more responsibility and power, but it is also reciprocal because both are human beings. Culture is defined as a pattern of learned but dynamic values and beliefs that gives meaning to experience and influences the thoughts and actions of individuals of an ethnic group (Wikberg & Eriksson, p. 486). Intercultural caring has four dimensions: universal, cultural, contextual, and unique (Wikberg & Bondas, 2010). Universal caring is independent of culture and context. The goal of intercultural care/caring is to alleviate suffering and to strive for health and well-being. Intercultural caring is a complex whole influenced by external circumstances, for example, administrative, educational, legal, political, and economic factors. Setting In 2009, Finland s population was 5,351,427 (Official Statistics of Finland, 2010). Apart from the Finnish majority, there were 290,392 (5.4%) people made up of Finland-Swedish and other traditional minority groups, such as the Sámi, Roma, Jews, and Tatars. Immigration to Finland is not prevalent but has increased 6-fold since 1990. In 2009, there Katie Eriksson PhD, RN is a professor in the Department of Caring Science, Åbo Akademi University, Vaasa, Finland and director of Nursing at the Hospital District of Helsinki and Uusimaa, Helsinki, Finland Terese Bondas PhD, RN, PHN is a professor in the Faculty of Professional Studies, University of Nordland, Bodø, Norway and leader of the Qualitative Research Network Childbearing in Europe. JOGNN 2012; Vol. 41, Issue 5 639

Intercultural Caring From the Perspectives of Immigrant New Mothers The mothers belonged to different cultures but shared a common experience: being pregnant and giving birth in a foreign culture. were 155,705 (2.9%) foreign persons and 207,037 (3.9%) that spoke a language other than Finnish, Swedish, or Sámi (Official Statistics of Finland). The most common foreign languages spoken in Finland are Russian, Estonian, Somali, English, and Arabic. The immigrant population is younger and has a higher birth rate than the Finnish population (Malin & Gissler, 2009). Health care is accessible for all in Finland. Maternity care is free of charge and is tax funded. Pregnant women are recommended to have 9 to 17 visits to the public health nurses (PHNs) at a maternity clinic in the health care center, including one to three visits to a medical doctor (Viisainen, 2000). Preparation courses and visits to the hospital are arranged primarily for first-time mothers. Almost all mothers give birth at hospitals assisted by midwives. An obstetrician and/or a pediatrician is only called to assume responsibility if problems occur, but the midwife remains involved in care. The mother can have her partner or a support person with her. After delivery, the mother is transferred to a postnatal ward, where midwives and auxiliary pediatric nurses take care of the mother and the healthy infant. The normal length of the hospital stay for a vaginal delivery is two to three days. After hospital discharge, the care of the mother and infant is transferred back to the health care center, where a checkup of the mother is recommended 5 to 12 weeks after the delivery (Viisainen). The PHNs also make home visits. According to Finnish law, patients are entitled to good quality health care, a respectful encounter, autonomy, and information in their mother tongue of Finnish or Swedish (Finlex, 1992) or the right to an interpreter (Finlex, 2003). This study was conducted in a maternity ward with approximately 1,500 births annually in a medium-sized hospital. In this study, nurses refers to PHNs, midwives, or auxiliary pediatric nurses. Health care professionals refers to all of the above and medical doctors. Methods We used a focused ethnography method inspired by Nikkonen, Janhonen, and Juntunen (2001), Roper and Shapira (2000), and Spradley (1979) and an interview based on a thematic guide, observation, field notes, and other documents. Description of the Participants Seventeen mothers took part in the study. They were age 18 years or older and were immigrants. One mother was pregnant, and the others had given birth a few days earlier. All the mothers were first-generation immigrants with singleton births. See Table 1 for a description of the participants. The sampling of participants was purposive. Table 1: Description of Participants Age range Present pregnancy or birth 19 36 years Pregnant (1), vaginal delivery (14), vacuum extraction (2) Number of children 29: 8 mothers (1), 4 mothers (2), 3 mothers (3), 1 mother (4), children born in Finland (24) Time in Finland Country of origin Other countries where mothers had lived Religion Father of baby Reason for immigration Study or work in Finland 2 months to 10 years Australia (1), Bosnia (3), Burma (1), Colombia (1), Estonia (3), Hungary (1) India (1), Iraq (2) of which one was Kurdish, Russia (1), Thailand (1), Uganda (1), and Vietnam (1) China, France, Kenya, Sweden, Syria, Thailand, and Zambia Muslim (5), Catholic (3), Christian (2), Buddhist (1), Hindu (1), and no religious affiliation (5) Finnish father (4), father from the same culture as the mother (13) of which one is not living in Finland Quota refugee (2), own or husband s work (7), husband s study (2), family reasons, (6) of which one was an asylum seeker entitled to stay Studied Finnish or Swedish language (15), studying at a university of applied sciences (1) or university (1), working presently or previously in Finland (6) 640 JOGNN, 41, 638-649; 2012. DOI: 10.1111/j.1552-6909.2012.01395.x http://jognn.awhonn.org

Wikberg, A., Eriksson, K., and Bondas, T. Data Collection The data collection took place over 2 1 / 2 months in 2009 to 2010. After informing nurse leaders and nurses about the study, the first author was informed when there was a suitable mother in the ward, which language the mother spoke, and if an interpreter was needed. The nurses informed the mothers that the first author would approach them. The mothers were given written and oral information by the first author or oral information through an interpreter. A thematic guide was developed from studies on the intercultural caring model (Wikberg & Eriksson, 2008) and experiences of intercultural caring of mothers (Wikberg & Bondas, 2010). It comprised seven themes: background information about the mother, experience of the pregnancy, birth and the postnatal period, different dimensions of intercultural caring, caring and noncaring in the nurse/patient relationship, caring and health/wellbeing, acculturation and external factors. All interviews included these themes, but questions were expressed differently depending on what the mother had already said. The questions were general, Could you tell me about the care and caring you received during pregnancy, and specific Could you give me an example? All the mothers were also asked if they wanted to add anything at the conclusion of the interview. Most mothers repeated the core content, but a few added new information. The interviews were conducted in Finnish, Swedish, or English by the first author and lasted 28 to 58 minutes. The interviews were digitally recorded and transcribed verbatim. Professional interpreters were present during four interviews, and in three cases the fathers interpreted. Fathers were also present during four other interviews and observations. Unstructured observations (Mulhall, 2003) took place during nursing care encounters in the maternity ward. The first author observed who initiated the encounter, said and did what, how, when, and why. Observations deepened the understanding of cultural behavior, confirmed what participants said, and included an understanding of the process, context, environment, and situation. One to three observations, lasting from a few minutes to almost an hour, were made with 15 of the mothers, resulting in 30 observations. Twelve female Finnish or Finnish-Swedish auxiliary pediatric nurses, midwives, and/or pediatricians took part in the observations. Observations and reflections were recorded by hand as soon as possible. In addition, field notes were taken in connection with each interview and observation (Spradley, 1979). The care philosophy of the ward included family-centered care, being baby friendly, supporting breastfeeding, striving for a satisfied and safe family, encouraging self-care, individuality and support of motherhood. The care philosophy and other documents, including a world map with pins in different colors showing where the families were from, local newspaper articles, homepages, and information given to mothers were also noted and collected as well as notes from informal discussions with nurses and educational events. Data Analysis and Interpretation Data collection ended when no new themes emerged and the body of data was large enough to meet the aims of the research (Polit & Beck, 2004). All the steps were intertwined, and the analysis started while the interviews and observations were still ongoing. First, the recordings were listened to and all data (interviews, observation, and field notes) about each mother were read. Then a narrative of each mother was written. The data were systematically analyzed and interpreted for expressions of, and significant material about, intercultural caring. Codes were written in the margins of the original transcriptions and categorized into meaningful pieces (Roper & Shapira, 2000) to form themes. Then the data of all the mothers were analyzed and interpreted together. Reflections were written down and checked continuously. Pregnancy, birth, and the postnatal period were used as a frame for analysis (Nikkonen et al., 2001). The themes and the original data were finally examined for patterns that explain the phenomena of interest (Roper & Shapira) to create a thick description (Geertz, 1973). An effort was made to understand the views of the mothers and suppress any prejudice of the first author. The field notes and other documents collected brought a clarity and understanding of intercultural caring in maternity care. Ethical Considerations Recommendations of the Finnish National Advisory Board on Research Ethics (2002, 2009) were followed. A permit from the ethical committee of the hospital was granted. All participants, including HCPs, were informed and provided informed consent in writing. A gift of baby socks at a value of 5 was given to all the mothers after the interview. If there were questions about nursing care or something troubled the mother during the interview, the nurses were informed with the JOGNN 2012; Vol. 41, Issue 5 641

Intercultural Caring From the Perspectives of Immigrant New Mothers Mothers ability to express themselves and mutual understanding were considered essential, even though health care professionals were able to advocate some care nonverbally. mothers permission. Confidentiality, identity, autonomy, and vulnerability were carefully considered. The culture of the mother is not mentioned in the findings to prevent recognition but clustered together if relevant. Questions that could have stigmatized participants, or caused suffering (Liamputtong, 2007), were avoided by not asking further questions when the mothers seemed uncomfortable. Results The immigrant new mothers were grateful for the access to good maternity care services, material, and human resources, as well as the humane and excellent care they encountered in their new countries. However, a few of the mothers had uncaring experiences. The results are presented in four patterns. Tension between the Expectations of the Mothers and their Finnish Maternity Care Experience of Caring All the mothers said that they had received information but were not aware of facts taken for granted by Finnish mothers, for example, that midwives have a strong position in maternity care. The mothers did not know the health care system. Some did not know the profession of the HCP they had met. However, when they understood how maternity care was organized, they appreciated it. A few mothers did not understand the information and nursing care they received, or the information was incorrect, insufficient, or misleading. Sometimes what mothers asked about was deemed unimportant: Because I was curious and they recommend different things here (diet, vitamins), some misunderstandings occurred. When the nurse reacted (to my questions), she just laughed at me, and this made me feel bad... I felt stupid... when she (the nurse) reacted like this. If the nurse and the mother had no common language, or no interpreter was used, the relationship remained distant. Even though HCPs demonstrated some caring nonverbally, the ability to express themselves and understand information was essential for the mothers. A few mothers had PHNs who insisted on speaking their own mother tongue, Finnish. This was frustrating and information was lost. The mothers were happy to talk about their cultures, traditions, and wishes, but nurses did not ask about their backgrounds. Some nurses showed interest in the culture of the mother when they looked for information or knew some common traditions or habits: The midwife, she was searching on the Internet... about our culture (country). Some nurses showed more cultural knowledge and skills than others during the observations. In one instance, a first-time Asian mother and a nurse had different views on how many clothes to put on the infant. The nurse did not understand the Asian theory of hot and cold. The mother wears warm clothes and a warm cap, even when she sleeps. She dresses the infant and puts on a blanket. The nurse says that the blanket is not needed, but the mother continues using it anyway. Then the nurse says that the blanket could be left open. The mother does not answer. The mother puts the infant in the cot and adds yet another warm blanket wrapped tightly around the infant. The nurse takes the blankets away when the mother lies down. A few mothers mentioned traditional care in their home countries, such as herbs, ointments, exercises, food, or religious symbols. A non-western mother was discouraged from using any traditional medicine. Some Southeast Asian mothers missed the special hot meal after delivery that sometimes was provided by relatives. The nurses did not ask the mothers about their spiritual needs. The mothers did not expect this though, because religious beliefs were considered a private matter or not considered at all. However, Muslim mothers were happy when nurses knew that they did not eat pork and ordered the correct diet. Caring Was Related to the Changing Culture There were different stages of integration into their new countries among the mothers. Some were more traditional, following the customs of their original cultures, and others wanted to adapt to Finnish health care practices. Most mothers did not expect that the HCPs should know their cultures or languages: I did not expect this. I thought that When in Rome you do as the Romans. That 642 JOGNN, 41, 638-649; 2012. DOI: 10.1111/j.1552-6909.2012.01395.x http://jognn.awhonn.org

Wikberg, A., Eriksson, K., and Bondas, T. if I came here, then I have to learn the ways of the country. Some participants were married to Finnish men and knew one of the national languages almost perfectly, whereas some worked or studied and felt a part of Finnish society and did not even consider themselves foreigners. But even the most integrated mothers thought some part of maternity care was different or unknown to them. Other participants had just arrived and felt lonely and isolated because they had no occupational education, work, friends, or had scarce knowledge of the local languages and Finnish society. According to the participants, the length of time in Finland, the reason for immigrating, and the country of origin influenced their acculturation. Most mothers immigrated voluntarily to work, get married, or join family members. Many of them knew at least some Finnish or Swedish or intended to learn. They emphasized that knowing the language is the most important factor in becoming independent and integrated. The mothers saw caring as part of their cultures. They described how culture and caring had changed over time. It was not the same now as when they were children in their countries of origin. Sometimes there had been political change or a crisis that had caused or accelerated the change. The mothers also emphasized that there were different ethnic groups in their countries, and all did not have the same culture or practices. They mentioned that families and individuals might have unique ideas and preferences. One mother thought her family had been more restrictive in the use of medicine and visiting doctors in her childhood than other families. The mothers said that they had changed their ways of thinking and behaviors in their new countries. Some mothers described how they had become more open and had been encouraged to speak after leaving societies that restricted the independence of women or political regimes that restricted the ability of people to express themselves freely: Yes, yes you get used to it, but maybe I have become more open and courageous.... That in my country there is.... No, I do not think that I would have expressed my opinion so bravely, or openly... it is more like you keep your opinion, it is your own knowledge.... And you just listen, so nobody dares to really say anything. Some expressed relief and said they were more harmonious and felt safer because there was no political unrest in the society around them. Finnish Maternity Care Traditions Were Imposed on the Immigrant New Mothers, Which in Turn Influenced Caring Finnish maternity care traditions that were taken for granted were the starting point for the care rather than the unique cultural needs of the mother: I have understood that there are two principles: Pregnancy and birth are not illnesses and Everything is going to be alright. Midwives assisted the birth in a calm and unhurried environment. Another first-time mother said, They do not shout or anything like that, (they are) just ok. Everything happens calmly and slowly. Interventions, like prescribing vitamins and inducing labor, were avoided or carefully considered before implementation during pregnancy and birth. However, fast and effective expert medical care was available if needed: So, I find that really different, because here it s not like a first option to have a cesarean section, unless something goes really wrong. The mothers enjoyed the preparation courses and the visit to the delivery hospital during pregnancy, which also soothed them: Yes, I wanted to see where I would end up (laughing). It calmed me a bit. All the mothers enjoyed having the father or a support person with them during the birth in a delivery room of their own. For many mothers, this was not possible in their country of origin. A few mothers had sisters or their own mothers as support persons, which is rare in Finland. The HCPs kindly received female relatives, but husbands often replaced them in subsequent births. The mothers also enjoyed home visits by PHNs after the delivery. Pain was expressed and understood differently. The women who expressed their pain loudly or explicitly were interpreted as being very sensitive to pain. A mother felt offended when her expression of pain was stereotyped and announced to a student nurse at the prenatal clinic, This nurse... when she had a student with her and she had examined me and then, for example, said, these (nationality) women do not endure pain as well as Finnish women. On the other hand, Asians and others who did not express their pain verbally were not always noticed. Several mothers said that at the end of the first stage, no pain relief was given, even if they asked for it. The midwives explained JOGNN 2012; Vol. 41, Issue 5 643

Intercultural Caring From the Perspectives of Immigrant New Mothers to them that it was too late, or it would soon be over. Rooming-in was practiced in the postnatal ward. Mothers enjoyed having their infants close and liked it when nurses assisted them and gave them practical advice about breastfeeding and child care: It was quite good that at night they took him (the baby) so that I could sleep. I had not slept for 36 hours. Yes, this was quite good, otherwise I would never have managed. The nurses encouraged and appreciated fast recovery, independence, and active infant care. Some of the mothers seemed to want the nurse to take into consideration that they were tired, weak, or in pain. Several mothers said they would have preferred to stay longer in the hospital to recover from the birth and feel secure about breastfeeding and child care. All the mothers wished to breastfeed, and all the nurses said, The breast is the best for the baby and gave support and advice. However, almost all the infants were given milk supplements according to observations. Some first-time mothers were worried that their milk production would not start, or that there would not be enough milk, and that they would have no one to ask if there were problems at home, because many had no female relatives nearby. The Female Nurse Was Seen as a Professional Friend and the Conflicts Encountered Were Resolved, Which Promoted Caring The mothers preferred female HCPs, and this seemed to be satisfactorily arranged. Encounters with male doctors were experienced as more formal and distant, and the mothers felt shy: The doctor was good, first I was a bit (shy)... because it was a man. The Muslim mothers said that in an emergency it was acceptable to have a male doctor if no female doctor was available. One Muslim woman, who insisted on seeing a female doctor, had to sometimes wait longer for scheduled appointments, but this was always arranged. The professional interpreters used during labor were also female. Some mothers said they experienced PHNs as friends, who for some were their only Finnish friend. The mothers felt that the PHN wished them and their infants well, and it felt good to be in their presence: I think the nurses are especially kind to foreigners. I have experienced that they speak respectfully... so that everybody will feel at home and be welcome. Most nurses were described as happy, smiling, nice, friendly, patient, close, good, wonderful, helpful, and professional persons with expert knowledge. Several mothers said that Finnish HCPs are always there if needed, and that they have a calling for their professions. The care was described as cooperation or teamwork. The PHN guided the pregnancy, and the midwife guided or sometimes led the birth, Like a captain steers a ship. The mothers did not need to be afraid. They said that the nurses did not force them but gave them informed choices and were flexible toward their wishes and needs. If needed, the HCPs did their utmost for them and their infants. The continuity of the nurse encounter and consistency of maternity care meant safety. When the nurse knew the previous history of the mother, and the mother could trust that the nurse would implement what they had agreed upon, it enabled a closer relationship: For example, when I was struck by panic again, I went to the delivery ward, and there was the same midwife, and (she) immediately knew me. Yes, she remembered the name and that it was the first pregnancy, it was nice.... It felt like she was a relative. When the relationship did not work, or the language exchange was poor, it was a disadvantage to have the same nurse. Some mothers did not always enjoy going to the prenatal clinic, but they felt they had no choice, and that they had to trust the HCPs. They had no knowledge or experience of pregnancy or childbirth, and no female relatives to ask for help, and therefore the only option was to continue attending maternity care. A few mothers considered making written complaints. However, the mothers were very loyal to the HCPs and did not accuse them of anything. The mothers blamed themselves for negative experiences or excused mistakes made by the nurses or doctors. A firsttime mother who had a poor relationship with the PHN in the beginning of the pregnancy said, It may have been because of me, I was too sensitive in the beginning. None of the mothers admitted to being subject to racism, discrimination, intolerance, or hostility in maternity care. They felt that they had the same equal access to maternity care as Finnish mothers. However, they noticed that Finnish mothers had easier access to information. Conflicts seemed to be resolved and difficulties were overcome. The mothers started to get along 644 JOGNN, 41, 638-649; 2012. DOI: 10.1111/j.1552-6909.2012.01395.x http://jognn.awhonn.org

Wikberg, A., Eriksson, K., and Bondas, T. with the PHNs or received another permanent PHN who spoke their language. Nurses who were inattentive or disorganized apologized and corrected their mistakes and tried to resolve misunderstandings. Negative experiences were discussed and explained afterwards or corrected at the next birth according to observations and interviews. It seemed that no conflicts or hard feelings remained and trust was reestablished. Discussion The four patterns above were used to describe and interpret caring from an intercultural perspective in maternity care, in other words, from the perspective of immigrant new mothers. The mothers in this study were from different cultures but shared a common experience (Roper & Shapira, 2000), being pregnant and giving birth in a foreign culture. They were strangers to the Finnish maternity care culture, even if some of them had adapted or integrated well into Finnish society. As women giving birth in another culture, they had multiple vulnerabilities (Liamputtong, 2007): they are women, pregnant, immigrants, members of ethnic groups, often had low social status, and spoke another language. Most of the mothers had immigrated voluntarily to work, study, or join family members. They did not have the traumatic backgrounds of refugees, but they were still vulnerable because they had communication problems and had to learn about the Finnish health care system themselves, especially if their schools, work places, or families did not help. These mothers did not have the same government organizations or financial support as refugees and asylum seekers. When language skills were missing, the thoughts and feelings of the mothers were not discussed. Spiritual needs were not considered, even if there were no language problems. Communication was essential for receiving information and self-expression (Brämberg, Nyström, & Dahlberg, 2010), and being able to choose and make decisions, for a caring relationship to develop. Not arranging for interpreters could be perceived as discrimination, because the mothers did not have the same access to information as Finnish mothers. Previous transcultural studies often highlight the cultural background of the mothers. In this study, the culture of the host country s maternity care, which influences the caring, is described. Caring Women giving birth in another culture have multiple vulnerabilities, often have low social status, and speak a foreign language. implicitly considers the unique needs of a patient (Eriksson, 2002). The mothers might have similar difficulties expressing their cultural traditions, ways of living, and communication styles, as nurses have explaining Finnish maternity care culture that is normally taken for granted. For example, Finnish maternity care is characterized by a natural approach to pregnancy and birth, a direct communication style, the presence of husbands at the birth, ritualized care to build respect and trust (Lamp, 1998), accepting care and advice given (Abdelhamid, 2004), enduring hardships and pain without complaining (Leininger, 2006), and being independent and able to manage on your own (Abdelhamid; Callister, Vehviläinen-Julkunen, & Lauri, 2001). The mothers would have liked the nurses to ask about their cultures and background (Small et al., 1999). Instead, the mothers accepted whatever they were given, even if it was minimal (Brämberg et al., 2010). The suffering or negative experience became more explicit when a common language was missing or not offered. Being kind and going beyond the call of duty in small things (Arman & Rehnsfeldt, 2007), such as calling the mother at home, was considered to be an expression of genuine concern and caring. If the relationship with the PHN did not include caring, the mothers might experience loneliness and isolation and be at risk for postpartum depression (O Mahony & Donnelly, 2010), because the PHN might be the only person the new mother perceived as a friend. The opportunity to discuss a significant experience like childbearing with an HCP gives perspective and meaning (Callister, 2004). Resolving conflicts and discussing fears is essential for maintaining the relationship, and might be essential for health outcomes (Berggren, Bergström, & Edberg, 2006; Essén et al., 2000). The results are compared with the model for intercultural caring, containing universal, contextual, cultural, and unique caring, which was included in the theoretical perspective. Some caring was universal and similar for all, independent of culture or context. The women mentioned, for example, respect, listening, and hope. Some caring was specific to the maternity context. The intensity, fear, pain, and the closeness to life and death JOGNN 2012; Vol. 41, Issue 5 645

Intercultural Caring From the Perspectives of Immigrant New Mothers during birth was present for all. The changes of the mother s body during pregnancy, birth, and the postnatal period, were specific to maternity care, as well as breastfeeding, childcare, tiredness, sensitivity, and worries about the infant s health. First-time mothers often felt afraid of childbirth, were insecure about childcare and breastfeeding, and needed more support. When the first child was born, the woman became a mother and a family was established, and later the family constellation was changed. Some caring was dependent on cultural background. The Southeast Asian mothers in this study clearly followed the hot and cold theory, which is a way of understanding health as balance or harmony. Mothers had different dietary demands and expressed pain in different ways. Some of the mothers came from paternalistic cultures, where women are expected to be quiet and obedient whereas the husband is the spokesperson. Some mothers came from collective cultures (Hanssen, 2004), where the family makes decisions. Although some had a strong belief in the power of authorities, or came from strict regimes where they did not dare to express themselves freely, other mothers came from more Western cultures, which emphasize the importance of the individual (Hanssen). Each mother also had unique caring needs. Her experience might be different from the ethnic group she belonged to. The mothers received different amounts of assistance from the nurses, depending on their expressed needs. Limitations Alternative methods, such as in-depth interviews, focus interviews, and filming were considered but discarded because of language obstacles and ethical considerations (Liamputtong, 2007). A follow-up interview could have shed light on the perceptions and concepts of the mother, such as health, well-being, family, and, in particular, care and caring in their own culture. Instead, the mothers were asked about experiences during pregnancy, birth, and the postnatal period, and most mothers talked about their previous births as well to validate the data (Honkasalo, 2008). Most mothers seemed to like talking to the first author, except for two new arrivals who gave short answers. The disclosing of personal information by the first author (a mother of two, one born abroad, and a midwife, not working in maternity presently) might have encouraged willingness to share some experiences because reciprocity is needed to maintain the relationship, and disclosing personal information helps to create rapport and trust (Liamputtong, 2007). The use of professional interpreters was preferred, but when they were not available, it was considered better to include the mothers with the fathers as interpreters than to exclude them altogether. The observations validated the interviews and brought new information and understanding to the study. This ethnographic study is made from the perspective of the mothers (emic view), but since the first author is a Finnish midwife, and the supervisors have a professional background in health care, there is also a professional (etic) view. The aim is to observe and understand the world from the view of its members and then to apply your own interpretations and explanations (Roper & Shapira, 2000, p. 70). Implications Some suggestions for further research on intercultural caring are to study mothers with a similar legal status or patients from another context, for example, psychiatric care. Maternity care research could be done with fathers, interpreters, or support persons. A comparison between the Finnish majority and the traditional Finnish-Swedish minority would also be interesting to study. Furthermore, the model for intercultural caring could be applied to practice. To improve the caring perspective of maternity care for immigrant mothers, the following implications, implicitly including caring, are suggested: continuity of care, improvement of communication, further education, experience and employment, information, antidiscrimination and antiracism strategies, a reconsideration of maternity care philosophy, delivery and parental preparation, and support networks. See Table 2. Conclusion The results of our study demonstrate the perceptions and experiences of intercultural caring of immigrant new mothers. The influence of Finnish maternity care culture on caring is highlighted from the perspective of the mothers. Intercultural caring was described as universal, cultural, contextual, and unique. Women were not familiar with the Finnish health care system, which was a strain on the care received. Many immigrant mothers lacked a support network from their relatives. The nurse/patient relationship could partly replace their support if the relationship was perceived as caring. The cultural competence of the nurses 646 JOGNN, 41, 638-649; 2012. DOI: 10.1111/j.1552-6909.2012.01395.x http://jognn.awhonn.org

Wikberg, A., Eriksson, K., and Bondas, T. Table 2: Clinical Implications to Improve Intercultural Caring Continuity of care Improvement of communication Further education Experience and employment Information Antidiscrimination and antiracism strategies Reconsideration of maternity care philosophy Delivery and parental preparation Support networks Continuity is essential for rapport and trust but can be experienced negatively if the relationship does not work. Continuity throughout the maternity care could be attempted. Nurses need to ask mothers about their cultural backgrounds and maternity traditions. Female professional interpreters need to be utilized more often in pre- and postnatal nursing care. The availability of interpreters out of office hours needs to be improved. Technology, for example, closed Internet connections could be tried if an interpreter is not available. Language courses could improve the communication skills of health care providers. Further education about intercultural caring, for example, the influence of the majority culture, could be considered. Intercultural caring discussions could be based on experience and research, focusing on different and common features and positive resources of human beings. Nurses with experience or education in intercultural issues could be employed to educate others and avoid and solve conflicts. Community workers could facilitate networks. It is essential to inform immigrants about how maternity care is organized in the new country. Visits need to be described and reasons for tests, for example, ultrasounds need to be explained. Cooperation between maternity units could facilitate the care for the mothers. Single prenatal clinics cause negative experiences for mothers due to the racist, ethnocentric, or stereotypic attitudes of the health care professionals. Strategies to prevent prejudice, stereotypes, discrimination, and racism need to be established and implemented. The wishes of the mothers need to be considered. Postnatal self-care might not be culturally appropriate to mothers, whose tradition is rest and help after delivery. Mothers should be allowed to stay longer in the ward if they do not feel ready to go home. The breastfeeding approach could be less inconsistent and more baby friendly. Family-centered care could be supported by flexible time schedules in prenatal clinics, family rooms in the postnatal ward, and fathers could be considered as fathers to be, instead of interpreters or practical support. Preparation courses were appreciated because of the information, support, and the opportunity to make friends. Prenatal labor ward visits calmed the mothers. These should be available in the mother s language or with interpreters present for all mothers who wish to participate. Immigrant mothers need support groups of women from their own culture or the extended use of public health nurses, especially after delivery. influenced the caring relationship. The women had multiple vulnerabilities and were prone to isolation and discrimination if they experienced communication problems. REFERENCES Abdelhamid, P. (2004). Hoitamisen itsestäänselvyydet ja näkymättömät haasteet. Hoitajien kertomuksia etnisesti erilaisten potilaiden hoitosuhteista [Self-evidences and invisible challenges of nursing. Nurses stories about caring of patients with different cultural backgrounds]. Licentiate thesis, University of Kuopio, Department of Nursing Science, Kuopio, Finland. Adjekughele, J. (2003). A reflection on Finnish maternity and child health clinics from the perspective of mothers from the African continent. In K. Clarke (Ed.), Welfare research into marginal communities in Finland: Insider perspective on health and social care (Research reports. Series A, No 8., pp. 31 73). Tampere, Finland: University of Tampere, Department of Social Policy and Social Work. Arman, M. & Rehnsfeldt, A. (2007). The little extra that alleviates suffering. Nursing Ethics, 14, 372 386. doi:10.1177/ 0969733007075877 JOGNN 2012; Vol. 41, Issue 5 647

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