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Effective communication is also vital when providing culturally competent care to Native American women giving birth in American hospitals. In order for Native Americans to be involved wholly in their own medical care, health services ought to be available in Native American languages. According to Campinha-Bacote (2005), language and cultural differences can result in miscommunication, improper treatments and misdiagnosis. Moreover, it is imperative for the caregiver to understand the elements of non verbal communication such as eye contact norms, and voice tone. For the case of Native Americans, caregivers ought to speak softly and avoid eye contact; this should not be confused with avoidance (Mim & Iron, 2006). In addition, many Native Americans are reluctant to express pain; consequently, it is imperative for the healthcare professionals to understand that the absence of complaints about pain does not necessarily imply that the patient is not experiencing pain (Campinha-Bacote, 2005). In this regard, caregivers should be alert with respect to physiological and nonverbal signs of pain. Caregivers should always seek for permission of the patient before touching any part of the body; this is because touching is considered extremely personal among Native Americans. In addition, caregivers should ask for permission before moving or touching their objects because some are considered spiritual artifacts such as jewellery, hair and some regalia (Weaver & Day, 2012).