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Understanding and measuring emotion could be key to cultural safety in maternity care

Why cultural safety matters in maternity care

In Australia, the chance of dying or being unwell around the time of birth is higher for Aboriginal and Torres Strait Islander mothers and babies than non-Indigenous peoples (Australian Institute of Health and Welfare, 2020). Health professionals need to understand that racism fundamentally determines these health outcomes (Paradies et al., 2015). Institutionalised racism occurs when racism is hidden in the governance, policies, and practices of the organisation – in ways that work best for some groups and worse for others. One of the reasons Aboriginal and Torres Strait Islander families may avoid maternity care is that they do not feel safe or respected (Sivertsen et al., 2020). In part, this is because the western, biomedical approach to healthcare is at odds with Aboriginal and Torres Strait Islander holistic approaches to birth and birthing practices. These holistic approaches recognise the intricate relationships mothers and babies have to Country. There is a national drive for Birthing on Country, to provide Aboriginal and Torres Strait Islander families with a holistic, integrated and culturally safe model of care that supports the best start in life (Molly Wardaguga Research Centre, 2019).

Learning culturally safe practice

Recognising that institutional racism underpins Australian healthcare, has sparked new ways of teaching and learning to promote health equity and social justice. Indeed, midwives must learn to practice in culturally safe ways when working with Aboriginal and Torres Strait Islander families and communities. This requirement has been mandated by Aboriginal and Torres Strait Islander leaders and peak professional bodies (Australian Nursing and Midwifery Council (ANMAC), 2017; Australian Health Professional Regulation Agency (AHPRA), 2018). But learning cultural safety learning is not just about understanding Aboriginal and Torres Strait Islander culture, outcomes and social determinants of health. Primarily, it is about how non-Indigenous health students grapple with institutional racism within the healthcare system and critically reflect on their role within it.

Why emotion impacts learning cultural safety

Students react in different ways when learning cultural safety content. Some may begin to adopt anti-oppressive practice quickly, while others can become defiant, or experience significant emotional adversity. Non-Indigenous students may lack knowledge of the effects of settler colonialism and/or feel that their social identity is being challenged. This may lead to emotional reactions that are complex, and often semi-conscious. As students work through these emotional experiences, protective mechanisms (such as outward displays of anger) may arise. Alternatively, students may become caught in feelings of guilt and shame (Mills and Creedy, 2019). Becoming ‘stuck’ in these emotions reinforces inertia and preserves the status quo. Staying stuck makes institutional racism difficult to address in any meaningful way. Despite the complexity of teaching and learning in cultural safety, research about students’ complex emotional reactions has been rare.

Measuring emotion

Our research team developed and tested a survey tool to understand non-Indigenous student emotional learning experiences in cultural safety education (Mills, Creedy, Sunderland & Allen, 2021). The tool, named the Student Emotional Learning in Cultural Safety Instrument (SELCSI), is First Peoples-led with two scales of measurement: witnessing and comfort. The SELCSI was tested with 109 nursing and midwifery students after finishing a semester-long cultural safety course. Our results showed that the SELCSI is a valid and reliable measure of emotion in cultural safety education. In addition, the comfort scale can be used to support students to reflect on their level of comfort with cultural safety content. For educators, the scale can be used to see how students are sitting with the content to enable them to adapt to students’ needs.

Where to from here

Understanding and measuring non-Indigenous students’ emotions when learning cultural safety will support student reflection and learning. At the same time, it will promote responsive and innovative approaches to cultural safety education. Significantly, measuring emotion using the SELCSI may be fundamental to culturally safe health practice. Cultural safety is required to achieve health equity for Aboriginal and Torres Strait Islander peoples.

References

Australian Health Practitioner Regulation Agency (AHPRA). (2018). Aboriginal and Torres Strait Islander Health Strategy – Statement of Intent. https://www.ahpra.gov.au/About-AHPRA/Aboriginal-and-Torres-Strait-Islander-Health-Strategy/Statement-of-intent.aspx

Australian Institute of Health and Welfare. (2020). Australia’s Mothers and Babies 2018 – In Brief. Canberra: AIHW.

Australian Nursing and Midwifery Accreditation Council (ANMAC). (2017). Enrolled Nurse Accreditation Standards 2017. https://www.anmac.org.au/sites/default/files/documents/ANMAC_EN_Standards_web.pdf

Mills, K., & Creedy, D. (2019). The ‘Pedagogy of discomfort’: A qualitative exploration of non-indigenous student learning in a First Peoples health course. The Australian Journal of Indigenous Education, 1-9. https://doi.org/10.1017/jie.2019.16

Mills, K., Creedy, D. K., Sunderland, N., & Allen, J. (2021). Examining the transformative potential of emotion in education: A new measure of nursing and midwifery students’ emotional learning in first peoples’ cultural safety. Nurse Education Today, 104854. https://doi.org/10.1016/j.nedt.2021.104854

Molly Wardaguga Research Centre. (2019). Birthing on Country. Retrieved from www.birthingoncountry.com

Paradies, Y., Ben, J., Denson, N., Elias, A., Priest, N., Pieterse, A., Gee, G., 2015. Racism as a determinant of health: a systematic review and meta-analysis. PLoS One 10 (9), e0138511.

Sivertsen, N., Anikeeva, O., Deverix, J., & Grant, J. (2020). Aboriginal and Torres Strait Islander family access to continuity of health care services in the first 1000 days of life: a systematic review of the literature. BMC Health Serv Res, 20(1), 829. https://doi.org/10.1186/s12913-020-05673-w

Building birthing on country for the Yuin community

First Nations women of Australia have given birth on their country and within their cultural practices for most of their history. The colonisation of Australia by Europeans disrupted this, and it is now challenging for Aboriginal and Torres Strait Islander women to access maternity care that is local to them, and which honours their culture. Midwifery continuity of care delivered in models designed by and for Aboriginal and Torres Strait Islander women, by clinicians who are answerable to their local community can build the strength and vitality of communities.

The IBUS study (Hickey, et al., 2018) has been examining the outcomes of providing birthing on country services within a midwifery continuity of care model. Preliminary findings have shown a significant reduction in preterm birth rates (Kildea, et al., 2019). Preterm birth rates are higher for children born to indigenous women compared to non-indigenous women, and these children are at a life-long disadvantage. Few interventions designed to prevent preterm birth have been as effective as these structural changes to the way care is provided. Despite this, midwifery continuity of care models remain limited around Australia and access to such care is particularly lacking for Aboriginal and Torres Strait Islander women living in regional areas.

Waminda, the South Coast Women’s Health and Welfare Aboriginal Corporation – located on Yuin land in Nowra, NSW – is poised to solve this access issue for their local community. Extensive consultation within the community occurred in 2017 in the form of the Building on Our Strengths (BOOSt) project (Roe, Kildea, & Briggs, 2017). Participants identified that they wanted maternity systems based on Aboriginal ways of knowing and doing, that provide holistic care, and that were committed to giving their children the best start in life.

Waminda have designed a Birthing on Country program that puts the needs of the community first and is underpinned by sound research. A central part of this program is to build a Birthing and Community Hub which will enable the provision of maternity services, including birthing services. The major obstacle in their way at the present time is funding. To overcome this, Waminda are seeking public funding for the project. You can help make this happen by making a donation to support this work.  More information is available on the Waminda Birthing on Country website.

 

References
Hickey S, Roe Y, Gao Y, Nelson C, Carson A, Currie J, et al. The Indigenous Birthing in an Urban Setting study: the IBUS study: A prospective birth cohort study comparing different models of care for women having Aboriginal and Torres Strait Islander babies at two major maternity hospitals in urban South East Queensland, Australia. BMC Pregnancy Childbirth. 2018;18(1):431.

Kildea, S., Gao, Y., Hickey, S., Kruske, S., Nelson, C., Blackman, R., Tracy, S., Hurst, C., Williamson, D., & Roe, Y. (2019, Jul). Reducing preterm birth amongst Aboriginal and Torres Strait Islander babies: A prospective cohort study, Brisbane, Australia. EClinicalMedicine, 12, 43-51. https://doi.org/10.1016/j.eclinm.2019.06.001

Roe, Y., Kildea S. and Briggs, M. (2017). Birthing on Country, Best Start to Life, Illawarra Shoalhaven, 2017. Birthing on Country Working Group, Midwifery Research Unit, University of Queensland.

Transforming maternity care requires the full contribution of the midwifery profession

Adjunct Professor Jocelyn Toohill PhD

Midwives play a critical role in healthcare. Unfortunately, most health leaders, and many health professionals have little understanding of what midwives can do. As a consequence, we have a significantly under-recognised and underutilized midwifery workforce relative to their scope of practice. For communities to have access to the highest standard of maternity care, and for health services to deliver world-class care we must have a midwifery workforce who are supported to work to full scope of practice.

Why is this important?

The “State of the World’s Midwifery” report is the 3rd international report to be published with a global focus to improving availability, accessibility, acceptability, and quality midwifery care. Importantly the report will demonstrate that “Power Comes from the Womb” and will be published by the United Nations Population Fund in 2021. This report will outline the 60-fold benefit that will come from investing in midwifery and highlight the impact midwifery can achieve through adopting a lifetime approach to care. Eighty-seven percent of all essential sexual, reproductive, maternal and newborn healthcare can be provided by midwives. Fifty-six maternal and neonatal outcomes are improved through midwifery practice alone. If we want a first-class health system, we must begin by acknowledging the value of midwives in saving lives and preventing lifetime morbidity, and midwives must be ready to meet this welcome but long overdue recognition.

Acknowledge

To make use of the all the opportunities quality midwifery care might provide for Queensland communities, we need to begin by knowing our existing midwifery workforce. Midwifery is relatively invisible within workforce systems, and is confused within a career structure not designed for the profession . We need to develop and articulate more clearly midwifery position description and generic level statements, that describe what it is that midwives do, when they do it, and where they do it.

Midwives are regulated to provide woman-centred care, and to promote normal physiology for women, both with and without complexities. When a woman has physical, medical, or psycho-social challenges her care does and will include members of the multidisciplinary team and will be guided by the Australian College of Midwives National Consultation and Referral Guidelines. Often health professionals have little understanding of the education preparation or lifesaving skills and knowledge midwives have and this lack of understanding of the scope of a midwife contributes to fragmented care for the woman and disrupts away from providing relationship based care within midwifery continuity. As such the professional role of the midwife must be articulated and embedded in human resource management systems, so that workforce numbers and workforce planning are focused to achieve best practice models where every woman has access to her own midwife. To promote and progress this, midwives must be included in all discussions to have a voice with executive health staff relating to the importance of midwives and of midwifery care.

Innovate

To innovate maternity care, midwifery continuity of carer models need to be scaled up. Despite overwhelming evidence of benefit, few women have access to this model of midwifery care. By tapping into the benefits to women and their families of consistent professional support from midwives during the first 1,000 days of life, we can provide a continuum of connected care and a professional career pathway for midwives that is integrated with child health. We recognise that a consistent and trusted carer means that psychosocial health needs, such as postnatal depression and domestic and family violence, are more likely to be identified earlier and addressed.

Home birth

Queensland is one of only two Australian jurisdictions without publicly funded homebirth. Homebirth is safe and provides improved outcomes in the right population of women. Queensland has strong consumer interest for home birth. During COVID-19 private midwives have reported a 35% increase in homebirths, and higher levels of demand than they can meet. There are concerning reports suggesting that women are giving birth without a midwife or doctor because they cannot afford a private midwife and are fearful of birthing in a hospital. Public health messaging of the safety of birth in hospital has not diminished the numbers of women continuing to seek out this choice. Equity of access to maternity and birth care that is physically and psychologically safe is important. Identifying opportunities for how homebirth could be facilitated remains a significant gap, with ‘hospital in the home’ arrangements perhaps an option.

Birthing on Country

Actioning and embedding culturally appropriate care and acknowledging the importance of birthing on country to Aboriginal and Torres Strait Island women is paramount in providing a world class health system and achieving sustainable development goals. Scaling up midwifery continuity of care with Aboriginal and Torres Strait Island women is vital. A major contributor to poor outcomes for Aboriginal and Torres Strait Island women is preterm birth, and we know that this is reduced by 50% where mothers receive midwifery continuity of care. Through implementing recommendations of the Queensland Rural Taskforce Report, maternity care can be provided closer to home and build continuity models. Technology will be a major conduit for midwives to connect women living rurally with specialist services.

Transform

Transforming maternity care will only come from the realisation of the full capacity of the midwifery profession. Currently, there are few midwives who have graduated in the past 12 years from a Bachelor of Midwifery program holding leadership roles. In 2018 surveys showed that contemporary midwifery education and practice remain poorly understood, with significant numbers of midwives indicating they were restricted from working to their full scope of practice. For those in leadership roles, a clear understanding of the differences between nursing and midwifery is necessary to grow and show the benefits of the midwifery workforce. Upon graduation midwives should be articulated directly to continuity models rather than restricted to and deskilled in historical and fragmented graduate programs. Ensuring culturally appropriate support is in place to attract and retain Aboriginal and Torres Strait Islander midwives is also key to building an equitable and inclusive workforce.

Additionally, through ensuring all women have access to a midwife – and specifically within a relationship-based continuity model where they are working to full scope – will assist in addressing the one in three women who have trauma symptoms from a poor birth experience or from feelings of having been treated disrespectfully. The protective factor for women is having a known midwife who understands her needs. Trust builds over time through cumulative education, information sharing, and decision-making, where the woman can feel confident in her midwife’s advocacy of her needs. Through this support – and regardless of birth or maternity outcome – the woman’s feelings of safety and control are likely to result in improved perinatal mental health, adaption to early parenting and greater capacity to meet the developmental needs of her child. Women who receive midwifery care are more likely to feel empowered, experience shared decision making and be more satisfied with their care.

Summary

For ongoing improvements in maternity care to be achieved we need to make the best use of our existing workforce by expanding opportunities for midwives to provide continuity of care. We need to be ready for the recommendations coming from the State of the World’s Midwifery report.

All midwives – regardless of the model they choose to work – in are vital to promoting the profession and to achieving a world class maternity system. Midwives are potent, and we must ensure that how midwives are educated and regulated to work is supported, translated to practice, and for women to have increased access. It has been said previously, that if midwifery were a pill, everyone would be prescribed it. I commend all midwives to primarily advocate for women, but fundamentally understand that universal access to best practice midwifery continuity is dependent on us all.

While our profession is predominantly women, all midwives, regardless of gender must safeguard gender equality. We must call out poor care or inequity. To be effective we must continue to strengthen our profession and stand united so women know, our communities know, and our governments know who we are, what we do and why midwifery is so fundamentality important to women, to strong communities and to generational health. Without this commitment the usefulness of the 2021 State of the World’s Midwifery report to our profession may be lost.