Introduction
Literature and research have consistently highlighted the extent of the motivation or non-motivation of midwives to engage with the concept of culture and even to embrace people from the diverse cultural mix who entrust their lives to them (Rowe & Garcia 2005). Houghton (2008) holds the view that caring for a woman who speaks little or no English and often has complex care needs is a common occurrence for many midwives in the UK today.
Indeed, the essential nature of midwives working in a culturally sensitive manner has long had a steady footing in midwifery circles (Bowler 2008, English National Board 2001). A moder midwife lives and works in a complex multiracial and multicultural society, one in which she is perceived as a role model, friend, confidante and advocate (Hunt 2003). It is therefore vital that she is able to think, feel and act inside and outside the societal box to enhance midwifery care for those of her clients who are considered already to be at a disadvantage in society.
Some midwives may shy away from political issues that have a direct impact on the care of the client. Two such political issues are poverty and health inequalities. (Smith et al. 2005). Thinking outside the box would require the midwife to move away from what would be considered safe territory (Wickham 2007). She would need to network with agencies and personnel who would not normally be considered part of the healthcare team. Agencies such as the Citizens Advice Bureau (CAB) have resources and expertise potentially useful to the clients to whom this chapter intends to give a voice. The National Institute for Health and Clinical Excellence (NICE) (2008) provides up-to-date and evidence-based literature and guidance to healthcare professionals and women. It emphasises to women that ‘your care and the information you are given about it should take account of any religious, ethnic or cultural needs you may have’. Indeed, the significance of the client and health professional being aware of the role of advocacy in enhancing quality care was stated (NICE 2008).
Helen Begum was born in Birmingham though her parents are from Pakistan. She speaks fluent English but because of her cultural beliefs and practices, she is having problems conforming to what are considered the norms of antenatal care.There is no one definition of culture and it is important not to be constrained by any one definition; howeverm it is useful to have ideas around the concept of culture. This may offer the student of midwifery and midwives guiding tools that can enhance understanding of the diverse needs and expectations of people, such as Helen, who may be similar and different from themselves.
It may also facilitate a mindset in which they are receptive to change in the way they perceive clients who do not visibly conform to the norms of society, for example, travellers, refugees and asylum seekers (Wiseman 2011). Risk to health increases because of different health-seeking behaviours of different cultural groups (Bridle 2012, Wiseman, 2011;). The Nursing and Midwifery Council (NMC) requires midwives to act as advocates for those in their care, helping them to access relevant health and social care, information and support (NMC 2008).
These norms of society are not usually transparent particularly to people who may have limited language skills and also low or infrequent exposure to people and/or experiences from the dominant culture. They do, however, have equality rights and in some cases protection from discrimination (Griffith 2010).
There is no one ‘lens’ through which to construct a definition of culture (Hoffman 2007). This is because the midwife is often unconscious of her thinking, feelings and actions that may be influencing her decision making and attitudes to a particular client. Burr (2003) warns against the tendency to believe that knowledge and assumptions that guide us in our dealings with other people are ‘truths’. She is of the opinion that ‘our current accepted ways of understanding the world is a product not of objective observation of the world, but of the social processes and interactions in which people are constantly engaged with each other’. This view is supported by Reynolds & Manfusa (2005), who argued that a significant number of midwives do not believe that cultural issues are relevant or significantly important. Their lack of awareness and familiarity of interaction with people from diverse cultural backgrounds prevent them gaining deeper understanding of the cultural aspects of midwifery care. Reynolds & Manfusa therefore suggest that midwives give greater priority to getting to know about the client’s cultural beliefs and expectations so as to meet their individual needs and preferences. Sudworth et al. (2012) endorse this view. They highlighted the significance of trust in the midwife–woman relationship and asserted that ‘communication is the key to effective delivery of care and in understanding cultural barriers which may impinge on the quality of care’ (Sudworth et al. 2012, Thompson 2003).
For the purposes of this chapter, various definitions will be suggested to facilitate the student’s autonomy in determining a personal working definition of culture; this free choice is in keeping with the philosophy that underpins the contents and tone of the text. The expectation is that midwives and student midwives will feel personally committed to working in a culturally sensitive way with their clients rather than just doing it because it is a professional obligation. Development of cultural competence is vital to a high standard of midwifery care.
Schott & Henley (2007) expressed the view that culture is a set of norms, values, assumptions and perceptions (both explicit and implicit) and social conventions which enable members of a group, community or nation to function cohesively. Schott & Henley are of the opinion that ‘culture vitally affects every aspect of our daily life, how we live, think, behave and how we view and analyse the world’.
Burnham & Harris (2002) argue for the usefulness of understanding the difference between three inter-related concepts, namely, race, ethnicity and culture. They define race as ‘a personal biological inheritance’. Clearly a person’s race is immediately apparent and assumptions, stereotypes and equally dangerous judgements can be readily made which are believed to be truths (Burr 2003). Culture is defined (Burnham & Harris 2002) as ‘the social network within which conversations about race and ethnicity evolve’ and ethnicity is the ‘way a person thinks about the biological inheritance’. They imply that the meaning of ethnicity and culture is constantly emerging and changing; they are not static concepts but dynamic. This suggests that as the practitioner familiarises herself with the client’s cultural norms and expectations, she will be more willing to become transparent about prejudices, ideas and practices so that her ideas and biases may become more open and available for refreshment and reconstruction (Burnham & Harris 2002, Sudworth et al. 2012).
Helman (2007) defines culture as a ‘set of guidelines that individuals inherit as members of a particular society, and that tell them how to view the world, how to experience it emotionally and how to behave in it in relation to other people, to supernatural forces or gods and to the natural environment’. Norms and rules are usually obscure and only come to light when they are broken. Midwives are in a privileged position in which they have the necessary education and training (NICE 2010) accept difference in their clients’ knowledge and behaviour without judging them harshly.
There are many similarities in the authors’ definitions of culture in that they have personal, familiar and societal connotations. However, Helman (2007) highlights the significance of an individual’s belief system around the kind of person she is or can become, personal responsibility or even duty to transmit these beliefs across generations by the ‘use of symbols, language, art and ritual’. It is apparent that the client’s cultural lens through which she perceives and understands her world is extremely important to her and will be fiercely protected from perceived threat by anyone, including the midwife, who may seem likely to do harm.
Amy is 16 years old. She is a single young woman who has limited social support. She is at the antenatal clinic for a routine check up at 28 weeks’ gestation. Your practice mentor has asked you to do the antenatal examination. This includes questioning Amy about her well-being. On enquiring about her nutritional state, you discover that she is not eating regularly and sufficiently. She is worried about finance and identifies this as the main reason why she is neglecting her nutitional intake.When responding to Case study 14.2, it is important that Amy is treated with respect and concern, which includes not falling into a parent/child mode of conversation (Walsh 2005). The student is in a powerful position because Amy, like most women, wants the best for her baby and is therefore receptive to advice even when it is not given in a sensitive manner. It would be helpful to show genuine curiosity about the reasons why she felt that she could not afford nutritious food. Once you have gathered the relevant information, it is important to consult your practice mentor so that a possible solution can be found. This might be to:
- arrange for the community or teenage pregnancy midwife to visit Amy at home. This might enable her to feel supported and the midwife to assess her social situation and needs
- refer her to the dietician so that her nutritional needs can be determined and she can increase her motivation to meet the dietary requirements necessary to sustain a healthy pregnancy
- provide her with information about the CAB so that she can enquire about her eligibility for social benefits
- think further outside the box and make an appointment to see her Member of Parliament to discuss pregnancy-related issues in the context of poverty and inequalities.
Having considered Case study 14.2, the midwifery student should be in a position to consolidate a working definition of culture. This may facilitate a mindset that supports a personal and professional position where she treats her clients as individuals irrespective of their cultural or other differences.
The morality of working in a cultural context
Hart et al. (2003) highlight the ‘positive ways in which health professionals work, often in stressful and under-resourced contexts’, to achieve health benefits for disadvantaged groups of clients. However, though they acknowledge this positive approach, they stress that this is not universal. They highlight the consistent nature of evidence of how interactions between health professionals, healthcare institutions and service users result in clients feeling oppressed and humiliated rather than cared for, particularly in the case of disadvantaged service users. These are issues also revealed by he Centre for Maternal and Child Enquiries (CEMACE 2011) and (Esegbona-Adeigbe 2011). It is important that practitioners feel good about the way they work with their clients. However, it is also necessary for midwives to be willing to reflect on and face the challenges and criticisms about any shortfall in care provision and/or delivery that negatively impacts on clients who already suffer disadvantages in the society in which they live (Ahmad & Bradby 2009).
Carter (2001) asserts that by having a ‘greater understanding of ourselves through developed self-awareness we are more likely to have increased self-respect, which in turn leads to a greater respect of others’. It appears that the practitioner’s sense of self, who she is, how she arrived at this awareness and the social and professional context in which she operates provides a rich source of information that will inform her moral and ethical position.
The NMC (2008) supports an ethico-legal position of equity for all the midwife’s clients/patients. It states that:
all registered nurses, midwives and specialist community public health nurses are personally accountable for their practice and that they should in the exercise of their duty:
- respect the patient/client as an individual
- obtain consent before you give any treatment and care
- protect confidential information
- co-operate with others in the team
- maintain your professional knowledge and competence
- be trustworthy
- act to identify and minimise risk to patients and clients.
Jane has arrived on the delivery suite and is in established labour. She is a single white woman with no supportive birth partner. She is extremely scared and appears not to be coping well with the pain.
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