Elsevier

Collegian

Volume 17, Issue 3, September 2010, Pages 105-111
Collegian

Cultural safety and its importance for Australian midwifery practice

https://doi.org/10.1016/j.colegn.2009.11.001Get rights and content

Summary

Cultural safety is an important concept in health care that originated in Aotearoa (New Zealand) to address Maori consumer dissatisfaction with health care. In Australia and internationally, midwives are now expected to provide culturally safe midwifery care to all women. Historically, Australia has received large numbers of immigrants from the United Kingdom, European countries and the Middle East. There have also been refugees and immigrants from South-East Asia, and most recently, from Africa. Australia continues to become more culturally diverse and yet to date no studies have explored the application of cultural safety in Australian midwifery practice. This paper explores how cultural safety has evolved from cultural awareness and cultural sensitivity. It examines the importance of cultural safety in nursing and midwifery practice. Finally, it explores the literature to determine how midwives can apply the concept of cultural safety to ensure safe and woman centred care.

Introduction

Australia is a multicultural nation with migrants and refugees from over 200 countries who practice more than 115 religions and speak more than 180 different languages (ABS, 2007, ADI, 2008, Johnstone and Kanitsaki, 2007). Women accessing maternity services in Australia have very diverse needs and these may be unknown to the midwives providing care. The provision of culturally safe midwifery practice is essential if health outcomes for women and their newborn infants are to be optimised.

Cultural diversity may relate to social context, religion and/or gender, as well as ethnic background. The concept of cultural safety is a broad one that aims to identify and protect the culture of groups. Internationally, much has been written about transcultural nursing, cultural competence and cultural safety when providing nursing care (Baker, 2006, Betancourt et al., 2003, Chenowthm et al., 2006, De and Richardson, 2008, Johnstone and Kanitsaki, 2007, Leininger, 2002, Narayanasamy, 2003). There have been studies concerning the concept of cultural safety in human services. These studies have investigated the meaning of cultural safety and its evolution (Belfrage, 2007, Bin-Sillik, 2003, Dowell et al., 2001, Ramsden, 1993, Ramsden, 2002, Wepa, 2001, Wepa, 2003), cultural safety in health and nursing care (Chrisman, 2007, Jacobs and Boddy, 2008, Richardson, 2003), and the promotion of cultural safety when providing health care (Hughes and Hood, 2007, Lipson, 2007).

Culturally appropriate nursing care has been widely explored in the literature (Belfrage, 2007, Chrisman, 2007, Purnell and Paulanka, 2003, Ramsden, 2002, Richardson, 2003, Wepa, 2001, Wepa, 2003, Wepa, 2004) however it is not well known what has been written about midwifery and cultural safety. A search of multiple electronic databases, including CINAHL, MEDLINE, Health Science, SocINDEX, and Psychology and Behavioural Sciences, from 1980 to 2008 was carried out. This period is relevant when establishing current and salient midwifery research concerning cultural safety, as cultural safety emerged in the nursing literature during the 1980s. To facilitate the search, keywords and terms, including cultural safety, cultural competence, cultural respect, cultural security, immigrant, refugees and women were used in conjunction with midwifery.

No previous research was located in the literature which specifically examined cultural safety in midwifery care. We were however able to locate six studies involving women from various multicultural backgrounds and their experiences of accessing midwifery care in Australia. These studies explored the midwifery care provided to Aboriginal and Torres Strait Islander Australians (Kruske, Kildea, & Barclay, 2006); the experience of pregnancy, labour and birth of Thai women in Australia (Liamputtong & Naksook, 2004); Vietnamese, Turkish and Filipino women's views about care provided during labour and birth in Australian maternity units (Small, Yelland, Lumley, Brown, & Liamputtong, 2002); antenatal care for African refugees (Carolan & Cassar, 2007); the meaning and experiences of motherhood among Afghan immigrant women living in Australia (Tsianakas & Liamputtong, 2008); and the perceptions of pregnant African women attending maternity services in Melbourne (Carolan & Cassar, 2008).

In all six studies women did not explicitly report or even imply feeling cultural safe and neither did the researchers discuss the importance of cultural safety. Given that no previous research was found, the remainder of this paper discusses how cultural safety has evolved and describes its importance for and application to midwifery care.

Section snippets

Concept of cultural safety

Cultural safety was developed in the context of nursing theory and is widely discussed in terms of health care practices (Ramsden, 1993, Ramsden, 2002, Richardson, 2003, Wepa, 2001). Cultural safety was introduced in Aotearoa/New Zealand in the late 1980s in response to improving Maori wellbeing, reducing the impact of colonisation and reducing culturally inappropriate practices in health care (Dowell et al., 2001, Jacobs and Boddy, 2008, Papps and Ramsden, 1996). Maori health status was

Evolution of cultural safety

The concept of cultural safety evolved from cultural awareness and cultural sensitivity (Ramsden, 1993, Ramsden, 2002, Richardson, 2003). Williams (1999) purports that cultural safety “extends beyond cultural awareness and sensitivity” and Eckermann et al. (2006) consider cultural awareness and cultural sensitivity as important foundations for the attainment of cultural safety. Fig. 1 illustrates that cultural safety builds upon cultural awareness and cultural sensitivity in developmental

Australian health

Johnstone and Kanitsaki (2007) argue that the health status of racial and ethnic minority groups, including immigrants and refugees, is poorer than that of the local population of the country they are living in. In Australia there are disparities in health among minority racial, ethno-cultural and Indigenous groups, and most recently, new immigrants and refugees (Allotey, 2003, ABS, 2007, AIHW, 2005, Wepa, 2004). This is despite the fact that Australians are one of the healthiest populations

Cultural safety in nursing and midwifery

Cultural safety is not synonymous with transcultural nursing. Transcultural, cross-cultural and inter cultural care are, however, terms that are often used interchangeably and are primarily concerned with cultural interactions (Leininger, 2002, Robb and Douglas, 2004). These terms are predecessors to the principle of cultural safety. The concept of transcultural care was developed by the American nurse theorist, Leininger in response to a lack of understanding by nurses in the United States of

Cultural safety in midwifery practice

The process of moving toward cultural safety in midwifery must acknowledge the uniqueness of the relationship between a midwife and a woman. This relationship is enhanced when there is continuity of care. Eckermann et al. (2006) describe this unique interaction or relationship as a convergence of two cultures, that is the professional culture of the midwife and the culture of the woman. It is likely that this interaction will encourage the development of trust between a midwife and a woman (

Strategies to help ensure culturally safe midwifery practice

Cultural safety puts the woman at the centre of midwifery care by identifying her needs and establishing a partnership built on trust. Culturally safe midwifery care strategies would incorporate optimal communication, building sound relationships and acknowledging women's cultural preferences. Clear, value free, open and respectful communication is fundamental in identifying and acknowledging the woman's requirements when planning care (De and Richardson, 2008, Eckermann et al., 2006, Ramsden,

Conclusion

As a matter of urgency, the strategies highlighted in this paper ought to be promoted to ensure cultural safety in midwifery practice. Midwives practising in Australia need to identify and acknowledge that cultural differences exist between themselves and all women. Cultural safety requires midwives firstly to engage in self reflection of their values, attitudes and beliefs in order to recognise that power imbalances occur during everyday midwifery practice. This should be followed by the

Conflict of interest

I wish to state that there is no conflict of interest of any kind in the event the article is published by the Collegian. There is no financial or other interest in the product or distribution of the product.

References (91)

  • Australian College of Midwives [ACM]. (2006). Standards for the accreditation of bachelor of midwifery education...
  • Australian Department of Immigration. (2008). Settler arrivals 2006–2008....
  • Australian Institute of Health and Welfare [AIHW]. (2005). The health and welfare of Australia's Aboriginal and Torres...
  • Australian Institute of Health and Welfare. (2007). Aboriginal and Torres Strait Islander health performance framework...
  • ABS & AIHW. (2008). Health and welfare of Australia's Aboriginal and Torres Strait Islander peoples. ABS Cat. No....
  • Australian Nursing & Midwifery Council. (2006). National competency standards for the registered nurse. Dickson ACT:...
  • C. Baker

    Globalization and the cultural safety of an immigrant Muslim community

    Journal of Advanced Nursing

    (2006)
  • M. Belfrage

    Why culturally safe health care?

    Medical Journal of Australia

    (2007)
  • K. Bentham

    Maternity care for asylum seekers

    British Journal of Midwifery

    (2003)
  • J.R. Betancourt et al.

    Defining cultural competence: A practical framework for addressing racial/ethnic disparities in health and health care

    Public Health Records

    (2003, July–August)
  • M. Bin-Sillik

    Cultural safety: Let's name it

    Australian Journal of Indigenous Education

    (2003)
  • K.H. Bulman et al.

    Somali refugee women's experiences of maternity care in west London: A case study

    Critical Public Health

    (2002)
  • A. Burnett et al.

    Meeting the health needs of refugee and asylum seekers in the UK

    (2002)
  • M. Carolan et al.

    Pregnancy care for African refugee women in Australia: attendance at prenatal appointments

    Evidence Based Midwifery

    (2007)
  • M. Carolan et al.

    Antenatal care perceptions of pregnant African women, attending maternity services in Melbourne, Australia

    Midwifery

    (2008)
  • Centre for Culture Ethnicity and Health. (2003). Diversity in hospitals: responding to the needs of patient and client...
  • B. Chalmers et al.

    432 Somali women's birth experiences in Canada after female genital mutilation

    Birth

    (2000)
  • L. Chenowthm et al.

    Cultural competency and nursing care: An Australian perspective

    International Nursing Review

    (2006)
  • N. Chrisman

    Extending cultural competence through systems change: Academic, hospital, and community partnerships

    Journal of Transcultural Nursing

    (2007)
  • J Coffin

    Rising to the challenge in aboriginal health by creating cultural security

    Aboriginal & Islander Health Worker Journal

    (2007)
  • I. Correa-Velez et al.

    Australian health policy on access to medical care for refuges and asylum seekers

    Australian and New Zealand Health Policy

    (2005)
  • L. Culley

    Transcending transculturalism? Race, ethnicity and health-care

    Nursing Enquiry

    (2006)
  • D. De et al.

    Cultural safety: An introduction

    Paediatric Nursing

    (2008)
  • R. Deery et al.

    Supporting midwives to support women

  • Department of Education, Science and Training [DEST]. (2001). National review of nursing education multicultural...
  • Department of Health South Australia. (2004). Cultural respect framework for Aboriginal and Torres strait Islander...
  • E. Dietsch et al.

    We ask that the world please hear us: Women from the Democratic Republic of Congo (DRC) share their stories of survival

    MIDIRS Midwifery Digest

    (2006)
  • L.T. Dowd et al.

    Culture and ethnicity

  • A. Dowell et al.

    The first sunrise: An experience of cultural immersion and community health needs assessment by undergraduate medical students in New Zealand

    Medical Education

    (2001)
  • M.E. Duffy

    A critique of cultural education in nursing

    Journal of Advanced Nursing

    (2001)
  • A. Eckermann et al.

    Bridging cultures in aboriginal health

    (2006)
  • J. Gage et al.

    Development of the New Zealand nursing workforce: Historical themes and current challenges

    Nursing Inquiry

    (2007)
  • D. Grant-Mackie

    Yesterday, today and tomorrow: Colonisation, the Treaty of Waitangi and cultural safety

    Diversity in Health and Social Care

    (2007)
  • B. Gray

    Cultural competence and interpreters

    Nzfp

    (2008)
  • K. Harper-Bulman et al.

    Somali women's experiences of maternity care in West London: A case study

    Critical Public Health

    (2002)
  • Cited by (41)

    • A global review of the inferred meaning of woman centred care within midwifery professional standards

      2023, Women and Birth
      Citation Excerpt :

      This is achieved by providing programmes of care and support for women: ‘which are appropriate to the needs, contexts, culture and choices of women, babies and their families’. The enactment of cultural sensitivity ensures that the woman's cultural requirements are met through culturally appropriate care [37]. Understanding cultural safety also requires acknowledging and recognising the unique connection between the culture of the woman and the culture of midwifery as a profession.

    • Cultivating awareness of sexual and gender diversity in a midwifery curriculum

      2021, Midwifery
      Citation Excerpt :

      Cultural safety, builds on enhanced awareness. It requires the HP to reflect on their own unique cultural background in order to understand the impact and power of professional and personal dynamics on healthcare relationships ((Phiri et al., 2010) ). A health curriculum and its content should foster a critical consciousness of the self, others and the world in order to address health inequity (Muntinga et al., 2016) is cannot be done without helping the student to reflect on their own norms and values and the systemic issues that sustain differences in health outcomes (Muntinga et al., 2016)

    • Meta-Synthesis of the Needs of Women Cared for by Midwives During Childbirth in Hospitals

      2021, JOGNN - Journal of Obstetric, Gynecologic, and Neonatal Nursing
    View all citing articles on Scopus
    View full text