Part 1

Amaani is a 29-year-old Muslim Somalian newcomer to Hamilton who is planning to have a home birth. Amaani does not speak fluent English so you have arranged for a professional interpreter to assist at your visits. After the second visit, Amaani speaks to her daughter who is eleven years old. Amaani’s daughter tells you that her mother does not like the interpreter that you have chosen because she thinks that she is untrustworthy and is providing you incorrect information. She is dissatisfied and has suggested that her daughter interpret instead. You notice that Amaani’s daughter seems very intelligent and think she might be up to the task.

Question 1

Should you proceed by agreeing with Amaani? Why or why not? What are the things you should consider in formulating your response?

Accuracy is important when using interpreters. Family or friends of the client who are untrained interpreters may omit important information or may not be able to speak English confidently or fluently enough to translate the information at the required level needed for informed consent. Children and adolescents, in particular, may not be aware of all relevant information or terms.

When family or friends, rather than professional interpreters, are used, client confidentiality cannot be guaranteed. Family and friends may also be biased in the delivery of medical information to a loved one; for instance, they may avoid relaying some information in order to avoid interpersonal conflicts.

Furthermore, communicating sensitive health information can be a stressful experience for children and adolescents, especially where there is a negotiation or debate within the family about a health decision and the child is forced to play the role of broker between a health professional and family member. For this reason, the use of children, adolescents or other family members is not recommended.

Unfortunately, in some locations, professional interpretation may not be available due to a lack of accessibility, funding limitations, or other practical issues. In these cases, telephone interpretation is often available . When professional interpretation is not possible, arranging for the client to bring a relative or friend to the appointment is the next best option. However, using untrained interpreters, especially older children is riskier, and midwives need to be aware of and advise clients of the potential pitfalls. (1)

Part 2

As her pregnancy progresses you want to understand Amaani’s preferences for attendants at her birth.

Question 2

Which of the following options is the best way to discuss birth preferences  using cultural humility?

1. “I know that most Somali women in our city prefer not to have any men present at the birth. Which female relatives are you planning to have attend?”
2. “It is your decision to determine the people that will observe and help you at your birth. Who are you planning to have present at your birth? For example, some women prefer to have only female friends and family members present. Others like their husbands and other male family members to attend as well.”
3. It is best to not ask specific questions about birth attendants in order to avoid making assumptions and acting on cultural stereotypes.

Answer: #2

This represents an approach that identifies more closely with cultural humility. Some health care providers, as in response #3, aim to take a neutral approach to avoid stereotyping. They are concerned that if they notice a patient’s race, culture or class they will be enacting prejudice. However, in seeking to treat clients only as individuals this leads them to become ‘colour blind’ or ‘culture blind,’ hindering recognition of the ways in which sociocultural processes influence clients’ experiences of health, health care and access to care. (3)

On the other hand, some health care providers, as in response #1, take an approach more aligned with cultural competence, the understanding that cultural knowledge and belief systems can be studied and mastered. (4) The problem with this approach is that it does not recognize that cultural knowledge is dynamic. While there is a need to consider the role of cultural beliefs in understanding experiences of health and access to healthcare, there is a need to consider how cultural practices and beliefs may be adopted and uniquely adapted by different individuals, families and communities. Generalizations may be necessary for the purposes of illustration, however, they should not be interpreted as a representation of characteristics applicable to all members of a specific community or cultural group.

Rather than focusing on learning about each culture to master each culture’s belief systems, or taking a culture-blind approach, cultural humility is a reflexive approach that recognizes generalized cultural patterns in a specific locality while seeking to partner with clients to understand their unique characteristics and experiences. Cultural humility also incorporates a lifelong commitment to self-evaluation and self-critique and is a political stance that aims to redress power imbalances between health care practitioners and clients and their communities. (3, 4) Response #2 asks open-ended questions about birth attendants and recognizes the potential importance of the gender of attendants for Somalis without making assumptions about Amaani’s preferences. While it is true that in Somalia, men do not customarily accompany their wives during labour, studies with Somali communities in North America suggest that some women prefer their husbands to accompany them in labour. (2)

Part 3

Amaani is planning a hospital delivery and has requested that aside from her husband, only women should be present for the birth. A week before the due date, you  get a panicked call from Grace, Amaani’s neighbour, who says that baby is coming quickly and that she and Amaani are still at home. You are at another birth, so call EMS and the second attending midwife. When you arrive, the paramedics are already there but they missed the birth; Amanni delivered her baby lying on her living room floor. The baby is vigorous at birth and Amaani’s vital signs are normal. Next, you deliver the placenta and everything is going fine. You tell Amaani it is alright if she stays at home for a few hours because there is no reason to go to the hospital. Amaani says that she would prefer to go to the hospital and be monitored there.

Amaani’s husband requests that the paramedics, who are both male, leave, but they remain in the room.

Question 3

How do address your client’s request?

As Amaani’s midwife, you should explain to the paramedics that your client is a Muslim woman and that privacy is needed while Amaani is cleaned up and dressed in clean clothes. The paramedics may be reluctant, but they should exit to wait in the hall.

One of the dilemmas that midwives face is how best to work as allies with clients who are less privileged in order to promote client-centered care and health equity. In this situation, Amaani is disadvantaged by the fact that she does not speak English, and her husband is disadvantaged by the fact that he is not a health professional. The fact that the paramedics are also credentialed as health care professionals and are the midwife’s colleagues put her in a good position to advocate for Amanni. Midwives should be aware of their unearned privileges and the principles of allyship. The Anti-Oppression Network, in collaboration with PeerNetBC and Stephanie Nixon, describe how being an ally involves ‘an active, consistent, and arduous practice of unlearning and re-evaluating, in which a person of privilege seeks to operate in solidarity with a marginalized group of people.’ (5)

References

1. Canadian Paediatric Society. Using Interpreters in Health Care Setting. [Internet]. Canadian Paediatric Society. 2016. [cited 2018 Jan 2]. Available from: https://www.kidsnewtocanada.ca/care/interpreters
2. Missal B, Kovaleva M. Somali Immigrant New Mother’s Experiences in Minnesota. Journal of Transcultural Nursing. 2016; 27(4): 359-367.
3. Beagan B, Kumas-Tan Z. Approaches to diversity in family medicine: ‘I have always tried to be colour blind.’ Canadian Family Physician. 2009; 55(8): e21-28.
4. Tervalon M, Murray-Garcia J. Cultural humility versus cultural competence: A critical distinction in defining physician training outcomes in multicultural education. Journal of Health Care for the Poor and Underserved. 1998; 9(2): 117-124.
5. The Anti-Oppression Network, PeerNet BC. Allyship. [Internet]. The Anti-Oppression Network. 2015. [cited 2017 Nov 2]. Available from: https://theantioppressionnetwork.com/allyship/