Case Study: Poverty

Lauren Wallace, PhD

You are meeting Abena, a 28-year-old Muslim newcomer to Hamilton for her second appointment; she is 4 months pregnant. By reading her intake form, you find out that she arrived alone from West Africa three months ago to start her undergraduate degree at McMaster University. Abena plans to stay in Canada for the duration of her degree while raising her child. She has secured subsidized housing and Ontario Works.

At her first appointment, Abena expressed that she was feeling positive about the pregnancy. When you ask her how things have been going lately, she is visibly distraught and describes how she has been feeling lonely. She is also stressed about the energy it will take to raise her baby in Canada as a full-time student without family and without much financial support.

Question 1

You want Abena to feel that you empathize with her situation. How can you express empathy for Abena’s feelings of loneliness and financial stress and establish rapport having never experienced her exact economic or social situation?

  1. “That’s so horrible. I can’t imagine how you feel. I am sorry you’re in this situation”
  2. “It sounds like you are in a difficult place. Can you help me understand what you would need in order to feel more supported?”
  3. “At least you and the baby are healthy”
  4. “Well you don’t need to worry because there are lots of resources available in Hamilton for mothers who are in difficult financial and family situations. I can connect you with a newcomers group at the North Hamilton Community Health Centre and a program for subsidized daycare since you may not have anyone to take care of the baby once you are back in school. There is also Essential Aid who can provide you with used clothing.”
  5. Both B and D are good responses.

Answer: 2

Clients experiencing low income often tend to seek healthcare later in pregnancy and attend fewer visits than women of median and high income. One reason for this care-seeking pattern is clients’ experiences of shame in their interactions with healthcare professionals. One of the determinants of a client’s engagement with the health system is a healthcare professional’s attitude and willingness to genuinely listen and express empathy and compassion. (1)

It might seem like a good idea to express that you are sorry for the situation (response #1), however, this is confusing empathy with sympathy. Expressions of empathy are driven by the shared connection of being human and may help clients to move away from feeling shame and further isolation. On the other hand, sympathy can actually exacerbate the feeling of shame and reinforce the differences between healthcare practitioner and client rather than promoting their connection. Inherent in sympathy is the sentiment “I don’t understand your situation, but things look pretty bleak.”

“At least” (response #3) is usually not a good lead in for empathetic responses since rather than expressing an understanding of the client’s feelings, it shuts down the conversation with the sentiment that things are not as bad as described.

Response #2 is the best response because it conveys that the midwife is listening to the client’s perspective and is open to assist. At first glance, it may also seem like a good idea to immediately describe the resources available in Hamilton for pregnant newcomers experiencing low income (response #4 and #5). However, responding with a list of resources immediately may be overwhelming for Abena. This response is also based on the assumption that Abena wants these types of assistance. Response #2, which is more open-ended, allows you to take time to get to know Abena, her unique situation and approach to mothering, whether she wants assistance, and if so, the types of support that she would prefer.


Example Dialogue
Midwife It sounds like you are in a difficult place. Can you help me understand what you would need in order to feel more supported?
Abena Well I want my baby to grow up in a Muslim community but so far, I have not been able to connect with a mosque where there are other people from West Africa. I have been going to one mosque but the people there are mostly from the Middle East.
Midwife I see. Ok, I know of a mosque downtown where another one of my African clients and her family attends. I could find out the name of the place if you are interested.
Abena Ok. Thank-you. I would like to know more about that place.
Midwife Alright I will give you a call when I find out. You also mentioned that you are feeling worried about money. Is there anything that would help you feel less stressed?
Abena I don’t know what I will do when I give birth and I have to attend class. My neighbour Grace says that she will be able to watch the baby sometimes but I hear that daycare is very expensive in Canada.
Midwife It is true that daycare is very expensive. There is actually a government program that mothers can apply to which allows them to pay a much lower amount for daycare.
Abena Oh. I would be interested to find out more about how I can pay less.
Midwife Ok. I can give you the website where you can find out more. There is an application form and mothers who want to enter the program have to apply in advance. If you decide you want to apply I am willing to help you with the application form.
Abena Thank-you.

It is important for midwives to understand that the primary factors that shape health are not medical treatments or ‘lifestyle choices’ but rather the conditions in which people live and work – the social determinants of health. (2) In addition to having clinical knowledge and expertise, midwives should be aware of the social determinants of health and the resources available in community to their clients. The midwife in the dialogue above uses open-ended questions and responses to explore Abena’s situation without making assumptions about the resources that they need or want. This dialogue is client-centered and promotes autonomy since the Abena is treated as the expert on her social and economic situation and needs.


  1. Sword W. Prenatal care use among women of low income: A matter of “taking care of self”. Qualitative Health Research. 2003; 13(3): 319-332.
  2. Mikkonen J, Raphael D. Social determinants of health: The Canadian facts. [Internet].York University School of Health Policy and Management. 2010. [cited 2017 Jan 10]. Available from:


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Case Study: Poverty Copyright © 2017 by Lauren Wallace, PhD is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License, except where otherwise noted.

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