7 Working Across Differences in Midwifery
Nadya Burton, RM, PhD; Andrea Roberston, RM, MA, PhD(c)
This chapter is intended to help midwives think about differences both as a conceptual construct and as the substantive and prompt thought about particular differences between individuals and categorical groupings of people. Midwives need to consider which differences matter, why they matter, and how they may want to think about and attend to them. Here, ideas are introduced to help foster an approach to and an aptitude for attending to differences.
7.1 Fundamental Considerations
Health care settings are political spaces that enact and reproduce relations of power. Although often presented as sites of caregiving, treatment, and cure, they are of course also, ‘scenes in which subjects are being created so as to fit into relations of power.’ (1–3) The starting points for working across differences are developing a critical consciousness of one’s own assumptions, beliefs, values, and biases; an understanding of how one’s own perspectives may differ from those of other people; and acknowledging the unearned advantages, privileges, and power that derive from multiple aspects of one’s own social position. (4,5)
The practice of working across differences is contextual and varied and does not lend itself to easy answers. The most important skills are openness, a sense of equity and justice, critical thinking, good communication, compassion, flexibility, self-reflexivity, (6) commitment, and humility. Fostering these, alongside a critical political analysis of power and how it is distributed, will go further than any claim to knowing exactly what to say or do in every situation. Ongoing reading, reflection and dialogue are required, as well as an openness to making mistakes.
Lawrence Shulman (1992), a professor of social work practice, described this learning process: we will make many mistakes along the way – saying things we will later regret, and having to apologize to clients, learning from these mistakes, correcting them, and then making more sophisticated mistakes. (7) It is the effort we put forth and the personal growth that takes place when we reflect upon and learn from our mistakes that are important.
While midwifery is a clinical practice, it is for many, also a practice of social justice. (8) Midwifery, like all health care practices, is situated within complex social, cultural, political and economic contexts and can work to alleviate rather than reinforce inequitable distribution of power and resources. Many see challenging and destabilizing relationships of power as an integral component towards improving health care experiences. Therefore, being able to work skilfully and compassionately across differences of power is a core competency for midwives.
Working across differences is not easily learned through facts or through mastering concrete, tangible tasks. Instead, this practice most often involves thinking about attitudes, perspectives, beliefs, and strengthening relational and reflexive capacities. The ideas and concepts presented in this chapter should be talked about with peers and colleagues to gain the benefit of learning communities, which are a vital resource for skills development.
Each person encountering this chapter has unique experiences and perspectives. Some people may have grown up in families and communities where they were taught to not see difference as though to notice differences in body size, skin colour or physical abilities is to participate in discriminatory and repressive behaviour. Others may have grown up in environments where differences from majority or dominant cultures could not be ignored, being integral to themselves, their families and their communities. Some people may have grown up thinking a lot about differences between people, and some may not have thought about this idea much at all. Consequently, being attentive to difference will come more naturally to some than to others but being able to recognize and attend to differences strengthens midwives’ capacity to work skilfully, thoughtfully and compassionately with clients and colleagues
Differences matter. Differences are meaningful, and can be positively or negatively productive in interactions between midwives and clients. Rather than deny or ignore this, which can be damaging, it is important to acknowledge and engage accountably with differences. Doing so has the potential to foster greater equity and justice. Differences are situated in time and place, and are intricately entwined with and embedded within relationships of power; and some differences seem to matter more than others.
It is important to remain aware of the assumptions that are sometimes embedded in language and ideas, which may then be unconsciously enacted in the interactions between midwives and clients. Midwives (as health professionals) and clients (as people accessing care) must work together to bring their assumptions into consciousness as much as possible.
Even diversity and social justice frameworks warrant critical reflection. For example, in some cross-cultural competency literature there is an implicit assumption that the health care providers are members of dominant or majority groups, with ‘difference’ or ‘culture’ residing in the people accessing care. This binary thinking ignores the diversity that exists among midwives and reinscribes an ‘us and them’ relation between midwives and clients. It is important to attend to the fact that differences reside in everyone.
When do you notice difference within yourself? When do you notice differences in another person? What are the effects of locating difference in another rather than in oneself? Consider that we may reinforce the following concepts:
- Those in professional capacities (midwives) are the ‘regular’ or ‘typical’ folks who are seeking to work well with ‘others’.
- Those seen as being ‘regular’ (or not embodying difference) become the implicit yardstick against which difference is measured (9); they become the centre to the ‘other’s margin. (10)
- We render invisible those of us who are midwives and who are also from communities that are marked as different.
Reflect on your direct or indirect experiences in practice. What examples of assumptions embedded in language do you recall that could depict power or injustice? How have these impacted interpersonal relationships in a positive or negative way? Think about approaches to inclusive language that honour diversity across all members of client/provider relationships.
Once the idea that differences matter to midwifery work has been embraced, then the job is to keep thinking and trying to work competently and compassionately. There is no point of arrival, no moment when the skills have been mastered and when there is no further work to be done. A commitment to social justice requires an ongoing and lifelong practice. Some people may come to the work of equity and social justice with long histories of doing this work in other parts of their lives; some may continue to engage in thinking about working well across differences in their current personal, social, academic, political and working lives. What is most often necessary for learning about this topic is a willingness to engage new ideas, and a comfort with relinquishing or claiming power (depending on one’s social location). Testing new approaches, making explicit underlying assumptions, and revisiting and revising ideas can be vital parts of growth and learning. Examining one’s own beliefs and encountering new ideas with an openness to learning may foster shifts in one’s thinking, it does not inherently mean giving up one’s own closely or strongly held beliefs.
7.2 What is Difference?
In some ways, the concept of difference is so normative and ubiquitous as to seem benign. However, difference is a fundamental category of analysis and is constantly relied upon. When thinking about distinctions between people and groups, some differences tend to stand out and seem to matter more. Differences that carry more weight or meaning at a particular time and place are dynamic, rather than static truth, reflecting a complex social reality that shifts over time and place. By attending to the differences that matter, midwifery can deliver better care to clients and has the potential to generate more equitable health care practices and to contribute to broader social change.
Some differences are easily visible between people, but do not necessarily carry much weight in certain contexts. For example, some people have short hair and others have long hair, some people wear a lot of jewellery, others wear little or none, some people have blue eyes, others have brown. In many situations, these distinctions are not understood or leveraged as the basis for significant social inequality.
For example, it is not always true that hair length is a benign or insignificant difference between people. There are contexts in which hair length can be enmeshed with experiences of inclusion and exclusion, with identity, and cultural expression, challenge or change. Hair length therefore is used as a tool to distinguish between people. Think, for example, about: hair length and gender presentation, diverse cultural and religious contexts in which hair length or style connotes or defines beauty, power or privilege, and contexts in which length of hair is used to signal an experience such as loss or grief. In these circumstances, hair length might matter a lot.
While it can be helpful to make a general distinction between differences that are or are not meaningful, it can be problematic to draw too firm or rigid a line between these categories. It is important to acknowledge that although limited significance may, at times, be ascribed to a certain difference that significance may change depending on circumstances or experiences.
Some differences do carry significant weight in this time and place, and require attention. Differences that midwives need to particularly attend to are those that are entwined with power and the ways in which power is distributed. Skin colour, for example, matters a lot in the current Canadian context; much depends on it. Unearned privilege is granted to those with white skin while Indigenous people and people of colour (individuals and communities) often experience racism and discriminatory behaviour because of the colour of their skin.
In order to consciously and skilfully work well across such differences, midwives need to think about how the realities of the social context of the midwife and client impact on care relationships and processes.
Reflect on the following quote about Indigenous nurses and the health care system in New Zealand from Anderson et al. (2003):
The supposition that it is the White health professional who subordinates the patient of Color is challenged in an era when societies and health care workforces are increasingly diverse (…) the construct of race is powerfully deployed in healthcare settings to counter traditional nurse-patient roles by subordinating the nurse of Color. Racialized micropolitics of power operate in such a way that power is not held in certain professional positions per se, but rather is negotiated in each particular encounter and context, and is mediated by the social signifiers of race, gender, culture, age, and class. (11, p.209)
Consider your clinical experiences. Have you witnessed enactment of power in health care settings? From your observations, how does context influence power and how do race, gender, culture, age and class specifically mediate power?
Although there is no single correct way to approach differences based on skin colour, race or ethnicity, the practice of thinking about, addressing, and being comfortable talking about these differences is an important skill for midwives. For example, for a white midwife working with a client of colour, it may be important to make room for how the client might see them, might interpret their behaviour, and to acknowledge and validate the experiences the client brings to this interaction. Indeed, if a client experiences an aspect of care as racist, it is important to start from the assumption that the care was/is racist. Recognizing personal experience can be an important entry point for critical analysis of contributing systemic factors.
Openness to constructive criticism and relinquishment of some of the unearned privilege and authority that can come to those with white skin, is important. For example, it may be important that midwives of colour providing care to white clients be supported by colleagues, if required, to rebuke challenges to their authority and expertise in the face of subtle racism, such as a client expressing a lack of confidence in the skills of the midwife, or overt racism, such as not wanting care by particular midwife, based on race. In their study of cultural safety in transcultural nursing practices, Anderson et al., encountered Indigenous nurses that spoke of their experiences of discrimination in caring for white patients who did not want to be cared for by a person of colour. In such cases, the health care professional felt demeaned, disempowered, and culturally unsafe. (11) Good midwifery care is socially just care that seeks to undermine rather than replicate relationships of power, for both midwives and clients.
Noticing and attending to differences is central to working across them. This is in contrast to the perspective that focusing on differences is detrimental to equality and that instead what matters most is our shared humanity. Such an approach assumes that in the end people are far more similar than different, thereby diminishing the significance of differences and how they are experienced, in an effort to look ‘past’ or ‘through’ differences to the human being at the core.
One way to critically engage with this approach is to ask, what is the cost of privileging sameness, and of erasing or ignoring differences? While not seeing is often intended to express the position that the individual or institution will not discriminate or judge on the basis of factors, such as skin colour, religion, sexuality, gender identity or ability, the ‘not seeing’ position can be experienced as uninformed or uncaring, and along a spectrum of micro-aggression to overt discrimination. Choosing not to see can communicate avoidance or discomfort on the part of the person or institution suggesting that such differences do not matter. Refusal to see or acknowledge particular aspects of someone can also be felt as refusal to validate that person’s experiences and refusal to embrace the whole person, in their richness and complexity. When people are not respected as whole persons, the opportunity for meaningful and effective health care is compromised.
There is a balance to be struck between the pitfalls of not seeing differences and those of recognizing sociocultural differences. Beagan and Kumas-Tan (2009) state:
Treating patients as individuals reflects the most common approach to diversity discerned in our study: avoiding discrimination or stereotyping. This is, in fact, the dominant response to diversity in Canada as a whole, and arises from a genuine desire to not treat others badly. In this approach, sociocultural differences are recognized not only as important aspects of both patients and physicians, but also as a basis for discrimination. However, in seeking not to discriminate, physicians aim to neither see sociocultural differences nor apply generalizations at all and inevitably fail to acknowledge generalized social patterns in experiences, life chances, and influences on health. Striving to not notice someone’s skin colour is unhelpful when it causes patients to experience racism on a regular basis… In other words, in striving not to notice differences, practitioners denied the effects of shared experiences that arose from historical and contemporary power relations – experiences of racism, for example. (12, p.27)
When would it be problematic to choose not to see difference, even if well intentioned? Who might be made comfortable or uncomfortable? Consider that it is possible to:
- Miss or ignore parts of people that might be very important to them, leaving people feeling unseen or unrecognized for all of who they are
- Inadvertently discriminate against or hurt others as a result of not seeing something important about them
- Miss the opportunity to acknowledge and appreciate what is different about people
- Impart one’s own discomfort with differences, thus making it a difficult topic to raise
One limitation of trying to look past differences is that not everyone shares the same capacity to do so, and often it is connected to where one is socially located, or to what one’s identity is. In many parts of Canada, those who are white, for example, might have an easier time saying that skin colour doesn’t matter. They might in fact have never had to consider their own skin colour and how whiteness factors into their own lived experiences; this perception is inseparable from white privilege. People of colour may be more likely to feel that skin colour matters quite a bit. It is less likely that they will be unaware of their skin colour when it is different from the majority, and it is harder to say that skin colour doesn’t matter when how one is treated is often connected to skin colour. If someone has experienced discrimination or racism, or people in one’s family or community have, they are less likely to be able to say that skin colour doesn’t matter. The experience of living in a white normative society is more likely to tell them that skin colour does matter.
Midwives must understand, and keep in mind, that ignoring differences or saying they don’t matter can be a practice or privilege of those whose identities are seen as the ‘norm’ in a given social context. Instead of not seeing, midwives are expressly encouraged to attempt to see and understand as much as possible, with openness and a willingness to learn and to be held accountable.
It is important for midwives to create open spaces for differences to be comfortably present, but not to make assumptions about which differences to prioritize in interactions with clients or colleagues. Each person’s collection of identities is complex and shifting, and it is important that people be able to determine for themselves which differences are important to them at any given time or relationship. Midwifery clinics strive to be inclusive spaces, wherein differences can be comfortably engaged, without clients being put in the position of having to assert their relevant life experiences either voluntarily or in a compulsory fashion, or having to deny or hide them. Overt symbols of inclusivity within clinics contribute to the creation of open spaces welcoming diversity.
There are many guides for creating open spaces online. One such guide, ‘Asking the Right Questions’ was created by Dalhousie University, and is available here: https://cdn.dal.ca/content/dam/dalhousie/pdf/campuslife/studentservices/healthandwellness/LGBTQ/asking_the_right_questions.pdf
In order to attend to differences well, midwives and other health care providers must make both distinctions and connections between individual experiences (what the experience of the individual is) and group or collective experiences (what a group of people might commonly experience).
Patterns of experience, and systems which support inequitable patterns, are important to identify. So, while an individual (e.g. person of colour, with a disability, from the LGBTQQ+ community) may enjoy a considerable degree of privilege in their life, this does not negate the reality that those groups experience discriminatory behaviours (e.g. racism, ableism, homophobia and heterosexism). This interplay between individual and collective experience of identity demonstrates some of the complex ways that differences are lived out.
Categories can function as a starting place to think about differences. Casting a wide net to include a broad range of differences and to acknowledge the complex ways individual and collective experiences interact and intersect will be helpful. Differences that may be useful to consider include but are not limited to: skin colour (often socially constructed as ‘race’), religion, socio-economic status, age, language, ability/disability, sexual orientation, sexual identity, gender identity, family structure, individual and family status, culture, ethnicity, body size, geographic location, historical location, population membership as Indigenous or settler, citizenship status (citizen, resident, refugee, immigrant, undocumented, Canadian-born), and experiences of trauma.
Think about examples of difference. What differences exist beyond those listed in the text? Since lists are inevitably incomplete, how might you find out what is missing or problematic from your viewpoint? What might these variations mean to clients?
Think of examples from your own life when it has been useful to use categorical framing for analysis and understanding. When have you revised your categorical awareness and understanding based on something new you learned? When have you found categorical framing was, or could be, frustrating, inadequate or inappropriate?
A limitation of categorical thinking is that it artificially imposes boundaries on aspects of daily living, and identity factors, such as skin colour, sexuality, socioeconomic status and treats them as discrete and separable. This does not align with a more holistic way of understanding identity and experience in which identity and experience are often with co-dependent and co-constituent and are sometimes contradictory.
Categorical thinking/list making tends to reinforce binary ways of thinking about and understanding the world. Identity and experience are far more complex, fluid, nuanced and negotiated. Further, lists tend not to account for the important ways that people resist, succeed, and thrive. They risk simplistically painting communities as static and as victimized, and are not able to account for the nuance, complexity and richness that is part of identity. It is also important to remember that:
‘…social categories such as race, class, gender, sexualities, abilities, citizenship, and Aboriginality among others, operate relationally; these categories do not stand on their own, but rather gain meaning and power by reinforcing and referencing each other.’ (13, p.9)
7.3 Diversity & Equity in Midwifery
7.3.1 Framing Concepts
In order to work competently across differences, it is more important that midwives be thoughtful and reflexive than to apply to singular strategy. Looking at examples of how differences have been conceptualized and theorized can help midwives evaluate their own models for understanding their personal participation in health care and in broader social dynamics.
Contemporary approaches to thinking about differences attempt to dispel the notion that there is one central aspect of identity that always comes first or that conditions all other experiences. Rather, current ways of thinking about differences draw on ideas of intersectionality, In other words, there is a complex and fluctuating blend of gender, race, ethnicity, age, ability, religion, class, sexuality and more. Intersectionality highlights the complex and multi-faceted aspects of identity impacting how we understand social change. (10) In seeking to provide care that accounts for the full richness of a client’s identity, it is important to acknowledge and embrace their complexity.
Often, we are not consciously aware of, nor able to trace, how we have come to have the perspectives we do. Our viewpoint is inextricably linked to the context in which we live. Parents, families, friends, teachers, religious and cultural leaders, legal institutions, media and other parts of the social and cultural landscape inform how each of us conceptualize and make sense of differences. Understanding how these influences shape how we think about difference is an important step towards evaluating if we are satisfied with, or need to change, our perspective. Both knowledge and self-reflexive capacities are enhanced through dialogue with other people, especially those with viewpoints diverse from our own.
What is your framework for thinking about differences? Is the way you think about differences helpful in the context of midwifery work? Are there changes or adjustments you want to make, or does the way you think about differences, both conceptually and specifically, work for you?
As an approach to creating knowledge that has its roots in analyses of the lived experiences of women of color (…) intersectional scholarship focuses on how structures of difference combine to create a feminist praxis that is new and distinct from the social, cultural, and artistic forms emphasized in traditional feminist paradigms that focus primarily upon contrasting the experiences of women in society to those of men. Intersectionality is intellectually transformative not only because it centers the experiences of people of color and locates its analysis within systems of ideological, political, institutional, and economic power as they are shaped by historical patterns of race, class, gender, sexuality, nation, ethnicity, and age but also because it provides a platform for uniting different kinds of praxis in the pursuit of social justice: analysis, theorizing, education, advocacy, and policy development. (14, p. 157)
Reflect on this statement. Does it change the way you think about feminism? Do you see yourself as a feminist with a role to play in promoting equity and social justice? Can you appreciate how systems and structures in society and history influence the complexity of multiple identities in ways that impact how people experience the world?
7.3.2 Differences that Matter: Relationships of Power
Throughout most of the world, albeit to differing degrees, power and resources are inequitably distributed. Some people tend to have more decision-making power and control and some people tend to have easier access to resources of all kinds, especially those necessary for survival, such as food, shelter, health care, as well as cultural and social resources that are important aspects of a full life. Inequality is not something that simply ‘is.’ Rather, there are stakeholders who gain from the sustained oppression of certain groups of people. Such oppression may be violent, beyond deprivation of rights and necessities for living, and may extend as far as genocide.
When social markers of difference between people are not merely descriptors, but the institutionalized basis on which resources are unevenly distributed, relationships of power are at work. It is important to think about how relationships of power are inevitably a part of working conditions and present in all interactions with clients, families and colleagues. Contemporary health inequities need to be understood not only within present day distributions of power, but historical ones as well. There are many examples of inter-generational effects of trauma, such as the Holocaust, the residential school system in Canada, and slavery in North America.
Pretending that power relationships are not present, or trying to ignore them is not an effective strategy for addressing or redressing inequality. Being able to identify the impact of power on relationships offers more potential to practice midwifery in ways that support social justice. This is in part because social change usually involves some redistribution of power so that those more privileged relinquish power and those with less privilege gain access to it.
In midwifery, one articulation of redistribution of power is the ideal of non-authoritarian midwife-client relationships, wherein clients are regarded as experts of their own experiences, and primary decision-makers, with midwives sharing knowledge to support informed choice and shared responsibility. The model of midwifery practice seeks to reduce power inequities between the midwife and client. In this way, midwives and clients also challenge conventions of power across the broader health care system. It is worth considering when and how similar intervention strategies can extend beyond those grounded in professional/layperson differences, and when other interventions may be needed to challenge deeper and more complicated inequalities.
7.3.3 Power, Education & Health Care Change
Critical components of revising ideas and changing practices are a willingness to listen to and engage with a broad range of experiences and perspectives, and a willingness to redistribute power. Within health care educational institutions and practice settings, ideas continue to evolve about how best to train and support learners and professionals to work well with people engaging their services, regardless of interpersonal similarities or differences. Beagan (2003) states:
A course intended to produce [care providers] able to work effectively across differences of race, culture, gender, sexual orientation, religion, and so on must explicitly address power relations. It must be about racism, not just cultural differences; it must be about homophobia and heterosexism, not just differences in sexuality; it must be about sexism and classism, not just gender differences and the health issues faced by ‘the poor.’ (15, p.614)
Further, such a course must be focused on helping students develop ways to recognize and challenge their own biases, their own sources of power and privilege.
7.3.4 Cultural Awareness & Sensitivity
Cultural awareness and sensitivity, cultural competence, and cultural safety are interrelated strategies intended to improve access to healthcare, experiences of healthcare, and ultimately healthcare outcomes. Although their development is not strictly linear, it is useful to notice a pattern of deepening critical assessment, relational accountability, and commitment to equity and justice.
What does it mean for a health care provider to be aware of and sensitive to diversity? Awareness refers to being cognizant of the differences between self and others and being intentional in action to not discriminate on the basis of difference. This requires acceptance of the idea that all people’s lives are shaped significantly by culture.
While some differences may not seem very significant to either party, others may be very important to one or both. It is also possible (sometimes probable) that a midwife will not be well attuned to differences that matter to a client, especially when taking notice relies on comparing others to the self, from the point of view of the self. Education and critical thinking are therefore perceived as essential components of equitable health care.
A common example of cultural awareness (noticing) and sensitivity (caring) is to offer print and electronic materials in the languages spoken by people accessing care, and to offer translation services during in-person, over the phone, or other conversational encounters. Visual cues within the environments, such as wall mounted equity statements and posters reflecting community populations, are also common.
Sexuality, childbearing, and family organization, are often socially charged topics. What do you already know and feel about these topics? How did you come to know what you know and to feel what you feel?
Have you ever been in a situation in which you felt confident expressing your viewpoint or questions? Have you ever been in a situation in which you felt too vulnerable or threatened in some way to express your views?
Some people feel that to eliminate bias and become more self-aware about one’s own social position and the impact this could have on relations with others, what is mostly required is a disposition of curiosity and openness. The logic behind this position is that when someone is open and curious, and is exposed to more ideas and ways of being in the world, they become more flexible in their viewpoints and more accepting of diverse viewpoints. However, accepting that multiple points of view exist does not necessarily require revision of one’s own point of view. Relying only on comparison with oneself for noticing differences can be problematic, without critical attention to power and context, oppressive norms can be experienced as natural and acceptable to the people in positions of privilege. In this way, well-intentioned people who perceive themselves as committed to social change and equitable health care can continue to perpetuate oppressive harms.
Curiosity and openness are requisite starting points, but are not enough alone. They must be combined with critical engagement with power and privilege. In acknowledging that people are inescapably, socially embedded in the world, and that differences in access to power exist, it is then possible to recognize when oppressive power is exercised in both overt and subtle ways. The latter can be more difficult to recognize and therefore to resolve.
7.3.5 Cultural Competency
Being aware that people have different ideas, beliefs and values, and accepting differences, does not require care providers to ‘know much’ about other people’s cultural particularity. This can lead to situations in which people with differences from care providers and institutional norms, are put in the position of having to disclose, explain, and/or defend ‘their difference’, and may be at risk of being misunderstood, over-ridden, ignored or otherwise harmed. When people have a lot of negative experiences interacting with the health care system, usually in tandem with other systemic oppression, they may become reluctant to share information with care providers, and may withhold information in the interest of self-protection. Conversely, people seeking a health care service are more likely to build trust with and share important information about themselves with care providers if they are not worried about being perceived negatively or treated unfairly. (16,17)
Most care providers want people using health care services to feel entitled to respectful and high quality care that is responsive to their unique needs. Cultural competency through intentional knowledge seeking and acquisition, on the part of care providers is one route to achieve this. It is perceived that acquiring knowledge about cultural specificities will better equip care providers to establish relationships, and gather information and provide services more effectively.
However, cultural competency as a framework has also been subject to critique.
The dominant response to health disparities within and among populations has been the establishment of cultural competence training, which generally examines cultural sensitivity (focusing on awareness and attitudes), multicultural understanding (focusing on knowledge about particular groups), or cross-cultural interactions (focusing on tools and skills). Yet such approaches have been soundly criticized for encouraging stereotyping; for emphasizing individual attitudes rather than social context and power relations; for overemphasizing knowledge of ‘other’ minority groups and underemphasizing critical self-reflection; and for entrenching the notion that only those from minority groups have ‘culture’ or ‘diversity,’ while the dominant group is ‘normal’ and therefore not in need of examination. (12, p.23)
Although utilization of the framework is intended to work against bias, it can actually generate bias when care providers rely on it explicitly. (18) People do not experience aspects of their culture discreetly so a framework that includes a checklist approach implies that there are distinct, identifiable and expected criteria that define a culture. The term ‘competency’ also suggests an end point where culture is understood, predictable and static and positions providers with power and authoritative knowledge rather than recognizing the client as the expert in their experience of culture. (4,18,19)
Is there an aspect of cultural diversity that you would like know more about? How would you go about finding out more? How might attending a workshop be useful?
Think about something about yourself that could be interpreted by others as tied to cultural specificity. Would you be comfortable with people learning about ‘how to care for someone like me’ in a workshop format? What would you want people to learn and how would you want this to be learned? What might make this way of learning about differences more or less effective?
Case Study: Culture, Language & Privilege
7.3.6 Cultural Safety
While cultural competence applies to understanding different ethno-cultural group interactions, cultural safety is a term that originated with a strictly Indigenous purpose and context. It recognizes the historical effects of colonization and social structures that disadvantage people. (5) It requires explicit, detailed recognition of the cultural identity of Indigenous people and is unlike universalism and multiculturalism, where all cultures are assumed to possess equal and undifferentiated claims on rights and resources in Canada. (19)
Some people perceive cultural safety as continuous from competency, while others see it as a radical departure. (19) Core features include engagement in lifelong learning, practitioner humility, collaboration between care provider and client, critical analysis of systems of power, and explicit commitment to decolonization and redistributions of power. Unlike with cultural competency, in cultural safety, the client is the centre of care and is an expert holder of knowledge.
Cultural safety requires movement beyond being aware of cultural distinctiveness through a checklist approach. It requires development of respect and value, integrating culturally-specific ways of knowing and doing into care. It originated as a conceptual framework in New Zealand in the 1980s through the work of Indigenous Maori Peoples and organizations attempting to address health inequities. (20,21)
Within Canada, cultural safety continues to conceptually evolve and is most strongly advanced in theory and practice, by First Nation, Métis, and Inuit peoples. This Indigenous-led midwifery care includes same-language service and a blending of Western medicine and culturally-specific, traditional medicine and ceremony. These practices in culturally safe health care vary to the extent desired by individual clients and by communities. (22)
Inuit midwives provide care in Inuktitut, an Inuit language, and encourage practice of cultural traditions such as having multiple friends and family attend and witness the birth. (23) Preservation of culture and power over health are embedded within the Inuulitsivik’s education model which serves to ensure its sustainability of locally-led and culturally appropriate approaches to care. (24) The power redistribution in this model further extends to the government of the hospital in Puvirnituq, Nunavik, where an interdisciplinary council receives feedback from the Perinatal Committee, which is led by the team of Inuit midwives. (24)
Increasingly, insights and practices drawn from Indigenous models of cultural safety are being extrapolated to working with diverse populations across Canada. Only the surface of cultural safety has been highlighted here. As cultural safety continues to develop in response to community based needs, practices of harm reduction, trauma informed care, and strengths based care are interwoven as essential to culturally safe care.
7.4 Working Across Differences in Practice
In addressing the complex issues surrounding differences it should be remembered that not all strategies will work for all people in all places at all times. Rather, social justice in health care is a process that requires ongoing commitment and engagement. Midwives will need to engage in an ongoing process of gathering multiple strategies. Growth will include mistakes, revision, and expansion. Attentive listening, responsiveness, flexibility and accountability are all valuable skills. Seeing that power influences relationships with both clients and colleagues, and addressing inequities of power, will be another ongoing process for midwives. For midwives to work effectively across differences they need not be members of the communities they serve to provide excellent care. Even when membership is shared to some degree, there is always diversity between people. Both taking direction from communities, and attending to the specific needs of each client as a unique individual, will guide midwives towards respectful and effective care practices.
The following presents introductory skill building strategies that are broadly applicable to goals of social justice.
7.4.1 Working from Within and Alongside
Working within one’s own community to generate change and garner support for challenging situations, and working alongside communities who are seeking to do this work, is social justice work that midwifery must engage.
The practice of working across differences is something that requires support and community. This can be the case when midwives themselves experience racism, homophobia, sexism, classism, etc. In this context, working well across differences is less about learning skills to understand and work with differences, and more about coping with and responding to oppressive behaviours, actions and words from clients or colleagues. A community of informed and action-supporting and/or collaborating colleagues will make this work easier. Both individual midwives and midwifery groups may strive to communicate commitments to equity and social justice in a variety of ways (e.g. posters, participation as midwives in community and activist events, etc.), and they may also choose to prioritize service to populations that have conventionally been under-represented and underserved.
In some situations, midwives will have more privilege than others. Midwives with more privilege must be attentive to the unrelenting nature of anti-oppression work and recognize the added burdens and costs that may fall to peers and clients who experience oppressive attitudes and behaviours.
Every midwife has a role in instigating change. It can be meaningful and effective to work alongside colleagues in pursuit of more equitable and just social relations. This is done by leveraging one’s power and privilege to advance the political work of supporting clients and colleagues who belong to groups and communities subjected to marginalization or discrimination. This working alongside requires investment on the part of the midwives with privilege to become informed, to trust-build, and to relinquish centrality. Midwives who are positioned with privilege must be open to critique and receptive to changing their own behaviours.
Case Study: Intimate Partner Violence
7.4.2 Learning from Mistakes
One aspect of successful working across differences is acceptance of making mistakes. A care provider who thinks they know all they need to know already, or that they are capable of meeting the needs of everyone, is not likely to be open to recognizing mistakes, or revising their practice. A care provider who is afraid of making any mistakes is not likely to work beyond their own comfort zone. Instead, being receptive to the idea of mistakes as inevitable, and a part of learning, is more conducive to social justice work in health care. Feedback from others, self-reflection, taking responsibility for mistakes, and critical exploration of mistakes in relation to power and privilege can contribute to personal and political change. Expecting accolades for recognizing one’s mistakes and making change, however, is problematic and can reflect privilege. Humility requires embracing discomfort, and accountability accepting the cost of one’s mistakes, alongside a commitment to not repeat them.
Handling mistakes and learning from mistakes is challenging in both the classroom and fields of practice. When recognizing one’s own mistakes, it is important to do this type of work without expecting to be comforted, forgiven, or helped by those who have been unintentionally hurt through discriminatory belief or practice. Too often students and professionals who experience the greatest marginalization are put in the position of both having to enlighten their more privileged peers, and supporting the emotional fallout of their peers, at the expense of themselves.
Generosity also needs to be extended toward the self and others. People should be able to express themselves without fear of being reprimanded for not being ‘in the know’ about ideas and terminology that have gained currency in particular settings. Revision and growth is more likely to happen when people are genuinely respected, while challenged to think with and beyond their prior experiences and comfort zones.
Accepting the inevitability of mistakes also does not mean being complacent about mistake-making. Accountability entails seeking to understand how the mistake came into being in the first place (at both personal and social levels) and how it can be prevented in the future. Too much grief or guilt over making mistakes is ineffectual, and in fact, works to maintain rather than disrupt the status quo. Recognizing, accepting, and taking responsibility for mistakes creates opportunities for crucial learning and capacity building.
7.4.3 Multiple Truths
It is inevitable that midwives will work with clients and colleagues who have different understandings of the world, and these understandings can sometimes be in tension with each other. Acknowledging that diverse and multiple truths will coexist can help midwives work respectfully and sincerely with clients and colleagues, even when midwife-client beliefs and values diverge or conflict. Cultivating a comfort with multiple truths benefits from having clear sense of one’s own beliefs and an understanding that validating someone else’s truth does not necessitate compromising one’s own. Unlike in clinical situations, where there may sometimes be a ‘best’ or a ‘strongly recommended’ way to proceed, the domain of beliefs and practices is plural. A care provider and client do not need to share the same beliefs to create and maintain a positive and effective health care relationship.
The holding of multiple truths does not make all truths equal and does not abdicate individual health care providers from social justice responsibilities. Some ‘truths’ (personal or social) are inextricable from power and privilege and are sustained through oppression. There will be times when a ‘making-room-for-difference’ approach will not be enough, and in fact will work against rather than for equity. For example, if a colleague says something discriminatory about another person, not asserting a difference in belief or attitude can contribute to an unsafe health care environment for many people. Finding ways to indicate a commitment to health and social equity sometimes entails providing care in a context wherein some values and beliefs do over-ride others. Accepting and honouring multiple truths does not mean that everything that everyone thinks is fine; it is rather, a generous way of understanding that people’s truths will at times collide. Discerning when, how, and with which supports to engage with differences is part of health care and social justice activism.
7.4.4 Partial Knowledge
Midwives are steeped in a world that encourages them to bank facts and be expert knowers. Students are regularly tested and examined on what they know, and people come to midwives for care, in significant part, because of their expert knowledge in the area of childbirth. It is helpful to be aware of this general pressure, and of self-expectation, as it can extend into areas of learning and care in which dispositions toward completeness, exactness, and ‘rightness’ do not hold well, and indeed, are detrimental.
In the arena of working across differences, it is not feasible to fully know things beyond the confines of personal experiences and perspectives, and it is difficult work to bring into consciousness aspects of individual experiences and perspectives that inform interpretation. Embracing the partiality of what is and can be known, is crucial. Embracing partiality means that we are accountable and should gain knowledge about, and try to understand, things beyond our own particular location and identity. Acknowledging what is not known can provide an impetus to learn more. In this way, humility can be perceived as a strength. Recognizing and accepting the (at best) partial view that any person can have about another, and pairing this with a willingness to learn more, can help people work well together, without having ‘to know everything already.’
7.4.5 Pairing Critical Generosity with Critical Scepticism
Critical thinkers, must draw on both generosity and scepticism. When health care providers find themselves facing things they don’t entirely understand, or are not entirely comfortable with, starting with critical generosity can be a good way to keep an open mind to learning and help avoid the quick judgment that can be a first reaction. Starting with the assumption that people are likely acting in ways that make sense to them, or that are consistent with their values, or beginning by erring on the side of generosity, can make it possible to learn about the actions, beliefs or motivations of others, as well as ourselves. Exploratory conversation can be started from a place of seeking understanding, rather than judgment. At the same time, generosity does not need to be uncritical. It is possible to work towards an understanding of something without agreeing with it or adopting it for oneself. Understanding a client’s perspective, as much as possible, is integral to providing informed choice and participating in shared responsibility.
Scepticism is equally important, as it allows for more comprehensive evaluation. As an analytical resource, it is not the same as a negative approach of fault finding. Rather, it is a form of critical thinking that encourages a more robust and dynamic process of consideration.
Both generosity and scepticism are important. The balance of generosity and scepticism may fluctuate from situation to situation, and there may be times when it is necessary to lean more to one side. However, excessive generosity can lead to being unable to identify when a critical response is needed and excessive scepticism can lead to overlooking a lack of experience or unintentional error. Excessive generosity may come from a place of unconscious or even conscious privilege, where overlooking grievous actions sustains status quo relations of power whereas scepticism could reveal and disrupt relations of power potentiating social justice. This critical analysis may be deeply warranted given legacies of colonialism. However, excessive scepticism from suspicion or disparagement due to historical and systemic inequalities can obstruct opportunities for sharing perspectives and broadening understanding.
7.5 Lifelong Learning
Midwives and their clients and colleagues are always positioned in multiple ways, connected to and embedded in communities with privilege, and as members of communities subjected to marginalization and discrimination. Working across differences is a core competency of midwifery work and poses both challenges and possibilities. Striving to do this work skilfully contributes to health equity and social justice more broadly, and in this way, is political.
Each person is at once a unique being, who is socially situated, with knowledge and beliefs that are enabled and constrained by context. This chapter therefore advances the importance of critically examining personal sources for comprehending the world, and the importance of remaining open to multiple possibilities, with the caveat of recognizing that there are limits on how well any person can imagine another person’s point of view.
Differences between people exist, and in the context of uneven distributions of power, matter in ways that they otherwise would not. As midwives, it is important to think about how relationships of power are inevitably present in all interactions with clients, families and colleagues. Midwives have a role to play in fighting injustices leveraged on the basis of difference. Fighting injustices is not the same as eradicating differences. Rather, it can be a deliberate appreciation and valuing of differences.
There are many approaches for working across differences and the ones introduced in this chapter will continue to evolve or be challenged or revised over time. Midwifery students and midwives are encouraged to engage in a lifelong commitment to social justice and personal learning. This chapter advances that openness, a sense of equity and justice, critical thinking, good communication, compassion, flexibility, self-reflexivity, commitment, and humility comprise essential components for working well across differences. Fostering these, alongside a critical political analysis of power and how it is distributed, is an excellent place to start.
7.6 Key Points Summary
- Midwifery, and all health care, is situated within a complex social, cultural, political and economic context. The differences that you encounter between midwives, other health care practitioners, and clients matter.
- The most important skills for working across differences are openness, a sense of equity, justice, critical thinking, good communication, compassion, flexibility, self-reflexivity, commitment and humility.
- Social and political changes mean that differences can carry more meaning in one place and time than another. The ability to say that ‘differences don’t matter’ is a privilege of those whose who are seen as the ‘norm’ in their particular social context.
- Adapting a reflexive strategy that is individualized to the situation will be more successful than a one-size-fits-all approach when working across differences. Identities are intersectional, and so midwives also need to acknowledge this complexity when addressing others and when reflecting on their own identity.
- It can be difficult to trace and identify our own differences. Parents, families, friends, teachers, religious and cultural leaders, legal institutions, media and other parts of social and cultural landscapes help to inform how we conceptualize and make sense of ourselves and differences.
- Power is created by an institutionalized basis that distributes resources unevenly. Relationships of power are inevitable in the workplace and in all interactions with clients, families and colleagues. Contemporary health inequities need to be understood not only within present day distributions of power, but also historical ones as well.
- The model of midwifery practice seeks to reduce power inequities between midwife and client: clients are regarded as experts of their own experiences, and primary decision-makers, with midwives sharing knowledge to support informed choice and shared responsibility.
- Health care providers should practice cultural competency – actively gaining knowledge about cultural specificities. People that have negative experiences with the health care system, and that experience other systemic oppression, often become reluctant to share information with care providers.
- People are more likely to build trust with and share important information about themselves with care providers if they are not worried about being perceived negatively or treated unfairly.
- Cultural safety, which has been advanced by Indigenous peoples in Canada, should also be practiced by Canadian midwives.
- Working alongside those who are marginalized or discriminated against requires investment from those with privilege. Midwives with more power and/or privilege should recognize the unrelenting burdens that peers and clients may face due to oppressive attitudes and behaviours.
- Becoming informed, building trust, and leveraging privilege to advance the work of others can help in the pursuit of equity.
- A care provider and a client do not need to share the same beliefs to create a positive and effective health care relationship. Understanding your beliefs will help you in acknowledging and respecting the beliefs of others.
- Validating someone else’s truth does not mean compromising one’s own truth.
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