A Cultural Safety model provides the key to unlocking the door to equality in maternity care, say Amali Lokugamage and Alice Meredith
Black women are five times more likely to die during childbirth, and Asian women are twice as likely to die during childbirth compared with white women in the UK. These are the findings of the “Mothers and Babies: Reducing Risk through Audits and Confidential Enquiries across the UK” reports (MBRRACE) in 2018 and 2019. [1,2] The US has similar inequalities in rates of maternal mortality. In a 2019 BMJ Opinion piece, I (AL) wrote about this racial disparity and drew attention to a concurrent rise in “black feminism” protesting about these findings in the UK and the US. Women from ethnic minorities are voicing their concerns that they face endemic structural racism when seeking and accessing healthcare, and they feel that their symptoms and signs are more often dismissed. From a medical perspective this disparity was initially thought to be because of a difference in the manifestation of hypertensive disorders or diabetes. However, it is vital that we listen to our patients when they say that they feel this is also due to structural racism in healthcare. Sadly, there are also similar disparities in neonatal infant mortality in the UK and in the US. [2,3]
Serena Williams, US tennis player, helped raise awareness of these inequalities and the sense that ethnic minority women are “not being listened to” by talking about her own experience of pulmonary embolism in her postpartum period.  So, as further work is done in the UK to unpick why there is this disparity in maternal and infant mortality, we cannot ignore patient experience. It is heartening that the Royal College of Obstetricians and Gynaecologists (RCOG) has developed a women’s network to embed the voices of women in RCOG meetings and guidelines.  The RCOG also published an article in the Winter 2019 Membership magazine, “O&G” by Christine Ekechi called “We need to talk about race,” in which the “uncomfortable truth” about underlying service biases is discussed. 
We have engaged in broadening the area of decolonising medical education and healthcare, as well as getting involved in the use of patient narratives as a tool for organisational development. [7-9] Through this work, we feel that a Cultural Safety approach to healthcare, which has been welcomed by Indigenous people in New Zealand, Australia and Canada as a way of producing fairer healthcare delivery, may have potential application to the UK. [10,11] Cultural Safety is a process of overturning systemic/personal biases and privileges in interactions between patients and healthcare professionals. For a doctor, midwife, or nurse to engage in Cultural Safety they have to acknowledge the potential power imbalances between healthcare professionals and patients during interactions and undertake ongoing self-reflection and reflexivity regarding their own assumptions, biases, and values.
In order to translate Cultural Safety to a UK healthcare setting we would have to utilise established professional development tools in reflective practice as well as listening to and learning from patient experience. However, some components still urgently need to be developed such as picture atlases of clinical signs in skin of different tones. We currently don’t effectively teach what cyanosis looks like in a black patient, pulse oximeters can be affected by skin pigmentation, and we do not have good teaching resources to show us what skin manifestation of pathological conditions look like in various skin colours. [12,13] These are examples of covert racism within our healthcare system which could be playing a role in the ethnic disparities in maternal morbidity and mortality. This is also applicable to all diagnostic areas in medicine.
We propose that the foundation of any translation of Cultural Safety education to maternity services should consider these five key ingredients:
- A catalogue of patient experience videos explaining their encounters with structural inequity in healthcare from a diverse group of patients. These should take an intersectional (taking in to account women who have multiple interlocking oppressions) approach 
- The creation of a basic module of education in decolonising the history of health, raising awareness of lingering colonial racial bias. This should include understanding about the biases in the foundation of medical knowledge which means that the global north is over-represented in medical research and knowledge creation compared to the global south and these phenomena are known as “geographical biases.”  Training in recognising clinical signs in humans of differing skin tones is essential.
- An educational tool is required to enhance healthcare professional’s reflective practice. This tool would intend to not just reflect on difficult cases, or the application of new biomedical knowledge to cases, but also to develop self-reflection on personal biases, privileges, and power imbalances in their interactions with their patients. Video materials of healthcare professionals role modelling this approach may be very helpful to visualise these behaviours. Such educational tools need to include voices from various geographical regions and from diverse voices in healthcare and be accompanied by communication skills workshops.
- In addition, and specific to maternity care, there is good evidence that continuity of care and continuous emotional support women by midwives or doulas improve health outcomes. So, access to continuity of care models are vital for disadvantaged women. [16,17]
- Part of the Cultural Safety model is that when vulnerable patients feel culturally unsafe (due to racial discrimination), they can request carers from a similar ethnic background as themselves.  However, there may not be enough numbers of appropriately trained personnel from the same cultural background requiring affirmative action in recruitment. An additional confounding consequence may be to cause “auto segregation” in society and could limit personal development in all healthcare personnel or systems in order to produce equitable healthcare for all. Also, the global phenomenon of disrespectful maternity care, described by the World Health Organisation in their document on the prevention and elimination of disrespect and abuse during childbirth, points to the existence of unjust interactions in countries where care is delivered by professionals from a similar background to their patients.  Furthermore, by potentially allowing such requests to become day-to-day practice, there are recognised pitfalls as described recently by Roger Kline, including increased segregation towards healthcare providers, and even racism against doctors from ethnic minorities. So, this final element could be thorny when considering possible translation to a UK setting.
Much needs to be improved in the structure of healthcare service provision in order to “undo” ongoing systemic racism that patients from ethnic minorities are continuing to experience. Improving interpreter services is also important. However, we believe in educating healthcare providers about how to be culturally safe, perhaps utilising and exploring the five components we have discussed. The first three elements could work through facilitated workshops, which embody transformational learning methodology to create lasting emotionally intelligent behavioural change and insights.
Amali U. Lokugamage is a consultant in obstetrics and gynaecology at Whittington Health NHS Trust, London, UK and a deputy lead for clinical and professional practice at UCL Medical School, London, UK.
Alice Meredith is a final year medical student at UCL Medical School, London, UK.
Competing interests: AL is on the Board of Directors of the International MotherBaby Childbirth organisation. She is a company director of a small publishing company called Docamali Ltd. AM has no interests to declare.
- Knight M, Bunch K, Tuffnell D, Jayakody H, Shakespeare J, Kotnis R, Kenyon S, Kurinczuk JJ (Eds.) on behalf of MBRRACE-UK. Saving Lives, Improving Mothers’ Care – Lessons learned to inform maternity care from the UK and Ireland Confidential Enquiries into Maternal Deaths and Morbidity 2014-16. Oxford: National Perinatal Epidemiology Unit, University of Oxford 2018
- Draper ES, Gallimore ID, Smith LK, Kurinczuk JJ, Smith PW, Boby T, Fenton AC, Manktelow BN, on behalf of the MBRRACE-UK Collaboration. MBRRACE-UK Perinatal Mortality Surveillance Report, UK Perinatal Deathsnfor Births from January to December 2017. Leicester: The Infant Mortality and Morbidity Studies, Department of Health Sciences, University of Leicester. 2019.
- Owens, D. and Fett, S. (2019). Black Maternal and Infant Health: Historical Legacies of Slavery. American Journal of Public Health, 109(10), pp.1342-1345.
- Stylist (2018) Serena Williams’ terrifying childbirth story highlights alleged racism in US healthcare. (2018). Stylist. [online] Available at: https://www.stylist.co.uk/people/serena-williams-black-women-racism-american-health-care-childbirth-maternal-mortality-rates/183207 [Accessed 19 Jan. 2020].
- Royal College of Obstetricians & Gynaecologists. (2020). RCOG Women’s Network. [online] Available at: https://www.rcog.org.uk/en/patients/rcog-womens-network/ [Accessed 19 Jan. 2020]
- O&G (2019) We need to talk about race. Royal College of Obstetricians and Gynaecologists. [ebook] RCOG. Available at: https://www.rcog.org.uk/globalassets/documents/members/membership-news/og-magazine/winter-2019/we-need-to-talk-about-race-winter-2019.pdf [Accessed 19 Jan. 2020]
- Gishen, F. and Lokugamage, A. (2018). Diversifying and decolonising the medical curriculum. [Blog] The BMJ opinion. Available at: https://blogs.bmj.com/bmj/2018/10/18/diversifying-and-decolonising-the-medical-curriculum/ [Accessed 19 Jan. 2020]
- Lokugamage AU, Ahillan T, Pathberiya SDC. Decolonising ideas of healing in medical education. J Med Ethics. 2020 Feb 6. pii: medethics-2019-105866. doi: 10.1136/medethics-2019-105866
- Lokugamage A, VanLessen L, Kyei-Mensah A, Megroff R, Howitt R, Harman T. (2017). A “Footprints” approach to patient experience and organisational development. [Blog] The BMJ opinion. Available at: https://blogs.bmj.com/bmj/2017/01/26/a-footprints-approach-to-patient-experience-and-organisational-development/ [Accessed 19 Jan. 2020]
- De, D. and Richardson, J. (2008). Cultural safety: an introduction. Paediatric Care, 20(2), pp.39-44.
- Kurtz, D., Janke, R., Vinek, J., Wells, T., Hutchinson, P. and Froste, A. (2018). Health Sciences cultural safety education in Australia, Canada, New Zealand, and the United States: a literature review. International Journal of Medical Education, 9, pp.271-285.
- Kirkland, L. (2009). Pulse oximeter a valuable tool, but has limitations. [Blog] ACH Hospitalist. Available at: https://acphospitalist.org/archives/2009/12/tech.htm [Accessed 19 Jan. 2020].
- Buster, K., Stevens, E. and Elmets, C. (2012). Dermatologic Health Disparities. Dermatologic Clinics, 30(1), pp.53-59.
- Yuval-Davis, N. (2006). Intersectionality and Feminist Politics. European Journal of Women’s Studies, 13(3), pp.193-209.
- Pan, R., Kaski, K. and Fortunato, S. (2012). World citation and collaboration networks: uncovering the role of geography in science. Scientific Reports, 2(1)
- Sandall, J., Soltani, H., Gates, S., Shennan, A. and Devane, D. (2016). Midwife-led continuity models versus other models of care for childbearing women. Cochrane Database of Systematic Reviews.
- Bohren, M., Hofmeyr, G., Sakala, C., Fukuzawa, R. and Cuthbert, A. (2017). Continuous support for women during childbirth. Cochrane Database of Systematic Reviews.
- Marriott, Rhonda et al.“Our culture, how it is to be us” — Listening to Aboriginal women about on Country urban birthing. Women and Birth, Volume 32, Issue 5, 391 – 403.
- The prevention and elimination of disrespect and abuse during facility-based childbirth. (2015). [ebook] World Health Organisation. Available at: https://apps.who.int/iris/bitstream/handle/10665/134588/WHO_RHR_14.23_eng.pdf;jsessionid=0C3FAFADC59C87B58B9E1F8B61DAE5A1?sequence=1 [Accessed 16 Feb. 2020].