This is the third blog in our series on maternity inequalities and comes from midwifery educators Olamide Solanke and Joanna Andrews. This week considers how we might realise equity in care through Education.

Joanna Andrews is a Senior Instructor of Midwifery at Fatima College of Health Science in UAE, and Oalmide Solanke is a Senior Lecturer in Midwifery at the University of Derby.

What is Cultural Competence?

Culturally appropriate care is a crucial component in providing effective healthcare services to diverse populations (1). Culture encompasses shared patterns of behaviour, interactions, cognitive constructs, and affective understanding learned through socialisation. Competence, as defined by the World Health Organization (2), is “the combination of knowledge, psychomotor, communication, and decision-making skills that enable an individual to perform a specific task to a defined level of proficiency.” The term “cultural competence” emerged in the early 1980s in social work, later entering counselling psychology and nursing literature in the 1990s (1). Leininger (3) describes cultural competence as “care that is meaningful and fits cultural beliefs and lifeways.”

In midwifery, cultural competence involves “knowledge of how to promote respectful and responsive midwifery care in cross-cultural settings that reflects the cultural and linguistic needs of the diverse population” (4). Contemporary literature is shifting towards terms like cultural appropriateness or transcultural care, focusing on ongoing knowledge development rather than training as an endpoint.

The Need for Culturally Sensitive Care in Midwifery

Culturally appropriate care is integrated into midwifery through various statutory and policy documents. The International Confederation of Midwives (5) highlights that midwifery promotes, protects, and supports women’s human, reproductive, and sexual health, and rights, respecting ethnic and cultural diversity. The ICM’s code of ethics, 2008 (6) mandates that midwives provide care respecting cultural diversity while working to eliminate harmful cultural practices.

The UK’s Nursing and Midwifery Council (7) advises registrants to consider cultural sensitivities to better meet individuals’ personal and health needs. Midwives should integrate clinical knowledge with interpersonal and culturally appropriate care skills to ensure quality and safety in maternity care. They should demonstrate an understanding of cultural contexts, provide culturally sensitive care, and assess, plan, and deliver care that promotes cultural safety across the continuum of care.

How to Embed Culturally Sensitive Care in Midwifery Education?

WHO (2) stresses that midwifery education should extend beyond task-specific training to include values like good communication, individualised care, and cultural understanding. The ICM (8) asserts that midwives should support women in making individual care choices, understanding cultural norms and practices related to sexuality, reproductive health, marriage, the childbearing continuum, and parenting.

Addressing cultural diversity in healthcare education is crucial for improving care quality and eliminating disparities. However, implementing a culturally appropriate care curriculum is often fragmented, and educators may lack clarity on necessary content (9, 1). WHO (2) advocates for midwifery education that involves women and communities, ensuring the curriculum reflects women’s rights and needs, and includes their voices. This approach involves collaborating with community care providers and promoting culturally appropriate, respectful care to empower women and avoid the over-medicalisation of birth.

A multifaceted approach involving educators, students, birthing people, and local communities can enhance cultural competence education. Researchers have argued that culturally appropriate care should be a continuous process rather than a set of educational goals (9). Reflective practice is crucial as it helps student midwives learn from their experiences. Specific training methods, such as role play, group discussions, case scenarios, mini-lectures, and sharing personal experiences, significantly improve healthcare providers’ cultural awareness (10).

Currently, efforts to improve culturally appropriate care education in midwifery include novel programs like an eLearning ‘culturally appropriate care training’ introduced by King in a UK NHS Trust (11). In Turkey, a 28-hour ‘Transcultural Midwifery’ course was positively evaluated by final-year student midwives and suggested to be made compulsory (12). Key reports, such as the Black maternity experience surveys (13) and the NHS Race Observatory report on neonatal assessment (14), have been incorporated into the midwifery curriculum, offering first-hand insights into clinical experiences. Educators can use these insights to integrate culturally appropriate care aspects into the curriculum. For example, avatars are used in midwifery curricula to discuss the value of culturally appropriate care for women and birthing people (15).

In conclusion, fostering cultural competence in midwifery is essential for delivering safe and quality care that meets the diverse needs of women and their families. Integrating comprehensive cultural appropriate care training into midwifery education prepares future midwives to provide respectful, responsive, and effective care in diverse cultural settings. While there are ongoing efforts to improve understanding and implementation of culturally appropriate care, a more collaborative approach between institutions could yield better outcomes for students, educators, and birthing people.

@joanna.andrews@actvet.ac.uk,

Linkedin: @Joanna Andrews  @Ola Solanke

References

1. Shen, Z. (2015). Cultural Competence Models and Cultural Competence Assessment Instruments in Nursing: A Literature Review. Journal of Transcultural Nursing, 26(3), 308–321. https://doi.org/10.1177/1043659614524790
2. WHO (2019) Strengthening quality midwifery education for Universal Health Coverage 2030: framework for action.
3. Leininger, M. M. (1999). What is Transcultural Nursing and Culturally Competent Care? Journal of Transcultural Nursing, 10(1), 9–9. https://doi.org/10.1177/104365969901000105
4. NMC (2019) Standards of proficiency for midwives – The Nursing and Midwifery Council (nmc.org.uk), 61
5. ICM (2011) Core document: International Definition of the Midwife. Accessed on 21/05/2024 08l_en_international-definition-of-the-midwife.pdf (internationalmidwives.org)
6. ICM (2008) International Code of Ethics for Midwives International Code of Ethics for Midwives  | International Confederation of Midwives (internationalmidwives.org)
7. NMC (2015) The Code: Professional standards of practice and behaviour for nurses, midwives and nursing associates – The Nursing and Midwifery Council (nmc.org.uk)
8. ICM (2019) Essential Competencies for Midwifery Practice Essential Competencies for Midwifery Practice | International Confederation of Midwives (internationalmidwives.org)
9. Seeleman C, Suurmond J, Stronks K. (2009) Cultural competence: a conceptual framework for teaching and learning. Med Educ. Mar 2009;43(3):229-37.
10. Fair, F., Soltani, H., Raben, L., van Streun, Y., Sioti, E., Papadakaki, M., Burke, C., Watson, H., Jokinen, M., Shaw, E., Triantafyllou, E., van den Muijsenbergh, M., & Vivilaki, V. (2021). Midwives’ experiences of cultural competency training and providing perinatal care for migrant women a mixed methods study: Operational Refugee and Migrant Maternal Approach (ORAMMA) project. BMC Pregnancy and Childbirth, 21(1), 340–340.
11. King HA. MIDIRS Midwifery Digest: The use of Cultural Safety Huddle and Handover guides to improve care delivery for Black, Asian, and Minority Ethnic patients. MIDIRS Midwifery Digest. Vol 31, no 1, March 2021, pp 46-51.
12. Güner, S., Bülez, A. (2023). Improving the cultural competence of midwifery students: an evaluative study. European Journal of Midwifery, 7(Supplement 1). https://doi.org/10.18332/ejm/172371
13. Awe T, Abe C, Peter M, Wheeler R. (2022)The Black maternity experiences survey: a nationwide study of black women’s experiences of maternity services in the United Kingdom.London: Five X More; 2022.
14. Furness, A., Fair, F., Higginbottom, G. et al. A review of the current policies and guidance regarding Apgar scoring and the detection of jaundice and cyanosis concerning Black, Asian and ethnic minority neonates. BMC Pediatr 24, 198 (2024). https://doi.org/10.1186/s12887-024-04692-4
15. Solanke, O., & Todd, S. (2022). UTILISING SOCIAL MEDIA IN MIDWIFERY EDUCATION. Practising Midwife, 25(10).

To view other blogs in this series please see:

Empowering Change: The Association of South Asian Midwives Advocating for Equitable Maternity Care

https://blogs.bmj.com/ebn/2024/05/26/what-is-the-role-of-a-consultant-midwife-lead-for-inclusivity-and-why-is-this-needed/