Cultural Differences in Midwifery Care

Introduction

The provision of holistic midwifery care is a fundamental role of the midwife (NMC, 2004). However, holistic care must encompass a wide range of practices, including care for the psychosocial and spiritual needs of the women and families within their caseload. One concept which arises within the general healthcare debate and within professional midwifery practice is the notion of cultural competence. This essay focuses on a critique of one article from the midwifery literature which addresses of the needs of one distinct religio-cultural group. Leishman (2004) demonstrates the complex nature of the provision of healthcare in a multi-cultural society. Inequalities exist in the provision of care to diverse ethnic and cultural groups (Salt, 1997). The article being critiqued addresses two issues – the provision of care to parents who have been bereaved, and specifically, the preferences, beliefs, behaviours and needs of one group of clients, those of the Muslim faith. It is published in a midwifery journal and specifically deals with aspects of care which would come under the remit of the midwife within the UK, as specified by the NMC (2004).

Discussion

The title of the article is clear and simple, and defines the client group as religiously distinct (which also implies cultural distinction) and in a particular state of need due to bereavement. That the client group is defined as Islamic, however, does not take into account the different cultural and racial associations of those who practise Islam. A broad spectrum of cultures and races are associated with the Islamic, faith, suggesting that Islamic people are not a homogenous group. Conversely, it has also been argued that it is important to distinguish between culture (which has racial and religious overtones) and religion as a separate form of difference or identification (Eade, 1997). The failure of research on ethnic and racial or cultural lines to distinguish between religion and culture is notable (Eade, 1997), and it may be the intention of the authors of the critique article to ensure that the distinction is both clear and unequivocal. It may also be another example of the prioritisation of Islam over other social identities which is found so often in the literature (Eade, 1997).

The authors further identify the group under consideration as those originating from migrants from the Indian Sub-Continent in the 1950s (Arshad et al, 2004). This group is limited to Asians (2^nd and 3^rd generation) originating directly or indirectly from this area (Arshad et al, 2004). Such a distinction may be important. Marks and Worboys (1997) discuss the fact that multiple meanings can be attached to the terminology surrounding discussions of culture and ethnicity, terms such as ‘migrant’ and also ‘minority.’ In order to attain cultural competence in the provision of healthcare, it is important to understand the distinctions between those terms utilised within the debate (Srivastava, 2007). Race is usually associated with biological, genetic and physical distinguishing characteristics (Srivastava, 2007). Ethnicity is associated with commonalities of birth, descent, kinship and cultural traditions (Srivastava, 2007). However, culture is harder to define, and includes racial, social, linguistic and other common patterns or characteristics within groups (Srivastava, 2007). This level of ambiguity within the debate does not help illuminate the current situation.

By so clearly defining the focus of the client group in this article, the authors are claiming association with religious meaning (Islam) and racial and ethnic groupings (Asian, Indian Sub-Continent). They also support their focus with figures from the locality in question, thus establishing this group further as being of one predominant ethnic group, that of people of Pakistani origin (Arshad et al, 2004). This author can only question whether this adds to the understanding of the reader or further confuses the issue. The group are clearly defined, but what distinguishes them from other Muslims, or even from other ethnic groups from Asia, is not defined at all. Given the continued lack of understanding or awareness of cultural difference in the NHS in the UK (Le Var, 1998), further elucidating details might have been useful here. However, Cortis (2004) found that deficits exist in Registered Nurses’ knowledge about Pakistani patients in the United Kingdom, which might suggest that a greater understanding of this particularly group is necessary for all healthcare professionals. The Healthcare Commission (2006) found in their investigation of 10 maternal deaths in one hospital trust that women from minority ethnic groups are at higher risk of a pregnancy-related death. In this report, 9 out of the 10 women who died in the time period 2002 to 2005 were from minority ethnic groups, and seven out of these were from Asia (Healthcare Commission, 2006). This would suggest that the maternity care provided to women from these ethnic groups needs to be explored, evaluated and improved. This perhaps relates to the continued drive towards cultural competence in the healthcare services (Srivastava, 2007). It also suggests that there is a need for more specific information and evidence regarding distinct sub-groups within the ethnic mix of clients of the NHS. This article provides information, but its status as a form of evidence could be somewhat questionable.

This is a descriptive article containing practical details for the maternity care professional to be able to provide culturally or religiously competent care for Muslims who experience the loss or death of a baby or fetus. Callister (2005) describes descriptive literature in this field as literature which identifies cultural practices to increase understanding of how nurses can more effectively provide culturally competent care for specific racial/ethnic and/or cultural groups of women and children. Establishing the client group’s distinctions early on, however, does not achieve much more than also establishing the authority of the authors in the writing of such an article, as it contains some references, but not as many as would be expected in a research-based article. There is no critical review of the literature, and very little critique or discussion, but rather a presentation of the (assumedly) accepted facts that relate to care for the family and dead infant. As such, this is useful and informative, but the critical reader cannot but be aware of the lack of reliable evidence. The authority of the authors must be trusted here.

Cortis (2003) suggests that culture furnishes the beliefs and values that give individuals a sense of identity, self-worth and belonging, as well as providing rules and guidelines or standards for behaviour. If we believe that culture is something commonly understood by those who share it (Srivastava, 2007), then it could be that a common understanding of Pakistani emigrant Muslim culture exists between the authors of the article, to such an extent that they fail to illuminate certain perhaps important details that would inform the general reader. This is a significant issue in the light of the continued debate about the nature and importance of culture in how people engage with healthcare services and each other. Recent views on culture, although not discarding the importance of a person’s cultural inheritance of ideas, values, behaviour and practices, also acknowledge that culture can be affected dynamically by social transformation, social conflicts, power relationships and migration (Cortis, 2003). Yet there is no notion of that here, perhaps because the authors are dealing with the strictures of faith rather than culture.

There is some statistical evidence of the rates of pregnancy loss infant death in the locality in question, but again, this is poorly related to the rest of the article and seems perhaps a token gesture towards relevance and importance of the information. Also, these statistics refer to White British, Pakistani and Other (Ashard et al, 2004), without making any further distinctions. Without such distinctions, the reader can only understand part of the picture. The ‘Other’ group might also contain people of the Muslim faith, as might the White British group. Again, the authors could have included more critical discussion here of ethnic mix.

Some readers might consider that, having identified the group in question, the authors have gone far enough in setting the context of the paper. However, this author also feels that there is a degree of ambiguity in the presentation of this article. By distinguishing the client group to such a degree, it could be assumed that the customs, rites and beliefs referred to in the article are peculiar to this particular ethnic group who subscribe to the Muslim faith. However, it could also be that readers would assume that because the terms used in the article are more general, referring to Muslims as a religious group rather than making ethnic distinctions, these are guidelines to be applied to all Muslims. This ambiguity does not assist the reader in understanding how best to apply this information.

Similarly, there is no real acknowledgement of the issue and dangers of stereotyping. Stereotyping has been described as a limiting and intellectually crude way of seeming to understand individuals (Schott and Henley, 1996). There is a tendency for people to stereotype those in groups that they do not belong to or know little about (Schott and Henley, 1996). Again, a critical reader could infer from this article that the authors have stereotyped the client group in question as being similar to all other Muslims. However, the article does raise some other issues which may not be explicit, including the importance and behaviours of family and friends in Islam during such a challenging time (Arshad et al, 2004). There is a clear undertone here that all Muslims behave in this manner because of their common faith.

The article is referenced correctly but not very well referenced. Conversely, Leishman (2004) carries out a literature review which highlights some of the more topical issues surrounding the notion of culture and the needs of distinct diverse groups within the healthcare system. One issue that Lieshman (2004) raises is the fact that there is a need not only for health professionals to be aware of other cultures and belief systems, but also to be aware of their own. Addressing this issue, of understanding one’s own reaction to the beliefs and practices of others, might be raised in this article when discussing the practices and behaviours that are associated with Muslim clients following the death of a baby. This would be a useful and relevant practice point for midwives and other healthcare professionals to consider.

Another point raised by Lieshman’s (2004) literature review is the need to take into account the past and experiences of ethnic groups, particularly those who, for example, have entered this country as asylum seekers. Similar issues have been raised by other literature (Maternity Alliance, 2004). The group in the critique article are not asylum seekers, but their parents, grandparents, family and friends may be, and the experiences and shared realities may affect their relationship with healthcare services and professionals. Such a potential is highlighted by a report by the Maternity Alliance (Maternity Alliance, 2004). Discounting this issue leaves out the level of detail midwives may require to fully understand and respond to the needs of diverse ‘minority’ groups, perhaps even promoting stereotyping rather than combating it. Thus it can be seen that another author, utilising a more critical and academic approach to the topic, can provide more of a discursive understanding of relevant issues.

Similarly, Callister (2005) reviews the literature on cultural competence in the care of women and children, and draws conclusions about the nature of that literature. Through this detailed examination the author is able to define and suggest potential outcomes for clinical care, for education of the professionals who deliver that care and for nursing research to properly explore the most important issues (Callister, 2005). Again, this article misses important opportunities to link the issues of concern to the current literature and to opportunities to develop better practice through educational development and research. For example, Callister (2005) suggests that studies are needed exploring organisational and work environment issues to better promote cultural competence. Simply being conversant with the basics of Islamic beliefs and practices surrounding death is not enough to promote true sensitivity and individualised care.

Cultural sensitivity has been described as the attitudes, values, beliefs and personal insight of healthcare providers (Doorenbos et al, 2005). Such sensitivity involves acknowledgement of personal heritage and beliefs, openness to otherness, and respect for the complex ways in which cultural issues influence every aspect of healthcare (Doorenbos et al, 2005). However, the Arshad et al, (2004) article does not deal with the challenges of promoting cultural sensitivity, not does it distinguish between the different kinds of knowledge, understanding and skills necessary to provide care for this client group in these circumstances. A thorough, critical literature review, especially perhaps of any research or case studies that might illuminate the issues, would have considerably enhanced the paper.

Doorenbos et al (2005) highlight and discuss existing models of cultural competence within healthcare, and evaluate one of the models used to assess one cultural competence assessment instrument. Application of such models to the situations described by Arshad et al (2004) might also have enhanced the quality of their argument and elevated their paper into the realms of evidence for practice rather than information for practice. Doorenbos et al (2005) describe cultural competence of healthcare providers as being central to the healthcare system’s ability to provide access to and provision of high-quality healthcare services, and link it to the drive to reduce health disparities. Srivastava (2007) links cultural competence to respect, knowledge and skills, and the ability to use them effectively in cross-cultural care situations. Some discussion of cultural competence in the Arshad et al (2004) article might also have perhaps allowed a more critical awareness of the subject.

The conclusions the authors draw are that individuals have unique responses to grief and loss, regardless of religious background or belief systems (Arshad et al, 2004). This is no innovative or surprising finding, but the fact that they make no other conclusions is surprising. They also conclude that the resulting distress is often overwhelming (Arshad et al, 2004), another generalisation which is not new and does not really add anything to the debate. These conclusions do not really relate to the rest of the article, which is chiefly concerned with describing the beliefs and practices of Muslim people around the death of a child (Arshad et al, 2004). They also highlight that health professionals may not feel properly equipped or be well enough informed to support families of different faiths at such a time (Arshad et al, 2004). This is a fact well established by a range of other literature within healthcare and within midwifery (Srivastava, 2007; Marks and Worboys, 1997; Schott and Henley, 1996).

The recommendations which are given are similarly brief and somewhat vague. Arshad et al (2004) suggest that an insight into religious beliefs and practices can only be beneficial when delivering care in the field of loss and bereavement. This is a rather sweeping statement, because while they do take into account the need to avoid generalisation, they have in fact generalised throughout the article and failed to provide any critical evaluation or insight into, for example, the differences in culture, race, background and practices that may exist between people who nevertheless subscribe to Islam. However, this may be this author’s own ethnocentrism surfacing – it could be that the expression of Islamic faith is universal and changes little between ethnic, racial or cultural groups. This article might be simply stemming from such a simple fact.

The Maternity Alliance (2004) found that serious inequalities still exist in the provision of maternity care to women from minority ethnic groups, especially women who were asylum seekers. There is a need for more investigation of the reasons why staff are still improperly equipped to provide the highest standard of individualised care free of bias, prejudice or stereotyping. There is also a need to investigate the reasons for continued inequalities in access to and experience of healthcare, and any possible links between the two.

There are a number of implications for midwifery practice, though these are not as explicitly stated within the article as they could be. The main and most useful implication is the need to provide correct and sensitive care for Muslim clients when they experience pregnancy loss or the death of an infant. This article is ideal to use to inform midwives of this. Other implications for midwifery practice are inherent in the article, and include, for example, implications for the practicalities of care provision in often busy maternity units within the NHS. The placing of the body so that it is facing Mecca, for example, is an important consideration for midwives who are usually the professionals who prepare the body of an infant or fetus following death. Another consideration is the fact that the whole of the body including the placenta and umbilical cord, should be buried (Arshad et al, 2004). It would be easy for a midwife to cause significant distress to a family by following usual hospital protocol for disposal of placenta, membranes and cord. There may also be issues of health and safety to be considered in the storage and transport of these tissues.

If a midwife was aware of these particular religious practices, she might be able to discuss them with the client at an appropriate time and ensure that all their needs are met. Cortis (2003) suggests that nurses should appreciate how the domains of culture need to be used for data collection to identify specific cultural needs. It is through this process that important domains health beliefs, communication, spirituality, death and dying distinguish the needs of patients (Cortis, 2003). Cultural assessment also offers midwives and other healthcare professionals the opportunity for identifying potential differences between theirs and their patients’ value systems (Cortis, 2003). Chenowethm et al (2006) describes the common clash between healthcare professional’s perceptions of the professional responsibility to deliver care in a particular way, and the patient’s view of how they wish to be cared for. Such clashes are somewhat inevitable, but if anything can help to overcome them or minimise them, it can only be of benefit to the midwifery profession. Chenowethm et al (2006) suggest one way to ensure cultural sensitivity is to access community resources appropriate to the cultural or ethnic group under consideration. This issue, however is not explicitly addressed in the Arshad et al (2004) article.

More general issues for midwifery are those which apply to the broader, clinical governance spectrum of the maternity services as part of the healthcare services. The Department of Health (2007) in its operating framework for 2007-08 lay out core principles for the provision of care in the NHS. These include individualised care, partnership working, respecting dignity, reducing inequality and providing access to all based on need (DOH, 2007). Such a vision is nothing new, but does once again remind midwives of the need to provide both culturally sensitive and appropriate services. The information in this article may contribute to the development of such services, but it is the opinion of this author that it is still inadequate in addressing the complexity of the issues. However, Arshad et al (2007) do not address a range of other issues which can be found in the literature. For example, Park et al (2007) state that recruitment and retention efforts for non-white midwives, regular education for cultural competence of midwives, and provision of culturally and linguistically appropriate care for women from ethnic minorities should be considered in future provision of maternity services. Neile (1995) also pinpoints education as important in supporting midwives gain a realistic insight into how the needs of the multiracial community may be met. There appears to be a need for a comprehensive programme of multicultural education for all midwifery professionals (Neile, 1996), a view which is echoed by Campinha-Bacote (2006) and Brathwaite and Majumdar (2006). If the Arshad et al (2004) article more directly targeted itself at professional education, it might have greater impact on the improvement of services.

The Arshad et al (2004) article was published in the British Journal of Midwifery, which claims to be the leading clinical journal for midwives (BJM, 2007). This is well known as the pre-eminent peer-reviewed Journal for midwives in the United Kingdom, and the editorial board contains a range of the most senior and well respected midwives and midwifery academics in the country (BJM, 2007). The article is available by subscription online and in print, and is available in most Universities and Trust libraries. Contents, discussions and abstracts can also be found online, making this very accessible. This would give the article a degree of weight and authority, and as the BJM has such a large distribution – national and international – this adds further authority to the article.

The writers themselves appear well qualified to write an article on this topic, in that it is written by two Muslim chaplains (one of whom is an Imam) and one bereavement support midwife. Thus the reader would be more inclined to accept and use their assertions in practice. This may explain why such a respected, peer-reviewed journal has accepted an article which is not related to research or a literature review. The authors do not appear to have published in other peer-reviewed journals but have contributed to the development of Trust policies and publications locally (Bradford NHS Trust, 2007).

The rationale for the article seems sound. Arshad et al (2004) suggest that supporting parents who are bereaved following pregnancy loss can be complicated by a lack of knowledge and understanding of specific spiritual needs, leaving professionals feeling helpless and families feeling dissatisfied. The purpose, therefore, of their article is to provide information to address this issue (Arshad et al, 2004). This proposal seems reasonable and even necessary, given the need for improved understanding, knowledge, awareness and attitudes highlighted by the literature (Srivastava, 2007; Marks and Worboys, 1997; Schott and Henley, 1996).

Cortis (2004) highlights the fact that there is a continued need for research into multi-cultural aspects of care. Through one research study, Cortis (2004) also identifies the danger of ethnocentrism in the health services, suggesting that it may contribute to racism, as ethnocentric practice fails to recognize significant cultural differences and their importance for the people concerned. If this is true, then such an article, informative and descriptive in nature, may contribute to the quality of care by informing those with ethnocentric tendencies of important details relating to this client group. However, in the provision of individualised care, this article may not supply the level of critical detail that the truly client-centred midwife would need to fully enhance their practice in this area. They also claim that the rituals and beliefs of Islam in these circumstances are complex and may appear strange to the uninitiated (Arshad et al, 2004).

Conclusion

As has been demonstrated, this article provides a descriptive, factual picture of the beliefs, practices and behaviours that Muslims experiencing pregnancy loss or infant death might display. It is of some use to midwives in an informative manner, but also does not seem to address the complex and challenging nature of the provision of care to a range of clients whose only common factor may be their Islamic faith. It does not address the issue of evidence-based care, and fails to engage in any real critique of the evidence base, literature or debate which does exist around this topic. It also fails to highlight some key terms of the current debate, including notions of cultural competence and cultural sensitivity, to any great degree. There are a range of issues which could have been highlighted such as education, communication and immigration. However, any truly client-centred midwife can only conclude that the information itself is vital to the provision of midwifery care to such clients and it also serves to highlight the notion of the great differences that exist in responses to and behaviours around pregnancy bereavement within different racial, ethnic and religious groups in society. Any such article has a place in the drive to improve care standards and quality, and should be incorporated into client-centred care.

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