Introduction
This paper describes the reflection on an incident that occurred when I was working in the maternity ward at Royal Darwin Hospital. This incident changed my perception of young teenage Indigenous girls’ attitudes regarding pregnancy and motherhood. Critical reflection on this particular incident brought me the insight that, as healthcare workers, our assumptions and clinical judgments without realizing or understanding the situation can be inaccurate in many circumstances. I believe that reflective practices help us to learn from our experiences, the relationships between the clients and professionals, and in a broader sense society and culture.
Description
Jane was a 16-year-old Indigenous girl who was 34 weeks pregnant and admitted with antenatal complications. Ultra Sound report at 32 weeks showed baby’s growth was less than 6 percentile and AFI (Amniotic Fluid Index) of 4. She received 2 doses of steroids, the plan was to closely monitor the baby and induction of labor at 36 weeks or earlier depending on the well-being of the baby. Her pregnancy was concealed until 27 weeks and she was a school-going girl during conception. Her Grandma Carol was the official escort, Jane was a very quiet, shy girl, and her grandma was always talking to us and the doctors. I looked after her continuously for 5 days and managed to build a good rapport with her. Later she started talking to me very well. During those days, daily CTG (Cardio Toco Graph) monitoring sometimes continued for hours to get a normal trace because of the earlier abnormal findings with the baby. Grandma Carol goes outside regularly to smoke and to meet with other family members. One day Jane told me that Carol is planning to raise the baby and she has to go back to school. Jane doesn’t want to leave her baby, but it was Carol’s wish to raise the child and send Jane back to school. I was surprised to hear that from Jane, then I realized that none of the health professionals had a conversation with Jane in the absence of Grandma. Then I asked Jane whether the hospital staff can address the issue and Jane replied: “Someone has to talk to my grandma. I want my baby with me and I don’t want to go to school”.
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Feeling
I felt sad and confused at the same time; none of us who was caring for her days didn’t know what was going on with her as always Grandma Carol was the medium of communication. Cultural influences in communication can be misinterpreted, so if it is appropriate and interpreters are available, health workers are strongly encouraged to use interpreters (Taylor & Guerin, 2019). I felt glad that, Jane was comfortable with me telling her worries. I informed the information I obtained from Jane the ward’s team leader and escalated the matter to our social worker who was responsible for our ward. Indigenous health workers were already involved in the case because of her age and social situation. I contacted the ILO (Indigenous Liaison Officer), organized an interpreter, and started involving an adolescent nurse. When Carol returned, I informed her that a meeting has been organized between Jane and the hospital team. Carol was passively aggressive when she realized that she was not invited. She commented that “Jane is a little girl, anything you want to talk to her you have to tell me”. After explaining the situation, Carol was happy for Jane to attend the meeting. The communication gap between health professionals and Indigenous Australians has a significant impact on health outcomes, especially for people from remote communities where cultural and linguistic differences are at greatest (Kildea, Tracy, Sherwood, Magick-Dennis & Barclay, 2016).
Evaluation
Australian Nurses and Midwifery Council’s competency standards explain that values are not imposed on clients and if clients’ values conflict with the health professional, do not compromise on client care and should be respected (Taylor & Guerin, 2019). As per the WA (Western Australia) Guidelines, young women’s choices should be respected at all times and in all service settings. The model of care should be open, and non-judgemental and if possible, include local Aboriginal women elders and grandmothers in pregnancy support and education. Evidence suggests that culturally sensitive antenatal care that links teenage pregnant women to other services may increase access and acceptability for those who are highly disadvantaged (Reibel, Morrison, Griffin, Chapman & Woods, 2015). Adolescent pregnancies mostly result in low birth weight and premature birth, which negatively impact the whole life outcome of the infant. The antenatal period is crucial for interventions to protect the mother and baby, especially in vulnerable groups (Reibel et al., 2016). In Jane’s case, she was disadvantaged, didn’t receive any early antenatal care, and her baby was already small for gestational age (SGA). Young women prefer a familiar and continuous relationship with health workers, then they trust the carer to maintain their privacy. Mostly they feel comfortable with female health workers (Reibel et al., 2016). In Jane’s case, she was privileged with continuity of care, she had trust in her midwife to disclose her choices and her privacy was well maintained, which all contributed positively to the pregnancy experience.
Analysis
Access and effectiveness of health services are less ideal in certain circumstances in terms of treating the Indigenous population (Taylor & Guerin, 2019). Our practice can be improved by reflecting on our experience, exploring the knowledge or lack of knowledge, and employing new strategies and remedies (Taylor & Guerin, 2019). In Jane’s case, the involvement of a multidisciplinary team which also included an interpreter and a community elder was an optimal model of care we provided to protect Jane’s choices and wishes. Midwives develop a partnership with individual women, they share relevant information, and this leads to informed decision-making. Midwives support the rights of women or families to participate actively in decision-making about their care ('Core Document International Code of Ethics for Midwives', 2014). Maternity models of care which include the cultural expertise of community elders and strong women workers will strengthen the partnership between the women and midwives, which will improve maternity care and health outcomes for mothers and babies (Kildea et al., 2016). Australian Nursing and Midwifery standards promote shared decision-making, a woman-centered approach to managing the woman’s care and concerns. The standards allow the midwives to advocate on behalf of the woman where necessary and recognize when substitute decision-makers are needed such as legal guardians or holders of power of attorney (Cusack, 2018).
Conclusion
Treating the whole population the same regardless of their cultural identity fails to acknowledge the unique needs and issues affecting people who are culturally different (Taylor & Guerin, 2019). On reflection of this incident, I can say, if she was with the hospital’s Midwifery Group Practice (MGP), she would have received quality midwifery care. The MGP team includes strong women workers, community elders, social workers, and adolescent nurses. Jane would have had an opportunity to disclose her worries to the midwives because of the continuity of care and the woman-centered approach. The participation of Aboriginal and Torres Strait Islander workers in the multidisciplinary team is crucial for the provision of culturally competent care (Kruske, 2011). Continuity in midwifery care is very helpful for disadvantaged and marginalized young women like Jane, so must be offered to all Indigenous and Torres Strait Islander women (Kruske, 2011)
Action plan
This incident influenced me to think about how we can provide culturally secure models of care. We have a successful model of care for our women from remote communities running at Royal Darwin Hospital, where I practice. All young Indigenous pregnant women from communities get nominated to Midwifery Group Practice (MGP) and the benefits and structure of the program are described in the Conclusion session above. When we (midwives) receive women from Indigenous communities, referral to the MGP team is a standard policy within Royal Darwin Hospital to make sure that they receive culturally competent midwifery care.
References
- Core Document International Code of Ethics for Midwives. (2014). Retrieved 5 April 2020, from https://www.internationalmidwives.org/assets/files/general-files/2019/10/eng-international-code-of-ethics-for-midwives.pdf
- Cusack, L. (2018). Nursing and Midwifery Board of Australia - October 2017. Retrieved 8 April 2020, from https://www.nursingmidwiferyboard.gov.au/News/Newsletters/October-2017.aspx
- Kildea, S., Tracy, S., Sherwood, J., Magick‐Dennis, F., & Barclay, L. (2016). Improving maternity services for Indigenous women in Australia: moving from policy to practice. Medical Journal of Australia, 205(8), 374-379. doi: 10.5694/mja16.00854
- Kruske, S. (2011). The characteristics of culturally competent maternity care for Aboriginal and Torres Strait Islander women. Retrieved 3 April 2020, from https://www.catsinam.org.au/static/uploads/files/characteristics-of-cultural-competent-maternity-care-wfjmbiuiames.pdf
- Reibel, T., Morrison, L., Griffin, D., Chapman, L., & Woods, H. (2015). Young Aboriginal women's voices on pregnancy care: Factors encouraging antenatal engagement. Women and Birth, 28(1), 47-53. doi 10.1016/j.wombi.2014.10.003
- Taylor, K., & Guerin, P. (2019). Health care and Indigenous Australians (3rd ed., pp. 183-197). London: Palgrave Macmillan.
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