Cultural Safety and Prenatal Care

nursing for women's health

Earlier this year, Sherri Di Lallo wrote an article for the journal Nursing for Women’s Health called “Prenatal Care Through the Eyes of Canadian Aboriginal Women” (Vol 18, Issue 1, pp. 38-46).

The article provides an overview of the Aboriginal Prenatal Wellness Program (APWP) in central Alberta, Canada. The four Maskwacis First Nations of Hobbema border Wetaskiwin and Ponoka Counties in Central Alberta and have a total population of 13,784 people.

The Aboriginal Prenatal Wellness Program is a culturally safe program that provides client-centered prenatal care that is designed to empower women, families and communities.

The program was created in 2005 to serve Aboriginal women who weren’t accessing the traditional system for prenatal care. Between 2002 and 2007, 16.5 percent of all women in Central Alberta who delivered at Wetaskiwin Hospital and Care Centre had received little or no prenatal care prior to their delivery. Of those, 82 percent were from the Maskwacis area.

The article discusses aspects of providing culturally safe care, including the importance of assessing cultural biases, understanding the roots of health disparities in Aboriginal communities, and understanding cultural history and current practices. Central to cultural safety is self-reflection and building trustful and respectful relationships.

The article provides a summary of an evaluation of the program. Overall, between November 2005 and February 2009, 281 women participated in the program and the percentage of women having limited or no prenatal care dropped.

In terms of substance use, forty-four percent of women stated that they quit drinking and using drugs once they found out they were pregnant while 39 percent decreased their smoking and 16 percent quit smoking.

For more on cultural safety and FASD prevention, see earlier posts:

FASD Informed Practice for Community Based Programs

FASDInformedPracticeFinalVersionSeptember9-2013_pdf

FASD informed practice can include:

  • An awareness that FASD (diagnosed and undiagnosed) is a reality for many individuals involved with a variety of community-based programs
  • A strong theoretical and practical understanding of the traits, characteristics, barriers, and needs of those affected by FASD
  • A willingness on the part of program staff, including administration, reception, and frontline workers, to participate in ongoing FASD education and training initiatives
  • Agency policies that accommodate the unique needs of individuals living with FASD in order to create a program that works for all participants
  • A respectful and individualized approach to service delivery that recognizes individual strengths

This guide from the College of New Caledonia is designed to assist programs in providing FASD-informed services and supports. The approaches discussed were developed from evidence-based research and from the practical experience of individuals working with women and their families who may be living with FASD.

The guide includes sections on promoting dialogue about alcohol and drug use during pregnancy, contraception, trauma-informed practice, effective group facilitation, strategies for individual support, and examples of exercises that can be used in group programming.

FASD Informed Practice for Community Based Programs can be downloaded from the College of New Caledonia website here.

For more about FASD-informed work at the College of New Caledonia, see an earlier posts:

 

 

Supporting Pregnant and Parenting Women Who Use Substances: What Communities are Doing to Help

Specialized, Single-Access Perinatal Community Programs in Canada

Members of our Network Action Team on FASD prevention have recently developed a 12-page overview of community programs in Canada that support pregnant and early parenting women who use alcohol and other substances.

Since the 1990s, several communities in Canada have developed specialized programs  to address barriers to accessing prenatal services that exist for many women who use substances. These barriers include:

  • fear of losing custody of children;
  • fear of forced treatment or criminal prosecution;
  • lack of treatment readiness;
  • coexisting mental illness;
  • guilt, denial and/or embarrassment regarding their substance use;
  • and lack of transportation and/or child care.

These programs have been developed with an awareness of how substance misuse is often intertwined with other issues such as homelessness, gender-based violence, involvement with the law, loss of cultural connectedness, and food insecurity.

This overview describes the development of four programs in Canada:

  1. Maxxine Wright Place Project for High Risk Pregnant and Early Parenting Women in Surrey, British Columbia
  2. H.E.R. (Healthy, Empowered, Resilient) Pregnancy Program (Streetworks Program) in Edmonton, Alberta
  3. HerWay Home in Victoria, British Columbia
  4. The Mothering Project in Winnipeg, Manitoba

The document describes how the programs started, how they evolved to meet the unique needs of each community, and describes the research evidence that shows why they work.

If you take a look at the Four-Part Model of FASD Prevention below (see Poole, 2008 here for more on this model), you’ll notice that these type of programs fall under levels 3 and 4.

The third level of FASD prevention is about the provision of recovery and support services that are specialized, culturally specific and accessible for women with alcohol problems and related mental health concerns. These services are needed not only for pregnant women, but also before pregnancy and throughout the childbearing years.

The fourth level of FASD prevention is about supporting new mothers to maintain healthy changes they have been able to make during pregnancy. Postpartum support for mothers who were not able to make significant changes in their substance use during pregnancy is also vital. This will assist them to continue to improve their health and social support, as well as the health of their children. Early interventions for children who potentially have FASD are also important at this stage.”

You can download “Supporting Pregnant and Parenting Women Who Use Substances: What Communities are Doing to Help” from either the Canada FASD Research Network website here or the the BC Centre of Excellence for Women’s Health website here.

For more on this type of community program, see previous posts:

Cultural Safety and FASD Prevention

The term “cultural safety” is popping up in all sorts of fields these days, ranging from law to education to social policy. It’s also a term connected with a growing number of FASD support programs, such as the Alberta Parent-Child Assistance Program (PCAP) and the FASD Key Worker and Parent Support Program in British Columbia, which include cultural safety as part of the program framework.

So, what is cultural safety? Cultural safety is still a relatively new term in the Canadian context, but it first evolved out of nursing practice in New Zealand with regards to health care for Maori people. It was suggested that in order to provide quality care for people from different ethnicities and cultures that nurses needed to provide care within the cultural values and norms of the patient.

In Canada, the concept is often used to describe an approach to healthcare that recognizes the conditions that Aboriginal people experience today as a result of a history of colonization, residential schools, and other practices of cultural and social assimilation. This has resulted in a lack of trust and understanding between health care providers and patients and power imbalances that affect care and treatment. Culturally unsafe practices can be considered “any actions that diminish, demean, or disempower the cultural identity and well-being of an individual.”

Cultural safety can be a tool for understanding relationships between health care providers and patients, for analyzing organizational practices, and developing policies that support healing and self-determination.

When cultural safety does not exist, we see issues like the reluctance of individuals to visit mainstream health facilities even when services are needed (and a subsequent discussion by programmers about the “low utilization” of available services by Aboriginal people), inappropriate discussions about the “non-compliance” of individuals with referrals and recommendations, and feelings of fear, disrespect and alienation.

When we apply cultural safety to FASD prevention, we start to recognize things like how:

  • FASD is a medical diagnostic label based on a Western bio-medical model; FASD prevention interventions are based on this same bio-medical model of care
  • FASD continues to be described in mainstream media as a problem primarily in Aboriginal communities
  • Discussions of FASD often build on the historical ‘deficit’ view of Aboriginal people and, in particular, of Aboriginal women as ‘deficit’ mothers
  • The solutions to preventing FASD still continue to focus on addressing alcohol use during pregnancy and do not recognize the historical relationships between colonization, trauma, and alcohol use
  • FASD prevention frequently views alcohol use in pregnancy as an act by an individual women that must be targeted with various interventions (e.g., awareness campaigns and screening by health care providers) and ignores strategies that focus on families and communities (e.g., policies to redress residential schools or addictions programs that include a cultural component on intergenerational trauma)

There’s a growing number of resources on cultural safety available on-line. You can take a look at the resources below as well as the National Aboriginal Health Organization website and the National Native Addictions Partnership Foundation website.

 

References

Brascoupe, S. (2009). Cultural Safety:  Exploring the Applicability of the Concept of Cultural Safety to Aboriginal Health and Community Wellness.  The Journal of Aboriginal Health.  Ottawa: National Aboriginal Health Organization. Download free full-text here.

FASD Network Action Team on FASD Prevention from a Women’s Health Determinants Perspective. (2010). 10 Fundamental components of FASD prevention from a women’s health determinants perspective.

Gerlach, Alison J. (2012). A critical reflection on the concept of cultural safety. Canadian Journal of Occupational Therapy, 79(3): 151-158.

Indigenous Physicians Association of Canada and The Association of Faculties of Medicine of Canada.  (2009). First Nations, Inuit, Metis Health Core Competencies: A Curriculum Framework for Undergraduate Medical Education.

National Aboriginal Health Organization. (2008).  Cultural Competency and Safety: A Guide for Health Care Administrators, Providers and Educators. Ottawa, ON.

Tait, Caroline L. (2008) Ethical Programming Towards a Community-Centered Approach to Mental Health and Addiction Programming in Aboriginal communities. Pimatisiwin: A Journal of Aboriginal and Indigenous Community Health, 6(1), 29-60. Download free full-text from here.