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Book review: This Bridge called my back

I have been a long-time fan of the New Zealand Mental Health Foundation. Starting in 1996 I did some workshops in Northland and around for the community about Depression, while I worked in perinatal mental health. Later, I co-produced a brochure about perinatal mental health for them. So, when the fabulous Kim Higginson asked me if I would feature in a new section on their website, I had to say yes! In My Kete features book reviews and stories from people in the mental health sector sharing what they have found most helpful in their own work and lives. The word/kupu “kete” symbolises the sharing of knowledge and prosperity.

Ceramic kete gifted to me with found sulphur crested cockatoo feathers

Long before social media, my family would eagerly watch the 6pm news. As new migrants to Aotearoa, we would watch with anticipation for even a tiny glimpse of the places we had left behind, that we were connected to. Goa, our turangawaewae, the home of our ancestors, or Tanzania or Kenya, where we had all been born and lived. But it was the seventies, and the closest we ever came was hearing about the famines in Ethiopia and civil war in Angola, until the Montreal Olympics of 1976. We couldn’t wait for the Kenyan and Tanzanian runners like Filbert Bayi to absolutely smash all the other athletes. We knew they were the best!

Our anticipation was thwarted by bigger events. The New Zealand All Blacks had been playing rugby in apartheid South Africa despite the United Nations’ calls for a sporting embargo. 28 African countries led by Tanzania decided to boycott the games after they had asked the International Olympic Committee (IOC) to exclude New Zealand from the Games and were refused. The United Nations secretary-general said he recognised the “deep and genuine concerns” felt by African countries but, “at the same time I wish to point out that the Olympic Games have become an occasion of special significance in mankind’s search for brotherhood and understanding.”

The story about the Olympics shows how keen I was to see anything of my world reflected to me through the collective sphere or mass media. But this was rare, and when I did see something, it was often a globalised reflection of famine, disease or deficit. So I turned to literature. I was a frequent visitor to Titirangi Library in West Auckland, where I discovered Ms Magazine and read every issue I could get my hands on. Through authors like Germaine Greer and Andre Dworkin, I read that white feminism was good and brown women were oppressed by their cultures. I struggled to reconcile this idea of brown men as bad. The men I knew in my community (who were very few in NZ in those days), were also struggling with racism, economic disadvantage and white supremacy. My Dad worked two jobs (as a teacher and then as a cleaner) so that my mother could study to become a teacher. He then came home and did the cooking, while my three sisters and I administered the household so that my mother could study, and our collective free time could be spent on family outings.

Reading This Bridge Called My Back was life changing. For the first time, I saw women of colour foregrounded. They were powerful, knowing, wise, and full-bodied; not deficient, in need of rescuing or pathological. I saw them navigating complicated worlds that were not built for them. I saw collective struggles and collective joy. These stories resonated with me so much I developed a desire for collective solidarities, which led to conference organising (for refugees and Indian social service professionals) and connecting and bringing diverse voices together (the Aotearoa Ethnic Network). I moved beyond exploring gender and incorporated other axes of difference including race, class and sexuality into my academic life. I still carry this work with me as I think about race and health as a researcher. I remain indebted to the solidarities that were brought together in this anthology, for giving me hope and pride in my differences, while also reminding me to always think about who and what is missing from the room, whose voices are not heard and how this can be remedied.

Book Details
Moraga, Cherríe., & Anzaldúa, G. E. (eds.). (1981). First edition. This bridge called my back: Writings by radical women of color. Persephone Press. ISBN 978-0930436100
Moraga, Cherríe., & Anzaldúa, G. E. (eds.). (2021). This bridge called my back: Writings by radical women of color. Fortieth Anniversary Edition. Suny Press. ISBN: 9781438488288

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I Smell You

]De Souza, R. (2017). I Smell You, Life Matters, Radio National, Australia. Thursday 14 September 2017.

The wonderful Masako Fukui from Life Matters interviewed me for this story about olfactory assimilation.

I am a committed foodie, ‘somebody with a strong interest in learning about and eating good food who is not directly employed in the food industry’ (Johnston & Baumann, 2010, 61) who is also interested in the politics of food. In particular, the politics of food in public spaces like public transport and hospitals.

I am interested in the ways in which admission into western medical health services requires assimilation into a distinct patient subculture. This coercive incorporation and relinquishment of clothing and belongings is accompanied by the loss of autonomy over everyday activities and routines, which is ceded to health professionals and institutional processes. From being a socially integrated member of a community, the person within the dominant mode of biomedicine is reduced to being an individual, then a physical body or parts. The person becomes an object who receives care.

Food is more than sustenance and nutrition, it has social, cultural and symbolic meanings which structure not only our daily lives, but also life transitions such as maternity. Food represents an arena where powerful values and beliefs about being a human are evident. Food practices also demarcate cultural boundaries of belonging and not belonging. Forthcoming: De Souza, R. (in press). Going Without: Migrant Mothers, Food and the Postnatal Ward in New Zealand. In F. Guignard and T. Cassidy (Eds.), Moving Meals and Migrant Mothers. Toronto: University of Toronto Press.

Check out Masako Fukui’s great piece in ABC News: Is our dislike of ‘smelly’ food actually cultural intolerance?

Fish is OK, as long as it isn’t pungent. Curry is nice, as long as the spices don’t cling to the curtains. Kimchi is healthy, as long as the fermented garlic doesn’t linger on the train.

But for the migrant who feels displaced from their homeland, foods that olfactorily offend may play an important role in reinforcing identity, Dr De Souza says.

She says cooking and eating a beautiful curry is akin to “putting lotion on the part of me that feels dislocated, lonely, and isolated”. But that same curry can reek of spices that ultimately isolate her by making her smell different, even invoking disgust.

Okra and eggplant

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Wearable devices and the potential for community health improvement

Written for and first published in in the August 2016 edition of Nurse Click  (the Australian College of Nursing’s monthly electronic, interactive PDF publication available to ACN members, and to stakeholders, the wider nursing and non-nursing community who subscribe to it.). Cite as: DeSouza, R. (2016). Wearable devices and the potential for community health improvement. Nurse Click, August, 14-15 (download pdf 643KB nurseclick_august_2016_final)

TV Glasses (1964)

TV Glasses (1964)

“Wearable technology“, “wearable devices“, and “wearables” all refer to electronic technologies or computers that are incorporated into items of clothing and accessories which can comfortably be worn on the body. These wearable devices can perform many of the same computing tasks as mobile phones and laptop computers; however, in some cases, wearable technology can outperform these hand-held devices through their integration into bodily movements and functions through inbuilt sensory and scanning features, for example. Wearables include: smart watches, fitness trackers, head mounted displays, smart clothing and jewellery. There are also more invasive varieties including implanted devices such as micro-chips or even smart tattoos, insulin pumps, or for contraception. The purpose of wearable technology is to create constant, seamless and hands-free access to electronics and computers.

Wearables are all about data. Thanks to recent advancements in sensors, we’re able to collect more information about ourselves than ever and use that data to make healthcare personal and tailored to our needs. Traditionally, qualitative health research and much clinical interaction relies on self-reporting by consumers, which is then interpreted by researchers and published for incorporation into practice by health practitioners. Along the way, much important information is “lost in translation”. New consumer healthcare technologies are brokering a shared informational interface between caregivers, clinicians, communities and researchers, allowing practitioners to access richer and more detailed empirical data on health consumer activity and their participation in health-seeking activities.

Consumer health technologies offer potential for care to be more equitable and patient-centred. The technological promise also brings concerns, including the impact on the patient-provider relationship and the appropriate use and validation of technologies. Technologies are also developed with particular service-users in mind, and rarely designed with the participation of people from structurally and culturally marginalised communities. In turn, the impacts of these technologies on health service education, planning and policy are far reaching. It is important that technology is not demographically blind, from a public health and community health perspective it must not reinforce the structural inequalities that exist between those who have access to health and those who haven’t.

The Centre for Culture, Ethnicity and Health, in partnership with the University of Melbourne’s Research Unit in Public Cultures and the Better Health Channel, recently organised a seminar and stakeholder consultation in Melbourne on July 28th with the aim of shaping a research agenda on wearable health technologies and culturally and linguistically diverse (CALD) communities. Typically wearables have been marketed toward the ‘wealthy worried and well’ demographic and the purpose of the seminar was to discuss both the generic issues that emerging wearable technologies present, as well as the unique issues for people from diverse backgrounds. The three hour event brought together clinicians, academics, developers, community organisations, and policymakers to consider the future issues with these technologies.

Seminar. Photo credit Jared Kuvent

Seminar. Photo credit Jared Kuvent

The first speaker was University of Melbourne researcher and lecturer Suneel Jethani who expressed scepticism about what wearable health technologies really may deliver for health, particularly for CALD communities. Suneel explored the growth of wearable health technologies through the notion of the pharmakon, the notion that every medicine is also poison, with the devices having capacity to be both beneficial and harmful. Janette Gogler, a Nurse Informatician from Melbourne’s Eastern Health described a randomised control trial of emerging technologies for remote patients with chronic heart failure and chronic obstructive pulmonary disease (COPD). In this trial patients took a number of their own physiological measurements including electrocardiography (ECG) monitoring, blood pressure, and spirometry. While the trial led many patients to feel more in control of their health through a better understanding of their physiology, there were also challenges, including having to manage their expectations of the technology, where patients who became suddenly unwell were upset that the system had not given them forewarning, even though the issues were outside the scope of the devices. Janette also raised the issue of research excluding speakers of additional languages. The final speaker was Deloitte Digital partner Sean McClowry, who noted that the uptake of wearable health technologies has been slower to reach ‘digital disruption’ compared to the smart phones, but saw the likelihood of exponential growth through a new model of care. Sean raised questions about the unprecedented nature of data: how to make it high quality and its analysis meaningful. The session by the three panellists was followed by two youth respondents and a question and answer session and then break out groups which developed further questions and issues for an emerging research program.

In the stakeholder consultation a number of critical themes emerged from many participants: the need to carefully manage privacy; the lack of accuracy of much consumer information; certification of apps; Western models of individual health hard-wired into the platform; the potential of peer support from new technologies; challenges for existing workforces and roles; and the potential of research to stigmatise as well as assist CALD communities. What was agreed was that consumer health technologies were only going to continue to grow and that no part of the health system would be undisrupted by the changes ahead, both intimidating and exciting!

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Providing Culturally Safe Maternal and Child Healthcare

Cite as: DeSouza, R. (2016, June 1st). Keynote address-Providing Culturally Safe Maternal and Child Healthcare, Multicultural Health Research to Practice Forum: Early Interventions in Maternal and Child Health, Program, Organised by the Multicultural Health Service, South Eastern Sydney, Local Health District, Australia. Retrieved fromhttp://ruthdesouza.dreamhosters.com/2016/06/11/cultural-safety-in-maternity/

 

Image from the film, the Namesake

Image from the film, the Namesake

A paragraph haunts me in The Namesake, Jhumpa Lahiri’s fictional account of the Indian immigrant experience. Ashoke and Ashima Ganguli migrate from Calcutta to Cambridge, Massachusetts after their arranged wedding. While pregnant, Ashima reflects:

Nothing feels normal. it’s not so much the pain which she knows she will survive. It’s the consequence: motherhood in a foreign land. For it was one thing to be pregnant to suffer the queasy mornings in bed, the sleepless nights, the dull throbbing in her back, the countless visits to the bathroom. Throughout the experience, in spite of her growing discomfort, she’s been astonished by her body’s ability to make life, exactly as her and grandmother and all her great grandmothers had done. That it was happening so far from home, unmonitored and unobserved by those she loved, had made it more miraculous still. But she is terrified to raise a child in a country where she is related to no one, where she knows so little, where life seems so tentative and spare. The Namesake, Jhumpa Lahiri

Ashima’s account beautifully captures the universality of the physical, embodied changes of maternity, the swelling, the nausea and other changes. But what Lahiri poignantly conveys is the singular emotional and cultural upheaval of these changes, the losses they give rise to. The absence of loving, knowledgeable, nurturing witnesses, the absence of a soft place to fall.

Arrival of baby girl in Prato, Tuscany. Credit DeSouza (2006).

Arrival of baby girl in Prato, Tuscany. Credit DeSouza (2006).

In 1994 I worked on a post-natal ward where I was struck by the limits of universality and how treating everybody the same was problematic. For example, ostensibly beneficial practices like the routine administration of an icepack for soothing the perineum postnatally, or the imperative to mobilise quickly or to “room in” have potentially damaging effects on women whose knowledge frameworks differed from the dominant Pakeha culture of healthcare. These practices combined with a system designed for an imagined white middle class user, where professionals had knowledge deficits and monocultural and assimilatory attitudes, led to unsafe practices such as using family members and children as interpreters (my horror when a boy child was asked to ask his mother about the amount of lochia on her pad). The sanctity of birth, requiring the special, nurturing treatment of new mothers and a welcome from a community was superseded by the factory culture of maximum efficiency. Not all mothers were created equal, not young mothers, not older mothers, not single mothers, not substance using mothers, not indigenous mothers, not culturally different mothers. The sense that I was a cog in a big machine that was inattentive to the needs of “other” mothers led me to critique the effectiveness of cultural safety in the curriculum. How was it possible that a powerful indigenous pedagogical tool for addressing health inequity was not evident in clinical practice?

Photo of me as a staff nurse back in the day.

Photo of me as a staff nurse back in the day.

Leaving the post-natal ward, I took up a role helping to develop a new maternal mental health service in Auckland. There too I began to question the limitations of our model of care which privileged talking therapies rather than providing practical help and support. I was also staggered at the time at the raced and classed profile of our clients who were predominantly white middle class career women. Interestingly, the longer I was involved in the service the greater the number of ethnic women accessed the service. For my Master’s thesis, I interviewed Goan women about their maternity experiences in New Zealand, where the importance of social support and rituals in the perinatal period was noted by participants.

As much as it was important to register and legitimate cultural difference, I was also aware of the importance of not falling into the cultural awareness chasm. As Gregory Philips notes in his stunning PhD, it was assumed that through teaching about other cultures, needs would be better understood as “complex, equal and valid” (Philips, 2015). However, it didn’t challenge privilege, class and power. As Joan Scott points out:

There is nothing wrong, on the face of it, with teaching individuals about how to behave decently in relation to others and about how to empathize with each other’s pain. The problem is that difficult analyses of how history and social standing, privilege, and subordination are involved in personal behavior entirely drop out (Scott, 1992, p.9).

The problem with culturalism is that the notion of “learning about” groups of people with a common ethnicity assumes that groups of people are homogenous, unchanging and can be known. Their cultural differences are then viewed as the problem, juxtaposed against an implicit dominant white middle class cultural norm. This became evident in my PhD analysis of interviews with Korean mothers who’d birthed in New Zealand. In Australia and the US, cultural competence has superseded cultural awareness as a mechanism for correcting the limitations of universalism, by drawing attention to organisational and systemic mechanisms that can be measured but as a strategy for individual and interpersonal action, several authors draw attention to competence as being part of the “problem”:

The concept of multicultural competence is flawed… I question the notion that one could become “competent” at the culture of another. I would instead propose a model in which maintaining an awareness of one’s lack of competence is the goal rather than the establishment of competence. With “lack of competence” as the focus, a different view of practicing across cultures emerges. The client is the “expert” and the clinician is in a position of seeking knowledge and trying to understand what life is like for the client. There is no thought of competence—instead one thinks of gaining understanding (always partial) of a phenomenon that is evolving and changing (Dean, 2001, p.624).

In Wellness for all: the possibilities of cultural safety and cultural competence in New Zealand, I advocated for a combination of cultural competence and cultural safety. Cultural safety was developed by Indigenous nurses in Aotearoa New Zealand as a mechanism for considering and equalizing power relationships between client and practitioner. It is an ethical framework for practice derived from postcolonial and critical theory. Cultural safety proposes that practitioners reflect on how their status as culture bearers impacts on care, with care being deemed culturally safe by the consumer or recipient of care. In my PhD I wrote about the inadequacy of the liberal foundations of nursing and midwifery discourses for meeting the health needs of diverse maternal groups. My thesis advocated for the extension of the theory and practice of cultural safety to critique nursing’s Anglo-European knowledge base in order to extend the discipline’s intellectual and political mandate with the aim of providing effective support to diverse groups of mothers. In Australia, cultural responsiveness, cultural security and cultural respect are also used, you can read more about this on my post on Minding the Gap.

So let’s look at culturally safe maternity care. My experience as a clinician and researcher reveal a gap between how birth is viewed. In contemporary settler nations like New Zealand, midwifery discourses position birth as natural and the maternal subject as physically capable of caring for her baby from the moment it is born, requiring minimal intervention and protection. The maternal body is represented as strong and capable for taking on the tasks of motherhood. In contrast, many cultures view birth as a process that makes the body vulnerable, requiring careful surveillance and monitoring and a period of rest and nurturing before the new mother can take on new or additional responsibilities. The maternal body is seen as a body at risk (Mahjouri, 2008), and vulnerable requiring special care through rituals and support. Therefore, practices based on a dominant discourse of birth as a normal physiological event and neoliberal discourses of productive subjectivity create a gap between what migrant  women expect in the care they expect from maternal services. These practices also constitute modes of governing which are intended to be empowering and normalizing, but are experienced  as disempowering because they don’t take into account other views of birth. Consequently there is no recognition on the part of maternity services that for a short time, there is a temporary role change, where the new mother transitions into a caregiver by being cared for. This social transition where the mother is mothered is sanctioned in order to safeguard the new mother, a demonstration to value and protect both future capacity for mothering and long term well being, in contrast with dominant discourses of responsibilisation and intensive motherhood. Thus, instead of a few days of celebration or a baby shower, extended post-partum practices are enacted which can include the following (Note that these will vary depending on in group differences, urbanisation, working mothers, migration):

  • Organised support- where family members (eg mother, mother-in-law, and other female relatives) care for the new mother and infant. Other women may also be involved eg birth attendants.
  • Rest period and restricted practices- where women have a prescribed rest periods of between 21 days and five weeks, sometimes called “Doing the month”. Activities including sexual activity, physical and intellectual work are reduced.
  • Diet- Special foods are prepared that promote healing/restore health or have a rebalancing function for example because the postpartum period is seen as a time when the body is cold, hot food (protein rich) chicken soup, ginger and seaweed, milk, ghee, nuts, jaggery might be consumed. Special soups and tonics with a cleansing or activating function are consumed eg to help the body expel lochia, to increase breastmilk. These foods might be consumed at different stages of the perinatal period and some food might be prohibited while breastfeeding.
  • Hygiene and warmth- particular practices might be adhered to including purification/bathing practices eg warm baths, immersion. Others might include not washing hair.
  • Infant care and breastfeeding- Diverse beliefs about colostrum, other members of family may take more responsibility while mother recovers and has a temporarily peripheral role. Breastfeeding instigation and duration may differ.
  • Other practices include: binding, infant massage, maternal massage, care of the placenta.

If women are confronted with an unfamiliar health system with little support and understanding, they can experience stress, insecurity, loneliness, isolation, powerlessness, hopelessness. This combined with communication gaps and isolation, poor information provision, different norms, feeling misunderstood and feeling stigmatized. What could be a special time is perceived as a lack of care. Fortunately in Australia there are some excellent resources, for example this research based chapter on Cultural dimensions of pregnancy, birth and post-natal care produced by Victoria Team, Katie Vasey and Lenore Manderson, proposes useful questions for perinatal assessment which I have summarised below:

  • Are you comfortable with both male and female health care providers?
  • Are there any cultural practices that we need to be aware of in caring for you during your pregnancy, giving birth and postnatal period? – For example, requirements with the placenta, female circumcision or infant feeding method.
  • In your culture, do fathers usually attend births? Does your partner want to attend the birth of his child? If not, is there another close family member you would like to be present? Would you like us to speak to them about your care?
  • Are there any foods that are appropriate or inappropriate for you according to your religion or customs during pregnancy, birth and the postpartum period?
  • Are there any beliefs or customs prohibiting physical activity during pregnancy, birth and the postpartum period? Do you plan to observe these? – For example, a confinement period.
  • What is the culturally acceptable way for you to express pain during childbirth? – For example, screaming or trying to keep silent.
  • Are there any precautions with infant care?
  • How many visitors do you expect while you are in the hospital?
  • Do you have anyone in your family or community who can help you in practical ways when you get home?

Negotiating between cultural practices, values and norms, religious beliefs and views, beliefs about perinatal care is a starting point. It is also important to consider language proficiency, health literacy, quality of written materials, and level of acculturation. For further information on health literacy see the Centre for Culture, Ethnicity & Health (CEH) resources including: What is health literacy?, Social determinants of health and health literacy.  Using professional interpreters improves communication, clinical outcomes, patient satisfaction and quality of care, and reduces medical testing, errors, costs and risk of hospitalisation. Lack of appropriate interpreter service use is associated with adverse health outcomes. Centre for Culture,Ethnicity & Health (CEH) has excellent resources in this regard: Interpreters: an introduction, Assessing the need for an interpreter, Booking and briefing an interpreter, Communicating via an interpreter, Debriefing with an interpreter, Developing a comprehensive language services response, Language services guide Managing bilingual staff, Planning for translation, Recruiting bilingual staff.

Assessment should also consider:

  • Genetics and pregnancy: women’s age, parity, planning and acceptance of pregnancy, pregnancy related health behaviour and perceived health during pregnancy. 
  • Migration: women’s knowledge of/familiarity with the prenatal care services/system, experiences and expectations with prenatal care use in their country of origin, pregnancy status on arrival in the new industrialized western country.
  • Culture: women’s cultural practices, values and norms, acculturation, religious beliefs and views, language proficiency, beliefs about pregnancy and prenatal care.
  • Position in the host country: women’s education level, women’s pregnancy-related knowledge, household arrangement, financial resources and income.
  • Social network: size and degree of contact with social network, information and support from social network.
  • Accessibility: transport, opening hours, booking appointments, direct and indirect discrimination by the prenatal care providers.
  • Expertise: prenatal care tailored to patients’ needs and preferences.
  • Treatment and communication: communication from prenatal care providers to women, personal treatment of women by prenatal care providers, availability of health promotion/information material, use of alternative means of communication.
  • Professionally defined need: referral by general practitioners and other healthcare providers to prenatal care providers

A review by Small, Roth et al., (2014) found that what immigrant and non-immigrant women want from maternity care is similar: safe, high quality, attentive and individualised care, with adequate information and support. Generally immigrant women were less positive about care than non-immigrant women, in part due to communication issues, lack of familiarity with care systems, perceptions of discriminatory care which was not kind or respectful. The challenge for health systems is to address the barriers immigrant women face by improving communication, increasing women’s understanding of care provision and reducing discrimination. Clinical skills including—introspection, self-awareness, respectful questioning, attentive listening, curiosity, interest, and caring.

Also:

  • Facilitating trust, control
  • Delivering quality, safe care, communicating, being caring, providing choices
  • Facilitating access to interpreters and choice of gender of care provider,
  • Considering cultural practices, preferences and needs/different expectations for care
  • Engendering positive interactions, being empathetic, kind, caring and supportive.
  • Taking concerns seriously
  • Preserving dignity and privacy
  • Seeing a person both as an individual, a family member and a community member
  • Developing composure managing verbal and non-verbal expressions of disgust and surprise
  • Paradoxical combination of two ideas— being “informed” and “not knowing” simultaneously.

In that sense, our knowledge is always partial and we are always operating from a position of incompletion or lack of competence. Our goal is not so much to achieve competence but to participate in the ongoing processes of seeking understanding and building relationships. This understanding needs to be directed toward ourselves and not just our clients. As we question ourselves we gradually wear away our own resistance and bias. It is not that we need to agree with our clients’ practices and beliefs; we need to understand them and under-stand the contexts and history in which they develop (Dean, 2001, p.628).

Conclusion

In this presentation I have invited you to examine your own values and beliefs about the perinatal period and how they might impact on the care you might provide. I have asked you to consider both the similarities and differences between how women from culturally diverse communities experience maternity and those from the dominant culture. Together, we have scrutinised a range of strategies for enhancing trust, engagement and perinatal outcomes for all women. Drawing on my own clinical practice and research, I have asked you to consider an alternative conceptualisation of the maternal body when caring for some women, that is the maternal body as vulnerable, which requires a period of rest and nurturing. This framing requires a temporary role change for the new mother to transition into being a caregiver, by being cared for, so that her future capacity for mothering and long term well being are enhanced. I have asked you to reflect on how supposedly empowering practices can be experienced as disempowering because they don’t take into account this view of birth. In the context of differing conceptualisations of birth and the maternal body I have drawn special attention to: negotiating between health beliefs; having cultural humility; considering ways in which your own knowledge is always partial; and recommended a range of resources that can be utilised to ensure positive outcomes for women and their families. As health services in Australia grapple with changing societal demographics including cultural diversity, changing consumer demands and expectations; resource constraints; the limitations in traditional health care delivery; greater emphasis on transparency, accountability, evidence- based practice (EBP) and clinical governance (Davidson et al., 2006), questions of how to provide effective universal health care can be enhanced by considering how differing views can be incorporated as they hold potential benefits for all.

Selected references

  • Boerleider, A. W., Wiegers, T. A., Manniën, J., Francke, A. L., & Devillé, W. L. (2013). Factors affecting the use of prenatal care by non-western women in industrialized western countries: A systematic review. BMC Pregnancy and Childbirth, 13(1), 8.
  • Dennis, C. L., Fung, K., Grigoriadis, S., Robinson, G. E., Romans, S., & Ross, L. (2007). Traditional postpartum practices and rituals: A qualitative systematic review. Women’s Health (London, England), 3(4), 487-502. doi:10.2217/17455057.3.4.487.
  • Mander, S., & Miller, Y. D. (2016). Perceived safety, quality and cultural competency of maternity care for culturally and linguistically diverse women in queensland. Journal of Racial and Ethnic Health Disparities, 3(1), 83-98. doi:10.1007/s40615-015-0118.
  • Small, R., Roth, C., Raval, M., Shafiei, T., Korfker, D., Heaman, M. Gagnon, A. (2014). Immigrant and non-immigrant women’s experiences of maternity care: A systematic and comparative review of studies in five countries. BMC Pregnancy and Childbirth, 14(1).

Additional web resources

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“I had to keep my options open”: White mothers and neoliberal maternity

Unpublished manuscript that never found an appropriate institutional home, but sharing for those who might be interested. Cite as: DeSouza, R., & Butt, D. (2016, June 11). “I had to keep my options open”: White mothers and neoliberal maternity. [Web log post]. Retrieved from: http://ruthdesouza.dreamhosters.com/2016/06/11/i-had-to-keep-my-options-open-white-mothers-and-neoliberal-maternity/

Where patriarchal healthcare institutions saw birth as a process controlled by male doctors and supported by female nurses, contemporary midwifery draws from liberal feminism the concept of “choice” as the marker of maternal agency. However, critiques of neoliberalism locate “informed choice”, “empowerment” and “partnership” as discursive markers of specific capitalist subjectivities that are unevenly distributed among class, race, and sex. The ideology of reproduction as choice aligns with Foucault’s notion of “governmentality”, where the managerial state promotes middle-class discourses of responsibilisation, transformation and empowerment to regulate and maximise the efforts of individuals within the social body. Previous research has shown how maternal care nurses and midwives are instrumental in reproducing these discourses, reflecting white middle-class ideals of the individual service user. This study explored these themes through a secondary discourse analysis on focus groups with white migrant mothers in Aotearoa New Zealand. While migrant mothers noted differences between the New Zealand context and their home nation, unlike ‘other’ migrant mothers they generally adhered to neoliberal requirements to make choices aligned with the expectations of the state. The mothers espoused ideals of natural birth that sat in tension with their notions of informed consumption, reflecting technoscientific discourses that have informationalised the maternal body and interpellated mothers into neoliberal ideologies. The paper argues that attention to the restricted discourses of choice as empowerment illuminates how settler-colonial maternal healthcare systems are limited in their universality, failing to escape cultural and class-based assumptions that empower some mothers at the expense of others. The paper concludes that critical healthcare analysis and methodologies such as cultural safety provide tools for the transformation of these discourses.

Keywords 
Maternity, whiteness, neoliberalism, Foucault, cultural safety.

Introduction

Midwifery discourses have advanced a feminist vision of women’s empowerment where women usurp patriarchal control of maternity institutions and increase their own power by becoming informed. However, the intrapersonal strategies of information accumulation and behaviour modification can leave structures of power intact and fulfil neoliberal ends. Facilitating a non-authoritarian, woman-centred ethic of care through liberal feminist values (such as individual choice and autonomy) allows mothers to choose to be healthy and productive, while also leading to a reduction in demands on the state as women govern themselves and each other (Collins, 2009). Although midwifery has positioned itself outside dominant norms as an anti-authoritarian discourse, these ‘choices’ are made within a neoliberal consumerist context of health care (Spoel, 2007). Midwifery is simultaneously constructed by these norms and reproduces them, masking new forms of social regulation shaping health care delivery in the process (Skinner, 1999; Spoel, 2006; O’Connell and Downe 2009). Consequently, the emancipatory promise of liberal feminism has disturbingly converged with the economic ‘freedoms’ of neoliberalism, in a discursive formation structured by whiteness. Where previous work established this formation in the discourses of maternal and child health nurses, this paper diagnoses neoliberal discourses employed by white informed consumers.
The dominance of whiteness in Western healthcare systems has been well established (see e.g. Allen, 2006). The liberal theoretical paradigm is deeply embedded in nursing, where those employed in care are rarely able to see how it structures their professional culture, in turn making it difficult to understand how adherence to seemingly neutral and egalitarian values (to white norms) can be oppressive. Whiteness here does not refer only to the visible phenotype of individuals, but to “a cultural disposition and ideology held in place by specific political, social, moral, aesthetic, epistemic, metaphysical, economic, legal, and historical conditions, crafted to preserve white identity and relations of white supremacy” (Bailey & Zita, 2007: vii). Although it is a scientific and cultural fiction like other racial identities, it has a real social impact on the distribution of resources due to a “possessive investment in whiteness” among white individuals (Lipsitz, 2006). A combination of public policy and private prejudice operate simultaneously to create this investment and perpetuate racialised hierarchies that structure access to resources, power and opportunity. Lipsitz contends that white supremacy is less a direct expression of contempt (as usually described by whites who distance themselves from the term), and more a system that protects white privilege and prevents communities of colour from accumulating assets and upward mobility. Complicating any direct identitarianism, Lipsitz contends that non-white people can become agents of white supremacy as well as passive consumers in its hierarchies— not all white people are equally complicit with white supremacy. White dominance and neoliberalism are two powerful and interrelated concepts that describe the systemic and structural forms that produce and reproduce ideal subjectivities. It is this relationship between subjective experience and institutional rationality that this paper seeks to illuminate.
Liberalism and neoliberal maternity
The revalorisation of liberal precepts into the global structures of institutional power termed neoliberalism has been most thoroughly documented by Michel Foucault. Foucault’s analysis of governmentality as “both a political discourse about the nature of rule and a set of practices that facilitate the governing of individuals from a distance” (Larner, 2006: 6) has particular resonance in health and in maternity. The birth of a future citizen is an event with great emotional, biological, cultural and social significance; and consequently the rites and routines that organize birth reflect core cultural values (Fox & Worts, 1999; Reiger, 2008). Maternal and infant public health has been shaped by state concern about the quantity and quality of population in the context of imperial rivalry, both in the centre of empire and the outer edge of white settlement (Lewis, 1988). The “health of the race” and infant health have been a central focus for doctors and politicians, with babies viewed as valuable assets in the struggle for imperial supremacy (Lewis, 1988). While such explicitly racial discourses are today less prevalent, maternity discourses and practices still reflect and reproduce historical and cultural visions of what it is to be a citizen (Georges, 2008). Good mothering and good governing are intimately linked. Foucauldian analysis in health has shown how institutions produce subjects as citizens, where health professionals are not simply individual agents constrained by institutions but develop their values, beliefs and skills within parameters guided (but not fully determined by) those institutions. Healthcare professionals such as nurses and midwives manage key processes through which hegemonic social subjects are reproduced, and thus reflect transformations in ideologies of the public and the citizenry (Fox & Worts, 1999). Maternal health is therefore a rich site to track shifts in public health from a sovereign technique of population management to a global industry in a neoliberal economic system.

Foucault’s analysis in The Birth of Biopolitics identified neoliberalism as the development of a “general regulation of society by the market” (Foucault, 2008: 145). It involves the enforcement of competition (rather than exchange) as the principle of the market in a game which one is not allowed to drop out of, “a sort of inverted social-contract” (Foucault, 2008: 201). Neoliberal economics becomes “no longer the analysis of the historical logic of processes; it is the analysis of the internal rationality, the strategic programming of individuals’ activity” (Foucault, 2008: 222). In this game, economics is redefined as a behavioural science governed by the “relationship between ends and scarce means which have mutually exclusive uses” (Foucault, 2008: 222). This “competitive ratio” is naturalised, and the neoliberal subject “accepts reality” by responding to “systematic modifications artificially introduced into the environment” — becoming “eminently governable” (Foucault, 2008: 270). Through the extension of market values to all institutions and social action, good neoliberal citizens are constructed as choice-making subjects, who take responsibility for maximising their healthy productivity and minimising risks to their health, reducing collective health demands upon the state.
Historically, women’s freedom during pregnancy was constrained by structural or physical factors to ensure the safety of mother and foetus. Improvements in health have led to the emergence of more subtle kinds of governmental regulation, where normalising strategies focussing on individual ‘lifestyle’ have developed in tandem with the new public health and risk discourses (Petersen & Lupton, 1996). Self-regulation through the internalisation of scientific knowledges and medical technologies and the corresponding modification of behaviour have become central to a type of ideal neoliberal subjectivity variously identified as the healthy citizen (Petersen & Lupton, 1996), the active consumer (Fox, Heffernan, & Nicolson, 2009) and the reflexive project of the self (Giddens, 1991).

Mothers are incited to take up the advice and guidance of experts; are incorporated into relations of surveillance and discipline; and are required to monitor and adapt their behaviour against normative discourses. Ideal neoliberal maternal subjects are scientifically literate, meet normative standards, and consume specialty objects and expert advice (Avishai, 2007). They invest in “intensive motherhood”, a pervasive ideology in Western culture that is: “child-centered, expert-guided, emotionally absorbing, labour intensive, financially expensive” Hays (1998: 46).
As Simon and Dippo (1986: 198) note, a historical and material perspective is required to understand the “nonarbitrary specificity” of power relations in the present, “for while the production and reproduction of social forms is a result of what people do, it can never be understood in terms of what they intend.” To that end, contemporary maternal speech must be linked to the historical conditions of its emergence. The history of midwifery development provides structural clues to the emergence of dominant discursive formations of maternity in New Zealand that enable, constrain and contest the narrated experience of migrant mothers.
Midwifery in New Zealand: erosion, erasure and re-emergence

Midwifery’s emergence as an autonomous feminist profession in New Zealand has been shaped by the desire for professional recognition among midwives and feminist aspirations for the control of birth to be returned to women, (Stojanovic, 2008). Midwifery training began in 1904 with the advent of the Midwives Act, prior to which trained midwives were imported from Britain. Free midwifery services became available to all women from 1938, either in their homes or in maternity hospitals (Pairman, 2006). The trends of medicalisation, hospitalisation and nursification eroded the autonomy of midwifery between 1904 and the 1970s (Stojanovic, 2008). For Māori, the Tohunga Suppression Act (General Assembly of New Zealand, 1907) curtailed the active involvement of tohunga (traditional knowledge specialists) in childbirth, and the expertise of Māori birth attendants or tāpuhi remained suppressed as midwives were trained in New Zealand. With fewer tāpuhi assisting birthing women in their homes, childbirth became relocated into state-owned maternity hospitals, which in the colonial view were thought to be safer and cleaner than Māori homes (Simmonds, 2011), even though Māori maternal mortality rose to three times that of non-Māori by the 1960s. Interventions to reduce infant mortality coupled with demands from women for pain-free childbirth increased the medicalisation of birth, leading to doctors supervising midwifery births and holding legal responsibility (Pairman, 2006). Nursification saw the merging of midwifery into nursing, the erasure of the word ‘midwife’ from legislation and the redefinition of the scope of midwifery practice within nursing (Stojanovic, 2008).
Autonomous midwifery practice (differentiated in scope from nursing) re-emerged through mutually beneficial political lobbying by consumers and midwives forcing legislative changes in the late 1980s. Spurred by decades of feminist struggle, maternity consumer activists saw autonomous midwifery practice as a mechanism for gaining increased control over their own birthing (Pairman, 2006). This pressure eventually led to the passing of the Nurses Amendment Act in 1990 which provided New Zealand women with the option of a caregiver (Lead Maternity Carer or LMC) who could either co-ordinate or provide the care they required from early pregnancy to six weeks postpartum (Pairman, 2006). Consequently, 75.3% of New Zealand women were registered with a midwife to provide lead maternity care in 2007 (Ministry of Health, 2007). Hence, partnership with women became a central tenet of New Zealand midwifery and to its claim as protector of the health of women from an intervening medical corpus (Reiger, 2008). The discourse of ‘partnership’ positions women as ‘naturally’ equipped and capable of carrying and delivering babies without physician monitoring or intervention in hospitals (Macdonald, 2006). The social model of this discourse locates risk not within the female body as under the medical model, but from power relations in the social world including poor support for women. In response, midwives have the capacity to nurture and empower the autonomous woman so that she is capable of birth without intervention (Lane, 2012). The study discussed here consisted of focus groups with mothers and maternal care professionals to evaluate the effects of these discourses and institutional arrangements on different groups of migrant women.
Study Design

The focus groups for this project were undertaken with the assistance of The Royal New Zealand Plunket Society (Plunket), and consisted of focus groups with five ethno-cultural groupings of new migrant mothers (including white mothers) about their maternity experiences (DeSouza, 2006; DeSouza, 2011). Ten first time mothers aged between 29-40 years, who had been living in New Zealand for between two and ten years took part in the white focus group. The women self-identified as ‘white’ and had migrated from South Africa (Jane and Charlotte), England (Nancy, Annette, Olive, Sarah, Carol), the US (Joan and Mary) and Scotland (Georgina). Four had post-graduate qualifications; four had under-graduate qualifications and one a trade certificate. Their occupations included: teacher, scientist, project manager, account manager, project manager, lecturer. Reasons for migrating included the New Zealand lifestyle and their husband’s careers. The group are not intended to be representative of all white female migrants, although the demographic bias of white migrants to New Zealand skews toward the upper-middle class. Of interest here are the range of available subject positions in the discourses represented and what implications those subject positions hold. Discourse analysis can aid understanding of the relationship between “subjectification (the condition of being a subject) and subjectivity (the lived experience of being a subject)” (Walkerdine, 2001: 20). In this case, the focus is on discourses of knowledgeable consumption, natural birth, and intensive motherhood.
Knowledgeable antenatal consumers

Mary invokes liberal feminist/woman centred tenets of choice, freedom and autonomy when she speaks about becoming pregnant through assisted reproductive technologies:

Mary: Artificial insemination… was something that was incredibly easy in New Zealand whereas in the States it would’ve been a lot more difficult and more expensive. For us moving to New Zealand was partly a life-style choice, we had a known donor and we found that we went to a fertility class and it was just incredible how helpful and inclusive they are and everything was really easy to do… more information is always good for us and we found that there was plenty of information for us. It’s like I said before we’ve been planning this for over five years so that was, their resources were there for us.

Mary’s excerpt reflects the liberal feminist ideal of a planned pregnancy and the control of reproductive processes (even in the context of assisted fertility), to which the democratisation of knowledge, its acquisition and demystification are fundamental. Mary positions herself as a responsible health consumer who makes choices (including migrating), within a caring and available system. She actively searches for and chooses the appropriate information, products and services from a saturated global market. Migration is a space where she can realise possibilities for mobility and self-actualisation, imbricating maternity in local and global patterns of consumption. Annette also positions herself as a knowledgeable and responsible consumer, who can both evaluate and challenge expert knowledges:

Annette: Although our doctor suggested certain paths that we could take I wasn’t necessarily in total agreement with what he wanted so I was trying to combine his knowledge with the information that I was reading as well.

Annette’s capacity to act and make choices is evident in her avoidance of informal and embodied knowledge in favour of formal knowledge:

Annette: When I found that I was pregnant the first thing I did was I bought a book named New Zealand Pregnancy Guide… although we have a lot of friends here I didn’t feel that I was in a position where I wanted to talk to anybody about the pregnancy because it was so early and I felt that the more people that I talked to and asked for their advice then if I did miscarry I’d have to tell everybody that I’d miscarried. So I was in that situation of having to try and discover a lot of information out by myself initially and I found that was a little bit overwhelming at times. But that book was particularly useful and then I phoned I think the Ministry of Health and got a list of midwives. And then to be quite honest it was absolutely useless, because I just looked at this list and I’m going, ‘well where do I start’? So you are in this catch 22 thinking ‘do I phone this person? Would they come to me because we’re on the other side of town?’ I didn’t have any recommendations. It was literally a list and it meant nothing to me.

Annette’s preference for purchasing a book of expert knowledge about pregnancy in New Zealand—rather than seeing her networks and friends as primary resources—is emblematic of her desire to produce herself as an autonomous, composed, and rational individual, avoiding public judgement upon her possible failure to reproduce. Her unwillingness to expose her pregnancy and potentially complicate social relationships means that she loses out on possible social support, information and referrals, which could enable the transition to parenthood.
Natural birth
The rewards of antenatal preparation are realised when women describe feeling informed and in control of their birth experiences, aligning with midwifery discourses of natural birth (Brubaker & Dillaway, 2009).

Mary: Well I thought we were going to have a very sort of natural birth with no drugs although I was hoping to take drugs if I was in pain. I found the antenatal explanation of how what happens in a C-section very useful as I ended up having a C-section. And the fact that they explained, ‘ok all of these people are going to be there and it’s going to be a person on your right is going to be your doctor and the person with the baby’, and all of that… I had a really negative reaction to all the drugs and when she explained again who was going to be in the room it was exactly the same as what the antenatal person had said.

Mary’s antenatal preparation equips her for an unintended Caesarean, but instead of feeling cheated by the requirement for medical intervention, she surfaces the woman-centred natural birth discourse of feeling in control and informed. Thus birth can be considered ‘natural’ despite medical intervention, as long as the labouring mother chose the intervention (Macdonald, 2006).
Charlotte’s narrative also captures the two competing discourses of birth that Mary situates herself in. On the one hand, Charlotte values having self-control (through being informed and behaving accordingly) and on the other is willing to surrender control—the choice to rescind action is also a choice (Lupton, 1994):

Charlotte: I just have to say to myself you know we’ve even had to go with the flow, and then also those booklets that you receive on feeding, those pamphlets. I did a lot of reading and my midwife gave me a lot of information. The information from those pamphlets helped me a lot and so I felt comfortable, like I’m on the right track now so everything is going well. So I was trying to speak to myself and keep calm (speaks quietly). I was in labour for since the Saturday and I gave birth on Monday morning so (laughter) I had to keep my options open as well about taking drugs so you know things like that.

Charlotte presents herself as a self-efficacious middle class maternal subject, able to internalise information and adapt her behaviour accordingly through self-discipline, self-denial and will power. Disciplining herself by subsuming her own distress and fear, aligns with the needs of the institution for calm consumers, who are more compliant and require less time and support than distraught ones.
Being given the right information at the right time made Charlotte feel supported:

Charlotte: The midwife that delivered my baby is actually from New Zealand but she worked in Cape Town for three years so that was good, that connection. She told me, step by step where and what stage I’m at. I think that’s the biggest support that you really need in the delivery room is to tell you at what stage you are at and what’s happening.

It is significant that Charlotte constructs her midwife as the person who delivers her baby rather than facilitates Charlotte’s ability to birth her baby. She discursively positions her midwife as a translator, who can link what is happening in her body to an identified physiological process. This positioning challenges midwifery discourses of the mother as ‘expert’ as the midwife’s role as a translator reinforces a hierarchy reminiscent of biomedicine.

Jane actively and discursively resists biomedical discourses, until she acquiesces to Entonox:

Jane: I was trying to still keep my energy up by eating and drinking as much water as possible. My choice was that I wanted to stay at home as long as possible, I didn’t want to be in the hospital for too long because when I start thinking of all the other options, and I wanted a natural childbirth, no assistant and also no pain relief. At the end for about 2 ½ hours before baby was delivered I chose Entonox with the gas and that helped. As the pamphlets also say I actually felt distance from the actual experience so if I think back I would’ve actually chosen nothing but I just felt at that stage I needed something and I chose that. So fortunately baby was in the right position, in a good position so I didn’t have to have a Caesarean. I was more scared of the Caesarean than the pain and I wanted a natural childbirth.

Jane positions herself within midwifery discourses of natural birth, disciplining her body so that she avoids hospital as much as she can, and engaging in deliberate bodily maintenance so she can maximise the efficiency of her body and have the energy to labour. She constructs a natural birth as one where she uses pain relief as a last resort.

Nancy disciplines her body through specific breathing techniques learned outside the health system:

Nancy: Yes. At the beginning of my pregnancy I was kind of really worried about actually giving birth. But what really helped me was I went to do yoga in pregnancy and through that they talked a lot about it and they did sort of breathing and just general exercises to help you kind of keep calm and focused. And at the end of it I really wasn’t worried about it at all and I thought I might even be able to get through this without drugs but I didn’t in the end, I gave in, in the last couple of hours.

Nancy positions herself as a good mother to be, taking control and acting to promote her own health and wellbeing through natural breathing. Nancy’s expectation that her body would be able to cope with birth naturally and without medical intervention reflects her incorporation in woman centred/natural birth discourses. Her acceptance of a biomedical intervention in the form of pain relief in the last few hours is presented as a capitulation, and reflects her perception of the control she had in the process and her failure to accomplish a natural process.
Intensive motherhood
The post-partum period is characterised by the demands of intensive mothering. Producing oneself in the discourses of the “good mother” requires taking sole responsibility for the well-being of the infant while being isolated and having minimal support. The post-natal ward represents a space where the rude transition from women-centred discourses to intensive mothering begins. There is a glaring shift from one-to-one attention from midwives, to competition for support and assistance with other new mothers:

Olive: I mean the actual labour and delivering – fantastic. I couldn’t fault them and the staff was superb, the midwife was just brilliant, the obstetrician fantastic. When I got on the ward I found it really hot, I felt really overwhelmed. I was right next to this buzzer and it just went buzzing all the time because everybody wanted help, I found that really quite distressing and I was absolutely knackered.

The clamour of the buzzer and interruptions signal a consequence of being returned to the factory model of maternity. Olive experiences a shift from care described in superlative terms to feeling overwhelmed, distressed and tired. Meanwhile, Nancy recognises that her expectations were primarily oriented to the birth event with no real preparation for the post-partum period:

Nancy: I just want to say in terms of thinking after the birth, and how it was compared to expectations, I didn’t really have any expectations of after the birth, everything was concentrated about the labour and, ‘oh God, it’s going to feel terrible’ and after the birth it just hit me like that and it was hell for six weeks more or less it was just hell… Yes and I wished somebody had actually told me that it was going to be that hard.

Nancy assumes that if she had been given the information, this post-partum period would have been easier for her, reflecting the notion of autonomous rational personhood that with planning and control of one’s circumstances, future success can be ensured (Wall, 2010).

Interviewer: What was the “hell”?

Nancy: Mainly lack of sleep, lack of sleep and just coping with a crying baby, and I had my Mum and I was lucky she was there for the first three weeks and she did the housework, the cooking and stuff. [Group laughter]
Jane: I also think you also just feel like a robot, cleaning the bottles, making a bottle, breast-feeding, in a little corner all the time, just you and the baby.

The mothers in the group identify a conspiracy of sorts. Much of their preparation for the world of parenthood revolved around knowledge acquisition, maintaining good health during their pregnancies and having control during their labour, none of which help in the postnatal period.
In the quotes that follow, the limitations of expert knowledge and self-sufficiency are identified and Nancy identifies the difference support might make for her.

Nancy: It would’ve been different in that I would’ve had a lot more support and for me a lot of my anxieties around that was I didn’t have anyone to talk to, and particularly (baby crying). And yes OK you meet people at your antenatal group but at that time they’re not your closest friends that you can say anything too. And having said that I did, you know… But I think that was it for me was thinking, ‘oh my God, I just need some adult conversation’. And that’s what I struggled with most probably.

Emotional support and having a confidant require time and energy, and an investment, which can be drawn on. The friendships Nancy has made cannot be drawn on for the kind of support she needs. For Georgina, the absence is emotional as well as practical—in the form of having ‘time out’ for errands or for ‘couple time’:

Georgina: Yes you do miss the support network, friends as well. I’ve got a lot of friends back home who have got kids and I think you miss that as well… Not just family but friends who would maybe be a bit more candour than you might take from them or what you feel than you take from close family and things. So I definitely miss that and also, we were just back home and it was just so nice…you know tight as you are, what simple things, like I needed to go out and do couple of things and I knew I was only going to be half an hour or so and to actually have somewhere to leave him and it would take me half the time.

Discussion and Conclusion

Women who identified as ‘white’ in this study constructed themselves within liberal feminist and neoliberal discourses as consumers who were rational unified actors. They were interpellated as competent selectors and consumers of maternity services, and moral value was attached to their ability to engage in self-reliant behaviours. They embraced the neoliberal psychological imperative to improve and transformed themselves, responding positively even in the most difficult of situations (Baker, 2009). These practices reflect women’s engagement in ‘techniques of the self’ that are constitutive of neoliberal subjectivity. The white mothers conform to the ideal of the good mother (to be) by discursively positioning themselves as taking appropriate individual care and responsibility for their pregnancies and maternal care.
The speech of the women reflects three specific discourses of liberal feminist maternity that form the basis of normative midwifery ideologies.
Firstly, the women routinely position themselves as knowledgeable consumers of authoritative maternity information provided by the health system. Critically interrogating the authority of biomedicine by coordinating and evaluating diverse sources of information is central to woman-centred discourses, where acquiring authoritative knowledge both bypasses medical control and is a way to claim empowerment, subjectivity and agency (Edwards, Davies, & Edwards, 2009). Her ‘preparation’ for motherhood through the acquisition of knowledge valorises scientific/professional knowledge rather than the informal and personalised information or social and emotional support that friends and extended family can provide (Marshall & Woollett, 2000). Authoritative professionals transmit information to individual women whose embodied, enculturated understandings and experiences are discounted or devalued. Yet individual women are expected to engage in reflexive techniques and /or practices of subjectification, to be accountable for the choices that are made, and to account for their behaviours to those who are tasked with monitoring and validated for monitoring them (Stapleton & Keenan, 2009). Thus regulatory technologies “construct an autonomous subject whose choices and desires are aligned with the objectives of the state and other social authorities and institutions” (Petersen & Lupton, 1996: 64).
Secondly, natural birth is positioned as a goal, suppressing technical and industrial discourses associated with medicalisation, except as far as they are in control of the mother. The women articulate being informed and having control, autonomy or authority despite experiencing various degrees of obstetric intervention. As middle-class women are more likely to receive the birth and/or medical treatments they desire, pregnancy and childbirth can be framed as contributing to their personal growth (Brubaker, 2007). In this paradigm of actualisation, it is assumed that intentional actions, self-discipline, self-denial and will power will achieve the ‘right’ kind of birth, and that intervention from a public health system is not a default practice but a considered choice of the mother based on information. In other words, a ‘natural birth’ does not happen naturally, but is chosen as an expression of the knowledgeable consumption discussed above.

Finally, the excerpts on intensive motherhood highlight how this responsibility for maternal self-expression and knowledge is a critical instrument of women’s control in the post-partum period. The mother’s needs are marginalised, as mothers take on most of the responsibility for nurturing and developing the sacred child. Pregnant women and their partners are subject to discipline, given that they are held responsible for maximising their own health and that of their foetus‘ and then infant’s body (Collins, 2009). Intensive mothering is intertwined with a neoliberal rationality, where individual responsibility and self-management are fore-grounded and social support is reduced compared with earlier in the perinatal period (Wall, 2001). Neoliberal discourses place individual responsibility for parenting on mothers, shifting the costs and the burden of work from public resources to household resources. The gendered aspects of these discourses are visible in the assumptions of reproductive heteronormativity, where market production separates the private and public spheres with women taking responsibility for childrearing. These discourses assume that households are based on a nuclear family; that caring labour is divided on the basis of gender, and that this labour is elastic and must expand to fit demand. In turn, the domain of the private is subject to surveillance and regulation to account for responsibilisation, or the ways in which public tasks become the responsibility of individuals, the private sector and community (Schinkel & Van Houdt, 2010; Clarke, 2004). In the postpartum, women note that they are treated like a “normal person”, a labouring, productive figure rather than the choice-making perinatal consumer. The responsibilities for infant care and repetitive ‘robotic’ household tasks seem overwhelming, and there is a sense of failure and disillusionment with the system and with providers that cannot be displaced through their well-developed information gathering strategies.
The interplay of the three discourses has significant implications for maternal mental health, as they locate the “specialness” of birth in decisions which are seen to be under the mother’s individual control, when in fact broader class positions are strongly determinant of what services and support are available. The incentives to locate maternal knowledge in an individual relationship with an authoritative caregiver produce dependence on a system that shifts risk and responsiblity onto the individual. These assumptions come to structure the professional habitus of nursing and midwifery professionals, who adopt regulatory behaviours that fail to support women who do not subscribe to white middle-class ideals. Governing occurs through the aspirations of mothers, and while the state appears to be protecting the interests of infants and parents, little in the way of actual resources are provided. These neoliberal discourses of individual responsibility constructed through dependence on knowledge also disempower women who do subscribe to these ideals, as the institutional withdrawal of support in postnatal care cannot be addressed by the skills the knowledgeable consumer has developed.
Conclusion
In recent decades the capacity of liberal feminist frameworks to provide effective support to non-Western women has been questioned, and midwifery has not been exempt. In New Zealand, the discursive emphasis of being ‘with woman’ implied in the etymology of the word midwife is central to indigenous critiques of Pākeha (white/European) midwifery (Kenney, 2011). Kenney notes that the Pākeha liberal feminist agenda privileges the individual while neglecting the familial context of pregnancy and birth. In contrast, the Māori word for midwife ‘kaiwhakawhānau’ emphasises the facilitation, creation and development of whānau (family). This discursive contrast between Māori models of midwifery has heightened significance in the context of the under-representation of Māori midwives (6.4%) when Māori births comprise approximately 28% of total births and in the context of and inequalities in birth outcomes between Māori and non-Māori (New Zealand Health Information Service 2010 cited in Kenney 2011; Ratima& Crengle, 2012). Midwifery as a profession has attempted to redress these injustices by incorporating Māori cultural principles and values (Ngā Turanga Kaupapa) in midwifery practice competencies (Kenney, 2011), and the development of cultural safety has become a central, if contested tenet of nursing education in New Zealand (Ramsden 1997; DeSouza 2008).
A consistent aim of cultural safety training in nursing has been to deconstruct the implicit racism of the healthcare system, by asking practitioners to reflect on one’s practice, values and cultural assumptions (Browne et al., 2009). In other words, it asks all of us involved in the health system to understand our own position as culture-bearers. Yet, the assumptions of white culture are hard to identify as the norms and commitments of whiteness are naturalised by their ubiquity and dominance. This culture not only shapes practitioner values but also shapes the dominant voices of those consumers who receive and evaluate care, while marginalising women outside these cultural assumptions. Operationalising critical feminist and postcolonial critiques through cultural safety can help nurses understand how the discourses they use are shaped by wider social discourses, which can then be critically interrogated (Browne, 2005). This analysis has aimed to contribute to this project by identifying three norms of white maternity that are normalised in alignment with neoliberal principles: the knowledgeable consumer, natural birth and intensive motherhood. These norms contrast to the discourses that have been identified in the literature on migrant maternity, which generally reflect less of an individualised focus on choosing the experience of birth and more on the presence or exclusion of wider family and social supports. Given the shock and isolation many women experience in the transition from impending mother to intensive mothering, critically advocating for those diverse structures of support can potentially benefit all mothers.
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Acknowledgements

Many thanks to Debbie Payne, David Allen, Ray Nairn and Tim McCreanor for their helpful conversations and feedback.

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All I want for Christmas is… On International Day of Solidarity with Migrants 2015

December 18th marks the anniversary of the signing of the International Convention on the Protection of the Rights of All Migrant Workers and Members of Their Families by the United Nations in 1990. Lobbying from Filipino and other Asian migrant organisations in 1997, led to December18th being promoted as an International Day of Solidarity with Migrants. The day recognises the contributions of migrants to both the economies of their receiving and home countries, and promotes respect for their human rights. However, as of 2015, the Convention has only been signed by a quarter of UN member states.

2015 has seen the unprecedented displacement of people globally with tragic consequences. UNHCR’s annual Global Trends report shows a massive increase in the number of people forced to flee their homes. 59.5 million people were forcibly displaced at the end of 2014 compared to 51.2 million a year earlier and 37.5 million a decade ago.

Politicians and media have a pivotal role in agenda setting and shaping public opinion around migrants, refugees and asylum seekers. A 100-page report, Moving Stories, released for International Migrants Day reviews media coverage of migration across the European Union and 14 countries across the world. The report acknowledges the vulnerability of refugees and migrants and the propensity for them to be politically scapegoated for society’s ills and has five key recommendations, briefly (p.8):

  1. Ethical context: that the following five core principles of journalism are adhered to:
    accuracy, independence, impartiality, humanity and accountability;
  2. Newsroom practice: have diversity in the newsroom, journalists with specialist knowledge, provide detailed information on the background of migrants and refugees and the consequences of migration;
  3. Engage with communities: Refugee groups, activists and NGOs can be briefed
    on how best to communicate with journalists;
  4. Challenge hate speech.
  5. Demand access to information: When access to information is restricted, media and civil society groups should press the national and international governments to be more transparent.

Much remains to be done, but it is heartening to see Canadian Prime Minister Justin Trudeau’s response to the arrival of thousands of Syrian refugees: 

You are home…Welcome home…

Tonight they step off the plane as refugees, but they walk out of this terminal as permanent residents of Canada. With social insurance numbers. With health cards and with an opportunity to become full Canadians

Trudeau’s response sharply contrasts with that of the United States, where many politicians have responded to Islamophobic constituencies with restrictions or bans on receiving refugees. The welcome from Indigenous Canadians to newly arrived refugees has also been generous and inclusive, considering that refugees and migrants are implicated in the ongoing colonial practices of the state. These practices can maintain Indigenous disadvantage while economic, social and political advantage accrue to settlers. It is encouraging that Trudeau’s welcome coincided with an acknowledgement of the multiple harms Canada has imposed on Indigenous people since colonisation. 

Alarmingly, the center-right Danish government’s bill currently before the Danish Parliament on asylum policy, allows for immigration authorities to seize jewellery and other valuables from refugees in order to recoup costs. The capacity to remove personal valuables from people seeking sanctuary is expected to be effective from February 2016 and has a chilling precedent in Europe, as Dylan Matthews notes in Vox:

Denmark was occupied by Nazi Germany for five years, from 1940 to 1945, during which time Germany confiscated assets from Jewish Danes, just as it did to Jews across Europe. Danish Jews saw less seized than most nations under Nazi occupation; the Danish government successfully prevented most confiscations until 1943, and Danes who survived the concentration camps generally returned to find their homes as they had left them, as their neighbors prevented Nazis from looting them too thoroughly. But Nazi confiscations still loom large in European historical memory more generally.

The UN, the Parliamentary Assembly of the Council of Europe (PACE) and the International Organization for Migration (IOM) have advocated for the development of regional and longer term responses. Statements echoed by Ban Ki-moon which proposed better cooperation and responsibility sharing between countries and the upholding of the human rights of migrants regardless of their status (Australia take note). He proposes that we:

must expand safe channels for regular migration, including for family reunification, labour mobility at all skill levels, greater resettlement opportunities, and education opportunities for children and adults.

On International Migrants Day, let us commit to coherent, comprehensive and human-rights-based responses guided by international law and standards and a shared resolve to leave no one behind.

What does this all mean for Australia and New Zealand? I’ve written elsewhere about the contradiction between the consumptive celebrations of multiculturalism and the increasing brutality and punitiveness of policies in both countries; the concerns of Australia’s key professional nursing and midwifery bodies about the secrecy provisions in the Australian Border Force Act 2015 and the ways in which New Zealand is emulating a punitive and dehumanising Australian asylum seeker policy.

It is appropriate then in this season of goodwill and peace to write an updated Christmas wish list, but with a migration focus. As a child growing up in Nairobi, one of my pleasures around Christmas time was drawing up such a list. I was so captivated with this activity that I used to drag our Hindu landlord’s children into it. This was kind of unfair as I don’t think they received any of the gifts on their list. For those who aren’t in the know, a wish list is a list of goods or services that are wanted and then distributed to family and friends, so that they know what to purchase for the would-be recipient. The idea of a list is somewhat manipulative as it is designed around the desires of the recipient rather than the financial and emotional capacity of the giver. Now that I’ve grown up a little, I’ve eschewed the consumptive, labour exploitative, commercial and land-filling aspects of Christmas in favour of spending time with family, as George Monbiot notes in his essay The Gift of Death:

They seem amusing on the first day of Christmas, daft on the second, embarrassing on the third. By the twelfth they’re in landfill. For thirty seconds of dubious entertainment, or a hedonic stimulus that lasts no longer than a nicotine hit, we commission the use of materials whose impacts will ramify for generations.

So, this list focuses on International Day of Solidarity with Migrants. All I want for Christmas is that ‘we’:

  1. End the Australian Government policy of turning back people seeking asylum by boat ie “unauthorised maritime arrivals”. 
  2. Stop punishing the courageous and legitimate right to seek asylum with the uniquely cruel policy of mandatory indefinite detention and offshore processing. Mandatory detention must end. It is highly distressing and has long-term consequences.
  3. Remove children and adolescents from mandatory detention. Children, make up half of all asylum seekers in the industrialized world. Australia, The United States, the United Kingdom, Germany and Italy directly contradict The Convention on the Rights of the Child (UNCRC).
  4. Engage in regional co-operation to effectively and efficiently process refugee claims and provide safe interim places. Ensure solutions that uphold people’s human rights and dignity, see this piece about the Calais “Jungle”.
  5. End the use of asylum-seeker, refugee and migrant bodies for political gain.
  6. Demand more ethical reporting by having news media: appoint specialist migration reporters; improve training of journalists on migration issues and problems of hate-speech; create better links with migrant and refugee groups; and employ journalists from ethnic minority communities, see Moving Stories.
  7. Follow the money. Is our money enabling corporate complicity in detention? Support divestment campaigns, see X Border Operational matters. Support pledges that challenge the outsourcing of misery for example No Business in Abuse (NBIA) who have partnered with GetUp.
  8. Support the many actions by Indigenous peoples to welcome refugees. Indigenous demands for sovereignty and migrant inclusion are both characterised as threats to social cohesion in settler-colonial societies.
  9. Challenge further racial injustice through social and economic exclusion and violence that often face people from migrantnd refugee backgrounds.
  10. Ask ourselves these questions:‘What are my borders?’ ‘Who do I/my community exile?’ ’How and where does my body act as a border?’ and ‘What kind of borders exist in my spaces?’ The questions are from a wonderful piece by Farzana Khan.

Seppo Leinonen, a cartoonist and illustrator from Finland

Seppo Leinonen, a cartoonist and illustrator from Finland

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Medical pluralism: Supporting co-existing diverse therapeutic traditions in mental health

This was first published in the Spring 2015 edition (Issue 41) of the Federation of Ethnic Councils of Australia (FECCA) national magazine, Australian Mosaic. Cite as: DeSouza, R. (2015). Medical pluralism: Supporting co-existing diverse therapeutic traditions in mental health. Australian Mosaic (FECCA). 41, 34-36.

Decades afterward, I still recall the frequent waking, getting out of bed and moving around our Nairobi house in the dark. Sometimes I moved pots and pans, re-arranged furniture, but mostly I caused a disturbance. My parents decided to address my distressing behaviour by taking me to an older woman from our Goan community who chanted
prayers and anointed me with chilli and garlic. Her incantations arrested the nocturnal disturbances, which never perturbed me again. The evil eye was diagnosed, the somnambulism caused by envy, inflicted on me with a look. I later learned that the
evil eye is seen as the cause of many problems and illnesses globally with a multitude of rituals and remedies to either prevent or cure it.

Charm- Niall Corbet on Flickr

My own experience of being a multiple migrant and then a clinician, led me to consider many possible antecedents to mental illness. The dominance of biomedicine to manage health and illness, assumes cross-cultural universals. Yet, mental health is a contested specialty with problematic treatments. Culturally derived norms and values from a specific location impose labels on behaviour from another context, which drive treatments, or management that flattens those contexts. Psychiatry and counseling are often viewed skeptically by people from refugee and migrant backgrounds who instead turn first to informal sources outside the health system including self-help, family, community, social networks, various forms of spirituality, religion and church. Increasingly, clinicians are appreciating the part these sources of support play.

Once mental health services are accessed, if staff focus on mental illness without understanding the cultural context or without realising that clients and their families might integrate both biomedical and more “traditional” beliefs, quality psychiatric assessment can be impaired and the potential for inaccurate diagnosis and inappropriate treatment and care can occur. Incorrectly identifying culturally appropriate behaviour or experiences as psychopathology is problematic, just as assuming that something is cultural rather than psychopathology or symptoms. However, every culture has frameworks for understanding health and illness and how these are demarcated.

In Aotearoa New Zealand, where I have spent most of my life, Maori psychiatrist Mason Durie has conceptualised Maori health as encompassing mental (hinengaro), physical (tinana), family/social (whänau), and spiritual (wairua) dimensions. In Australia, the National Aboriginal Health Strategy (1989) views wellbeing through a communal lens, broadening the concept of well-being beyond the to the social, emotional and cultural well-being of the whole community. Situating Aboriginal and Torres Strait Islander mental health within a framework of social and emotional wellbeing emphasise wellness, harmony and balance rather than illness and symptom reduction (AIHW 2012). Connection to land, culture, spirituality, ancestry, family and community, interdependence between families, communities, land, sea and spirit are also seen as necessary for health. The Ways Forward National Aboriginal and Islander Mental Health Policy Report 3 (pp19-20) adapted from Swan and Raphael also prioritises holism, self-determination, the need for cultural understanding, the impact of history in trauma and loss, human rights, acknowledges the impact of racism and stigma, kinship, cultural diversity and Aboriginal strengths.

Contemporary neoliberal health discourses have co-opted patient rights movements and positioned patients as consumers ­­-active partners in health who are responsible for their own health. Consumer engagement and health literacy form a suite of strategies for inducing medical citizenship, so that individuals can participate and become knowledgeable consumers. Some would argue these are assimilatory processes. However, in order for medical citizenship to be a two way process, one’s own beliefs about the causes of illness and the corresponding treatments must also be considered. Health literate organisations must also be open to a multiplicity of illness explanations and to those locations from which such beliefs are derived. As Beijers and de Freitas (p.245), note:

Health care is transforming social suffering into illnesses and diagnoses, while often denying the social and moral origins and implications of the suffering

David Ingleby suggests that two perspectives are available for thinking about culture and mental illness. A technical perspective assumes mainstream frameworks and treatments can be universalised to all patients/clients and that more sensitivity and overcoming linguistic and cultural barriers will assist therapeutic efforts. With a technical approach to mental health, the goal of care is to deliver it efficiently and increase utilization (efficacy). Strategies can include access to language matched information and professional interpreting services, or improving mental health literacy and awareness, supporting community resilience and coping strategies. However, technical approaches do not ask questions about power imbalances between groups.

On the other hand when care is given through a critical lens (equity), the questions become what is going on when interventions developed for one population are applied to another? What are the underlying power relations? Whose interests are being served? Is there a covert attempt to impose the values and perspectives of the dominant group? Ingelby suggests that becoming a user of Western health care involves accepting its underlying philosophy and values and “acquiring health literacy”.

It is important that collaborations between traditional healing mechanisms and western practice are made possible, however within professional discourses traditional healing is frequently viewed as primitive and unprofessional, yet people often utilize different health beliefs simultaneously in their search for optimal treatment. Furthermore, assimilation and acculturation into the dominant culture are thought to negatively impact on migrant health status and to contribute to migrant ill health and disparities as the healthy migrant advantage that people arrive with reduces after a year. Developing collaborative models that combine traditional and Western health knowledges and combining health literacy and consumer participation with better access and quality of staff can indeed facilitate better health outcomes.

As an educator, I am interested in how I can do my part to increase the awareness and openness to pluralism, so that the next generation of nurses can be effective and therapeutic. There is guidance available from The Cultural Diversity Plan for Victoria’s Specialist Mental Health Services. There is an emphasis on being respectful and having non-judgmental curiosity about other cultures. Mental health workers are encouraged to seek cultural knowledge in an appropriate way, tolerate ambiguity and develop the ability to handle the stress of ambiguous situations. In addition, developing a family-sensitive practice, where family and community resources are viewed as partners in recovery as appropriate allow syncretism and innovation to take place. There are significant institutional barriers remaining to this in mental particularly the emphases on privacy, independence and the one-to-one relationship between consumer and professional.

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Knowledge and action, developing evidence for an equity agenda

Speech given at the launch of a partnership between Monash University and Centre for Culture, Ethnicity and Health (CEH) April 29th 2015 and the celebration of CEH’s 21st birthday.

I would like to show my respect and acknowledge the traditional custodians of this land on which this launch takes place, the Wurundjeri-willam people of the Kulin Nation, their elders past and present. I’d also like to acknowledge our special guests: The Honorable Robin Scott – Minister for Multicultural Affairs/Minister for Finance, Phillip Vlahogiannis the Mayor of the City of Yarra, Chris Atlis the Deputy Chair of North Richmond Community Health (NRCH), Councillor Misha Coleman and Baraka Emmy, Youth Ambassador for Multicultural Health and Support Services. I’d also like to acknowledge: Professor Wendy Cross; CEO of the Centre for Culture Ethnicity and Health (CEH) Demos Krouskos; General Manager of CEH Michal Morris, representatives from the Department of Health and Human Services and other government departments, healthcare service partners, clients, NRCH and CEH staff and community members.

It’s an honour to take up this joint appointment between the Centre for Culture Ethnicity and Health (CEH) and Monash School of Nursing and Midwifery, there are some wonderful synergies which allow both organisations to jointly advance a shared goal of equity and quality in health care for our communities, and in particular for people from refugee and migrant background communities. As most of you know, Victoria is the most culturally diverse state in Australia, with almost a quarter of our population born overseas. Victorians come from over 230 countries, speak over 200 languages and follow more than 135 different faiths. This role is an acknowledgement of this diversity, and the need for health and social services that are equitable, culturally responsive and evidence based.

The gap this role addresses

Monash takes its name from Sir John Monash:  an Australian, well known for being both a scholar and a man of action. He is quoted as having said “…equip yourself for life, not solely for your own benefit but for the benefit of the whole community.” I am excited about the ways in which this new role can both strengthen CEH’s leadership and expertise in culture and health; and strengthen Monash’s position as a provider of dynamic and collaborative research-led education. In thinking about the world of the university and the world of practice, the words of Abu Bakr resonate: “Without knowledge, action is useless and knowledge without action is futile.”

What we have in common

I believe this relationship combines knowledge and action which will benefit both organisations and their staff, but even more importantly the communities that we are all here to serve. Key to this partnership success is the generous and collaborative spirit with which the leadership of both organisations have come together and which bodes well for the future. What we have in common as organisations is:

  • Firstly, a commitment to responsive clinical models of care that consider social determinants of health. In a world where health is increasingly industrialised and individualised, both Monash and CEH affirm the importance of communities in a healthy society
  • Secondly, both organisations aim to develop a health and social workforce that can work effectively and safely with our communities. CEH and NRCH know how to work with communities, having expertise in advocacy and community-building roles advocacy and community-building roles to contribute to healthier social and physical environments. Monash know how to educate and inspire practitioners to link their practical knowledge to the centuries of research and scholarship that universities are custodians of around the world.
  • Thirdly, the two organisations aim to keep clients and their families at the centre of care, to recognise that despite all our professional expertise it is the recipient of care who ultimately determines successful outcomes.
  • Fourthly, the organisations seek a system of care that is both just and equitable – just as the university seeks truths that are universal while we research in the here and now, so too we need more than ever to maintain our ideal of a healthy society for all.

Dr Ruth De Souza, Professor Wendy Cross, Michal Morris, The Hon Robin Scott – Minister for Multicultural Affairs/Minister for Finance.

Dr Ruth De Souza, Professor Wendy Cross, Michal Morris, The Hon Robin Scott – Minister for Multicultural Affairs/Minister for Finance.

 Benefits of the relationship

I forsee a number of benefits for both organisations from this role. CEH has a distinguished track record in supporting health and social practitioners to respond sensitively and effectively to the issues faced by people people from refugee and migrant backgrounds , and this will be of benefit to students and staff at Monash as we prepare a rapidly changing workforce for a  rapidly changing workplace.

Monash has an international reputation for high quality and research and education, and CEH will use this expertise to advocate and campaign for change. CEH will be exposed to the university’s dynamic intellectual environment and its knowledge of global currents in cultural research and health research, strengthening its expertise in cultural competence and giving the organisation a platform to lead a much needed translational research agenda.

There have been enormous amounts of work undertaken internationally in my own research areas of cultural safety and cultural competence. Yet there is still so much more to be known about what works and how institutions and practitioners can respond to our changing world. The relationship with Monash will provide both organisations with an opportunity for research output that is grounded, that can be disseminated both in academic settings such as conferences, academic  books and journals, into the sphere of practice and to a range of audiences. The relationship allows for a reciprocal re- examination of priorities and practices about equity in health in research, teaching, and service delivery. I am excited to be working in this dynamic partnership and look forward to helping the partners in their quest for an innovative, resilient and responsive health system for our changing world.

To conclude, I am grateful to the leadership that has made this role and partnership happen, my profound thanks go to the CEO of CEH Demos Krouskous, GM Michal Morris, Professor Wendy Cross, all the magnificent staff here at Monash and at CEH who have made me so very very welcome and lastly to all of you here who have made time to provide your presence and support.

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Cultural safety in Aotearoa New Zealand 2nd Edition

Very excited about the 2nd Edition of Cultural safety in Aotearoa New Zealand being published by Cambridge Press in December 2015.

I’ve contributed two chapters and I have excerpted the introduction of each chapter below:

8. Navigating the ethical in cultural safety

Caring is an ethical activity with a deep moral commitment that relies on a trusting relationship (Holstein & Mitzen, 2001). Health professionals are expected to be caring, skilful, and knowledgeable providers of appropriate and effective care to vulnerable people. Through universal services they are expected to meet the needs of both individual clients and broader communities, which are activities requiring sensitivity and responsiveness. In an increasingly complex globalised world, ethical reflection is required so that practitioners can recognise plurality: in illness explanations; in treatment systems; in the varying roles of family/whanau or community in decision making; and in the range of values around interventions and outcomes. To work effectively in multiple contexts, practitioners must be able to morally locate their practice in both historical legacies of their institutional world and the diversifying community environment. This chapter examines the frameworks that health professionals can use for cross-cultural interactions.I then explore how they can select the most appropriate one depending on the person or group being cared for.

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13. Culturally safe care for ethnically and religiously diverse communities

Cultural safety is borne from a specific challenge from indigenous nurses to Western healthcare systems.It is increasingly being developed by scholars and practitioners as a methodological imperative toward universal health care in a culturally diverse world. The extension of cultural safety, outside an indigenous context, reflects two issues: a theoretical concern with the culture of healthcare systems and the pragmatic challenges of competently caring for ethnically and religiously diverse communities. As discussed throughout this book, the term ‘culture’ covers an enormous domain and a precise definition is not straightforward. For the Nursing Council of New Zealand (‘the Nursing Council’) (2009), for example, ‘culture includes, but is not restricted to, age or generation; gender; sexual orientation; occupation and socioeconomic status; ethnic origin or migrant experience; religious or spiritual belief; and disability’.

In an attempt at a precise two-page definition, Gayatri Chakravorty Spivak (2006, p. 359), captures the reflexive orientation required to grasp how the term ‘culture’ works:

Every definition or description of culture comes from the cultural assumptions of the investigator. Euro-US academic culture… is so widespread and powerful that it is thought of as transparent and capable of reporting on all cultures. […] Cultural information should be received proactively, as always open-ended, always susceptible to a changed understanding. […] Culture is a package of largely unacknowledged assumptions, loosely held by a loosely outlined group of people, mapping negotiations between the sacred and the profane, and the relationship between the sexes.

Spivak’s discussion of the sacred and the profane links culture to the more formal institution of religion, which has historically provided the main discourse for discussion of cultural difference. Particularly important for cultural safety is her discussion of Euro-US academic culture, a ‘culture of no culture’, which has a specific lineage in the sciences of European Protestantantism. Through much of the 19th century, for example, compatibility with Christianity was largely assumed and required in scientific and medical knowledge, even as scientists began to remove explicit Christian references from their literature. This historical perspective helps us see how the technoscientific world of the healthcare system, and those of us in secular education, are working in the legacy of white Christian ideals, where the presence of other cultures becomes a ‘problem’ requiring ‘solutions’. Cultural safety, however, attempts to locate the problem where change can be achieved in the healthcare system itself.

 

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Other contributors include: Irihapeti Ramsden, Liz Banks, Maureen Kelly, Elaine Papps, Rachel Vernon, Denise Wilson, Riripeti Haretuku, Deb Spence, Robin Kearns, Isabel Dyck, Ruth Crawford, Fran Richardson, Rosemary McEldowney, Thelma Puckey, Katarina Jean Te Huia, Liz Kiata, Ngaire Kerse, Sallie Greenwood and Huhana Hickey.

Book cover

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Learning to listen: Mental health and migration for CALD communities

In Victoria the goal of the Victorian Mental Health Reform Strategy 2009-2019 is to achieve better social and economic outcomes for people with mental illness, their families, carers and friends. Specifically Reform Area 6 outlines areas for reducing inequalities. The Cultural Diversity Plan for Victoria’s Specialist Mental Health Services, 2006-2010 suggests that achieving more culturally responsive services for culturally and linguistically diverse (CALD) and refugee communities is a clear priority given that:

  • Victoria has a diverse population with 24 per cent of Victorians being born overseas.
  • A third of this group come from non-English speaking countries.
  • Culturally and linguistically diverse (CALD) groups often have poorer mental health outcomes compared to Australian-born people, because they tend to present to services when their illness is more severe and therefore are also likely to experience higher rates of involuntary treatment.
  • There are sub-groups articularly refugees and older people who are at risk of developing a mental health problem.
  • Each year Victoria accepts over 3,500 humanitarian entrants (refugees and asylum seekers).
  • Victoria’s CALD population is increasingly being dispersed across the state. in regional and rural areas which requires primary health and mental health services provide culturally appropriate care.
  • Almost half of all CALD Victorians report having experienced some type of discrimination based on their ethnicity or nationality.
  • Experiences of discrimination are associated with depression, stress, anxiety and problematic substance use.

Better mental health outcomes for people of CALD backgrounds must include:

  • Strategies to promote social inclusion;
  • Acceptance of cultural diversity;
  • Workforce development ie develop work practices and cultures in mental health services that support high quality, effective, consumer-focused and carer-inclusive care;
  • Improving access to culturally competent mental health care at earlier stages of illness;
  • Enhancing the capacity of primary health services and workers in CALD community settings to identify, respond earlier to, and refer people with emerging mental health problems;
  • Enhancing mental health literacy and reduce stigma among refugee and asylum seeker groups;
  • Provide mental health literacy training to multicultural, ethno-specific and refugee agencies to improve their understanding of mental illness, so that workers in these agencies can better navigate the mental health service system on behalf of CALD consumers and;
  • Encourage practical partnerships between these agencies and specialist mental health services to facilitate culturally-specific input into clinical treatment and psychosocial rehabilitation plans;
  • Address language needs of CALD clients in specialist mental health services and address supply of interpreters  and promote client and carer awareness of language services;
  • Build on the work of Victorian Transcultural Mental Health and the Action on Disability within Ethnic Communities (ADEC) to improve training.

Migrating minds

In the last week of March 2015 I was honoured to be one of six panelists ranging from consumers, carers, filmmakers, and mental health practitioners to be part of a panel at an event called Migrating Minds: A forum on mental health within Culturally and Linguistically Diverse (CALD) migrant communities.The panel was organised by Colourfest in partnership with Victorian Transcultural Mental Health and held at the State Library of Victoria (SLV). Colourfest celebrates films about diaspora and migrant experiences and shares them with the broader community through free events, professional development/training, distributing films and producing resources.

What was especially wonderful about Colourfest was that consumers and carers were central to the event and got to tell their own stories in the films at the start and in the panel discussion at the end. The event began with seven short films which were stories told by people with a personal experience of mental health issues and perspectives of relatives/carers. Five of the short films were produced by Multicultural Mental Health Australia (MHiMA) and Victorian Transcultural Mental Health. There was also an international short film produced by a second-generation Vietnamese-American who shares their experiences with Depression and Post-Traumatic Stress Disorder.

These fabulous examples of cross-sectoral collaboration were evident in the partnership between Mental Health in Multicultural Australia (MHiMA) in conjunction with the Australian Centre for the Moving Image (ACMI) to produce Finding our way. This unique project focused on migrant and refugee stories where the personal stories of people living with emotional and mental health issues who were negotiating migrancy. Managed by Victorian Transcultural Mental Health (VTMH), St Vincent’s Hospital, Melbourne and the Global and Cultural Mental Health Unit at the University of Melbourne. Erminia Colucci & Susan McDonough coordinated the project for MHiMA. We watched The Visual Conductor by Maria. A story about family expectations, taking charge and staying well involving art, personal goals and play. We also viewed Dear Self by Akeemi, which was about childhood memories, moving to a new country, feelings of isolation and efforts to connect including original drawings and paintings. Both Maria Dimopoulos  and Akeemi from the Finding Our Way film project were also on the panel.

The Our Voices project told the stories of carers from refugee and migrant backgrounds through five short films, showing a poignant insight into the lives of carers from migrant and refugee backgrounds. At the Colourfest panel we were fortunate to view Kevser‘s story. Kevser arrived from Turkey in the late 60’s with her husband and is the primary carer for her daughter. What was extraordinary about this film and the other four (from Afghani, Egyptian, Somali and Vietnamese communities) were the common challenges they faced in finding culturally sensitive and culturally-responsive mental health care and support. The aim of the forum was to help healthcare practitioners, community workers and the general population to understand some of the needs of the CALD community and the films were a powerful mechanism for leading the audience to empathise with the experiences of families. Leyla Altinkaya spoke on behalf of her mother, Kevser on the panel. Our other panelists were Munira Yusuf , a young person speaking from a youth perspective on their lived experiences with mental health issues and David Belasic: A psychologist based at Drummond Street Services. He has a strong interest in community psychology and queer mental health.

Me answering a question from Pham Phu Thanh Hang Colourfest Melbourne Coordinator. Also in the shot from left to right, fellow panellists Akeemi, Maria Dimopoulos, Munira Yusuf and David Belasic.

Me answering a question from Pham Phu Thanh Hang Colourfest Melbourne Coordinator. Also in the shot from left to right, fellow panellists Akeemi, Maria Dimopoulos, Munira Yusuf and David Belasic.

One of the priorities of The Framework for Mental Health in Multicultural Australia: Towards culturally inclusive service delivery is that services evaluate their cultural responsiveness and develop action plans to enhance their delivery of services to CALD communities as part of core business. Central to this responsiveness is having processes where consumers, carers and family members can have a say in the planning, development, delivery and evaluation of services. Particularly important given that CALD consumer and carer participation lags behind mainstream participation. Hence, the importance of this event which placed the experiences of consumers and carers at the forefront.

Cultural competence in mental health emphasises the attributes of the service provider and outcomes of the cross-cultural encounter rather than the unfamiliar culture of the consumer/carer. I love the key elements of cultural competence identified in the Cultural diversity plan for Victoria’s specialist mental health services 2006-2010:

  • Respectful and non-judgemental curiosity about other cultures, and the ability to seek cultural knowledge in an appropriate way;
  • Tolerance of ambiguity and ability to handle the stress of ambiguous situations;
  • Readiness to adapt behaviours and communicative conventions for intercultural communication.

What’s lovely about this list is that it does not constitute a recipe or tick box that can be memorised and then deployed in every intercultural encounter. These qualities are about how we developing a capacity for being in relationship with other people when we cannot assume common ground (which is really kinda always).  I believe that watching the films provided a way to facilitate the beginnings of such a journey..

I am grateful to all those who made the films happen and for making visible the experiences of CALD consumers and carers. A grateful thanks to Gary Paramanathan and Pham Phu Thanh Hang Colourfest Melbourne Coordinator for the opportunity to be part of this wonderful panel.

Note that the Victorian Mental Health Reform Strategy 2009-2019 defines Cultural and linguistic diversity as:

the diversity of society in terms of cultural identity, nationality, ethnicity, language, and increasingly faith. Individuals from a CALD background are those who identify as having a specific cultural or linguistic affiliation by virtue of their place of birth, ancestry, ethnic origin, religion, preferred language, language(s) spoken at home, or because of their parents’ identification on a similar basis. CALD does not refer to an homogenous group of people, but rather to a range of cultural and language group communities.
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