Research – ruthdesouza-dreamhosters

Australia, Consumer participation, digital health, Digital inclusion, Health, Inequalities, Media, Models of care, Power relations, Research, self-tracking, Technology, wearable technology

Ruth De Souza on Wearable Technology

I am speaking at the WT | Wearable Technologies conference in Sydney next month. I spoke to Wearable Technologies Australia (WTA) about the future of the wearable tech industry and some of the challenges the industry is facing. Check out the full program here.

Here’s a link to the interview we did and I’ve also reproduced it in full below.

WTA: Tell us a little bit about yourself and your journey within the wearable technology space

RDS: I am a nurse, educator and researcher by background and currently work in a unit called the Centre for Culture, Ethnicity and Health at North Richmond Community Health Centre in Melbourne. I came from Monash University to this role with an interest in translating research into practice. I was really interested in doing research in the community and being based there, so that there wasn’t such a big lag between research and knowledge implementation. Wearable tech seemed a good area to explore in a community setting where there is a high percentage of overseas-born residents (38%). Many speak a language other than English at home which has an impact on health literacy. I have been working with colleagues at the University of Melbourne and Paper Giant using “design probes” to engage women from culturally and linguistically diverse (CALD) backgrounds in discussions about health tracking and wearable health technologies in the context of pregnancy and parenting. We started with a stakeholder forum where we explored the research issues around wearable tech and cultural diversity to develop an agenda. More recently with the the University of Melbourne we have conducted a health self-tracking week where we provided daily community education sessions on a range of topics including diabetes and nutrition and self-tracking. Before the end of the year we will be following up with interviews with trackers and asking them about the barriers and enablers to self-tracking.

WTA: Wearable Tech is the next big thing now. Where do you see the industry heading in the next 5 years?

RDS:I am interested in what changes need to be made in health care systems to really maximise the benefits of Wearable Tech. What kinds of educational preparation will the future health workforce need? How will health workers need to modify their roles from being traditional gate-keepers of information in light of the democratisation of information access? What skills will they need to support patients who are activated, motivated and informed? How will health care systems need to change so they can really make the most of patient generated health data? How will workflows and practices change in order to accommodate the new models of care that are emerging with wearable tech?

WTA: According to your expertise in the wearables space which industry do you think will be impacted most by wearable technologies in the next few years

RDS: Technology is moving faster than the health care and education industries. In order to realise the benefits of advances in wearable tech, it’s going to be crucial for the health care workforce to be well prepared educationally and to develop digital literacies both at the undergraduate level and then in terms of continuing education and training. There’s going to have to be a huge shift not just in terms of knowledge and skills, but also in terms of understanding how to be more collaborative in health care.

WTA: Do you think personal IoT has a sustainable future? Will people need more than one platform to handle all their wearable devices?

RDS: I think interoperability is a big issue. Merely generating personal health data without the capacity to have it integrated into your health care means that the potential benefits may not be realised. For this our current models of care and institutional systems need to become more agile and nimble. Many health workers are sceptical about the benefits of wearable technology and concerned about who gets to benefit from the aggregation of health data. They need reassurance about the ethical treatment of data.

WTA: What do you think is the biggest challenge within the wearable technology industry?

RDS: I think the biggest challenge is how wearable technologies can work for people who are marginalised. Working in community health as a researcher I am interested in what wearable self tracking devices mean for people who don’t fit the wealthy, worried, well and white demographic, that typically wearables are marketed to. There is an urgent need to bring people and communities into processes of information handling that are more transparent and accountable. Health workers adhere to codes of conduct and have a duty of care, I’d like to see the developers of technologies engage in more careful scrutiny and have more transparency about the uses of data. I think also that if wearable tech is to be democratised and benefit everyone then communities who are wary of surveillance must have greater control of their data and personal health information.

November 13, 2017/by ruth

Cultural safety, Health, Inequalities, Maternity, Racism, Refugees, Research

Women’s health across cultures

Mother and her baby (Getty images).

Social and economic disadvantage are important contributors to poor maternal and perinatal outcomes in high-income countries such as Australia. For example Australian research shows women from refugee
backgrounds have higher rates of stillbirth, fetal death in utero and perinatal mortality compared with Australian born women. However, the recent publication of findings from a retrospective (looking back) population based cohort study of all individual (as opposed to multiple) births at 24 or more weeks gestational age from 2000–2011 in Victoria, Australia, found that the mother’s country of birth was also an important factor in having a baby who was stillborn.

The place of birth of pregnant women has important implications for risk of stillbirth in high-income countries, as research in the UK, Netherlands, Sweden, Singapore and Australia has shown. Yet, only the American Congress of Obstetricians and Gynecologists (ACOG) clinical guidelines recognise ‘black women’ as being at increased risk of stillbirth. Other clinical guidelines are silent on maternal region of birth including the Royal College of Obstetricians and Gynaecologists, the National Institute of Clinical Excellence, and the Royal Australian and New Zealand College of Obstetricians and Gynaecologists. A significant omission considering migration remains a feature in those countries. The authors found that women who were born in South Asian or Africa have a significantly higher rate of stillbirth. However, women who were born in South East/East Asian had lower rates of stillbirth. This equates to women born in South Asia having an almost two and a half times greater chance of having a late pregnancy stillbirth than a woman who was born in Australia accessing the same public maternity services. The authors recommend that all clinical guidelines should recognize the importance of maternal region of birth (as an independent) risk factor for stillbirth.

This is only one example where ethnicity, faith, culture and place of birth matter, not just in terms of attitudes and expectations about pregnancy, labour and birth but in the context of risk factors for adverse maternal and perinatal outcomes. Recently, I was part of a webinar panel hosted by the Jean Hailes centre, a women’s health organisation, which focused on: culture and its impact on health; culturally safe practice; communication and health literacy and strategies to enhance practice. Along with Monique Hameed (Multicultural Centre for Women’s Health) and Natalija Nesvadba (Multicultural Services, Mercy Health, Victoria). The free ninety minute webinar for which participants are eligible for
RACGP – 3 Category 2 QI&CPD points can be accessed here. It’s structured with three presentations and then two case studies. Further resources below.

Further reading

Useful multilingual resources from the Health Translations Directory

The Health Translations Directory managed by the Centre for Culture, Ethnicity and Health, comprises a searchable database with over 14,000 translated online health resources in over 100 languages:

Pregnancy and post-natal care resources
Women’s Health resources

Refs

Davies-Tuck, M. L., Davey, M.-A., & Wallace, E. M. (2017). Maternal region of birth and stillbirth in Victoria, Australia 2000-2011: A retrospective cohort study of Victorian perinatal data. PloS One, 12(6), e0178727.
Yelland, J., Riggs, E., Szwarc, J., Casey, S., Dawson, W., Vanpraag, D., … Brown, S. (2015). Bridging the Gap: using an interrupted time series design to evaluate systems reform addressing refugee maternal and child health inequalities. Implementation Science: IS, 10, 62.

July 17, 2017/by ruth

Australia, Health, Models of care, Research

The impact of walk-in centres and GP co-operatives on emergency department presentations

It’s always such a buzz to get published, especially when it’s work done with a former student. You can read the article here: Crawford, J., Cooper, S., Cant, R., & DeSouza, R. (2017). The impact of walk-in centres and GP co-operatives on emergency department presentations: A systematic review of the literature. International Emergency Nursing. https://doi.org/10.1016/j.ienj.2017.04.002.

Highlights

Workload and resource pressures on EDs require the development of applicable minor illness and injury pathways.
Walk-in-centres have the potential to reduce ED workloads but more work is required to substantiate this pathway.
GP cooperatives can reduce ED workloads but further evidence is required to be confident of the efficacy of this care pathway.

Abstract

Background
Internationally, non-urgent presentations are increasing the pressure on Emergency Department (ED) staff and resources. This systematic review aims to identify the impact of alternative emergency care pathways on ED presentations – specifically GP cooperatives and walk-in clinics.

Methods
Based on a structured PICO enquiry with either walk-in clinic or GP cooperative as the intervention, a search was made for peer-reviewed publications in English, between 2000 and 2014. Medline plus, OVID, PubMed, and Google Scholar were searched. The Critical Appraisal Skills Program (CASP) guidelines were used to assess study quality and data was extracted using an adapted JBI Qualitative Assessment and Review Instrument (QARI). Subsequent reporting followed the PRISMA guideline.

Results
Eleven high quality quantitative studies met the inclusion criteria. Walk-in clinics do have the potential to reduce non-urgent emergency department presentations, however evidence of this effect is low. GP cooperatives offer an alternative care stream for patients presenting to the ED and do significantly reduce local ED attendances. Community members need to be made aware of these options in order to make informed treatment choices.

Conclusion
GP cooperatives in particular do have the potential to reduce ED workload. Further research is required to uncover recent trends and patient outcomes for walk-in clinics and GP cooperatives.

Keywords:
Emergency medical services, Triage, Outcome and process evaluation-health care, Physicians primary healthcare, General practice

June 11, 2017/by ruth

Cultural safety, Education, Feminism, Inequalities, Power relations, Research, Writing

What can The Handmaid’s Tale teach us about intersectionality in institutional life?

Margaret Atwood’s The Handmaid’s Tale focuses on women living in a theocratic totalitarian regime in a newly created dystopian, pronatalist society called Gilead. The regime attributes declining fertility to women’s rights, same sex relationships and an environment damaged beyond repair, which it solves with the creation of a society predicated on women stratified into their biological destinies to reproduce (Handmaids) or to fulfil household obligations in the private sphere (Marthas). The women are all white, and the story is told through Offred, the plucky white narrator enslaved in a white male supremacist society, where all the people of color have been banished to ‘the colonies'(we are also left uncertain about whether this includes indigenous peoples). Margaret Attwood doesn’t need to attend to characters of color in the book because in a matter of sentences we already know that they are not included in this new world. This lets Attwood off the hook for engaging with with characters of color in the novel. However, critiques of the book from an intersectional perspective have noted that the narrative banishment comes to extrapolate white women’s experiences as representative of the experiences of all women, even though many of the exploitative and cruel mechanisms to curtail maternity and bodily autonomy used on the white women were used specifically against women of colour in actual North American history that underpins the life of the author and the novel. Or were used on enslaved Africans in the United States including public lynchings and being named after their owners.

The television version attempts to address the invisibility and exclusion of the book where people of color were banished or exterminated. People of colour are visible on screen, as loving husbands, loyal running mates, a daughter, a housekeeper. The women of color characters are dispersed through the stratified roles of Handmaids or Marthas which also assumes levels of social mobility. But these characters are merely backdrop cardboard cutouts, holograms, one-dimensional, devoid of depth in this white supremacist tale. Characters like Luke and Moira don’t get to explore their racial identities, much less how religious totalitarianism would specifically affect their racialised experiences. In ignoring racism, the show misses an opportunity to show how racism would manifest and evolve in a puritanical theocracy. In the show, The Handmaid’s Tale assumes that racism has been solved or that it is trumped by gender in the cause of preserving fertility. But there is a lost opportunity to consider ‘racist sexism’, that is how policies and practices that discriminate against women, also discriminate in different ways against racialised women. It also fails to acknowledge that America has always been a dystopia for people of color or that American dystopia is founded on anti-Black violence.. It appears on the surface that all subjects other than the commanders and their wives are treated in much the same way as each other. Seemingly the biblical rules of law are applied equally for transgressions. But Bastien asks:

Are white Commanders and their wives really okay with having a handmaid of color? Is there a caste system for handmaids of color in which some are considered more desirable than others? Do Commanders of color have the same privileges as their white counterparts? If Gilead is meant to imagine a possible future for America, how could deeply entrenched racial dynamics disappear?

In this color-blind, post-racial idyll, there are people of color, but they are hollow and we know nothing about them, past or present. Evan Narcisse suggests it is like the comment made when you’re a non-white person in a predominantly white institution: “When I look at you, I don’t see a marginalised/minority person, I just see a person.” Although meant kindly, in its unmarked privilege it erases the fact of your difference and what it means to inhabit your body and your life. Whiteness is still the unacknowledged default. As Stephanie Brown observes, the men in power are white, as are most of the women. It’s important though that we care about all of this in real life, not just as fiction, as Berlatsky notes:

Because fictional tyrannical dystopias are primarily envisioned as affecting white people, it can be harder to see negative policies that oppress others. At the point where the fictional metaphor matters more than the current reality, something’s gone terribly wrong.

Several critics suggest that The Handmaid’s Tale represents a failure of intersectionality. The term ‘intersectionality’ originates in African American theorising and activism, and is most commonly associated with work by Kimberle Crenshaw and Patricia Collins. It describes how systems of oppression are viewed as interlocking. Therefore, attempts to dislodge one axis of oppression will impact on another. Globally, the term intersectionality is being appropriated as a way to activate attempts to address issues of under-representation in institutions without reverting to a single focus lens on issues such as gender, race, class, or sexuality. Intersectionality provides an understanding that identities can be simultaneously privileged and marginalised, depending on social context. Consequently we are all interpellated differently by racism and sexism through a ‘matrix of domination’ (Collins, 1990). For example, I can be a migrant woman of color who is marginalised through sexism and racism, but I am also privileged through class position, education, able body and heterosexuality.

Intersectionality is being introduced into diversity initiatives in Universities and is gaining momentum in the Science, Technology, Engineering, Maths and Medicine disciplines (STEMM) disciplines. Intersectionality is seen as a strategy for addressing the barriers to success and to widen and increase participation by women, working class, indigenous and ethnic minority groups, in order to leverage a diversity dividend. The use of an economic metaphor valorises innovation and economic competitiveness, rather than attempting to address a pressing social justice. Metaphors to account for inequities and the underrepresentation of groups in STEMM disciplines include the old boys club, the glass ceiling and the leaky pipeline. These metaphors also guide the strategies developed to address these failures of inclusion and their limitations. Merely creating a pipeline and applying force to propel people forward does not guarantee an increase numbers (Núñez, 2014). In the case of a pipeline, we know that it leaks at various stages and is still designed for an implicit ideal input, consequently women and ethnic minorities are more likely than white men to leak out. We also know that the leaking is progressive, so the farther along the pipeline, the fewer these groups are in number (Clark Blickenstaff*, 2005). Merely focusing on increasing or diversifying the supply hides the real issue which is at the ‘demand’ end of things, that is, the organization and the need for it to change (Riegle‐Crumb, 2009, p. 4). Similarly, the metaphor of the glass ceiling assumes the barriers facing marginalised groups are a one dimensional insurmountable barrier experienced at the ‘top’, when in fact marginalised identities experience discrimination and ‘hurdles’ throughout their careers (Husu, 2001, p. 177). Instead the analytic of intersectionality is being vaunted as an antidote to under-representation.

Diversity management is fast becoming a feature of the public image of the corporatised entrepreneurial academy. Standing in for structural or organisational change, diversity risks reproducing the issues I’ve identified in the screen version in the Handmaid’s Tale. Damon Williams suggests there are several political, social and economic imperatives for Universities to respond to diversity. In its place in the knowledge based global economy, it must respond to changing demographics and meet the need for creative and capable students and also demonstrate the viability and vibrancy of diversity. The diversity management strategies it employs range from access and equity; to creating a multicultural and inclusive campus climate; enhancing domestic and international diversity research and scholarship and preparing students for a diverse and global world (Damon Williams, p.19). However, the emphasis on diversity as a way of increasing numbers and improving Human Resources, is often not supplemented with an explicit engagement with the systems of power and inequality that structure the processes of knowledge production. Consequently, the white, elite and middle class structures and structural arrangements that reproduce inequality remain both invisible and intact (Dill & Zambrana, 2009). The neoliberal assumption of an asocial and ahistorical individualised world of meritocracy, means sometimes ignoring racism and sexism (Ong, Wright, Espinosa, & Orfield, 2011). Unmarked white, masculine values and norms instituted through colonial processes of political, cultural, and military dominance favor dominant epistemologies which claim universal truths that overlook social locations and identities (Carlone & Johnson, 2007).

The Handmaid’s Tale is being flagged as a universal wake-up call, about a white feminist dystopia. But as critics note, this ‘feminist’ rallying point ignores enduring prior calls by indigenous and women of color and is a failure of intersectionality. The assumption of a post-racial, ahistorical world limits the possibilities of imagining alternative futures for people of color, in a time of Turnbull, Trump, Macron and Trudeau. Similarly efforts in academia to engage with ‘diversity’ without attention to intersectionality and attending to systems of power and inequality, risks positioning people of color as economic resources who are mere backdrop in a white supremacist institution.

Refs

Amery, F., Bates, S., Jenkins, L., & Savigny, H. (2015). Metaphors on Women in Academia: A Review of the Literature, 2004–2013. In At the Center: Feminism, Social Science and Knowledge (pp. 245–267). emeraldinsight.com.
Archer, L., Dawson, E., DeWitt, J., Seakins, A., & Wong, B. (2015). “Science capital”: A conceptual, methodological, and empirical argument for extending bourdieusian notions of capital beyond the arts. Journal of Research in Science Teaching, 52(7), 922–948.
Ball, S. J. (2015). Accounting for a sociological life: influences and experiences on the road from welfarism to neoliberalism. British Journal of Sociology of Education, 36(6), 817–831.
Bolden, R., Gosling, J., O’Brien, A., Peters, K., Ryan, M. K., Haslam, S. A., … Winklemann, K. (2012). Academic leadership: changing conceptions, identities and experiences in UK Higher Education. Leadership Foundation for Higher Education,.
Cech, E. A., Metz, A., Smith, J. L., & deVries, K. (2017). Epistemological Dominance and Social Inequality. Science, Technology & Human Values, 0162243916687037.
Clark Blickenstaff, J. (2005). Women and science careers: leaky pipeline or gender filter? Gender and Education, 17(4), 369–386.
Collins, P. H. (1990). 2000. Black Feminist Thought: Knowledge, Consciousness, and the Politics of Empowerment.
Carlone, H. B., & Johnson, A. (2007). Understanding the science experiences of successful women of color: Science identity as an analytic lens. Journal of Research in Science Teaching, 44(8), 1187–1218.
Dill, B. T., & Zambrana, R. E. (2009). Emerging Intersections: Race, Class, and Gender in Theory, Policy, and Practice. Rutgers University Press.
Dodson, D.J. (1997). “We lived in the blank white spaces”: Rewriting the Paradigm of Denial in Atwood’s The. Utopian Studies, 8(2), 66–86.
Evans, M. (2004). Killing Thinking: Death of the University. Bloomsbury Publishing.
Eveline, J., & Booth, M. (2004). “Don’t write about it”: Writing “the other” for the ivory basement. Journal of Organizational Change Management, 17(3), 243–255.
Ferguson, H., & Wheat, K. L. (2015). Early career academic mentoring using Twitter: the case of# ECRchat. Higher Education Policy and Management. Retrieved from http://www.tandfonline.com/doi/abs/10.1080/1360080X.2014.991533
Fitzgerald, T. (2014). Advancing knowledge in higher education: Universities in turbulent times: Hershey, PA: IGI Global.
Harding, S. (1989). Taking Responsibility for Our Own Gender, Race, Class: Transforming Science and the Social Studies of Science. Rethinking Marxism, 2(3), 7–19.
Husu, L. (2001). On metaphors on the position of women in academia and science. NORA: Nordic Journal of Women’s Studies, 9(3), 172–181.
Jones, S. R. (2016). Authenticity in leadership: Intersectionality of identities. New Directions for Student Leadership, Winter 2016(152), 23–34.
Ko, L. T., Kachchaf, R. R., Ong, M., & Hodari, A. K. (2013). Narratives of the double bind: Intersectionality in life stories of women of color in physics, astrophysics and astronomy. AIP Conference Proceedings, 1513(1), 222–225.
Lynch, K. (2006). Neo-Liberalism and Marketisation: The Implications for Higher Education. European Educational Research Journal, 5(1), 1–17.
Lynch, K., Grummell, B., & Devine, D. (2012). Crafting the Elastic Self: Gendered Experiences of Senior Management. In New Managerialism in Education (pp. 134–153). Palgrave Macmillan UK.
Mignolo, W. (2000). The Many Faces of Cosmo-polis: Border Thinking and Critical Cosmopolitanism. Public Culture, 12(3), 721–748.
Miller, R. A., & Vaccaro, A. (2016). Queer Student Leaders of Color: Leadership as Authentic, Collaborative, Culturally Competent. Journal of Student Affairs Research and Practice, 53(1), 39–50.
Naidoo, R. (2003). Repositioning Higher Education as a Global Commodity: Opportunities and challenges for future sociology of education work. British Journal of Sociology of Education, 24(2), 249–259.
Núñez, A.-M. (2014). Advancing an Intersectionality Framework in Higher Education: Power and Latino Postsecondary Opportunity. In M. B. Paulsen (Ed.), Higher Education: Handbook of Theory and Research (pp. 33–92). Springer Netherlands.
Ong, M., Wright, C., Espinosa, L., & Orfield, G. (2011). Inside the Double Bind: A Synthesis of Empirical Research on Undergraduate and Graduate Women of Color in Science, Technology, Engineering, and Mathematics. Harvard Educational Review, 81(2), 172–209.
Riegle‐Crumb, C. (2009). Removing Barriers: Women in Academic Science, Technology, Engineering, and Mathematics . Edited by Jill M. Bystydzienski and Sharon R. Bird. Bloomington: Indiana University Press, 2006. Pp. 347. 75.00 (cloth); 29.95 (paper). The American Journal of Sociology, 114(4), 1231–1233.
Ruderman, M. N., & Ernst, C. (2004). Finding yourself: How social identity affects leadership. Leadership in Action, 24(3), 3–7.
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Williams, D. A. (2013). Strategic Diversity Leadership: Activating Change and Transformation in Higher Education. Stylus Publishing, LLC.
Winter, R. (2009). Academic manager or managed academic? Academic identity schisms in higher education. Journal of Higher Education Policy and Management, 31(2), 121–131.
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May 15, 2017/by ruth

Australia, Cultural safety, digital health, Digital inclusion, Health, Inequalities, Multiculturalism, Research, self-tracking, Technology, wearable technology, Writing

Six questions for culture in the age of consumer health technologies: Public lecture

I am visiting the University of Auckland as an international speaker for the Research Café on Migration & Inequality being organised by the Faculty of Science and School of Population Health. The Research Café is a project of the Engaged Social Science Research Initiative and funded by the Vice-Chancellor’s Strategic Development Fund. I’ll also be giving a public lecture on Wednesday 7th December in Room 730-268 at the School of Population Health: 11.30am -12.20pm:

“Wearables” are a growing segment within a broader class of health technologies that can support healthcare providers, patients and their families as a means of supporting clinical decision-making, promoting health promoting behaviours and producing better health literacies on both sides of the healthcare professional-consumer relationship. Mobile technologies have the potential to reduce health disparities given the growing ubiquity of smartphones as information visualisation devices, particularly when combined with real-time connections with personal sensor data. However despite the optimism with which wearable health technology has been met with, the implementation of these tools is uneven and their efficacy in terms of real-world outcomes remains unclear. Wearables have the potential to reduce the cultural cognitive load associated with health management, by allowing health data collection and visualisation to occur outside the dominant languages of representation and customised to a user experience. However, typically, “wearables” have been marketed toward and designed for consumers who are “wealthy, worried and well”. How can these technologies meet the needs of culturally diverse communities?

This presentation reports on the findings from a seminar and stakeholder consultation organised by 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. The consultation brought together clinicians, academics, developers, community organisations, and policymakers to discuss both the broader issues that wearable technologies present for culturally and linguistically diverse (CALD) communities, as well as the more specific problems health-tracking might pose for people from diverse backgrounds. This presentation summarises the key issues raised in this consultation and proposes future areas of research on wearable health technologies and culturally and linguistically diverse (CALD) communities.

Dr. Ruth De Souza is the Stream Leader, Research Policy & Evaluation at the Centre for Culture, Ethnicity & Health in Melbourne. Ruth has worked as a nurse, therapist, educator and researcher. Ruth’s participatory research with communities is shaped by critical, feminist, and postcolonial approaches. She has combined her academic career with governance and community involvement, talking and writing in popular and scholarly venues about mental health, maternal mental health, race, ethnicity, biculturalism, multiculturalism, settlement, refugee resettlement, and cultural safety.

Contact for Information: Dr Rachel Simon Kumar r.simon-kumar@auckland.ac.nz

December 4, 2016/by ruth

Cultural safety, digital health, Digital inclusion, Health, Inequalities, Migration, Multiculturalism, Research, self-tracking, Technology, wearable technology

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)

“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

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!

August 19, 2016/by ruth

Aotearoa New Zealand, Cultural safety, Feminism, Maternity, Migration, Nursing, Research, Women, Writing

“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.

June 11, 2016/by ruth

Australia, Cultural safety, Inequalities, Migration, Multiculturalism, Racism, Research, Writing

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.

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.

May 5, 2015/by ruth

Colonialism, Cultural safety, Feminism, Inequalities, language, Maternity, Migration, Multiculturalism, Nursing, Power relations, Professional development, Racism, Research, Women

Korean migrant mothers on giving birth in Aotearoa New Zealand

Cite as: DeSouza, Ruth. (2014). One woman’s empowerment is another’s oppression: Korean migrant mothers on giving birth in Aotearoa New Zealand. Journal of Transcultural Nursing. doi: 10.1177/1043659614523472. Download pdf (262KB) DeSouza J Transcult Nurs-2014.

Published online before print on February 28, 2014.

Abstract

Purpose: To critically analyze the power relations underpinning New Zealand maternity, through analysis of discourses used by Korean migrant mothers. Design: Data from a focus group with Korean new mothers was subjected to a secondary analysis using a discourse analysis drawing on postcolonial feminist and Foucauldian theoretical ideas. Results: Korean mothers in the study framed the maternal body as an at-risk body, which meant that they struggled to fit into the local discursive landscape of maternity as empowering. They described feeling silenced, unrecognized, and uncared for. Discussion and Conclusions: The Korean mothers’ culturally different beliefs and practices were not incorporated into their care. They were interpellated into understanding themselves as problematic and othered, evidenced in their take up of marginalized discourses. Implications for practice: Providing culturally safe services in maternity requires considering their affects on culturally different women and expanding the discourses that are available.

Keywords: focus group interview, cultural safety, Korean women, maternal, postcolonial, Foucault.

Introduction

A feature of contemporary maternity is the notion that birth can be empowering for women if they take charge of the experience by being informed consumers. However, maternity is not necessarily empowering for all mothers. In this article, I suggest that the discourses of the Pākehā maternity system discipline and normalize culturally different women by rendering their mothering practices as deviant and patho- logical. Using the example of Korean migrant mothers, I begin the article by contextualizing maternity care in New Zealand and outlining Korean migration to New Zealand. The research project is then detailed, followed by the findings, which show the ways in which Korean mothers are interpellated as others in maternity services in New Zealand. I conclude the article with a brief discussion on the implications for nursing and midwifery with a particular focus on cultural safety.

You can read the rest at: Journal of Transcultural Nursing or download DeSouza TCN proof.

March 12, 2014/by ruth