With the possibility of internal examinations, bodily exposure, and a raft of taboo subjects (like breastfeeding and vaginal health), it is little wonder that trust between patient and practitioner is considered so important in the ante- and post-natal healthcare space.
As a male midwife, earning this trust can be more challenging – especially in cultures that have sensitivities around the interactions of men and women.
Christian Wright, a midwife who works with Indigenous women in remote Arnhem Land understands this better than most.
Entering the profession, Christian had to learn the cultural sensitivities of these communities and think outside the box about how he could build trust and help the women feel safe.
Some of his lessons were hard earned, he told us ahead of the Obstetrics Malpractice Conference.
“I remember being (affectionately) slapped across the head by an Aboriginal elder after using an inappropriate word for part of the female anatomy,” Christian said.
“I try to learn as much of the language as possible to help people feel comfortable […] And while the word I had learned was not incorrect, I didn’t realise [until this elder subsequently taught me] that there was a more appropriate term I should have been using, as a man.
“The woman advised me that, given it is taboo for men to talk to women about these subjects, it was more appropriate for me to use the word ‘Yothu wanga’, which literally translates to ‘baby house’.
“Since using this term, I have been met with smiles instead, as the women can see I am trying to show respect and culturally-safe care.
“I also make sure to use a more hushed voice with nuanced pauses when having conversations about sensitive topics, to minimise embarrassment for my patients. I’m told this is a subtle, but important, cultural linguistic cue – one of many I’ve had to learn over the years,” he added.
Culturally safe practices
Christian believes respecting cultural and community rhythms is key to successful clinical outcomes. As such, he has adjusted his work schedule to better meet the needs of patients – performing things like glucose tolerance tests in the afternoon.
Glucose tolerance tests, which are recommended for women in the second trimester of pregnancy, are commonly performed in the morning, given the requirement for overnight fasting.
However, for one Aboriginal community, early morning tests are less practical, given a cultural tendency to engage in late night social or ceremonial activities, and wake in the afternoon.
In recognition of this, Christian changed his clinic hours to match the community’s rhythm. Performing glucose tolerance tests in the afternoon has resulted in significantly higher test completion rates and better health monitoring, he says.
Afterwards, he helps the women celebrate with a meal, attended by other expectant mothers in the community, as part of a ‘Mums and Bubs Antenatal Class’. “These get-togethers are a safe space to share stories; and serve as a further incentive for women to do the test,” he said.
Continuity of care
Finding opportunities to build continuity of care has been another important element of Christian’s work.
With their antenatal sessions carried out remotely, Indigenous women typically only attend the hospital where they will give birth for the first time during labour, or in the weeks leading up to it.
For many, this can be a terrifying experience, especially as there are no provisions in place for a birthing partner to be flown in (unless the mother has other children below the age of two, that need to be supervised during the birth).
“It’s a significant thing for a woman to travel from her homeland to what she sees as a foreign country where she does not know the language; and have to stay there for several weeks without a familiar person around, while she counts down the days until her birth,” Christian said.
To make this feel less intimidating, Christian has been facilitating video introductions between patients and staff at the district hospital, from early in the antenatal process.
“I get my patients to film or photograph themselves and talk about what makes them excited and afraid – and show those videos to the staff. I then send similar videos of staff and the hospital facilities to my patients, to help build those relationships from a distance. It makes it less daunting when they have to fly in alone.”
Christian has also been advocating for change to the existing policy that prohibits birthing partners from travelling with pregnant women. He hopes that a mandatory allowance of an escort (of the women’s choosing) could soon be on the horizon.
Culturally-safe provisions for birthing visits
A series of focus groups organised by Christian revealed the antenatal education and practices preferred by Indigenous women.
For example, oyster and mussel collecting excursions called ‘hunting trips’, were an important tradition for expectant Yolnu and Anindilyakwa mothers, seeking to gather nutrient-rich food to support lactation and foetal growth, in the lead up to their birth.
With the women residing in hospital prior to birth, these trips were not being performed.
Christian changed this, at first, taking women out with other midwives for excursions. He then formalised the trips into a program led by an appropriate female Aboriginal elder, with an arranged bus, social worker and midwife chaperone. This ensured the expectant mothers were routinely taken on hunting trips during their hospital stay.
While learning language and cultural norms is important for building trust, Christian believes cultural literacy needs to extend beyond these narrow applications. He believes trust is earned when a practitioner understands all behaviour associated with a culture, not just ceremonial or customary traditions.
A recent issue involving an Aboriginal mother of a premature baby is a case in point. When colleagues reached out to Christian to alert him to the mother ‘misbehaving’, while she and her newborn were in the neonatal intensive care unit (NICU), he immediately suspected there may be a deeper explanation.
“She had been trying to escape the hospital, which the staff construed and explained to me as ‘misbehaving’. It turned out that she was the primary carer for her elderly father at home and was concerned about his wellbeing.
“We alleviated her anxiety by arranging regular photos taken of her father, so that she could stay with her baby more comfortably in the NICU,” Christian said.
Christian has received a great deal of positive feedback for his efforts, but he said the most meaningful feedback for him is when Indigneous women requested him at their labour. One especially meaningful request came from a woman whose waters had ruptured at just 23 weeks of gestation.
“As a midwife, you are responsible with the life of the mother and her unborn baby. Trust-building is everything,” he concluded.
Hear more inspiring stories from Christian Wright the Obstetrics Malpractice Conference, hosted by Informa Connect. This year’s event will be held 13-14 September 2022.
Learn more and register.