,, WOMEN'S HEALTH,,,,, MULTICULTURAL, MULTIDISCIPLINARY AND PSYCHO--SOCIAL OBSTETRICAL CARE Beverley Chalmers, PhD, WHO Collaborating Centre in Women's Health, Centre for Research in Women's Health, University of Toronto ABSTRACT RESUME This paper is intended to highlight the importance of ethnocultural issues in maternity care, and to offer a multidisciplinary perspective to the care of women and their families during childbirth. Both these approaches are endorsed by declarations emerging from global United Nations meetings held in the past decade, and should become primary considerations in Canadian health care in the forthcoming mil1enium. Cet article vise it souligner l'importance des questions de nature ethno-culturelle en matiere de protection de Ia maternire et a. presenter une perspective pluridisciplinail'e au soin des fernmes et de leur famille durant I' accouchement. Ces deux approches ont ere adoprees par des declarations issues de reunions globales des Nations Unies ayant eu lieu dans Ia demiere decennie et doivent devenir des considerations de wute premiere importance pour les soins offerts au Canada, au cours du nouveau millenaire. J SOC OBSTET GYNAECOL CAN 1999;21{10}:975-79 KEY WORDS Multidisciplinary, multicultural, psychosocial, obstetric care. Received on June 10th, 1998. Revised and accepted on November 10th, 1998. JOURNAL SOGe 975 SEPTEMBER 1999
INTRODUCTION Given the multicultural nature of Canada, it is important for health care services and health education programmes to recognize and respond to the needs of individual communities while attending to the health needs and expectations that apply to people of all backgrounds. While it is probably impossible to become familiar with the characteristics of each community, it is possible to raise awareness of distinctive cultural differences and to emphasize the need for concern in caring for these. Even more important is the need to raise awareness of the similarities between cultures and, particularly, of the universal need for respect, sensitivity and, ultimately, understanding among different groups. The ethnocultural variation in Canada provides an opportunity to develop methods of cultural integration or co-existence which have not yet been well developed anywhere. This country can lead the way in initiating cultural interchange programmes which could become models for the world. Developing sensitivity and understanding in the health education arena is of particular importance as it is current education that will influence our future policy makers. This paper is intended to raise awareness of the ethnocultural components of obstetric and newborn care from a psycho-social perspective. Creating an ethnoculturally and psycho-sensitive approach to obstetric/neonatal care must be seen in an international perspective and not parochially. The epidemiological approach of the United Nations agencies to world health issues reflects a multicultural and multidisciplinary view, with traditional medical concerns increasingly tempered with psycho-social considerations. The objectives of this paper are threefold: 1. To raise awareness of ethnocultural issues in health care with a particular emphasis on the childbearing experience. 2. To offer a multidisciplinary perspective to the care of women and their families during childbirth. In essence, this cross-disciplinary approach provides a means of achieving the goal of family centred maternity care as advocated in the Canadian National Guidelines for Maternal and Newborn Care. l 3. To recognize the place of obstetric and newborn care within the recommendations emerging from United Nations agencies. Acknowledgement is given to the importance of declarations emerging from such meetings as the Cairo, Beijing, Vienna and Copenhagen conferences on care during pregnancy, birth and the post-partum period. OBJECTIVE 1 To raise awareness of ethnocultural issues in health care with a particular emphasis on the childbearing experience. WHY OBSTETRICS AND NEONATOLOGY AS THE Focus FOR ETHNOCULTURAL ISSUES? Childbirth offers a unique opportunity for study, as it is a universal experience with physical, psychological, social, cultural and spiritual components. In the West, it is one area of physiological change which has, over the years, been classified as both a healthy process and a sickness. 2 Its lack of definitive medical, psychological or social definition make it ideally suited to be a vehicle for the understanding of different cultural views on health. Cultural childbearing customs which markedly differentiate groups include such practices as: separation of mothers and babies after delivery or immediate skinto-skin contact; post-partum nursery or rooming-in based care; presence or absence of a partner or supportive companion during delivery; infant feeding practices; reactions to death or infant loss, including miscarriage, intra-uterine death or stillbirth; desire for intervention or non-intervention in birth; female genital mutilation; midwife, obstetrician or family physician delivery and care by a traditional birth attendant; position adopted for delivery (ranging from lithotomy to a supported standing position); and gender preference for birth attendants and place of delivery (ranging from hospital to home). The variations across cultures are evident world-wide. Health care providers practising within Canada will need to develop an appreciation of culturally diverse needs if they are to be sensitive to the expectations of their patients. Part of successful intercultural integration lies in the need to specify similarities, rather than concentrating JOURNAL SOGC 976 SEPTEMBER 1999
on differences between groups. While emphasizing differences may be of academic interest, of far more importance, from a health care perspective and from the perspective of achieving social harmony, is the need to determine the similarities within cultures. Achieving an appropriate balance between accommodating individual needs and achieving universal standards of good medical care is a complex challenge. Health care services should, ideally, be designed to meet both the universal needs of women and their families and to cater to their individual expectations as far as possible. One universal need of a woman in childbirth is for the safety of herself and her baby. What services are considered safe (home birth/ hospital birth/free standing delivery centre) or which care givers (midwife/obstetrician/family physician/traditional birth attendant) are seen to ensure such safety may differ from culture to culture or even from woman to woman. The need for respect, dignity, self-esteem and emotional support during pregnancy, and particularly during childbirth, is universal. How these requirements are met during childbearing can vary from culture to culture, and are linked to such issues as privacy, decision making responsibility and continuity of care. Discerning what health care services and practices could enhance each woman's experience within the confines of a 'safe' birth, and her culturally determined expectations, is the challenge faced by today's caregivers. OBJECTIVE 2 To offer perspectives which integrate some of the disciplines involved in the care of women and their families during pregnancy and childbirth. WHY A MULTIDISCIPLINARY ApPROACH? The childbirth experience is attended to by a number of health care professionals. Obstetricians, neonatologists, nurses, midwives, doulas and, in some cultures, traditional birth attendants, are key players. Also involved on occasion are childbirth educators, anaesthetists, physiotherapists, social workers, psychologists and psychiatrists. Research also indicates the importance of supportive companions in enhancing childbirth outcomes and points to the important role to be played by family and/or friends. The interplay and collaboration between professionals giving care to pregnant women and their families, can, and probably should, be integrated into the teaching model. Traditionally, the teaching of obstetrics, neonatology, nursing, psychology and other disciplines involved in childbirth has been separated along disciplinary lines. Students attend courses in these disciplines separately even if sequentially. Some components of caregiving may not be covered at all, particularly those relating to social science issues-social work, psychology and childbirth education. Even more importantly, the care of the normal birth and early neonatal care experience may be omitted in favour of a concentration on disease. Problem-based learning models require that these somewhat artificial distinctions between disciplines be relaxed. Instead of teaching obstetrics and neonatology separately, the care of the mother during birth, the baby immediately after delivery and the interaction between the two require a more closely integrated teaching model. Traditional distinctions between these disciplines allowed for the customary separation of mother and baby into post-partum maternity and nursery hospital systems. The need to integrate these disciplines at the academic level has made itself clear in the clinical setting. Changed health care services today encourage rooming-in for all mothers as well as early, if not immediate, contact between mother and baby at delivery and no separation from this moment on. To achieve this goal, close cooperation between obstetricians (or other delivery assistants) and neonatologists is required. It seems logical that the teaching of these disciplines should likewise be closely associated. WHY AN EMPHASIS ON PSYCHO-SOCIAL ISSUES? Any discussions of ethno-cultural issues will, of necessity, be imbedded in the social and psychological functioning of cultural groups. The importance of a woman's (and her partner's or other family members') psychological adjustment during pregnancy and in the post-partum period cannot be underestimated. While biological health is of prime importance, psychological health is necessary not only for the woman, but for the well-being of her infant and other family. In keeping with the long established WHO definition of health as JOURNAL SOGC 977 SEPTEMBER 1999
"a state of complete physical, mental and social wellbeing and not merely the absence of disease or infirmity",3 an integrated approach to learning about childbirth and related issues should, ideally, incorporate its psychosocial components. Traditionally, little emphasis has been placed on the psycho-social-cultural aspects of obstetric care in the training of medical students. 4 While undergraduate studies are more frequently offering courses in human behavioural sciences today, these are usually of a general nature. OBJECTIVE 3 To create recognition of the place of obstetric and newborn care within the recommendations emerging from United Nations agencies. Movements towards multicultural, multidisciplinary and internationally applicable concepts of appropriate obstetric and neonatal care are not confined to Canada. They are universal developments which have been spearheaded through the United Nations health agencies, primarily in the 1990s. While some countries have led the field in moving towards declarations about appropriate care of women and their families in general and with regard to reproductive health, others have learned from them and have followed the lead provided by the United Nations agencies in promoting international health care policies. While the documents supporting such initiatives as women's and children's rights and reproductive rights are extensive, they are summarized in the form of declarations which provide models for every nation of the world to espouse. Most of the member countries of the United Nations become signatories, although it may take some time for their mandates to be implemented in practice. These declarations have emerged from a series of global Consensus Conferences which have produced an action agenda for socially equitable and sustainable development for the 21st century. These conferences, including the Fourth World Conference on Women (Beijing 1995), the World Summit for Social Development (Copenhagen 1995), the International Conference on Population and Development (Cairo 1994) and the World Conference on Human Rights (Vienna 1993) have all resulted in a progressive agenda for development. Arising from these conferences have been the Convention on the Rights of the Child, the Convention on the Elimination of all Forms of Discrimination against Women and the Declaration on the Elimination of Violence against Women. In essence, these declarations reflect a policy of people-centred development based on the following key principles: 5 Every individual should be able to enjoy all human rights and fundamental freedoms. Achieving social equality and justice, in particular for girls and women, indigenous people and other vulnerable groups, is a priority of the global community. Empowering people and eradicating poverty, especially through access to information, resources and democratic institutions, are the keys to unleashing human potential and securing peace and development for all. Women's rights are human rights. National development cannot be achieved without the full and equal participation of women in public and private decision making, and their access to equal opportunities in all aspects of social and economic activities. Men's shared responsibilities and participation in all aspects of family and household responsibilities, including child-rearing and child support, sexual and reproductive behaviour and family planning practice, must be encouraged to enable men and women to develop partnerships based on equality and mutual respect. Health and education for all are core factors in dealing with inter-related social, economic and poverty eradication efforts. These principles form the basis of numerous international initiatives designed to safeguard sexual and reproductive rights, ensure conformity to ethical and human rights and standards and to monitor these through research and development. Some of the international programmes which have emerged from these principles include the WHO Safe Motherhood Initiative and the WHO/UNICEF Baby Friendly Hospital Initiative. JOURNAL SOGC 978 SEPTEMBER 1999
CONCLUSION It is apparent that the time is ripe for Canadian medical schools to evaluate their programmes, to look at integration of courses and to consider a multicultural focus, an integrated multidisciplinary care model and an emphasis on meeting families' psychological and social needs together with biological care. All this is necessary if they are to meet the challenges being advocated by the United Nations health care agencies. ACKNOWLEDGEMENT The preparation of this paper has been generously supported by the Association of Volunteers, Women's College Hospital, Toronto. REFERENCES 1. Ministry of National Health and Welfare. Family Centred Maternity and Newborn Care: National Guidelines. Ottawa, 1987. 2. WHO. Having a Baby in Europe. WHO, Copenhagen, 1985. 3. WHO. Preamble of the Constitution of the World Health Organization. WHO, Geneva, 1948. 4. Savage W.o. Training in Psychosomatic Obstetrics and Gynaecology. In: Van Hall EV, Everaerd W (Eds). The Free Woman. Lanes: The Pergammon Publishing Group 1991. 5. Family Care International. Commitments to Sexual and Reproductive Health and Rights for All. New York: Family Care International 1995. JOURNAL SOGC 979 SEPTEMBER 1999