The policy review confirmed that an explicit goal shared by all policies relevant to all maternal health services is to promote a woman-centred approach in order to take into consideration individual social, cultural, physical, psychological and spiritual needs, to improve the experience of antenatal, birth, and perinatal care. This goal is operationalised in both general maternal health service and refugee and migrant specific maternal health service policies as a set of recommendations to simultaneously: 1) ensure that refugee and migrant women and their families are provided with enough information in a culturally responsive manner to make informed choices about pregnancy care; and 2) respect women’s individual needs and care choices.
The Commonwealth and NSW guidelines for general maternity services (42, 43) provide recommendations to help to address the needs of service users through:
- recognising the importance of multicultural health workers to assist women to navigate the healthcare system,
- the provision of healthcare interpreters,
- the adoption of an individualised approach informed by cultural awareness and understanding, and
- the provision of culturally appropriate information and resources to enable women to make informed choices about their care.
As to local policies, the NSW Plan for Healthy Culturally and Linguistically Diverse Communities (44) aims to ensure that mainstream services provide culturally responsive care to CALD communities. The four outcomes are to improve access to and quality of care for CALD communities, build health literacy among CALD communities to ensure they can make informed choices about their healthcare, be responsive to individual’s needs, language, and culture, and understand the experiences and identities of CALD communities.
Turning to refugee and migrant specific guidelines, the current NSW Refugee Health Plan (45) focuses on delivering quality care through refugee-specific services and “referral to culturally competent mainstream health services” (p. 24). Eight strategic priorities are detailed including developing health plans and policies which prioritise refugees; working in collaboration with GPs and other health professionals to ensure newly arrived refugees and humanitarian migrants have access to health assessments and follow-up; providing specialised refugee health services; and providing high quality care to refugees within mainstream services (45).
Against this background, during analysis of the interviews it became clear that providers faced a variety of challenges when working cross-culturally. Their efforts to implement relevant cross-cultural policies such as improving access and quality of services, taking an individualised approach, and using interpreterswere hindered by structural and institutional constraints. In what follows, the findings are organized to clearly describe how providers work within and respond in their day-to-day practices to each set of policy recommendations (see Table 2 in Supplementary Materials for details). We then highlight the major similarities and differences in the experiences of the providers working in mainstream services and those affiliated with refugee/migrant specific organisations. We also include some of the providers’ recommendations offered during the interviews.
Understanding the Needs, Experiences and Identities of Refugee and Migrant Women
Policies and guidelines relevant to maternal health services in Australia emphasize that women should receive care which is clinically safe and culturally responsive. To achieve this, service providers in NSW are required to understand and accommodate, where possible, the needs, experiences, and identities of women from culturally and linguistically diverse communities (44). In concrete terms, improving the experiences of antenatal care among migrant and refugee women can involve the introduction of new roles, activities, and measures such as: appointing ethnic-specific cultural liaison officers, establishing women’s groups to maintain cultural connections, developing knowledge of cultural traditions and practices relevant to pregnancy and birth, and adopting “a cross-cultural approach to communication” (4, p7). During interviews, providers told us that efforts to meet these expectations revolved around attempts to create a safe and comfortable environment, being curious about the patient’s culture, being “extra kind” and compassionate, having “extra warmth”, and remembering that the women are the experts on their lives. Most importantly, when working with clients from refugee and migrant backgrounds, providers needed to avoid making assumptions and creating a perception that they were making negative judgement of other cultures.
Meeting the requirements for culturally responsive care, however, was challenging. Service providers described how the goals of appropriate clinical care and cultural respect were frequently brought into tension, resulting in both practical and moral dilemmas for staff and their managers. For example, several providers described how they struggled to accommodate and safely manage cultural practices important to their clients such as co-sleeping or use of jewellery (e.g., bracelets or crosses), that they believed might increase the risk of infant death. The NSW Health Maternity Care Policy (43) explicitly outlines safe sleeping recommendations which advises that infants sleep in their own cot or bassinet. Some providers reluctantly accepted co-sleeping with a child as culturally appropriate whereas others recounted instances where a parent’s decision to maintain this practice, against explicit advice, had led them to make a child protection report. Service providers also spoke of the difficulties in accepting and accommodating the presence and the role of male partners, often viewed as unsupportive and dominating, in service encounters. Again, the responses varied from viewing the partner’s presence as culturally appropriate to asking the male to leave the room and only talking to the woman. Difficulties adjusting care to refugee and migrant women extended to mandated protocols and assessment instruments. Although the Australian Government’s Pregnancy Care Guidelines (42) acknowledge the inappropriateness of several psychosocial maternal assessment tools for use with women from migrant and refugee backgrounds, many remain in use. For example, some providers questioned the cultural relevance and appropriateness of the widely used Edinburgh Postnatal Depression Scale (EPDS), which includes items that are not easily translatable to another language and/or cultural understanding.
Providers also described witnessing the displays of judgement and bias in their co-workers in mainstream settings – particularly when working in multidisciplinary teams. Others sought to take the onus of responsibility for providing culturally responsive care off individual providers, noting that the entire healthcare system could be at times patronizing, racist, and damaging to refugee and migrant women. As one participant reported: “There's a lot of racism in health sectors. I've seen it quite often working as a midwife.” Even though the Australian healthcare organisations acknowledge a responsibility to prepare and support their staff to deliver culturally responsive services (4, 44), the providers we spoke with, particularly those who worked in mainstream services, indicated that the “cultural competence training” available to them was inadequate and not improving standards of care. The current mandatory online cultural competence packages were described as “perfunctory”, and “a one-off thing” that, in the opinion of participants, risked harmfully categorizing groups of people. Providers worried about the dangers of making assumptions based on someone’s culture and the arrogance embedded in the term “cultural competence.” The training also did not address issues of racism.
For these reasons many providers across settings believed that more needed to be done to increase the cultural responsiveness of the services offered to the refugee and migrant women at an organisational level, especially in hospital settings. There were, however, different perspectives on what “cultural competence” training should entail and whether it should be mandatory. Those against mandatory trainings argued that these programs are ‘tick-and-flick’ requirements that do not change anything; what is required is and genuine interest in someone else’s culture, traditions, and lived experience. Whereas those in favour argued that this type of training is at least a start at getting where services needed to be.
Improving Access and Quality of Services
For participants who worked at refugee/migrant specific organisations providing access to quality healthcare for refuge and migrant clients was a major challenge. They described their clients’ cases as being highly complex and requiring an active and holistic management including having to “fight” for their clients’ access to quality services. Part of the problem was that their case records were not linked to those held by mainstream health services. They felt isolated in their role at times, because, as one refugee health nurse noted: “No one ever knows who we are or what we’re doing.” Mainstream providers, on the other hand, reported that the specialised refugee/migrant health services were not utilized properly because many of their colleagues lacked awareness of their existence or role. They also did not understand the rights of asylum seekers thus often denying their access to care.
Although hospitals made some attempts at providing culturally responsive services (e.g., accommodating families who need to bury a dead child on the same day, allowing visits of religious leaders), there were a variety of structural factors which limited their ability to respond to cultural needs such as staff or space limitations (e.g., lack of female doctors or inability to host large families in small hospital rooms). Hospitals also usually lacked bilingual/multicultural obstetric liaison officers and birthing classes. The policy directives of providing access and quality of services to refugee and migrant women were thus constrained by inadequate resource allocation and fragmented communication and referral pathways. As one midwife summarized: “From a service perspective, I think we can do so much better. I think we can do so much better for those women.” Participant recommendations on how to ease some of the challenges they experienced in working with refugee and migrant women included hiring more staff including female doctors, better referral pathways and coordination of services to overcome the disconnect between the refugee/migrant specific organisations, and better supervision and support when dealing with complex cases.
The mainstream providers also emphasised they were aware of the range of external barriers refugee and migrant women faced when coming to a hospital, including lack of transport and childcare. The women were also frequently dealing with poverty, health issues, and social isolation, which as one nurse explained made their lives “just really, really precarious”. She went on to describe how these challenges, although beyond providers’ control, would often create a sense of burden and powerlessness in the staff: “When you have that constantly with family after family, it can be really hard to maintain your own sense of well-being and optimism about the future.”
Taking an Individualised Approach
Taking an individualised approach to the provision of maternal healthcare was portrayed in relevant policies as integral to ensuring woman-centred and culturally responsive care (4, 42). Both mainstream and refugee/migrant specific providers acknowledged that taking the time to build trust and establish a relationship with a woman is essential. They believed it is important to be aware of cultural practices related to the perinatal period and maternity care provided in a woman’s home country and take the time to learn about a woman’s family background and level of support available. Attaining this goal was viewed as more challenging in mainstream settings due to the shorter timeframe a woman is engaged with services, limited appointment times, and persistent staff shortages that impacted on the time service providers can spend with each client. Mainstream service providers also noted that some organisational regulations and legislation such as mandatory reporting requirements can conflict with cultural practices (e.g., co-sleeping) thus making it difficult to build rapport and trust with a woman.
The individualised approach in maternal health services was also crucial to respond to the complex needs of many refugee and migrant women related to experiences of trauma, including sexual violence. Some providers reported that support services offered by the NSW government to assist new mothers with their mental health are not adequately resourced and equipped to assist refugee and migrant women with complex trauma. Providers believed that successfully meeting the needs of these women would require better coordination and communication between mainstream and refugee/migrant specific services and most importantly adopting a trauma-informed approach across health settings and policies.
Finally, the NSW Ministry of Health (44) policy indicates that provision of individualised care involves women being actively involved in decisions about their health. However, some providers highlighted that women from refugee and migrant backgrounds often have less opportunity for education resulting in low health literacy and subsequently relying on their male partners to articulate their health concerns. Providers’ recommendation was to hire bilingual/multicultural obstetric liaison officers to help women express their voice. Some providers also noted that women’s resilience and resourcefulness are not adequately acknowledged in the health policies and underestimated in practice. A social worker described this deficit perspective and “saving” attitude in the following way:
It’s important for us to remind ourselves that we are not here to save them. They don’t need saving. We’re here to support them and be that guiding hand when they need it. Because they have survived all this time without us. They have the tools themselves.
Although providers saw the value of taking the time to listen and learn from the women’s experiences and “not assume we know best”, their heavy workload would often prevent following these guidelines.
The use of healthcare interpreters featured in all refugee and migrant specific health policies. All healthcare providers have around-the-clock access to interpreters through the telephone-based Commonwealth Translating and Interpreting Service (TIS). Integrating this service into the day-to-day work of providers was often challenging, especially if clients were experiencing distress such as during labour or pregnancy complications. Providers identified specific issues with TIS such as poor telephone connection and interpreters being preoccupied (e.g., collecting children from school). They also reported that doctors may rush the call in emergency situations or misunderstand clients who were unable to articulate their health concerns to interpreters (e.g. where they feel pain and point to a body part). Face-to-face interpreting services were preferred by all service providers but were only available through NSW Health Interpreters during business hours. Even though relevant NSW policies mandate access to healthcare interpreters, the availability of such services differed between service providers and sites. Specifically, providers from the regional area reported rarely having access to onsite interpreters and a difficulty locating interpreters for some languages.
Individual service providers are responsible for organising healthcare interpreters for their clients (42). Providers generally took the initiative to schedule interpreters and did not report widespread reluctance among women to accept interpreting assistance. Nevertheless, mainstream providers reported that the joint scheduling of interpreters and antenatal appointments was difficult in practice. For example, if women were late for an appointment and the interpreter could not stay or had already left, women would prefer to conduct the appointment without an interpreter rather than reschedule. In these instances, women would sometimes express a preference for using Google Translate or a friend/family member who has accompanied them.
All providers are directed by the Pregnancy Care for Migrant and Refugee Women Guidelines to avoid using a “woman’s partner, friends or relative to act as interpreters unless absolutely necessary” (42, p. 6). Some participants expressed concern that informal interpreters may not understand medical terms and may translate them incorrectly. Some refugee and migrant specific providers also felt that informal interpreters may only translate what they think a woman needs to know or may make decisions on a woman’s behalf. Providers from mainstream services attempted to use healthcare interpreters as directed by the policy. However, this was not always possible, for example, if a woman had not requested an interpreter and insisted that the appointment continue without a formal interpreter. Informal interpreters were also used by when discussing matters that were not critical to the woman or baby’s care, for example, changing nappies.
In addition, in line with the Pregnancy Care for Migrant and Refugee Women (4),the use of female interpreters was preferred by service providers and by clients. Service providers reported that female interpreters may provide support to women, particularly if women do not have any family present, have disclosed a history of sexual violence, or in cases where it is culturally inappropriate for a male to be present such as during an examination or labour. However, providers reported that scheduling female interpreters was not always possible due to lack of availability.