A pregnant Somali woman was determined to have a vaginal delivery. Unfortunately, labor wasn’t progressing as expected, and the health care team recommended a C-section. The patient declined the recommendation and said it’s in God’s hands. After some persistence, the health care team convinced the patient to get a C-section. After the C-section, the patient felt disappointed that her wishes weren’t considered. The OB team, however, didn’t understand why the patient was so upset, as the baby was healthy, she was doing OK, and they had met their goals.
What do you think of this situation?
Right now, we tend to acknowledge that communities have different values, and then we think about overcoming this “other” person’s values and beliefs to achieve our team’s goals. Essentially, the question for the health care team was, how do we get this patient to get a C-section and let go of her silly beliefs?
And after we meet our goals, we say we did what we were supposed to do, and everyone is healthy. Yes, the patient is also dissatisfied, but “Oh well, what can you do.”
It’s not always like this. Some health care systems have evolved to disregard the idea of cultural competency since the goal is not to understand this “exotic” person to undermine their beliefs and have chosen to use cultural humility as a paradigm. This paradigm involves self-reflection of your own values and beliefs. If we used the cultural humility lens, we might say, “We are here to reduce the risk of harm to the baby and the mother.” If we reflect enough, we will also acknowledge that we are doing this because it’s our professional duty, and we are also worried about litigation.
But we’ve just moved from thinking of someone else to just ourselves. We are not thinking about the relationship—this shared world we are building in this moment.
Here’s where cultural safety comes in. Cultural safety is a term used to describe an environment free from physical, psychological, and emotional harm for the patient when receiving care. Cultural safety as a model has its limitations, but it’s time we, clinicians and health care systems, use it as a principle to care for people different from us. If we do this, we may have approached the situation completely differently.
For example, what is our understanding of this Somali woman’s beliefs and values? What do I know about their community’s history, and how could that contribute to our current interaction? Given what I know now, how can I look at this differently as a health care system and clinician? What else should I be doing?
This might lead to a different analysis of the situation, and you may learn the following.
Somalia has a long history of colonialism, beginning in the late 19th century with the arrival of European powers seeking to establish trading posts and control territory in the region. The British established control over the northern part of present-day Somalia, while the Italians controlled the southern and coastal areas. In the 1940s, following World War II, Italy officially relinquished control of Somalia to the British, who subsequently granted independence to the country in 1960. However, the newly independent Somalia soon fell into civil war and political turmoil, leading to intervention by foreign powers ever since.
This colonial past and continued foreign interventions have created a deep mistrust in institutions, including health care institutions.
Throughout this history, religion has been a source of resilience and strength for the Somali community. Most Somalis are Muslim, and Islam is a central part of Somali culture. The Somali community has maintained its religious and cultural practices despite the challenges posed by war, displacement, and economic hardship. It provides a source of wisdom and guidance for many Somalis, providing them with a framework for making sense of the world and their place in it.
By understanding all that, we may deeply empathize with why the patient declined the C-section. Of course, she wants to have a healthy baby and stay safe. But we may now understand her deep reverence for things she can’t control and how belief in God has sustained her and her community. Knowing this, we might analyze the situation this way:
Is the baby truly in danger, or are we just not willing to accept a level of risk that’s OK by the patient? Is there something else we should do if she doesn’t understand what we are communicating? Would a community birth worker be helpful if we don’t have it? Why don’t we?
It’s so much more than throwing up our hands and saying, “Oh well, we are just different.”
Let’s commit to understanding the history and culture of the diverse communities we serve and provide the best care possible. We can be so much better.