Providing woman-centred care

Woman-centred care focuses on the woman’s unique needs, expectations and aspirations; recognises her right to self-determination in terms of choice, control and continuity of care; and addresses her social, emotional, physical, psychological, spiritual and cultural needs and expectations (NMBA 2006). It also acknowledges that a woman and her unborn baby do not exist independently of the woman’s social and emotional environment, and incorporates this understanding in assessment and provision of health care.

2.1 Understanding the woman’s context

An individualised approach to care should be offered at all times rather than routine practice. Care provision needs to be flexible, friendly and non-threatening, making it accessible to all women, including young women. (Chalmers et al 2001)

Every woman has a right to antenatal care that considers her individual social and emotional situation. While many Australian women experience high levels of economic prosperity, educational attainment and good health, many live in poverty, subsist on inadequate pensions, are restricted by under-employment or low-income occupations, experience racism and violence and have poor health outcomes AWHN 2008. Gender inequalities persist, with women economically less secure, maintaining the primary carer role, and subject to violence (including physical and sexual assault, as well as emotional, psychological and financial abuse) AWHN 2008. 

The experience of pregnancy, especially in the early stages, differs for each woman. The stability of a woman’s relationships and social environment will influence her experience. In addition, if the pregnancy is unplanned or results from sexual assault, the woman may experience uncertainty about whether to proceed with the pregnancy. 

Although addressing all of these factors is beyond the scope of antenatal care, taking them into account will lead to a fuller understanding of an individual woman’s situation and the environment for the developing baby. This provides the opportunity for early intervention to reduce any risk to the woman and her baby. Referral to other services (eg housing, social services) should also be considered, in partnership with the woman.

2.2 Cultural safety in antenatal care

Cultural safety puts the woman at the centre of care by identifying her needs and establishing a partnership built on trust. (Phiri et al 2010)

Cultural safety is based on the basic human rights of respect, dignity, empowerment, safety and autonomy (Phiri et al 2010). The concept of ‘cultural safety’ comes from an approach that incorporates culture within a wider structural framework, focusing on social position to explain health status rather than on the ‘values, beliefs and traditions’ of a particular group (Williamson & Harrison 2010). This approach considers the dynamic nature of culture and the diversity within groups, avoids stereotyping and identifies the needs of the individual receiving care. 

Cultural safety is defined by the individual attending health care. It builds on the concepts of cultural awareness (appreciating cultural, social and historical differences and reflecting on one’s own culture, biases and tendency to stereotype) and cultural sensitivity (acknowledging differences and exploring self attitudes) (Thomson 2005). For example, if a woman prefers to see a female health professional, identifying this need is culturally aware, planning the woman’s care around that need is culturally sensitive and ensuring that the woman is not seen by a male health professional is culturally safe (Phiri et al 2010). Embedding this into routine care may contribute to a culturally responsive service (Reibel & Walker 2010). 

Strategies to ensure culturally safe care include optimising communication (eg through the use of interpreters), building sound relationships, acknowledging women’s cultural preferences (Phiri et al 2010) and reflecting on and analysing how power relationships and history have affected the health of individuals (Kruske et al 2006). It is also important to acknowledge that the interaction between the ‘culture’ of the health professional and the culture of the woman (regardless of ethnicity) may result in a power imbalance (Kruske et al 2006). Women from vulnerable and marginalised groups may feel particularly disempowered in healthcare settings. This can be reduced through (Kruske et al 2010): 

• mindfulness about symbols of power (eg uniform, stethoscope) and the way the room is structured (eg avoiding sitting behind a desk) 
• positioning: sitting alongside, not opposite, quiet or shy women and families 
• showing genuine respect for the woman: the woman will be more likely to feel trust, tell more of her experience and accept advice. 

2.3 Providing information and support so that women can make decision

Women should be provided with evidence-based information and encouraged to participate in decisions about care (Chalmers et al 2001)

In any health interaction, a woman has the right to (adapted from Charter of Health Consumer Rights CHF 2004):

• determine what treatment she accepts or chooses not to accept 
• be given easily understandable explanations in her first language of the details of her specific health concerns, any proposed treatments or procedures and the results of any tests performed 
• have access to all health information about herself and her baby
• have her privacy respected, be treated with respect and dignity and know that all her own health information is confidential.

Health professionals and women need to communicate and collaborate in a team approach Kryzanauskas 2005, NZ MOH 2008. The woman’s input (and her family’s when she chooses) is an important part of this process NHMRC 2010. Consistency of information, especially if this is provided by different professionals, is very important Jones et al 1999, Price et al 2005.

Making a choice or consenting should be an ongoing process of discussion between a woman and the health professionals involved in her care. Factors that may assist women in decision-making include:

• determining how much prior knowledge the woman has (Kruske et al 2010)
• asking open-ended questions and listening to the answers
• attending to verbal and non-verbal cues
• clarifying the information provided by the woman
• clarifying the woman’s understanding of the information provided to her
• providing easy to understand verbal explanation and written or audiovisual information in the woman’s preferred language (where available)
• where appropriate, using accredited interpreters to ensure effective communication.

Women have the right to decline care or advice if they choose, or to withdraw consent at any time and have these choices respected (UNESCO 2005). It is important that the level of care provided does not alter because of this choice FPA Health & Read 2006, Faunce 2008, NHMRC 2010.

2.3.1 Documenting discussions and decisions 

Documenting discussions and decisions should include clear and consistent records of NHMRC 2010:

• information provided to the woman and indications that the messages have been understood
• informed consent, responsibility and accountability for decisions
• the woman’s understanding of risk and her responsibility for her own choices and decisions about care, especially if these decisions are in conflict with professional advice (in such circumstances it must be clearly documented that the woman is aware of and has accepted a certain level of risk).^[8]

Shared and reciprocal documentation, including some form of woman-held record, ensures that all members of the collaboration are aware of essential information throughout maternity care. Several jurisdictions in Australia regularly use woman-held records, which have been found to be an excellent way to improve communication NHMRC 2010. A woman-held record means the woman has a better chance of controlling her health information, encouraging respectful language and, as a result, enabling her to feel more in control during her maternity care NHMRC 2010.

Electronic (eg web-based or e-health) or triplicate records allow sharing of accurate documentation and reduce duplication of effort, enabling more streamlined care for women NHMRC 2010.

2.4 Involving the woman’s family

Women and their families should be assisted to prepare for pregnancy, birth and parenthood. Fathers have needs of their own as individuals and not simply as companions or supports for their partner. (Chalmers et al 2001)

Woman-centred care encompasses the needs of the baby, the woman’s family, significant others and community, as identified and negotiated by the woman herself (NMBA 2006). Each woman should be asked about whom she would like to be involved in her care; some women may only want their partner involved while others may wish to involve a wider family or social network. A minority of women may have limited control over the family members who are involved in their antenatal care or the social environment in which the baby develops (eg exposure to passive smoking or domestic violence). 

Involving fathers/partners enables them to participate in decision-making and be informed about the care pathway and environmental factors that may influence the health of the baby during pregnancy (eg maternal passive smoking) and after the birth (eg infectious diseases such as pertussis). Education and information about pregnancy and childbirth should be provided using the principles outlined in Chapter 1. Assessment and intervention for fathers/partners may also be a consideration (eg mental health, smoking cessation, immunisation). 

Involvement of fathers/partners in antenatal care may also enable early intervention (eg family support) for families requiring additional assistance COAG 2009.

2.5 Resources

• COAG 2009 Protecting Children is Everyone’s Business. National Framework for Protecting Australia’s Children 2009–2020. An initiative of the Council of Australian Governments. Commonwealth of Australia.
• NHMRC (2004) General Guidelines for Medical Practitioners on Providing Information to Patients. Canberra: Commonwealth of Australia.
• NHMRC (2004) Communicating with Patients. Advice for Medical Practitioners. Canberra: Commonwealth of Australia.
• NHMRC (2005) Cultural Competence in Health: A Guide for Policy, Partnership and Participation, Next Steps. Canberra: Commonwealth of Australia.
• NHMRC (2010) National Guidance on Collaborative Maternity Care. Canberra: National Health and Medical Research Council.