Culturally Incompetent Care: Endangers Life

Antenatal care is an important aspect of the mother and child health from conception to delivery of foetus. Woman’s physical and mental preparation is one of the main purposes of this care for a successful labor and delivery process. The midwives play an important role in antenatal care especially in remote areas of Pakistan, where the people are bound to cultural norms. Culture plays an important role in the treatment and care of every individual. It is much important for the healthcare providers only provide to culturally appropriate care but also to prevent the patient from any inappropriate care, in order to prevent unwanted consequences. This is also important for healthcare providers to maintain healthy and therapeutic relationship with their patients, which definitely influence health related outcomes. It is also the sole responsibility of the organization to educate and train its staff on cultural competence and cultural sensitivity so that patient satisfaction with care could be improved and there would be less room for undesirable consequences.

A booked primi-gravida mother came to the health unit with labor pains. Initially her progress was well; however, at the second stage of the labor, the midwife identified that the client needs an instrumental delivery. The male physician at the centre was the only expert to conduct an instrumental delivery. The patient did not consent to be handled by male doctor; but the family and male doctor imposed the decision on the client, despite her disagreement, in order to save the life of both mother and child. After the procedure, the client expressed to the midwife that, she was feeling very guilty and intensely ashamed, especially, in front of her family and husband. She also told the midwife that she would never come to this centre again rather she would prefer to die. After two years, during the labor of her second child, she refused to come to the same doctor, and opted to go to a remote referral unit that was too far from her home. Unfortunately, she died on the way before reaching to the unit. The nurse midwife at the previous centre came to know about the patient and felt guilty about the previous forced decision on her by the family and health care team.

Analysis of Scenario
Working with limited resources is a challenging issue, but facing scenarios as mentioned above is another inscrutable challenge for health care providers especially, in third world country like Pakistan. Women always prefer female birth attendants, and mostly nurse midwives are the first contact and the most trusted healthcare providers for expecting mothers. Especially, in remote areas of Pakistan, midwives are the most accessible and affordable healthcare providers for these mothers. Above all, they trust nurse midwives, because besides being female; they are from within their own culture and can better understand their cultural values. Nurse-midwives are skilled birth attendants recruited from the local population by the public and private health sector, especially, in rural area of the country.
The questions arise here when there is a life threatening issue during childbirth; do the health care providers provide culturally appropriate and acceptable care to the mothers? Do we really protect the rights of the mothers? What causes to overlook and ignore the right of selfdetermination and self-esteem of patient? Why we are still feeling guilty besides saving lives? The answer to all the above questions is an ethical dilemma, in which the health care providers struggle with a puzzle and the decisions are always controversial.

The Ethical Dilemma
The scenario presents an ethical dilemma when the doctor, nursemidwife, and the family were facing a situation, where they were having a challenge to prioritize the best option for the patient and her child. The doctor was well aware of the cultural boundaries, but he was in a situation to ignore them for saving two lives. The nurse-midwife being the most trusted healthcare provider for that patient was facing a conflict between her professional codes of ethics, in which she has to protect the rights of her patients, and on the other hand, she has to ensure the safety of the patient and her baby. The family was more dependent on the healthcare team, but were still facing the dilemma to choose between standing with their cultural values and saving the lives of their beloved ones. However, in situation like this, the healthcare providers should act in such a way that ensures their professional integrity and ethical soundness and their decisions maximize the benefits and minimize the harms to the patients, families and community. The ethical principles in conflict with each other in the scenario are autonomy and beneficence.
The perspective of individuals involved in the above scenario needs to be taken into account to reach a conclusion or a decision. The nursemidwives perspective for being guilty was if she could have protected the mother's autonomy and could have maintained the trustful relationship with her patient. However, according to the situation, two precious lives were in danger, therefore, the principle of beneficence was overriding the cultural values (autonomy of the patient) and other ethical principles. On the other hand, if we look into the situation on part of male doctor in the scenario, his approach seems paternalistic, because the decision was forced on the patient. This approach was for the benefit of both the patient and the family, but again the principle of beneficence was overriding the autonomy of the mother. Nevertheless, the decision was for saving the lives and to safeguard the ethical principle of beneficence; hence, the right of autonomy, that is, to regard the cultural values were violated, which led to a permanent loss of a precious life, because she was feeling so guilty and unable to get out from the stigma of being exposed to a male doctor. In conservative and deeply religious society, like Pakistan, women do not prefer to be exposed to males, especially, where there gynecological examination or childbirth is involved.

Informed Consent and Autonomy
Respect for patient's autonomy is the duty of a nurse midwife in accordance with her professional code of ethics [1]. Thus, the health care providers are responsible for providing opportunities for the patients to decide for their treatment by providing the required treatment related information timely and prudently. According to Burckhardt and Nathaniel [2], patients are given free choice for deciding for a course of action based on the understanding of the information provided through informed consent. Consent means freely deciding for oneself without any pressure by others. Contrariwise, in the scenario the decision was forced on the mother to be taken care by a male doctor. Although the intent of the family and the healthcare providers was for the best interest of the mother and her child; however, there was a gap in communication between the healthcare providers and patient, right from the registration of mother for the maternity care, The informed consent for such type of emergency could have been taken during antenatal visits so that the mother could have planned for birthplace or any alternatives. Another gap was the lack of organizational preparedness to deal with such cases, especially, in the resource constraint settings.

Beneficence and Cultural Competence
Another ethical principle revealed in the scenario is beneficence, which is to promote good for the patient and act to provide benefit; a moral and professional obligation of the healthcare providers [3]. Taking care of patients by promoting benefit to the patients establishes a trusting relationship between healthcare professionals and patients. According to Leever [4], providing culturally competent care by respecting the deeply rooted cultural values of patients is very important because, it promotes the subjective good of the patient. In the above case, the health care providers had maintained the obligation of promoting the maximum good to the patient by saving her life. However, the part of care as being culturally competent was lacking, as the patient was influenced by the cultural values that she never came back to the same facility, where her cultural values were not safeguarded. Again, if the nurse-midwife could have discussed with her regarding unpredictable emergencies of childbirth, then the patient could have been saved from the unwanted consequences.

Non-maleficence and Expected Benefits
The principle is about doing no harm to the patient. According to Burckhardt and Nathaniel [2], "non-maleficence is avoiding harm as consequences of doing good and harm must be weighed against the expected benefits". In the scenario, the immediate goal of the health care providers and the family was to prevent the patient from a preventable death due to obstructed labor. On the contrary, the immediate benefit of life did not actually avoid the harm, but it delayed the actual harm. However, even during the labor it could have been explained to patient for the unpredictable emergencies so that she could have prepared herself to face the shock of breaking her privacy.
According to Burckhardt and Nathaniel [2], "ethical decision making process is spiral in nature, which can be moulded by the dynamics of changing facts, evolving beliefs and unexpected consequences". The decision of family and healthcare providers in the above scenario was based on the moral and ethical reasoning for the time being; otherwise, they could have lost a life in front of them that was immoral and unethical. After evaluating the situation in the light of ethical principles it is concluded that there are conflicts between cultural values of patient and professional values of healthcare providers.

Recommendations and Plan for Action
Though working in the resource constrained setting is very challenging; health care professionals can influence the policies of organizations to avoid such dilemmas. In the remote areas of Pakistan, where usually female doctors are unavailable, nurse-midwives can play a vital role in providing culturally sensitive and competent care by taking timely decisions as per their professional code of ethics. According to international code of ethics for midwives [5], "midwives develop a partnership with women in which both share relevant information that leads to informed decision-making, consent to a plan of care, and acceptance of responsibility for the outcomes of their choices". The nurse-midwife could not have been so much guilty for breaking the trust if she could have shared all the relevant information regarding unforeseen emergencies of childbirth during the antenatal visits of the patient to make her able to decide for her place of delivery leading to a well informed consent.
Besides fulfilling the professional obligations by the healthcare providers, it is also the responsibility of the organizational management to educate their staff on cultural diversity, sensitivity, and competence so that the patients and healthcare providers do not face such a dilemma. On the other hand, there should be inbuilt flawless protocols to be followed by the healthcare providers such as birth preparedness plans for pregnant mothers so that they can plan their deliveries as per their cultural preferences.