Cultural safety in maternity care — structured SAQ (15 marks)

(a) Cultural safety vs cultural awareness vs cultural competence (3 marks)

One mark per contrast, plus the framework citation. ^[1]

• Cultural awareness is the recognition that cultures differ. It is a knowledge-of-the-other starting point. Necessary but not sufficient. Risk: the "exotic other" stereotype.
• Cultural competence describes the clinician's skills and attitudes to work across difference. It is developmental — a clinician can move from "unaware" to "culturally competent" — and can be learnt and certified. Its limitation is that it centres the clinician as the expert and can become a tick-box.
• Cultural safety is the critical consciousness of the clinician's own culture, biases, and power, and the institutional accountability for the conditions of care. It is defined by the patient and the community, not by the clinician. It is not a level of attainment; it is a sustained practice.
• Reference: Curtis E et al. Int J Equity Health 2019;18(1):174 (PMID 31727076) — the Aotearoa framework paper.^[1]

(b) The culturally safe first antenatal consultation (5 marks)

One mark per element, maximum five. ^[1]

• Set the room. Acknowledge Country. Introduce yourself with full name, role, and pronouns. Ask the patient how she would like to be addressed and how she identifies culturally. Acknowledge her mother and sister and confirm she wants them present.
• Identify the cultural supports. Ask whether she would like the Aboriginal Liaison Officer, Aboriginal Health Worker, or community midwife to be present or contacted. Call them now if yes.
• Open with social yarn before clinical history. "Where are you from? Where did you have your first baby? What was that like?" The diagnosis is often in the answer.
• Take a trauma-informed history. Ask what she would like you to know about how she would like to be cared for, what has happened before, and what she would like you to avoid. Ask about prior birth experience, prior interactions with services, prior removals, and any safety concerns.
• Take the clinical history. Standard antenatal history; ask about smoking, alcohol, food security, housing, transport, mental health, intimate-partner violence, family and social support. Use the EPDS with cultural adaptation.
• Examine with permission. Explain every step. Ask before touching. Offer a chaperone. Allow the patient to maintain control over pace and position.
• Close the loop. Summarise what you have heard. Agree the next contact and the named clinician. Document the cultural safety questions and answers in the notes.
• Plan the pathway. Offer screening that is appropriate for the gestational age (second-trimester serum screening if the first-trimester window has closed). Plan to contact the ACCHO if she has one. Plan continuity of midwifery care. Plan a return visit before 28 weeks.^[1]

(c) Structural features of a culturally safe maternity service — RISE Framework (4 marks)

One mark per pillar, plus the BRISC citation. ^[2][3]

• R — Redesign the health service. Continuity of midwifery carer (caseload midwifery) — a named midwife, 24/7 phone access, fewer than 20 births per month per midwife — is the highest-evidence intervention. The BRISC service in Brisbane (Kildea 2019, EClinicalMedicine, PMID 31388662) reduced preterm birth with a matched OR of 0.50 (95% CI 0.31–0.83). Other redesigns: outreach clinics, flexible appointment times, group antenatal care, transport assistance, on-country birth where possible, integration with the ACCHO.
• I — Invest in the workforce. Grow the Aboriginal and Torres Strait Islander workforce — Aboriginal health workers, Aboriginal liaison officers, Indigenous midwives, Indigenous doctors, Indigenous student midwives supported through cadetships and clinical placements. Cultural safety training is necessary but is not a substitute for an Indigenous workforce.
• S — Strengthen families. Recognise the kinship structure. Include the grandmother, the aunt, the chosen family. Recognise that perinatal decisions may be made by the family, not the individual woman. Recognise the role of fathers, partners, and male kin where appropriate.
• E — Embed Aboriginal and Torres Strait Islander community governance and control. The ACCHO is the partner, not the referral. Co-design, co-govern, co-deliver. Share records with consent. Pay the ACCHO for the work it does. The Australian Nurse-Family Partnership Program (ANFPP), culturally adapted for First Nations mothers having a First Nations baby, demonstrates the model (Massi 2023, Women Birth, PMID 37302902).
• Reference: Kildea S et al. Women Birth 2019;32(5):466–475 (PMID 31279713) — the RISE Framework.^[3]

(d) Three audit or service-redevelopment actions for the stillbirth disparity (3 marks)

One mark per action, with the structural frame. ^[4][5][8]

• Audit the differential treatment. Compare induction rates, caesarean rates, analgesia rates, breastfeeding rates, and continuity of care rates for Aboriginal and Torres Strait Islander women against non-Indigenous women in your unit. Where the difference is unexplained by clinical indication, the audit is the team's starting point. Document the audit. Report to the head of department. Plan a Closing the Gap action.
• Adopt the stillbirth-prevention bundle with cultural safety. Smoking cessation with culturally appropriate support; fetal growth surveillance with additional scans where indicated; decreased fetal movements advice that is co-designed with community; sleep position advice; continuity of midwifery care. The five community priorities from Massi 2024 (PMID 38689763) are: family-centred stillbirth and Sorry Business Baby care; Indigenous ways of knowing, being and doing; Birthing on Country principles; yarning-based communication; and culturally appropriate, evidence-based resources.
• Establish or strengthen the ACCHO partnership. Co-design a Birthing on Country service with the local ACCHO. Apply the RISE Framework. Grow the Indigenous workforce. Provide continuity of midwifery care. The cost-effectiveness of such services has been published in Lancet Regional Health Western Pacific; the improvement in preterm birth is the BRISC matched OR 0.50.
• Embed cultural safety training in CPD. The 2024 RANZCOG CPD requirement is the regulatory driver. The training is the entry point; the sustained practice is the work. The Australian Indigenous Doctors' Association (AIDA) ATSHiCP workshop is the partner program. Audit the workforce safety metrics, not just the training attendance.^[4][8]