Cultural safety in maternity and gynaecological care

It is 09:30 on a Thursday antenatal clinic. A 26-year-old G2P1 Aboriginal woman from a remote community 800 km away has driven in for her second visit. Her first visit was at 22 weeks because the only bus runs on Tuesdays and she could not get leave. The clinic letter says she "did not attend" the 14-week appointment. She has a folder of loose-leaf paperwork. She does not look at you when you introduce yourself. The registrar in the next cubicle describes her as "again" to the midwife. Her pregnancy is not at risk because she is late; it is at risk because the service was not designed for her. This is the work cultural safety asks of you.^[1][2][4]

Overview and definition

Cultural safety is the goal of an ongoing practice — not a training module, not a checklist, not a credentialing event. It was developed in Aotearoa New Zealand in the late 1980s and early 1990s by Māori nurses, in particular Irihapeti Ramsden, in response to the failure of nursing education to address institutional racism and the persistent health inequities experienced by Māori. Curtis and colleagues, writing for the Te Kupenga Hauora Māori group at the University of Auckland, formalised the contemporary definition in 2019: cultural safety requires healthcare professionals and their organisations to examine themselves and the potential impact of their own culture on clinical interactions and healthcare service delivery, and to acknowledge and address their own biases, attitudes, assumptions, stereotypes, prejudices, and the structures and characteristics that may affect the quality of care provided.^[1]

The definition is set by the patient, family and community receiving care, not by the clinician. A service cannot be culturally safe simply because its staff believe it to be; the test is whether the people who use it experience it as safe. This is the central inversion of the framework. It is the reason cultural safety is not interchangeable with cultural awareness, cultural sensitivity, or cultural competence — those operate inside the clinician's head; cultural safety operates at the encounter and the system.^[1][5]

References16ShowHide

1. [1]Curtis E, Jones R, Tipene-Leach D, Walker C, Loring B, Paine SJ, Reid P Why cultural safety rather than cultural competency is required to achieve health equity: a literature review and recommended definition Int J Equity Health, 2019.PMID 31727076
2. [2]Kildea S, Gao Y, Hickey S, Kruske S, Nelson C, Blackman R, Tracy S, Hurst C, Williamson D, Roe Y Reducing preterm birth amongst Aboriginal and Torres Strait Islander babies: a prospective cohort study, Brisbane, Australia EClinicalMedicine, 2019.PMID 31388662
3. [3]Kildea S, Hickey S, Barclay L, Kruske S, Nelson C, Sherwood J, Allen J, Gao Y, Blackman R, Roe YL Implementing Birthing on Country services for Aboriginal and Torres Strait Islander families: RISE Framework Women Birth, 2019.PMID 31279713
4. [4]Massi L, Lewis C, Stewart S, Jans D, Gautam R, Jalloub L, Bowman A, Middleton P, Vlack S, Boyle FM, Shepherd C, Flenady V, Stuart-Butler D, Rae KM Looking after bubba for all our mob: Aboriginal and Torres Strait Islander community experiences and perceptions of stillbirth Front Public Health, 2024.PMID 38689763
5. [5]Shepherd SM, Willis-Esqueda C, Newton D, Sivasubramaniam D, Paradies Y The challenge of cultural competence in the workplace: perspectives of healthcare providers BMC Health Serv Res, 2019.PMID 30808355
6. [6]Priest N, Doery K, Truong M, Guo S, Perry R, Trenerry B, Karlsen S, Kelly Y, Paradies Y Updated systematic review and meta-analysis of studies examining the relationship between reported racism and health and well-being for children and youth: a protocol BMJ Open, 2021.PMID 34135031
7. [7]Basile Ibrahim B, Kennedy HP, Combellick J Experiences of Quality Perinatal Care During the US COVID-19 Pandemic J Midwifery Womens Health, 2021.PMID 34432368
8. [8]Kandasamy Y, Kilcullen M, Watson D Fetal autopsy and closing the gap Aust N Z J Obstet Gynaecol, 2016.PMID 27250705
9. [9]van der Breggen A, Leske S, Dean JA, Sanjida S, Wallace J, Lee N, Ward J Interventions to improve Cultural Safety in healthcare in CANZUS countries: a systematic mixed studies review of First Nations Peoples' experiences Int J Qual Health Care, 2026.PMID 42092988
10. [10]Hickey S, Kildea S, Couchman K, Watego-Ivory K, West R, Kruske S, Blackman R, Watego S, Roe YL Establishing teams aiming to provide culturally safe maternity care for Indigenous families Women Birth, 2019.PMID 31345659
11. [11]Temple JB, Kelaher M, Paradies Y Prevalence and context of racism experienced by older Aboriginal and Torres Strait Islanders Australas J Ageing, 2019.PMID 30632245
12. [12]Kildea S, Hickey S, Nelson C, Currie J, Carson A, Reynolds M, Wilson K, Kruske S, Passey M, Roe Y, West R, Clifford A, Kosiak M, Watego S, Tracy S Birthing on Country (in Our Community): a case study of engaging stakeholders and developing a best-practice Indigenous maternity service in an urban setting Aust Health Rev, 2018.PMID 28384435
13. [13]Massi L, Hickey S, Maidment SJ, Roe Y, Kildea S, Kruske S 'This has changed me to be a better mum': A qualitative study exploring how the Australian Nurse-Family Partnership Program contributes to the development of First Nations women's self-efficacy Women Birth, 2023.PMID 37302902
14. [15]Lin I, Flanagan W, Green C, Lowell A, Coffin J, Bessarab D Clinical yarning education: development and pilot evaluation of an education program to improve clinical communication in Aboriginal health care - participant, and health manager perspectives BMC Med Educ, 2023.PMID 38036987
15. [16]Knight M, Bunch K, Vousden N, Banerjee A, Cox P, Cross-Sudworth F A national cohort study and confidential enquiry to investigate ethnic disparities in maternal mortality EClinicalMedicine, 2022.PMID 34977514
16. [14]Hickey S, Couchman K, Stapleton H, Roe Y, Kildea S Experiences of health service providers establishing an Aboriginal-Mainstream partnership to improve maternity care for Aboriginal and Torres Strait Islander families in an urban setting Eval Program Plann, 2019.PMID 31563063