Cultural safety in maternity care — structured oral station (12 minutes)

Opening prompt — "Open the presentation."

Model response — say it in this order: ^[1]

• "Thank you for the opportunity. I would like to begin by acknowledging the Traditional Custodians of the land on which we meet, and to pay my respects to Elders past and present."
• "I want to talk about cultural safety in maternity care for Aboriginal and Torres Strait Islander women. The reason this presentation is on the agenda is that the stillbirth rate for Aboriginal and Torres Strait Islander women is approximately double that of non-Indigenous women, and the preterm birth rate is similarly elevated. The Kildea 2019 BRISC prospective cohort (PMID 31388662) showed that a co-designed Birthing on Country service reduced preterm birth with a matched OR of 0.50. The implication is that the gap is structural, not biological, and that the answer is a service redesign."
• "I will cover four things: the framework — the Curtis 2019 definition; the difference between cultural awareness, competence, and safety; the operational answer — the RISE Framework for Birthing on Country services; the audit — what we should measure; and the unit-level action plan."
• "I want to be clear that I am presenting this as a clinician who is on the journey of cultural safety, not as an expert. The framework was developed by Māori nurses in Aotearoa, refined by Curtis and colleagues in 2019, and is operationalised in Australia by the Birthing on Country research group and the Aboriginal Community Controlled Health Organisations."

Examiner is listening for: framework citation, the inversion of the safety definition (patient-defined), the BRISC evidence, the unit-level action, and the humility in the opening. ^[1]

Probe 1 — "Define cultural safety."

Model response: ^[1]

• "Cultural safety, as defined by Curtis and colleagues in 2019 in International Journal for Equity in Health, is the ongoing critical reflection by healthcare professionals and their organisations on their own culture, biases, and power, and on the impact of those on the care of Indigenous and marginalised peoples. The recommended definition is that healthcare professionals and organisations must examine themselves and the potential impact of their own culture on clinical interactions and healthcare service delivery, and acknowledge and address their own biases, attitudes, assumptions, stereotypes, prejudices, and the structures and characteristics that may affect the quality of care provided."
• "The critical inversion is that cultural safety is defined by the patient and the community, not by the clinician. The test is whether the patient experiences the care as safe, not whether the clinician believes it to be."
• "It is not synonymous with cultural awareness — knowing that cultures differ — or with cultural competence — having skills to work across difference. Both are necessary but not sufficient. Cultural safety adds the critical consciousness of one's own culture and the institutional accountability for the conditions of care."

Probe 2 — "Why is cultural safety more than cultural competence?"

Model response: ^[1][5]

• "Cultural competence is a developmental frame — the clinician acquires skills and attitudes, can be assessed, and can be certified. It centres the clinician as the agent who becomes competent. It can become a tick-box, and it does not require the clinician to challenge their own power."
• "Cultural safety moves the work from the clinician to the system and the relationship. It asks the clinician to examine their own culture, biases, and structural position. It asks the organisation to be accountable for outcomes. It is defined by the recipient. It is not a level of attainment; it is a sustained practice."
• "The Shepherd 2019 study (PMID 30808355) of 56 healthcare professionals found that almost half had not had formal cross-cultural training, and that the majority viewed cross-cultural care from a cultural awareness perspective — defined in terms of useful cultural knowledge and interpreter use. The systemic, structural concepts of cultural competence and cultural safety — racism, power imbalances, majority-culture bias, self-reflexivity — were scarcely acknowledged. That is the institutional gap that cultural safety is designed to address."

Probe 3 — "What is the RISE Framework, and what is the evidence?"

Model response: ^[2][3]

• "The RISE Framework was published by Kildea and colleagues in 2019 in Women Birth (PMID 31279713). It is the operational design for Birthing on Country services for Aboriginal and Torres Strait Islander families. The four pillars are: Redesign the health service; Invest in the workforce; Strengthen families; and Eembed Aboriginal and Torres Strait Islander community governance and control."
• "The evidence base is the Kildea 2019 BRISC prospective cohort study in Brisbane, published in EClinicalMedicine (PMID 31388662). The intervention was a Birthing in Our Community service, co-designed with two Aboriginal Community Controlled Health Organisations and a tertiary hospital. The cohort was 1024 women (461 intervention, 563 standard care); after one-to-one propensity-score matching (n=690), the matched OR for preterm birth was 0.50 (95% CI 0.31–0.83)."
• "The cost-effectiveness has been published in Lancet Regional Health Western Pacific. The qualitative implementation work has been published in Women Birth, Aust Health Rev, and Eval Program Plann (Hickey and colleagues, 2018–2019, PMIDs 28384435, 31345659, 31563063). The Australian Nurse-Family Partnership Program adapted for First Nations mothers (Massi 2023, PMID 37302902) demonstrates the model in a different community-controlled setting."

Probe 4 — "What should we audit in our unit?"

Model response — say it in this order: ^[4][5]

• "We should audit the differential treatment of Aboriginal and Torres Strait Islander women in our unit. Specifically: induction rates, caesarean rates, analgesia rates, breastfeeding rates, continuity of care rates, and adverse outcomes — perinatal mortality, preterm birth, low birthweight, admission to special care — compared with non-Indigenous women in the same unit. The audit is the team's starting point. Where the difference is unexplained by clinical indication, the gap is the answer."
• "We should audit the patient experience. The first audit is the Aboriginal Liaison Officer and the Indigenous midwifery workforce. What is the coverage? What is the demand? What is the gap? The second audit is the cultural safety training in CPD — attendance, content, and the assessment of changed practice. The third audit is the Indigenous artwork, language, signage, and Acknowledgement of Country in the unit. The fourth audit is the partnership with the local ACCHO — is it a partnership, or a referral?"
• "We should audit the stillbirth-prevention bundle. 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; 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."
• "We should also audit the obvious gaps in the perinatal mortality review. Kandasamy 2016 (PMID 27250705) identified culturally appropriate counselling for autopsy as a precondition for consent, and autopsy as the single most important investigative tool for understanding and preventing future stillbirths. The audit is the autopsy consent rate, and the cultural safety of the counselling that leads to it."

Probe 5 — "How would you communicate with an Aboriginal woman who has just been told her baby has died?"

This is a scored domain — communication, respect, rapport. Demonstrate it out loud. ^[1]

• "I would move to her eye level, use her name, and ask who she would like to be present. I would acknowledge Country and recognise that I am in her hospital, not in mine. I would say plainly: I am so sorry. The scan has shown that your baby has died.' I would pause, and not fill the silence with explanation. I would respond to the emotion before I gave more information."
• "I would ask about the cultural protocols — Sorry Business Baby, the family structure, the role of the senior kin, the Aboriginal Liaison Officer, the Indigenous health worker, the Elder's role. I would not lead the conversation; I would support the woman's family and community to lead it."
• "I would name the next person, the next time, and the route back. I would offer memory-making — photographs, footprints, a lock of hair, the name, the blanket, the identification bands. I would ask permission before every action. I would not coerce, and I would not refuse to offer."
• "I would document the conversation, the cultural protocols, the family structure, the autopsy conversation, and the follow-up plan. I would ask the Aboriginal Liaison Officer to attend the perinatal mortality review. I would offer a formal debrief to the woman and her family. I would stand down for the next shift only if the unit has the staffing to do so without compromising care."

Probe 6 — "What is the role of cultural safety training in CPD?"

Model response: ^[1][2]

• "Cultural safety training is the entry point, not the answer. The Australian Indigenous Doctors' Association (AIDA) Aboriginal and Torres Strait Islander Health in Clinical Practice (ATSIHiCP) workshop is the partner program. Mandatory cultural-safety activities commenced from 1 January 2024 — prioritised first for Board, Council, Committee Chairs and Training Supervisors, then all CPD participants from 2025 (RANZCOG CPD accreditation report). The training is the regulatory driver; the audit is the institutional change."
• "Implicit bias is not solved by awareness; it is solved by structural change. The training is the place to begin; the audit is the test of whether the training has changed practice. The change is the BRISC matched OR 0.50 for preterm birth (Kildea 2019, PMID 31388662)."
• "The four characteristics of a culturally safe team, from Hickey 2019 (PMID 31345659), are: a shared understanding of what cultural safety means locally; valuing different roles and knowledges; acknowledging the influence of race and culture on staff behaviour; and acting on individual and organisational responsibilities for continuous improvement."

Probe 7 — "What about Māori women in Aotearoa?"

Model response: ^[1]

• "Cultural safety originated in Aotearoa New Zealand in the late 1980s and early 1990s, developed by Māori nurses, in particular Irihapeti Ramsden, in response to the failure of nursing education to address institutional racism. The framework was formalised by Curtis and colleagues at Te Kupenga Hauora Māori, University of Auckland, in 2019."
• "The foundational document in Aotearoa is Te Tiriti o Waitangi (the Treaty of Waitangi, 1840). The Medical Council of New Zealand's Statement on Cultural Safety is a regulatory expectation. The RANZCOG CPD requirement applies in Aotearoa. The Māori midwifery workforce is a protected and grown asset. The principles of tino rangatiratanga (self-determination), partnership, and equity shape the relationship."
• "RANZCOG is a bi-national college. The Cultural Safety Steering Group, the ATSHiCP workshop, and the CPD framework apply across Australia and Aotearoa. The clinical principles are shared; the cultural expressions are local."

Probe 8 — "What is the next action you would take as the new trainee in this unit?"

Model response — demonstrate the institutional frame: ^[1]

• "I would arrange a meeting with the Aboriginal Liaison Officer, the Director of Obstetrics, the midwifery unit manager, and the local ACCHO chief executive. I would propose a 12-month service-redevelopment plan with the RISE Framework as the architecture. I would identify the local Indigenous workforce gap and propose a recruitment plan. I would propose a continuous auditing cycle of the differential treatment data. I would propose a partnership with the ACCHO for at least one element of the service, and I would propose a co-designed Birthing on Country element for the next financial year."
• "I would also propose a cultural safety debrief after every stillbirth, and I would invite the Aboriginal Liaison Officer to the perinatal mortality review. I would propose that the unit's Grand Round topics include specific cultural safety topics — the cultural safety of stillbirth care, the cultural safety of lactation support, the cultural safety of induction counselling, the cultural safety of child protection notifications — until the topics are normalised."
• "And I would acknowledge that the work is not mine to lead. It is the community's work. My role is to support the community to lead it, and to be accountable for the changes in my own practice and in the unit's practice."