Religion, Cultural Competency and Healthcare

Below is a piece that midwife Shannon Staloch and I wrote for the current issue of Midwifery Today (Issue 109). While we're writing about cultural competency and Muslim communities, I feel that it's just as relevant in thinking about any cultural minority community because it's about the questions that we ask ourselves. My thanks to Midwifery Today for allowing me to reprint it here.

Supporting Muslim Families as Midwives

Krystina Friedlander and Shannon Staloch In Midwifery Today, Spring 2014, Issue 109

In a recent Doctors without Borders (MSF) webinar titled, “MSF Delivers: Overcoming Challenges in Maternal Health,” I was taught that in Muslim cultures “women are very much the property of men.” The speaker was a Belgian obstetrician who was involved in MSF initiatives in Afghanistan and northern Pakistan. She cited a tragic example of a husband refusing possibly life-saving surgery for his wife.

I also attended this year’s Midwives of North America (MANA) conference in Portland, Oregon, where I attended a session designed as a primer for midwives working with Muslim families. There, a Muslim presenter described—just as confidently as the Belgian obstetrician—that withdrawal is the only Qur’anically sanctioned, and hence permissible, method of birth control in Islam. Her other points of emphasis included that Muslims dislike dogs (in the event, perhaps, that midwives may keep their furry friends in their offices) and that midwives should strive to make neither eye contact nor conversation with the husbands of their clients.

My co-author and I are both American Muslim birth workers, and both of us are bewildered by these examples. In one case, a midwife from outside the faith made blanket conclusions about the attitude of all Muslim men based on her experiences in two distinct regions of the world. In another case, a birth worker from very much inside the faith made equally blanket assertions about Muslim families and their religious lives. In neither case did we recognize the attitudes and behaviors of the vast majority of the Muslim men and women we know and work with as healthcare professionals.

Clearly something is amiss. Misunderstanding and misrepresenting Muslims doesn’t begin and end with the isolated examples we provide; it shows up in everything from the basic textbooks we study to the personal biases we may harbor. How, then, as practitioners committed to healthy women and healthy babies, can we serve clients who may have an attachment to a faith that loosely connects one in five people on this planet?

To start with, it’s worth recognizing that we live in a post-9/11 society where Islam is highly politicized and stereotyped in negative ways, typically without question or conversation. The old cliché goes: Muslim women are oppressed, Muslim men are oppressors and their religion sanctions this. Such a belief ignores diverse interpretations and perspectives and erases Muslim women’s agency in their own lives. Where oppression exists—and it certainly does—Muslim women, men and their allies seek to remedy it. What is more relevant to us as birth workers is that making assumptions about Muslim men and women limits our abilities to be competent care providers.

The truth is that there is immense diversity within the Muslim community. Islam is practiced by 1.6 billion people on this planet, from North America to China. This diversity is a product of our unique intersections with geography, history, culture, politics, economics and power. It encompasses a wide range of views on spirituality, practice, religious law and gender relations. In serving a population that shares a faith but not necessarily a culture, it is clear that while religious beliefs may define some practices during labor and birth, culture shapes their expression. One contemporary Muslim scholar has likened Islam to a river and culture to the bedrock over which it flows. So while we may understand the river, we don’t always understand the rocks over which it flows.

We’ve learned that certain Muslim cultures have a markedly different approach to female modesty during birth than others. Some are adamant about having female-only care providers, while others simply prefer female care providers and still others are fine with care providers of either gender. We’ve cared for Muslim women who have had abortions (some religious scholars assert its permissibility, while other scholars—and many Muslims—shun it) and women who use various forms of birth control and are open to discussing their options (plenty of Islamic scholars agree that birth control methods are permissible according to Islamic law). Other Muslims we’ve served drink alcohol or are unwed mothers. Still, each of them identified with their faith strongly enough to seek out a midwife or doula from that shared faith. By making assumptions about Muslim women, we risk not having important conversations that invite them to express their preferences and needs, which may or may not be religiously based.

What is cultural competence for anyway? Why learn about Muslim women or women from any other specific religious or cultural background? It’s certainly helpful to know how Islamic beliefs might inform someone’s preferences and how particular Muslim practices might affect the pregnancy and birth. Also, as midwives and birth workers, we are called to improve upon the current abysmal state of maternal health. Muslim women today—here in the United States and in the rest of the world—are disproportionately affected by poor maternal health outcomes. More than half of the Muslims in this country are African American, a population over four times as likely to die in childbirth as its white counterpart. Beyond that, in 2010, six of the ten countries with the worst maternal mortality rates had a Muslim majority.

Finally, cultivating cultural and religious literacy is about developing ourselves. As midwives, we are called to support women in having a birth experience that is meaningful to them and to their families, and for some of these women, meaning is made through faith. We inculcate an attitude of curiosity towards others and to what is meaningful in their lives with the goal of becoming better able to communicate with our clients and more respectful of—and receptive to—their needs. In so doing, not only are we able to better appreciate mothers and fathers, but we gracefully follow their lead in supporting them in one of the most meaningful experiences of their lives—the birth of their children.

Krystina Friedlander is a childbirth doula and student midwife in Cambridge, MA. She works at the Harvard Divinity School where she researches religious literacy and globalization.

Shannon Staloch is a licensed midwife and board-certified lactation consultant in the San Francisco Bay Area.

We need more Muslim doulas!

The quickening