Strengthening equity: Advancing Cultural Safety in UK maternity care

Our new report, Strengthening Equity: Advancing Cultural Safety in UK Maternity Care, is published today and captures the collective insights, recommendations and visions for change generated during our symposium in collaboration with The University of Birmingham.

“You people talk about legal safety, ethical safety, safety in clinical practice and a safe knowledge base, but what about cultural safety?” 

In the late 1980s in Aotearoa New Zealand, a Māori nursing student posed this question during a lecture. Her challenge inspired nurse educator Irihapeti Ramsden to develop the concept of Cultural Safety, or Kawa Whakaruruhau (“a safe place made from principles”), as a response to the enduring impacts of colonisation and the persistent health inequities experienced by Māori communities. More than three decades later, Cultural Safety is increasingly being adopted beyond Aotearoa New Zealand as a framework for addressing discrimination, inequity and exclusion in healthcare. 

Cultural Safety was conceived as a critique of transcultural nursing that sought to improve care through greater knowledge of the cultures and beliefs of others. While transcultural concepts such as cultural awareness and cultural competence encouraged healthcare professionals to understand and respect ethnic differences, Ramsden argued that health inequity could not be addressed by having some knowledge of a particular culture alone. Culture, she argued, is dynamic- shaped by traditions and beliefs but also class, race, dis/ability, sexual and gender diversity, language, experience and so much more. She called for an approach that instead drew attention to the power relations, institutional practices and wider social inequalities that shape healthcare encounters. Cultural Safety seeks to redistribute power by locating the authority to define safety with the care receiver rather than the caregiver.  The patient will only be deemed to be safe if they say that they are safe. It also requires that the healthcare provider is equipped with deeply reflexive skills as part of their individual training and institutional culture so that they learn to examine how their own values, beliefs and experiences impact care they deliver.  

Why Cultural Safety, and why now? 

Cultural Safety emerged in response to the failure of a colonial-imposed health system to adequately meet the needs of the indigenous Māori population in Aotearoa New Zealand and has since been most widely adopted in other settler-colonial countries such as Australia and Canada. So, how is it relevant and how does it translate to a UK context? Just as the British-imported health system in Aotearoa New Zealand was designed for British settlers rather than Māoris, the NHS was likewise designed from a particular historical, social and cultural context which carries assumptions about who services are designed for and how they should be accessed. White women and birthing people remain significantly more likely to survive childbirth in the UK than Black and Asian women and birthing people. Moreover, those with able bodies, secure immigration status, English language proficiency and wealth (resources?) navigate the maternity care system with greater ease than those without. As a midwife recently told me ‘Care is either designed in or designed out. It’s not an accident’. 

There is a growing recognition that inequalities in maternal outcomes require a more explicitly anti-oppressive lens with which to examine the structures that govern the provision of care. By directing attention towards systems, power relations and critical self-reflection, Cultural Safety offers a way of understanding how maternity services work better for some groups more than others.

Rather than treating inequity as a consequence of cultural difference alone, it asks how institutional norms, professional power and assumptions shape experiences of care and determine whose needs are recognised and accommodated. When systems and individuals have the skills to interrogate these forces, care can be adapted, partnerships flourish and bridges between the patient and the system can be built.  

Exploring Cultural Safety in UK maternity care 

Despite growing interest in Cultural Safety within UK maternity care, there has been relatively little opportunity to collectively explore what it means in practice, how it differs from transcultural approaches to health, and what it might contribute to addressing persistent inequities. It was against this backdrop that Birthrights, together with the University of Birmingham, convened the symposium Strengthening Equity: Advancing Cultural Safety in UK. Bringing together midwives, researchers, educators, advocates, regulators and community organisations, the symposium explored Cultural Safety through a process of Appreciative Enquiry. Participants heard examples of culturally safe practice already taking place across UK maternity services, from community engagement initiatives and changes to how racism is reported to cultural-bridging services and campaigns. These examples demonstrated that the foundations of culturally safe care already exist within the UK, even if they often remain fragmented and under-resourced. Participants also developed a collective vision of what culturally safe maternity care might look like in the UK, identifying actions across regulation, education, policy, research and clinical practice. 

Against the backdrop of a poly-crisis in UK maternity care and increasing hostility towards our migrantised and racialised communities, the symposium concluded that urgent and radical action is needed to address growing inequity. Cultural Safety offers both an ethical approach and a structure for change that moves us beyond the limits of cultural competence and cultural awareness in order to name and address discrimination and dismantle the harmful power imbalances that create unsafety for some women and birthing people. The symposium concluded that there is no safety without Cultural Safety. Yet achieving culturally safe maternity care will require more than individual commitment. It demands leadership, investment and a collective willingness to embed the principles of critical self-reflection and patient-defined safety across all levels of maternity practice and policy. 

More than three decades after a Māori nursing student first challenged healthcare educators to think beyond clinical and professional definitions of safety, her question remains as relevant as ever. If maternity services are to become equitable spaces in which all women and birthing people can thrive, then we must continue to ask not simply whether care is safe, but safe for whom. 

Our report, Strengthening Equity: Advancing Cultural Safety in UK Maternity Care, is published today and captures the collective insights, recommendations and visions for change generated during the symposium. 

Pip McKnight