Laura Sherwood Higgins, MPH, ASW, PPSC

When I was an MSW student, I spent a summer in Bolivia volunteering in a pediatric health program.  My plan was to shadow social workers in a medical setting, but I was invited to shadow and even assist physicians as well.  A particular incident highlighted the challenge of fusing conflicting healthcare priorities and policies with cultural mores — a challenge social workers regularly encounter domestically and abroad.

When I asked if I could put the baby on its mother, the doctor looked at me as if I had just requested a dozen oysters on the half shell.  Had I?  Having arrived in La Paz just four weeks earlier, my communication skills were limited, and I wondered if I had been misunderstood. 

I repeated my question, and the doctor shook her head brusquely and said, “Claro que no.”  She needed to oversee the delivery of the placenta and stitch up her patient who had undergone a routine episiotomy; a baby did not belong in the middle of all of that.  I was to wipe the baby down, dress him, swaddle him in his blanket, and set him down next to that other newborn baby, who was bundled up and squirming on a metal countertop next to the sink.  I could not argue; I did not have the vocabulary or medical expertise to do so, nor was there time for a discussion.  It was the dead of winter, and the unheated clinic sat at about 13,000 feet above sea level.  The baby needed to stay warm.  So, I held the baby as the nurse gave him a Vitamin K injection, and then I cleaned, dressed, and swaddled him as instructed. 

However, I did not put the baby down on the countertop.  Instead, I held him close to me, waited by the mother’s bedside as the placenta was delivered, watched the doctor finish her last stitches, and then, without asking any questions, I placed the newborn on his mother’s chest.

There were two loud and conflicting voices in my head: one called for cultural sensitivity and respect for the clinic and its policies (put the baby on the counter) and the other was talking about skin-to-skin contact, oxytocin levels, maternal-infant bonding, and breastfeeding (put the baby on his mama).  The latter voice moved me to do something that could have been interpreted as disrespectful and paternalistic.  Yet, despite being a foreigner both to Bolivian culture and the field of medicine, I wondered whether my instincts regarding infant and maternal care were somehow more valid than the standard care provided in that clinic.
 
After all, though the facility had been built to serve an indigenous population in El Alto, it seemed to me that little regard for the predominant culture’s mores existed.  The medical providers spoke in Spanish, though the primary language of their patients was Ayamara.  The women in labor were isolated from their support networks, as family members were not permitted access to the labor ward.  The clinic walls were painted white, a color that the Aymara associate with death and the burial of babies. 

In this severely under-resourced clinic in a country with some of the highest maternal and infant mortality rates, used needles were haphazardly thrown in cardboard boxes, body fluids were splattered on floors and countertops, and there was a dearth of plastic gloves.  Myriad issues needed attention, intervention, and resources.  Suggesting that this clinic reevaluate where a healthy baby was placed postpartum was, no doubt, a low priority.

Still, there are empirically-based physiological and psychological benefits associated with keeping healthy mothers and infants together immediately following birth.  Despite the doctor’s instructions, my scant medical ken, and my visitor status in Bolivia and in the labor room, I felt compelled to do whatever I could — whatever I knew how to do — to promote the health of the infant in his first moments out of the womb.

What I did felt justified on a visceral level, and it was supported by recent studies.  Yet, I had meddled in a system more complex than a newly-arrived gringa could comprehend.  The relationship of the clinic to the Ayamara community, the expectations of the mother and her family, and the priorities and responsibilities of the health providers were all unknown to me.  My actions may have been culturally insensitive, and I definitely overstepped boundaries.  Even so, I think I would do it again.

Attempting to demonstrate cultural humility in a complex, culturally-diverse field elucidates a sometimes-grey area where ethics can become convoluted.  When we work with disenfranchised groups within disenfranchised groups, how do we advocate for the most vulnerable group?  How do we reconcile our own knowledge, expertise, and personal experience when it is contrary to the prevailing culture in which we are working?  To what degree do we set aside our own expertise to adapt to policies and cultural mores?  How do we make positive change while practicing cultural humility?  While the answers to these questions seem abstruse and, at times, impossible to reach, continually asking such questions with curiosity and openness seems foundational to social service work.Laura Sherwood Higgins, MPH, ASW, PPSC has worked with children and their families as a School Social Worker in the San Francisco Unified School District since 2011.  Originally from Santa Cruz, California, she received her MSW with a concentration in Health from UC Berkeley's School of Social Welfare and her MPH with a concentration in Maternal and Child Health from UC Berkeley's School of Public Health.  Laura has worked in a series of positions — voluntary and paid — in the social services and health sectors, in diverse communities, and on a variety of issues, from food insecurity to mental health.  Outside of work, she likes spending time in redwood forests, fly fishing, and traveling the world over.