Using an Interpreter in a Personal Care Setting- A cultural Competency Perspective

As of 2007, when the most current Census data was available, over 55 million people in the United States were not using English as their primary language, with another 24 million stating that they could not speak English “very well”. In 1980, a mere 30 years ago, 23 million people in the US were not using English as their primary language. In three decades we’ve see the number of non-english speakers rise dramatically, more than doubling. Given this increase, we must consider- What is the current climate surrounding this issue? What are the barriers to providing quality care to non-english speaking women and how can we overcome those barriers and increase our cultural competency?

As childbirth becomes more complicated- technically, diagnostically, and socially, it is becoming even more difficult to communicate these intricacies to pregnant, laboring and postpartum women with Limited English Proficiency (LEP). Are providers and hospitals keeping up with these changes? In an study called, “Do Hospitals Measure up to the National Culturally and Linguistically Appropriate Services Standards?”, researchers looked at the federal regulations (The Culturally and Linguistically Appropriate Services) required of health care organizations to provide interpreter services to LEP patients. They found that of the hospitals studies, 13% met all the CLAS requirements, 68% met some of the regulations, and 19% met non of the requirements at all. They concluded, “Enforcement of these regulations is inconsistent, and thus does not motivate hospitals to comply...our study reinforces the importance of these efforts and helps target interventions to improve the delivery and safety of care to limited English proficient patients”(Diamond, Jacobs, Wilson-Stronks 1).

When interpreter services are available, are interpreters being utilized appropriately? In an qualitative study called, “Getting by: Underuse of Interpreters by Resident Physicians”, researchers used in-depth interviews with care providers working in a hospital with excellent interpreter services. The research concluded that although an interpreter was ready and accessible, physicians were not using them- “residents at the study institutions with interpreters readily available found it easier to "get by" without an interpreter, despite misgivings about negative implications for quality of care.”(Diamond, Schenker, Curry, Bradley and Fernandez 1) Instead of using interpreting services, most the of the physicians in this study were communicating with LEP patients using hand movements, the patients limited language skills or by asking a nearby family member or friend, which “normalized the underuse of professional interpreters, despite recognition that patients with LEP are not receiving equal care” (Diamond, Schenker, Curry, Bradley and Fernandez 1)

In the case of no interpreter available, what does research say about the abilities of non-interpreters in communicating care? In an article called, “Are Good Intentions Good Enough? Informed Consent Without Trained Interpreters”, Authors Hunt and Voogd found, “In observing consultations with Spanish speaking patients, we were often struck by the limited amount of information that was actually communicated. Interpreters often seemed to lack the linguistic fluency and/or the technical medical understanding necessary to provide an adequate interpretation” (Hunt, Voogd 1). Additionally, it is clear from a 2010 consumer survey called, “Language barriers and the use of interpreters in the public health services. A questionnaire-based survey”, consumers of interpreter services are dissatisfied with the care they are receiving- “Many survey participants expressed dissatisfaction with both their own methods of working with interpreters and with the interpreter's qualifications” (Syed 1)

It is clear that either the misuse of interpreters or no use of interpreters at all contributes to the growing health disparities we see in our country. In terms of risks an benefits, it seems the risks to the patient are considerable- uninformed consent and unequal care being the two central issues. The benefits seem to only be bestowed on the care provider, who without an interpreter to slow them down, is allowed to provide quick, easier to administer (though ultimately sub-par) care. Without the use of an interpreter for LEP client/patients, care is not specialized, informed or appropriate for the needs of the client/patient. Although most of the research on this subject is from hospitals, and more research is needed on Midwifery Care and interpreter use, it is fair to deduce that all care providers would benefit from increased cultural competency in this arena.

How do we, as providers of care, bridge the language gap and provide specialized care to our LEP clients? First, clients need to have access to professionally trained interpreters. Second, it seems clear that all providers within institutions need to create concrete policies for LEP patients. In a study called, “Overcoming language barriers with foreign-language speaking patients: a survey to investigate intra-hospital variation in attitudes and practice”, researchers came to the conclusion that, “Based on our results, we believe that other priority activities will include developing an explicit hospital policy statement on interpreter use (when, why and how interpreters should be called), and communicating this policy during orientation of all new staff” (Hudelson and Vilpert 1). Making correct, efficient and reliable translation services available must be a priority, as well as educating care providers on how to utilize these services correctly.




Annotated Bibliography

Syed, Kale. "Language barriers and the use of interpreters in the public health services. A questionnaire-based survey.." National Center of Minority Health Research. 81.2 (2010): Print

The authors of this study sought to examine consumer satisfaction with interpreter services. They studied how often health care workers had a need for translation services, how they work with interpreters in those situations, and how competently they felt the care was used. Both physicians and nurses answered the survey. From the outcome of the survey, the authors felt there was enough evidence to suggest that there should be come awareness raising of the interpreter issue and how they are used with clients/patience.

Diamond, Wilson-Stronks, and Jacobs. "Do hospitals measure up to the national culturally and linguistically appropriate services standards?." Department of Health Policy Research. (2010): Print.

In this study researchers investigated the issue of CLAS, a federal cultural and linguistics regulating body, and if hospitals were complying with their regulations. The authors used a cross-sectional survey of Hospital Interpreter Service Managers and found that over 30% of hospitals studies were non-compliant with these federal regulations. Ironically, they found that although patients were informed of their rights to interpreter services, they were only informed in English.


Diamond, , Schenker, Curry, Bradley, and Fernandez. "Getting by: underuse of interpreters by resident physicians.." Robert Wood Johnson Scholors Program, Yale University School of Medicine. (2009): Print.

In this study, the authors looked at language barriers and how it complicated physician-patient communication. They looked specifically at the decision making process of physicians who had access to “excellent” translation service for LEP patients. Interestingly, the physicians seemed to prefer to struggle though communication using incomplete information and hand gestures than waiting for interpreter services to communication with the patient directly. I can only draw from this that the physicians involved in the study were under the impression that translation services were too bothersome, time consuming or inefficient to be used.


Hunt, and Voogd. "Are Good Intentions Good Enough?: Informed Consent Without Trained Interpreters." Society of Generalized Internal Medicine. 22.5 (2007): 598-605. Print.

This is one of the few articles I found that was directly related to prenatal care. The study was framed within the context of informed consent- something that cannot be fully obtained if the client is not able to understand the provider. The authors mostly found that communication issues were a consequence of untrained translators relying on their own interpretation of what the client did or did not understand in the consent process.

Hudelson, , and Vilpert. "Overcoming language barriers with foreign-language speaking patients: a survey to investigate intra-hospital variation in attitudes and practices." BMC Health Service Reserves. 15. (2009): 187. Print.

I was not able to find much in the way of problem solving in this subject specifically (although much of the cultural competency reading we did could easily apply to this issue), but this article did offer some concrete ideas about improving the use of interpreters. Creating training standards and implementing policy level change are definitely changes that need to be implemented of this issue is going to be solved.

What It’s Like To Get a “Hands On” Education

My program is nothing like your program (unless, of course, you’re becoming a Midwife too). Sure, we do all the things you’ve done in school- group projects, discussion board posts, power point presentations, and listen to hours of dry lecture. The main distinction between you and I is that when I go to school, I take my pants off and my classmates look inside my vagina. As I’m sure you can imagine, I don’t really know how to respond when people ask, “How is school?”. You see, this kind of program fosters a kind of intimacy I’ve never felt for a group of people before. There is no simple answer to that question.

Prior to becoming a member of Bastyr’s 2013 class of Midwives, I was a a lowly community college student with a few years of Doula and Childbirth Educator experience under my belt. My relationship with my classmates ranged from polite and friendly to distant and disdainful. My classmates made no impact on my life. My classmates were not people I admired, loved, or wanted to commune with.

When I began the Midwifery program 6 weeks ago, I entered into it cautiously. I was afraid I’d make enemies with what I perceived to be a moderate, complacent student body at Bastyr University. Sure, I subscribe to all the same ideologies as the majority of students at our “natural” medical school, but I am far from moderate and complacent with these ideas- I am an outspoken (loudmouthed?), radically thinking student midwife entering into midwifery from a place of feminism and activism. I am not there to munch on Kale and fuss with homeopathy. I’m there to change the damn world.

Instead of a room full of enemies, I found a room full of peers. I found my village. I found my people. I found a program that was probably the closest anyone can come to the Our Bodies, Ourselves feminism of the 1970’s.

Why doesn't this happen anymore?

After our first week together, I had fallen deeply in love with all of these women. How the hell did that happen in a week?

In short, our program is designed to bond us together. Our professors put us though emotionally revealing team building exercises and required us to practice health assessment on one another. In both team building and in health assessment, we started out slowly, brief introduction and taking one another’s pulse. But, by week four, we were crying in each other’s arms as we worked though our emotional baggage and gently guiding one another though inserting a speculum inside our bodies.

I have to admit, I do take particular pleasure in revealing to outsiders that we practice pelvic exams on one another. I enjoy the way it scandalizes the listener, challenges their concept of “education”. With big, wide eyes, the listener exclaims, “But...but...WHY?”. The short answer to “why” probably has something to do with the cost associated with hiring models for us to work on, but I have a feeling our faculty understand the value transcends simply saving a few bucks.

 

Lisa and Helen, rooting around for my cervix

The value in being able to learn these difficult skills on one another is massive. Not only does it bond us together, but for the receiver of the exam, it fosters empathy for the process. After having 5 pelvic exams in one week, I can say with total certainty that I understand the broad range of feelings associated with receiving the exam, from painful to pleasant to unsuccessful. This will only enhance how I touch women as a Midwife and my how I allow practitioners to touch my body when I am examined in the future. For those of us performing the exam on our classmate, we get the best kind of feedback available- an honest critique from someone who is learning the same skills. A model would have no idea if I forgot to check the Bartholin glands during my examination.

Yeah, my program is not like your program. It’s life changing, mind altering, and beyond what most people can understand. It’s where I belong.

Vaginal Birth After Cesarean- 20 Years of Changing Attitudes and Practice, by Amber Parker

For Epidemiology for Midwives, Fall 2010           

Attitudes and practices abut Vaginal Birth After Cesarean (VBAC) have been changing since 1916, when it was declared “Once a Cesarean, always a Cesarean”. In the last 20 years, attitudes and practices have been especially pendulous, with countless studies being conducted and The American College of Obstetrics and Gynecology (ACOG) recommendations regarding VBAC changing several times. Each of these changes have has a dramatic effect on the kind of care women and their babies have access to. 

 In the 1990’s, there was enough evidence to support a trial of labor for women who had a previous cesarean, creating a new trend in practice. In “Trends in cesarean birth and vaginal birth after previous cesarean, 1991-99”, authors Menacker and Curtin report on these trends. They found that the US VBAC rate increased by 33% between 1991 and 1996 and fell 17% between 1996 and 1999 for all age and ethnic groups ( Menacker and Curtin 1). These dramatic differences in rate are due to ACOG recommendations, which were mostly in favor of VBAC.  

 In 1999 the ACOG revised their position on VBAC, making it stricter and subsequently ending the trend in practice. Their reasoning for the new guideline was, "Because uterine rupture may be catastrophic”, institutions needed to be “equipped to respond to emergencies with physicians immediacy available to provide emergency care” (Win 1). ACOG was unable to provide any scientific evidence to support this, however. Instead they were only able to offer medical-legal reasons, stating “...Increasingly, these adverse events during trial of labor have led to malpractice suits” (Wagner 1). This affected many rural communities which could not offer 24 hour emergency care, which subsequently contributed to an increase in the overall c-section rate and decreased the number of women “allowed” to have a trial of labor.  

By 2002, a mere 3 years after the new guideline had been created, the VBAC rate had dropped 12%, with no improvement or change in neonatal or maternal mortality rates (Win 1). Hundreds of hospitals across the US had either completely banned or had a de facto ban in place prohibiting women from having a trial of labor after a previous Cesarean, further driving the Cesarean rate up and the VBAC rate down. 

 In a 1999 article called “VBAC: Protecting patients, defending doctors” authors Deutchman and Roberts reflect on the complexity of the new, more restrictive  guidelines, stating that “The irony of the ACOG recommendation is that it may result in what it seeks to avoid: worse pregnancy outcomes and increased litigation risk. As more maternity services are discontinued and women must leave their communities for pregnancy care, mortality and morbidity rates increase for both mothers and infants” and concludes that,

“Large population-based studies have shown no difference in maternal mortality between the two delivery approaches. Compared with trial of labor, elective repeat cesarean birth is associated with a 2 percent greater risk of maternal infection and a 1 percent greater risk of maternal hemorrhage requiring transfusion. Uterine rupture occurs 0.24 to 0.77 percent more frequently with trial of labor than with repeat cesarean birth, and perinatal death occurs 0.10 to 0.40 percent more frequently” (Deutchman and Roberts).


Since the new 1999 ACOG guideline revision, the body of evidence in favor of VBAC has grown. In the article “Stricter VBAC Guidelines Does Not Affect Mortality”, Kenneth W. Win states, “Maternal death rates did not change significantly after the guideline revision, regardless of delivery type...pregnant women who have had a previous cesarean delivery (should) be informed about these encouraging findings in addition to the risks associated with VBAC” (Win 1). A retrospective cohort study called “A new perspective on VBAC: A retrospective cohort study” was

“undertaken comprising a consecutive cohort of 21,389 women who delivered, stratified by Robson's criteria into Robson groups 1-5. Those in Robson groups 6-10 were not included. Demographic data and maternal/neonatal outcomes were reviewed, with main outcome measures comprising uterine rupture, post-partum haemorrhage (PPH), 3rd/4th degree tears and neonatal morbidity” Authors Rozen, Ugoni and Sheehan found that for women who had a vaginal birth after a prior cesarean, there was no increase in postpartum hemorrhage, vaginal tears, or neonatal complications and concluded.The maternal and neonatal morbidity associated with VBAC is comparable to primiparous women undergoing a vaginal birth” (Rozen, Ugoni and Sheehan 1).

Despite mounting evidence in favor of VBAC, guidelines did not change. By 2007, the c-section rate had climbed to 31.8% of all births in the US.

In 2010, as a response to this record high c-section rate and to the growing body of research in favor of Vaginal Birth After Cesarean, both the National Institute of Health (NIH) and American College of Obstetrics and Gynecology reviewed and revised their statements regarding VBAC. In a 2010 article called, “NIH Consensus Development Conference on Vaginal Birth After Cesarean: New Insights” 21 experts in pertinent fields presented new data to a panel and audience. The conclusion of the data presented was as follows,   

“Given the available evidence, trial of labor is a reasonable option for many pregnant women with one prior low transverse uterine incision. The data reviewed in this report show that both trial of labor and elective repeat cesarean delivery for a pregnant woman with one prior transverse uterine incision have important risks and benefits and that these risks and benefits differ for the woman and her fetus” (NIH 1)    

Finally, in July of 2010, the ACOG revised their guideline regarding vaginal birth after cesarean-

“Attempting a vaginal birth after cesarean (VBAC) is a safe and appropriate choice for most women who have had a prior cesarean delivery, including for some women who have had two previous cesareans...the current cesarean rate is undeniably high and absolutely concerns us as ob-gyns..these VBAC guidelines emphasize the need for thorough counseling of benefits and risks, shared patient-doctor decision making, and the importance of patient autonomy. Moving forward, we need to work collaboratively with our patients and our colleagues, hospitals, and insurers to swing the pendulum back to fewer cesareans and a more reasonable VBAC rate.” (ACOG 1)


References

Kenneth W Lin.  (2006). Stricter VBAC Guideline Does Not Affect Mortality. American Family Physician, 74(8), 1411-1412.

Curtin SC., , and Menacker . "Trends in cesarean birth and vaginal birth after previous cesarean, 1991-99.." National Vital Statstics Report . 1.16 (2001): Print.

Mark Deutchman, & Richard G Roberts. (2003). VBAC: Protecting patients, defending doctors. American Family Physician, 67(5), 931-2, 935-6.

Rozen, , Sheehan, and Ugoni. "A new perspective on VBAC: A retrospective cohort study.." Women birth- Department of Obstetrics and Gynaecology. 1. (2010): Print.

National Institute of Health, "NIH Consensus Development Conference on Vaginal Birth After Cesarean: New Insights." Obstetrics & Gynecology. 115.6 (2010): Print.

Wagner, Marsden. "What Every Midwife Should Know About ACOG and VBAC: Critique of ACOG Practice Bulletin No. 5, July 1999, “Vaginal Birth After Previous Cesarean Section." Midwifery Today. (1999): Print.