Category: Chinese Culture

Since time immemorial, the nature of science fears the idea of subjective data due to its capricious and unpredictable characteristics. Wherein science is ultimately based on empirical evidence of cause and effect relationships, the nature of pain is highly dependent on physical, psychological and environmental factors. A pioneer in pain management once said, “pain is whatever the person experiencing it says it is and exists whenever he says it does” (1999, p. 98). Margo McCaffery meant to say that pain experience will always be subjective by nature and can only be disclosed by the patient in question. This creates an important emphasis on in-depth nursing assessments and individualized nursing interventions.

Referring to the International Association for the Study of Pain, mentioned in Linton’s “Introduction to Medical-Surgical Nursing”, pain is defined as “an unpleasant sensory and emotional experience associated with actual or potential tissue damage.” This means that pain signals danger and prevents humans from harming themselves while alerting the body to damages done unto one’s system. In some cases, too much pain can be crippling and can make living a form of endless agony. Essentially, even ‘good pain’ can turn bad, when the pain of a past injury persists after the damage has healed.

As a nurse, it is imperative that they should be “nonjudgmental and avoid comparing one individual in pain with another individual in pain” (Linton, 2016, pg. 213). It is acknowledged that there is no such thing as two exact patients even though they are matched on numerous aspects such as medical conditions or biological identities. For most patients, pain is temporary, lasting as long as the causal stimuli followed by a sudden disappearance. For other patients, pain evolves into a chronic problem that usurps one’s identity. Ultimately, both patients want liberation; an end to their ordeal.

Relationship between Culture and Pain

Based on 2018 Immigration Statistics of the Government of Canada, the country gained an influx of between “290,000 and 330,000 permanent residents, which is the highest level in recent history,” with numbers increasing by ten percent each year. This means that nurses will engage in constant ever-changing relationships with a multitude of cultures. Different cultures tend to have different values, beliefs, and experiences meaning different ways of handling pain. “Some cultures are expressive about their pain while others are introverted” (Potter, P. et. al, 2014). This creates a greater emphasis on cultural competence and cultural sensitivity to better help each individual with pain management.

Cultural Differences in Pain Perception

Cultural Sensitivity refers to a nurse’s awareness of how culture shapes the patient’s values, beliefs and world views. In doing so, nurses will strive to understand potential differences and ensure respect for these varying cultures. Following this attitude and respect, cultural competence is the knowledge and skills required to obtain positive outcomes in cross-cultural encounters. In knowing about a culture’s customs, nurses can achieve better pain relief and competency-based practice. For example, “[Caucasians] were two and a half times more likely than African Americans and nearly one and a half times more likely than Hispanics to use “self-care” for pain relief” (Hastie and Riley, 2005, Ethnic Differences and Responses to Pain in Healthy Young Adults). One reason for this likelihood is given that Caucasians had the highest proportion of insured participants thus they were more likely to pursue health care options for pain relief. Another possible conjecture is that people with higher incomes tend to fear pain and loss more than those of lower incomes. This is due to the fear of losing what one has. For cultures with more to lose, they have greater fear. Death and pain are unfathomable and more likely to instill fear in cultures with more to lose such as families, wealth, lifestyle etc. With this in mind, the Asian culture can be considered as the opposite of Hispanic, Caucasian and African culture in a sense where they value stoicism more than expression.

Interpretation of Patients’ Pain Experience

Bias

In a sense, an important aspect of the client-focussed provision of care is to recognize one’s own prejudices and biases and to care for one’s patients in a manner that does not affect the nurse’s own perception of a patient’s pain complaints. Imposing the nurse’s own way of handling pain creates a disconnect to the bridge that helps understand the patient’s pain. The moment this seed of mistrust begins, any form of pain management will be inadequate. Pain is a “highly personal experience, which can be accurately described only by the individual experiencing it and report of pain should be accepted as valid” (Potter, P., 2014) Thus, nurses are bound by their license to provide an accurate pain assessment while acknowledging the patient’s perception and culture into account, without this accuracy, pain management will be mediocre. Connecting this to the Chinese Culture, they prefer not to express pain for a variety of reasons such as being perceived as weak. If the nurse lacks cultural competence or continues to exhibit bias and generalization, pain management will become of poor quality thus increasing the level of anxiety and slowing down the healing process altogether.

Language

Communication issues such as linguistic and nonverbal differences can hinder the nurse’s understanding of the patient’s complaints and be considered as life-threatening. People from different cultures “describe pain and distress quite differently” (Meuter, R., 2015, Overcoming Language Barriers). It is problematic when health care practitioners lack the linguistic and cultural skills needed and translators are unavailable. As a result, patients may have to rely on their family members who are medically inexperienced which may worsen health outcomes due to the risk of miscommunication and lack of understanding.

Acculturation

According to Rethinking the Concept of Acculturation, acculturation is defined as “changes that take place as a result of contact with culturally dissimilar people, groups, and social influences” (Gibson, 2001). Realistically speaking, these changes can happen with any kind of crosscultural contact but the focus is on its effects on pain. The social norms of some Caucasian cultures are to report their pain as soon as possible. Adding to this scenario, a chinese immigrant were to move to Canada, they are disinclined to report their pain because they do not want to worry their family; they would rather endure the pain rather than explore relief options. Acculturation can be positive or negative in a sense where, a predominantly Caucasian community will influence the minority group to accustom to their tendencies of reporting their pain as much as possible. Similarly, a predominantly Chinese community may influence the minority group, which were originally more vocal about their pain, to become more stoic and reserved. Nurses need to be aware to not impose and to be very open to their patients so that they can diagnose the most accurate form of pain management.

Chinese Culture

For Chinese patients, their outlook on pain and treatment is deeply rooted in philosophical and religious beliefs that affect all aspects of pain assessment and management. To properly assess the patient’s pain complaint, it is “important to evaluate the meaning that pain has in the person’s life and the causal attributions that the individual gives to his or her pain. In addition, the philosophical approach that a patient has toward whether pain should be treated will need to be discussed before a pain education program and a pain management plan can be implemented” (Chen, L. 2008, The Cancer Pain Experience). Since they see their pain differently, nurses need to avoid generalization to better understand their patient’s views.

Taoism

Chinese patients may believe that pain is caused by a Yin and Yang imbalance in the body. If so, they will prefer to refer to Traditional Chinese Medicine or the use of acupuncture by “blocking their meridians” (Chen, L. 2008). If nurses do not understand this belief, they will assume that the patient is not adhering to their analgesic regimen. Yin energy represents negative energy while Yang energy represents positive energy. If an imbalance occurs, this just means that there is a nonharmonic situation that is causing this disease or symptom to occur. Taoism believed that to treat this disease, Chinese patients must enhance the “feng shui” meaning harmony of their environment such as “move some furnishings, ask clinicians to perform procedures at a specific time, and refuse visitors who are foes to them” (Chen, L. 2008)

Buddhism

Nurses need to understand that Chinese patients may believe that pain should be endured. Based on a variety of beliefs (eg, sin from last life, the Inn and Ko [cause and effect], a trial or sacrifice, a born-to-be fate, and afraid to bother either family or clinicians), “Chinese patients tend to bear and accept their pain. They report pain only when it becomes unbearable.” (Chen, L. 2008) Some patients may choose to endure intractable pain to accomplish their life trials. This form of persistence is in accordance with their belief. Any form of surrender is a sign of weakness and the lack of faith in Buddhism. Nurses need to discuss this belief with patients. They need to inform patients about the detrimental effects of unrelieved pain on their mood and functional status. In some cases, nurses may need to support the patient’s belief system and assure them that they will be available to assist with pain management. (Chen, L. 2008) By creating an open-door policy, Chinese patients will have a sense of comfort in times of distress.

Confucianism

Some Chinese patients may blame themselves for their illness, whereas others “may negotiate with God(s) to change their fate by praying in the temple or at home, intonating gospel, giving alms to the poor, becoming a vegetarian, or wearing a Fu (amulet)” (Chen, L. 2008). Confucianism is a form of bargaining with a higher power. This is exhibited by other cultures as well such as Hispanic and Filipino cultures. Filial piety and humaneness are essential values of Confucianism because in honouring one’s parents or by helping those of poorer opportunities, they are increasing the likelihood of good karma. Again, Nurses need to ask patients to describe the various approaches that they use to manage their pain and their illness. By involving the patient in their care, this can increase the relationship between patient and nurse while creating a sense of trust and improving the healing process due to increased pain tolerance.

History

Another deciding factor in the Chinese culture’s adherence to analgesic is opioid-phobia. Back in the 18th century till this day, there has been an increase in opioid addiction. The Chinese culture fears that they will be consumed by opioid dependence if they allow the medical team to use morphine for pain relief. Thus they would rather refer to other options of care.

Pain Assessment Tools

The Critical-Care Pain Observation Tool includes four behavioural categories: facial expression, body movements, muscle tension, and compliance with the ventilator for intubated patients or vocalization for extubated patients. (Yaowei, L. 2015) Items in each category are scored from 0 to 2 with the total score of the CPOT ranging from 0 to 8. In a sense, it is very similar to the pain scale commonly used in Canada where you rate your pain from 0 to 10 with 0 being no pain and 10 being unbearable pain. The Chinese version of the “CPOT used in this study was translated by Li et al. with evidence of reliability and validity demonstrated as an instrument for pain assessment in Chinese critically ill ventilated adults” (Yaowei, L. 2015)

Conclusion

In conclusion, it is necessary to consider the role of culture in patients’ pain experienced. In knowing the nature of pain, nurses can create better customized care. “Know thy enemy, know thy self” (Sun Tzu) In knowing about pain and how cultures perceive it, nurses can better battle this enemy and release the patients from this pain. Chinese perception of pain is certainly influenced by stoicism, philosophy and opioid history. Their culture has a great impact on assessment and pain management so it is best to be culturally competent. In order to provide ultimate care for these culturally influenced individuals; nurses should develop awareness and understanding of Chinese patient perception and behaviour. They often suppress pain and choose not to verbalize their concerns about pain. Their culture also influences how they seek treatment that is acceptable and favourable to them. Traditional treatment will be relevant for this group of people such as acupuncture, tai chi, and some herbal medicines.

References

1. Potter, P (2014) Canadian Fundamental of Nursing
2. Linton, M. (2016) Introduction to Medical Surgical Nursing
3. Tung, W (2015). Pain and Beliefs and Behvaiours Among Chinese

Issue

China has made a substantial progress in tackling its HIV epidemic. The HIV epidemic in China is largely characterized by low national prevalence at 0.037% with certain regions having higher and more severe HIV prevalence rates [1]. The country has also made substantial progress with regards to funding its HIV response as 99% of funding came from domestic sources in 2015 [UNAIDS, 2016]. Despite these efforts, in December 2016 the Chinese Centre for Disease Control and Prevention (CCDC) reports 96,000 new HIV cases in the first nine months of that year. This indicated that the number of new cases in 2016 is likely to exceed 115,000, the number of new cases in 2015 [2]. HIV epidemic is still a major concern for some of the key affected populations within the country.

HIV prevalence among men who have sex with men (MSM) have been rising in China. According to China’s Health and Family Planning Commission the MSM population has a HIV prevalence of 7.7% [2]. MSM represent over a quarter of new reported infections each year [UNAIDS,2013]. Each day of 2016, 10 Chinese university students were infected with HIV-eight of whom were MSM [3]. Unfortunately, in China, many MSM attending university first learn of HIV when they receive their HIV-positive test result. There are several factors that increase their vulnerability to HIV infection. MSM population do not feel safe in accessing public health resources due to widespread homophobia. Besides, sex education in schools is inadequate and many young people do not have basic sexual health knowledge [4]. Ignorance of HIV status is a major factor in rising epidemic amongst the MSM population.

The purpose of this paper is to investigate the gap in HIV diagnosis in MSM population in China and to identify the interventions targeted to this population to control their increasing HIV rates.

Methods

A systematic literature review was performed to collect the necessary data for this paper. Information for this paper was collected from UNAIDS & WHO websites, PubMed research papers, articles were searched using keywords-MSM HIV in China, Interventions for MSM HIV China. Information was also used from University of Pittsburgh-IDM Monday seminar presentation by Dr.Chongyi Wei.

MSM population accounted for only 0.3% of all HIV cases between 1985 and 2005 according to the Chinese ministry of health and UNAIDS statistics. This percentage however increased to 2.55 in 2006 and farther increased to 25.8% in 2014 shown in figure 1[5]. According to reports there is a prevalence of high-risk behaviors among MSM population in China. Approximately 45.7% of respondents were found to have unprotected sex with male partners and 10.9% had with female partners [5]. 22.9% of HIV infected MSM population have a blood donation history which in turn increases the likelihood transmission of HIV-1 through blood products. Apart from making the MSM population more vulnerable to infections, such high-risk behaviors also result in transmission of the disease to the uninfected general population.

The complex biology of HIV-1 virus and changes in demographic profile of Chinese MSM and pose serious challenges to prevention of HIV, development of ART and vaccines [5]. In 1997 the authorities decriminalized homosexual sex in China and in 2008 homosexual sex was erased from the official list of mental disorders [6]. However, due to cultural and economic reasons men who have sex with men often face the social stigma, abuse and tend to hide their identity from the world. Because of this stigmatization, men do not feel secure and comfortable in approaching clinics and other health resources to seek treatment or test for HIV. Thus, China’s MSM population remain hidden from the society of China which results in rapid transmission of HIV to both homosexual and heterosexual partners. These societal pressures and cultural factors prevent a greater understanding of the HIV epidemic in China among MSM population [7].

My paper talks briefly about some of the recent research studies done for the Chinese MSM population that helps understand what factors might be preventing them from seeking help, how we can improvise more to encourage them to seek help and what measures need to be taken for a healthy sexual lifestyle in China’s MSM population.

Findings/Results

IMPACT Project

For the control of HIV epidemic among the MSM population, community engagement as a whole is very important. Not-for-profit community-based organizations (CBOs) are responsible for providing the educational, environmental and social or public safety needs of the community in China. However, most of China’s public-sector funded HIV programmes failed in engaging CBOs and had very limited success in preventing the country’s HIV epidemic. Also, majority of the MSM-friendly CBOs lack in providing services like HIV testing, post- HIV test counselling, notification of results and follow-up, which reduce their ability in providing comprehensive care services.

To address these issues, an HIV care and prevention programme was launched in China in 2008 that was sponsored by the Bill & Melinda Gates Foundation [8]. An important function of this programme was to promote collaboration between CBOs and public sector agencies in the delivery of prevention and other support services. The preventive services were targeted to high-risk groups (MSM) and aimed to lessen risk behaviors and increase HIV testing. Some of the findings of the IMPACT project in Guangzhou are discussed here. This project had different components: Online Prevention Tool- an assessment system for the risk of HIV which evaluated an individual’s risk profile and then calculated an individualized HIV-risk score. This tool offered tailored guidance to promote testing of HIV and change in high-risk behaviors. HIV education was also provided online through social media. Online to Offline Service-people could choose to have a test in health facility from the online tool and they were notified about their test results by an online notification system. Service Center- in Guangzhou a one-stop service centre was built, which was coordinated by a Guangzhou CDC and a local CBO. In this centre, on-site blood sampling and HIV tests was provided by the public sector staff. The staff did several epidemiological investigations, like HIV sentinel surveillance among MSM and medical follow-up for the people who tested positive. Questions regarding sexual behaviors were also asked to the people who were tested.

As shown in figure 2 below, the project resulted in an increase in the annual number of tests from 1064 in 2008 to 7754 in 2013. By the year 2013, the project resulted in more than 80% of total HIV tests and new HIV diagnoses among men who have sex with men in Guangzhou. Right now, each day an average of 25 people make appointment and get HIV-tested through the project. Several needs of the community have been addressed by this project and it has also improved access to HIV services. Further, this project ensured continuum-of-care services, including linkage to HIV care, retention in HIV care, ART initiation and ART adherence [8].

However, one of the key limitations of this project was that it lacked a comprehensive pre-intervention data and therefore were unable to demonstrate the effect of their intervention. Also, they recruited only a subset of MSM residing in the area where the study was being done and found it difficult to recruit some of the other important subgroups like the rural or older MSM population who had poor knowledge about HIV, low education and less access to HIV health centres making them highly vulnerable to HIV [9]. The project maybe usefully adapted to other places in China and closer partnership with clinical facilities will further enhance the project.

Identifying Factors Determining MSM HIV Testing Preferences

In order to mediate proper HIV treatment and to limit its secondary transmission it is essential that HIV serostatus is diagnosed as early as possible (Charlebois, Das, Porco, & Havlir, 2011; Granich, Gilks, Dye, De Cock, & Williams, 2009). Even though there are many interventions that are working to increase the knowledge of MSM population regarding HIV serostatus, the uptake of HIV testing still remains low on a global scale (Arreola, Hebert, Makofane, Beck, & Ayala, 2012). Therefore, it is crucial to understand the modalities and factors which facilitate testing of HIV as this is the first step toward eliminating hindrance to test uptake. In order to make effective intervention strategies that can overcome the hurdles to China’s HIV testing among the MSM population, a study was conducted by L.Han et al., in 2016 to get more information regarding HIV testing preferences among MSM.

[bookmark: _Hlk7171522][bookmark: _Hlk7171244]Two of the largest MSM CBOs were used to conduct an online survey through their respective web portals: gztz.org in Guangzhou and ManBF.net in Chongqing. The people recruited for this study were biologically men of at least 16 years of age and at least once in their lifetime had performed anal sex with men. The study noted different measures of behavioral characteristics like- the number of male partners for anal sex in the past 3 months, HIV testing history, history of sex with women, and accounts of condom less sex for the past 3 months. Options of eight different HIV testing venues were given to the participants for rating their acceptance toward the venues which were- CDC, gay men’s CBO, gay bar, public hospital, private medical clinic, HIV/AIDS CBO, home, sauna. As shown in Table 1 below, the study identified that for HIV testing, the MSM population considered a guarantee of test quality (87.5%) a guarantee of confidentiality (89.7%) to be very important factors. 75.4% of men labelled the ability to test for HIV at home very important or quite important. The study also reported that MSM population find HIV testing at venues like CDCs, accept HIV testing at gay men’s CBOs and public hospitals acceptable. The study results also suggested that it may be feasible to have HIV self-testing among Chinese MSM.

Some of the other previous studies in similar fields have reported that many men do not prefer to test at facilities due to stigma associated with HIV testing (Myers et al., 2013; Tucker et al., 2013), inconvenience , confidentiality, lack of privacy and confidentiality, and stigma associated with HIV testing. Therefore, this studies identified that we need to improvise on the confidentialities and qualities of HIV tests at China’s MSM friendly CBOs and at the different HIV testing venues. Steps need to be taken to make the different testing venue MSM friendly so that they do not face any negative environment or discomfort. Further this study showed us that HIV-self testing can be a big solution to these societal problems.

HIVST (HIV Self-Testing)

HIV self-testing is a method in which people can conduct a rapid point-of care test with their own oral fluid or blood specimen at a convenient location of their own choice. This may help Chinese MSM overcome some of these barriers to HIV testing since it does not lead to disclosure of their sexual minority status [10]. According to reports, there is a high level of unrecognized HIV infection in China as a significant proportion of the country’s MSM population have either not been HIV tested or do not take routine testing. Studies in different countries have identified that acceptance/preference of HIV self-testing is very high among the MSM [11].

In Jiangsu’s MSM population, a cross-sectional study was conducted by H.Yan et al, in 2015 where questions about HIV self-testing were asked to the participants. It was found that 26.2% of the total 522 participants had ever self-tested. Most of the participants said performing HIV self-testing was “very easy” or “somewhat easy” and 86.1% reported that the most common self-testing modality was finger stick. 85% of the participants said they would routinely continue to use HIVST and 82% were willing to HIV self-testing with their partners [12]. Therefore, in China we need to utilize different platforms like campaigns, advertisement and posters across street and health clinics, social media, dating apps to spread the awareness of HIV self-testing intervention package in order to increase the frequency of HIVST uptake among the MSM population.

PrEP

A major reason for the increasing burden of HIV in MSM population of China could be the lack of integration of PrEP into the portfolio of HIV prevention strategies and the unavailability of PrEP in China. PrEP involves daily intake of oral ART by HIV-negative individuals and is a very effective biomedical intervention.

A study was done by Lei Zhang et al. in 2018 that evaluated the epidemiological impact of implementing PrEP for over the next two decades in Chinese MSM. The study reported that lack of PrEP in China could result in 1.1–3.0 million new HIV infections and 0.7–2.3 million HIV related deaths in the next two decades. Approximately 0.17–0.32 million new HIV infections could be prevented by moderate coverage of PrEP (50%) [13]. The study demonstrated that there could be major epidemiological benefits if PrEP is integrated into China’s national HIV prevention program as it estimates if PrRP is used for an average of 5 years each by 1.2 million high-risk MSM then 256,000 new infections would be averted over a twenty-year [13].

However, a drawback to the implementation of PrEP in China is that it might not be cost effective at the current annual price rate of US $3,500. Therefore, government in China need to take steps to cut down the cost of Truvada by about 50% to make ART more accessible to the MSM population. This could be achieved probably by negotiating with Gilead to reduce the price of Truvada in Chinese market by bulk purchase. However, despite the lack of cost-effectiveness the government must take measures to immediately implement PrEP in its HIV prevention strategy since delaying the implementation even by 5 years could result in tens of thousands of infections in MSM that could be averted by PrEP. Further, China also needs to think about how to reach out and deliver PrEP to the high-risk population. PrEP delivery needs to be initiated via multiple prevention service delivery systems like CDC that works in collaboration with local community-based organizations (CBOs), primary care practices, sexual health clinics to find out which system works best for MSM population in different regions of China [13].

Discussion

China’s MSM population accounts for one-third of new HIV infections in the country and there has been a rising burden of HIV epidemic in Chinese MSM population [14]. Many of these affected individuals either do not reach out to or cannot be reached by HIV prevention services. In support of this, a meta-analysis reported that in the past 12 months just 38% and 47% of Chinese MSM received HIV counseling and testing in their lifetime, respectively [15]. Although same-sex behavior is not illegal in China, MSM population has significant negative social and cultural consequences, like loss of employment and family rejection. As a result of this fear, most of the MSM do not reveal their same-sex behavior to their health-care providers. Also, in order to not encounter any discrimination or stigma and they do not access HIV prevention services [6]. Therefore, the above studies were critical to understand the different ways/strategies that can facilitate increased uptake of HIV testing among the MSM population of China and also prevent new incidence of HIV in them.

The top priority of the Chinese national HIV/AIDS strategic plan is to promote HIV testing uptake among MSM and there has been a growing body of literature on this topic. Even though HIVST has some limitations such as low sensitivity and failing to detect infection during the “window period”, there can be significant public health impact of this method. It can result in highly reduced transmission of the virus among MSM population if there is an increase in the uptake among self-testers and if it reaches never-tested people. Therefore, strategies are needed to encourage and expand adoption. HIVST kits should be made available over-the counter in order to increase the frequency of testing among the high-risk MSM population.

The most promising biomedical intervention for HIV prevention so far is Pre-exposure prophylaxis or PrEP. USFDA has approved a combined therapy of the antiviral drug tenofovir (TDF) and emtricitabine (TDF-FTC) as preventive drugs for MSM [15]. From 2003 to 2013 there was implementation of condom use and ART Condom use and ART in the Chaoyang district of Beijing. This resulted in 20-25% reduction of HIV incidence among MSM and it also reached the target of the National AIDS Comprehensive Prevention and Control Demonstration Area. There was also a decline in the relative risk of HIV infections from 0 to 31.53% because of condom use among the high-risk groups [18].

Challenges & Recommendations

Policy level: The ‘Regulation on the Prevention and Treatment of HIV-1/AIDS’ established rules in 2006 to erase public and legal prejudices against HIV infected individuals. Even though these recommendations have been approved by China’s State Council, breach of these recommendations currently do not entail any legal consequences. Therefore, China needs strict legislations with clearly defined legal consequences and enforcement policies. There should be proper MSM support/help centres where men facing any kind of prejudice or breach of confidentiality regarding their HIV status should be able to go in order to take legal actions. New policies need to be formed where intentional exposure of others to HIV could result in criminalization.

A challenge in the implementation of PrEP in China’s HIV prevention regimen is the high cost of Truvada. Therefore, government needs to make new policies so that these drugs could be made affordable for the high-risk MSM groups.

Program level: There needs to HIV-1 awareness programmes and campaigns targeted at MSM population in China to encourage people not to indulge in high-risk behaviors and encourage positive changes in behaviors. Studies have reported that majority of MSM population interact or connect via various social media platforms. [5] Blued is a very popular gay dating app in China with around 40 million registered users. Therefore, measures should be taken to promote safe-sex methods like advertisement of condom use, campaigns on PrEP uptake benefits, importance of routine HIV testing both on self and their partners through these dating app platforms and other technologies. There needs to organizations set up in China targeted at MSM population that will offer free advice on safe-sex methods, demonstrations on condom use, where to get HIV tested, how to seek medical help if an individual got positive results for HIVST. Popular regional figures affected by HIV should also be encouraged to act as role models for the minority population and raise awareness programs.

Research and clinical care level: Even though there have been a recent increase in epidemiological research, there needs to be a shift in focus of the utilization of the data for improved and applied public health measures and needs rather than data use only for analysis and surveillance. MSM population should be encouraged to participate in more clinical studies to identify proper therapeutic and vaccine strategies targeted for this highly vulnerable group. More research should be done in China to identify what results in the high susceptibility of HIV among men who have anal sex with men. Government should encourage more research studies that are targeting at MSM population and trying to develop therapeutics that can lessen HIV incidence in cases of anal sex among MSM population.

Population health: A potential intervention to prevent secondary transmission cases of HIV is ‘treatment as prevention (TasP)’which acts by preventing viral replication and this strategy has now been implemented in the Chinese MSM population.

However, a major challenge to this strategy is maintaining a good adherence to ART. There are reports which indicate that anxiety and depression are very common among HIV infected Chinese MSMs as they lack proper resources and face societal stigma due to which they cannot disclose their problems openly. This interrupts their ability to adhere to ART treatment regimens [5]. Therefore, there needs to some MSM counseling centres set up in China that can provide help to men who are suffering from low self-esteem or depression during their illness and motivate them to adhere to their treatment plans.

Some other recommendations would be to have sex education classes in schools where students will learn basic knowledge about sex safety, condom use etc. Initiatives should also be taken in schools where students should be advised to treat every individual with respect irrespective of their gender bias, so as to reduce the homophobic stigma in society.

Limitations

The paper is a review of some of the interesting strategies and research works that are being done to decrease HIV prevalence in MSM population in China. I did not carry out any of above research studies. There are a lot of current research studies going on regarding this topic. My paper probably does not cover all the current intervention strategies.

References

1. China Health and Family Planning Commission (2015)
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17. Holmes D. FDA paves the way for pre-exposure HIV prophylaxis. Lancet. 2012;380(9839):325
18. Tao, L., Liu, M., Li, S., Liu, J., & Wang, N. (2018). Condom use in combination with ART can reduce HIV incidence and mortality of PLWHA among MSM: A study from Beijing, China. BMC Infectious Diseases,18(1). doi:10.1186/s12879-018-3026-8

Du Huo is a Chinese herbal medicine that is normally used in treatment of cold and dampness. It is a Chinese herbal medicine that is mainly found in various parts of China including Sichuan, Hubei and Anhui provinces (Zhou & Milne, 2003). The origin of this Chinese herbal medicine is the roots of herbaceous plant known as “Angelica Pubescens Maxim.f.biserrata Shan et Yuan”; which is a popular herbaceous plant that is found in the family of Umbelliferae (Sacred Lotus, 2018). Du Huo, being one of the famous Chinese herbal medicines is botanically known as Radix Angelicae Pubescentis. It is popularly known for its botanical profile of being able to release the exterior syndrome by expelling wind and dampness in the human body thus relieving them from pain.

According to traditional theories, Du Huo is an herbal medicine that has a pungent, bitter, and slightly warm herbal medicine (Hou & Jin, 2012). By virtue of having these properties, this herbal plant has been able to utilize kidney and bladder as its main channels to the human body.

As stated in the properties section, Du Huo has features of being pungent, bitter and fragrant (F. Builders, 2019). These features are very vital to its medicinal value in terms of its contributions to its therapeutic actions. For instance, according to traditional theories, it is evident that by being pungent, bitter and fragrant, Du Huo has the ability to carry out various actions including the actions of diffusing, eradicating, warming and combing up body pains and headaches (Egger, Love, & Doherty, 2013). This is to mean that through these features, Du Huo has exemplary potentials to dispel wind-damp, as well as in alleviating arthralgia. This way, as Hou & Jin (2012) indicate, Du Huo is effectively and excellently being used in treatment for all types of arthralgia syndromes that emerges in humans due to various causes such as dampness, cold and wind.

It has been reported by Stevenson, Shusheng, & Chun-su (2014), that regardless of how acute or chronic an arthralgia syndrome is, Du Huo is able to effectively eliminate such as syndrome due to its properties of being pungent, bitter and fragrant. This way, these features are said to enable this herbal medicine to excellently disperse, eliminate and dredge arthralgia syndromes (Zhou & Milne, 2003). As time evolved, the ability of Du Huo to be pungent, bitter and fragrant has allowed the doctors to easily combine it with other herbs like Fang Feng and Fu Zi, all which are then soaked together in wine thus forming a complex cold-dispersing herbal medicine known as Du Huo Jiu (Egger, Love, & Doherty, 2013). Du Huo, when consumed by a human enters the human bladder and kidney meridians, and then proceeds to move in a descending direction , thus allowing it to effectively dispel wind-damp from the lower portions of the human body, as compared to its corresponding herbal medicine known as Qiang Huo (F. Builders, 2019). So, with such features, Du Huo is highly preferred for treatment of human waist and legs pains caused by pathogenic wind, cold and dampness.

In addition to its ability to offer various therapeutic actions including dispelling wind-damp from the lower portions of the human body, Du Huo has been one of the ideal herbal medicines that is mainly combined with liver-kidney tonics, as well as with blood activating and blood nourishing herbs like Du Zhong, Dang Gui and Sang Ji Sheng so as to treat concomitant symptoms in human’s like deficiency of liver and kidney, as well as to treat human symptoms such as insufficiency of qi and blood (Sacred Lotus, 2018). The ability of Du Huo to be effectively pooled with liver-kidney stimulants and blood stimulating herbs has been due to its key features of being pungent and flagrant (Zhou & Milne, 2003). Such features allows it to effectively be compatible with the above blood-activating herbs such as Du Zhong, and thus making it an ideal herbal item that is used in making drugs that are used in treating the human’s concomitant symptoms.

Secondly, as stated earlier, Du Huo is an herbal medicine that is pungent and warm. By virtue of these two properties, Du Huo has been able to effectively release the exterior syndrome in the human body (Flaws & Sionneau, 2001). Also, due to its ability to be bitter and warm, Du Huo herbal medicine has been able to treat the heavy sensation of the human’s head that comes as a result of cold and dampness (Hou & Jin, 2012). With such features, Du Huo has been said to have moderate impacts similar to that of Qiang Huo. This way, it has been said to be highly suitable in treatment of human’s head-pain and overall human body pain that mainly emerge as a result of affections of exogenous wind clod with dampness.

Additionally, due to its warm and pungent features, Du Huo has been able to serve as a cure of dermal pruritus (Zhou & Milne, 2003). Due to its pungent and warm features, Du Huo has the ability to be administered to human body orally or through external washout; and this allows it to be an effective dispeller of wind and remover of dampness, toothache and headache (Flaws & Sionneau, 2001). This has made it an effective pain alleviator in human body.

For proper functioning and proper working of Du Huo in human body, the patients using this herbal medicine should understand several cautions and contraindications that come along with its use (Stevenson, Shusheng, & Chun-su, 2014). For instance, one of the key cautions that patients using this traditional Chinese herbal medicine should take is to ensure that they are highly cautious with the quantity of Du Huo they take when treating special diseases such as Yin or blood deficiency (Zhou & Milne, 2003). The fact remains that Du Huo is a herbal medicine that is pungent and bitter. When a human body is suffering from Yin, it is highly prone to pungent substances because such a body has a sensitive stomach that is highly vulnerable to irritation (Sacred Lotus, 2018). So, by the virtue of being a drug that has a pungent feature, Du Huo has a high chance of causing stomach irritation to person suffering from Yin or blood deficiency. The fact that Du Huo is prudent, fragrant, bitter and dry means that this herbal medicine can readily create immense damage to the human’s Yin, and thus for this reason, patients suffering from blood deficiency should be able to cautiously ensure they use the actual required quantity of Du Huo, as this will prevent him from suffering from stomach irritation.

Secondly, the other key contraindication related to Du Huo herb is that it should not be used in the treatment of Liver Wind (NI, 2011). According to Hou & Jin, (2012), Liver Wind is a disease that occurs inside the human’s liver, which is a human’s body part that is always surrounded by body fluid. In most cases, due to its fragrant, pungent and bitter nature, Du Huo can easily cause a huge damage to human’s body parts that have body fluids such as liver (Flaws & Sionneau, 2001). This way, it is always important to ensure that patients suffering from Liver Wind should ensure they cautiously utilize Du Huo as a treatment herbal drug, as this type of drug can easily cause a huge damage to such body-fluid-filled areas.

Lastly, as it is indicated by F. Builders (2019), patients using Du Huo for treatment of their illnesses should ensure that they take the right quantity of this herbal medicine. This is due to the fact that an overdose of Du Huo in a patient’s body can result to human body poisoning (Egger, Love, & Doherty, 2013). Overdose of Du Huo mainly lead to severe body symptoms such as agitation, total body paralysis, hallucinations and also in severe overdose can result to death.

As stated by traditional theories, Du Huo herbal medicine can effectively be used to relieve pain through expelling, and clearing of dampness and cold (NI, 2011). However, in accordance to modern clinical and lab aspects, such claims haven’t been well explained, as there is no lab-proven way on how Du Huo works so as to help the human’s body fight against cold and dampness (Zhou & Milne, 2003). However, as stated by Egger, Love, & Doherty (2013), some modern clinical tries carried in China have proved that Du Huo can excellently treat the heavy sensation of human’s head that comes as a result of cold and dampness, due to its ability to carry out various actions including dispensation, elimination as well as dredging of human pain. This way, though some clarity has been established regarding the role of Du Huo in helping human’s treat and cure dampness and headaches, the fact remains that the modern medical experts still have a lot to do in establishing the actual usefulness of Du Huo to human’s effort to fight against pain, headache and dampness.

From the above paper, it is evident that Du Huo is one of the leading Chinese herbal medicines that are normally used in treatment of cold and dampness. As argued by Egger, Love, & Doherty (2013), it is apparent that due to its pungent, bitter and fragrant features, Du Huo has the ability to carry out various actions including the actions of diffusing, eradicating, warming and combing up body pains and headaches. From such evidence, it means that herbal medicines is a very vital part of the medical growth and development in China, as it still continues to play a key role in the curative and therapeutic roles in the modern day Chinese medicine. However, for such herbal medicines such as Du Huo to continue to be legally allowed to play their key role in the Chinese and global medicine, more modern clinical and lab aspects ought to be carried out to ascertain the effectiveness of these traditional medicines in the modern-day global medicine.

References

1. Egger, C. M., Love, L., & Doherty, T. (2013). Pain Management in Veterinary Practice. John Wiley & Sons.
2. F. Builders, P. (2019). Introductory Chapter: Introduction to Herbal Medicine. Herbal Medicine. doi:10.5772/intechopen.78661
3. Flaws, B., & Sionneau, P. (2001). The Treatment of Modern Western Medical Diseases with Chinese Medicine: A Textbook & Clinical Manual. Blue Poppy Enterprises.
4. Hou, J. P., & Jin, Y. (2012). The Healing Power of Chinese Herbs and Medicinal Recipes. Routledge.
5. NI, D. M. (2011). The Natural Health Dictionary: Your comprehensive A-to Z guide for healing with herbs, nutrition, supplements, and secret remedies. Ask Dr. Mao.
6. Sacred Lotus. (2018). Chinese Herb: Du Huo (Pubescent Angelica Root), Radix Angelicae Pubescentis. Retrieved from https://www.sacredlotus.com/go/chinese-herbs/substance/du-huo-pubescent-angelica-root
7. Stevenson, X., Shusheng, T., & Chun-su, Y. (2014). Handbook Of Traditional Chinese Medicine (In 3 Volumes). World Scientific.
8. Zhou, J., & Milne, G. W. (2003). Traditional Chinese Medicines: Molecular Structures, Natural Sources and Applications. Hoboken, NJ: John Wiley & Sons.

Pregnancy and childbirth are arguably the most significant periods in the lives of many women across the globe. Whilst the stages of pregnancy and childbirth are consistent biologically worldwide, the traditions surrounding them, the care of both the foetus and the mother, the amount of medical intervention and gender roles all differ substantially between varying cultures. Specific cultures explored in this essay include the Western culture, Indian culture, Chinese culture, Brazilian culture, the culture of the Canadian Inuits and the deaf community. It is important for us as current and future healthcare workers to be familiar with some of these differences in order to become more culturally competent and respect and manage the expectations and needs of a wider range of patients. It is also important to note that whilst certain cultures have a particular custom or belief, an individual of the community may have their own differing viewpoints, therefore it is always important to determine a patients particular needs and wishes.

In modern Western culture, pregnancy and childbirth have become highly medicalised (1). It is thought that the traditions of the past stemming from religion have been replaced by a more individualistic and clinical approach (2). In the past, most pregnancies were not medically monitored and only in cases of severe complications did a woman see her physician prior to giving birth (3). Now, the methods of Cesarean section and use of instruments and medication during delivery are common practice. In the West, pregnancy and childbirth were historically one of the only aspects of healthcare exclusively managed by females. In today’s Western culture there is a much higher number of male midwives and gynaecologists, further emphasising the rise of gender equality in modern times (1). Whilst there are not many traditions associated with childbirth in the Western culture accept for religious customs such as baptism and circumcision, a small amount of women may chose to consume their placenta following birth as it is thought to give them strength (4). The more recent medicalisation of pregnancy and childbirth, specifically advances in infection control, has contributed to a much lower mortality rate for both mothers and newborns (3).

The Indian community has a variety of unique traditions and beliefs surrounding childbirth and pregnancy, mainly stemming from religious customs. Whilst India is the birthplace of four major religions; Sikhism, Buddhism, Jainism and Hinduism (5), the most prominent religious belief is Hinduism (6). Hindus carry out a number of ceremonies and rituals throughout the different stages of marriage and pregnancy, for example ‘Garbadhana’- a foetus-laying ceremony in which a newly-wed couple are prayed for in order to be able to fulfil their parental duties at the consummation of marriage. Other rituals include ‘Punsavana’- the ‘male-making’ rite which is performed to try to predetermine the sex of the foetus as male in order for it to carry on the family name and legacy and ‘Simmanantannaya’ – the wearing of red or green glass bangles on the wrist in order to produce softs sounds that will comfort the foetus from the seventh month of gestation. Simmanantannaya is seen as the mother’s last opportunity to fulfil any last wishes she has such as food cravings, as after this time she has entered a more dangerous period of the pregnancy (7). Rather than an Indian woman staying in her own home in the weeks before and after giving birth, it is customary for her to stay with her mother (8). Many working class Indian women will continue to work and lift heavy loads whilst they are pregnant, and may chose to do so right up until labour (9).

In regards to the childbirth process, it is common that both Hindu and Indian women will prefer to been seen by a woman gynaecologist and midwife in order to preserve their modesty (7). Due to modern medical advances, many middle and upper class women in urban India will use medical intervention for childbirth however many women in rural India will stick to traditional home births with a midwife present (9). However, there are still many more advances that need to take place in regards to maternity in India, as in 2015 it had the second highest rates of maternal death worldwide (10). In Indian culture there are a number of protective customs regarding the baby once it is born, such as removing the baby’s hair a period of time after birth, burying the placenta (although this is not allowed by all hospitals and clinics), performing a sacrificial slaughter and dressing the baby in an amulet. Common customs followed by new mothers include wearing warm socks and shoes to strengthen the womb and wearing flannel around their abdomen following delivery (8).

Although there are major differences in political, social and economic dimensions between mainland China and other areas of Chinese culture, there are many core values and culture traditions shared by Chinese people no matter where they are from (11). Similar to western culture, Chinese women will find out they are pregnant at home using a pregnancy test and will attend some form of clinic or hospital throughout her pregnancy. In Chinese culture there are many restrictions placed on pregnant women in order to avoid complications such as stillbirths, miscarriages and maternal deaths. These restrictions originate from the ‘yin and yang’ (positive and negative forces that counterbalance) concept of traditional Chinese Medicine and entail the pregnant lady following certain dietary and behavioural rules. It is suggested that women avoid eating cold foods as they are thought to decrease blood circulation in the uterus and increase the chances of bleeding or miscarriage. It is also advised not to eat ‘wet-hot foods’ such as shrimp, lychee, mango, pineapple or longan as these are seen as poisonous and allergy-evoking to the baby (12). If a mother is financially well off she can chose to pay to have the baby’s gender determined before birth, or chose to have the baby delivered via Cesarean section. Women sometimes chose this over a natural birth in order to avoid pain and to keep the slimness of their hips and the tightness of their vagina (13). China as a country has the highest rates of Cesarean sections worldwide (14). It is advised that pregnant Chinese women avoid any emotional stress or worry as it is believed this can translate to physical illness and complications (12). An interesting aspect of the Chinese birthing culture was the presence of the now-abolished one child policy that began in 1979 in order to slow down the rapid growth of the population of China (15). A possible detrimental effect of the implementation of this policy on the Chinese culture is the emergence of an abnormal sex ratio at birth, with sex-selective abortions being requested in order to have a son to pass on the family name and legacy (16). It is customary in China for a woman who has just given birth to enter a ‘zuo yuezi’ period in which she is confined to the home for one month postpartum. In this period it is not advised for the new mother to wash her hair or touch cold water but is suggested that she eat hot food (for example eggs and chicken) in order to restore her health and strength. The woman is supported in care for the child by her family and both mother and baby are confined to the home until the end of the zuo yuezi period when they attend a checkup at the hospital (12).

Brazil is a multiracial country that is associated with being one of the most inequitable worldwide. In the 1988 Brazilian Constitution child healthcare was deemed a right universally, however although there was free birth coverage and outreach for immunisations, the accessibility and quality of prenatal care was not greatly increased (17). The typical diet of a pregnant Brazilian lady consist of rice or pasta with beans and/or beef, chicken and eggs along with artificial juice. This is the basis of a typical Brazilian diet, however more wealthy women may adopt a ‘high-risk, high cost’ diet including food that is more expensive but more readily available such as finger foods, whole milk, yogurt and ice cream (18). Gaining admittance to public hospitals in Brazil is difficult and mothers in labour risking being turned away if their cervix is not yet dilated, causing many women to wait until later stages of labour to present to the hospital in order to increase their chances of securing a bed (19). In Brazil the idea of midwifery is rather polemic, and being a midwife is not considered a legitimate profession. Their lack of training and isolation raises concerns about the quality of prenatal care provided to women emphasised by the fact that in a study of 127 female ‘traditional birth attenders’, only 39% had ever used pharmacological drugs on a mother giving birth (20). There is evidence of racism present in the healthcare system in Brazil, and the field of obstetrics is no exception. A study conducted in 1993 found that non-white pregnant ladies had less prenatal visits and were also less likely to receive Cesarean sections, episiotomies or the option of immunisations for their newborn (17).

Another culture group with its own unique approach to childbirth and pregnancy is the African culture, consisting of both North and South Africa. Since North Africa is a developing country with low-income, the quality of its healthcare system is sub-par (21). When South Africa’s first democratic government was elected in 1994 they brought about many changes in order to improve healthcare for all South Africans following many inequalities in services. In 2005 a survey was conducted in which 89% of the study population reviewed the healthcare service in South Africa as good or excellent (22). There are many childbirth traditions associated with African culture, specifically in Western Africa, for example the act of squatting to deliver the child which signifies the mothers connection to the earth. Sometimes a stool would be used during delivery and the woman is surrounded by her female relatives and a midwife, who is only paid if the birth is successful. Since the 19th century the act of burying the placenta has been recorded. It is customary for new West African mothers to complete this ritual in order heal her womb and restore her fertility. It is also tradition for an infertile woman to urinate over the burial site in order to restore her fertility (23). In traditional African culture multiple different herbal remedies were used during pregnancy as antenatal remedies, to encourage foetal growth or to induce or augment labour (24). In South Africa, there is concerning effects on maternal and foetal wellbeing due to the Human Immunodeficiency Virus (HIV), with a reported prevalence of 38.7% in women attending prenatal clinics in the province KwaZulu-Natal (25). Midwives in the African culture have a unique role in their provision of abortion care, as in South Africa abortion is legal on request up to twelve weeks in to gestation (26). Traditionally, men were never present during labour however in urban areas of Africa this practice is now changing and men are now more involved in the birthing process (23).

A Canadian Inuit is an individual from the group of indigenous people living in Arctic Canada (27). Like other cultures, the Canadian Inuits have their own specific pregnancy and childbirth culture. The diet of Canadian Inuits in general has changed drastically in modern times, from a more hunting based culture to now a more modern food-purchasing culture (however there is not a wide variety). It is recommended for pregnant Canadian Inuit women to take vitamin supplements to ensure they are not malnourished and that the baby is receiving enough nutrients, as a recent study on the diet of pregnant and lactating Canadian Inuit women suggested that there were high inadequacies in magnesium, folate and vitamins A,C and E (28). Many Canadian Inuits are unilingual, speaking and reading only in their traditional language of ‘Inuktitut’(29). Therefore it is extremely important that all medical staff, including maternity staff, are able to communicate in a way to patients that they will understand. A study conducted found that many Canadian Inuits were highly dissatisfied with the quality of healthcare they were receiving. It was suggested that increasing the Inuit medical interpreters ability to advocate for their patients would greatly increase the satisfaction in quality of healthcare (30). This further emphasises the significant impact of communication in patient comfort and satisfaction. Traditionally, midwifery was an internal part of the culture of the Canadian Inuits, however the standard of maternity care changed in around 1970 when all pregnant women were transported to hospitals in Canada in order to give birth in an attempt to lower mortality rates. However, Inuits seen this change as part of their culture being taken away and being substituted by a more medical model that split up their families, removed pride and strength from the women and weakened the health, spirit and strength of the community. This resulted in the formation of a community-led maternity service and education program which allowed Canadian Inuits to reclaim their birth, health and culture. Whilst this approach has shown some improved outcomes for Inuit women, midwives under this system have not yet received formal recognition of their graduates under the Quebec Midwifery Act (31). More centres have been adapted in Artic Canada in an attempt to adapt to local requirements and traditions (32). Although Canadian Inuits have their own childbirth culture, they like to view each birth as an individual experience and event rather than collective. In each birthing experience there is particular emphasis placed on courage, stoicism, obedience and virtue. It is advised that a pregnant mother works hard, remains active, is obedient to elders and does not over eat in order to have a quick birth and a small but healthy baby. Crying out in pain is frowned upon as it is seen as the mother not concentrating on pushing hard to achieve a faster and therefore safer labour (33).

Another community which has its own unique culture is the deaf community. Whilst there is disagreement as to whether other disabled communities have their own culture or are no different from the rest of the community, deaf culture is more distinguished due to the use of their own specific means of communication; sign language and lip reading. In 2005 the World Health Organisation (WHO) estimated that approximately 278 million people suffer from deafness worldwide, emphasising the magnitude of the community (34). In maternity services, deaf pregnant women are often neglected due to a lack of understanding on how best to care for them based on their differing communication needs. This is further emphasised by the fact that in a study, 76% of deaf or hard-of-hearing women missed their appointment or had to wait till the waiting room was cleared due to the fact that they could not hear their own name being called out (35). Deaf women are also at a greater risk of experiencing adverse pregnancy outcomes due to the communication barrier, with many women replying on writing down their thoughts in order to communicate (36). Studies show that it is not only maternity care that is sub-par for the deaf community, but their quality of health in general is less than the rest of the population as they are put at a higher risk of ill health due to under diagnosis and under treatment of chronic conditions (37). In all cases of deafness approximately 60% of cases are inherited genetically. Genetic screening is now available for mothers with this form of deafness in order to tell whether their baby will be affected or not. This is mainly frowned upon by the culturally deaf as they are proud to be deaf and are positive about belonging to a community with its own history, language, identity and culture and therefore they are sceptical about what a mother would do with this screening result, for example they would disagree with her considering aborting the perfectly healthy child (38). An example of genetic hearing loss is Usher’s syndrome, which combines hearing loss with visual impairment (39). Usher’s syndrome follows an autosomal recessive inheritance pattern as shown below in Fig.1 (40), therefore two unaffected parents that are carried have a 25% chance of having a child with the genetic disorder. This means that an affected mother will still have a 50% chance of having a child with the condition when crossed with a carrier father, as she will have two faulty alleles.

In conclusion, the inter-relationship between culture and health (specifically pregnancy and childbirth) is very complex. Many aspects of obstetrics remain constant regardless of the culture involved, for example the alteration of diet in order to nutritionally support the child, the obvious need for some kind of medicalisation and the actual process of giving birth, which unites women worldwide. However as I have clarified above, the nature of childbirth and pregnancy and the traditions surrounding them vary greatly between different cultures, only a few of which have been discussed in this essay. The main areas of differences appear to be the ways in which diet is varied, the quality of maternity care and the extent of medicalisation (including the roles of diffferent genders). It is of vital importance that each culture’s ‘norms’ are more understood by our healthcare workers worldwide in order to give each pregnant woman the quality of healthcare that she deserves, and achieve the best foetal outcomes possible.