About the author: Yana Richens, Consultant Midwife.
The information in this article is correct at date of publication: Originally published January 2011
Opinions expressed by the author are not necessarily those of the publisher or editorial staff.
In the United Kingdom (UK) today almost 25% of babies are born to mothers from a non-UK origin. London has more than twice the proportion of births to mothers born outside England & Wales compared to England & Wales as a whole (47% compared to 20%)1 and in some boroughs this figure is 75%2. This means that most Midwives and Health Visitors are coming into contact with mothers and babies from a vast range of different cultures and countries with associated diversity of languages attitudes, needs and challenges.
Healthcare Professionals now have to rise to the challenge to provide the best possible evidence based care to this group of women. This is essential, as more than 20% of maternal deaths in the UK between 2003-2005 occurred in women born outside the UK3. A total of 48 women who died spoke little or no English. It was noted in the report that very few had access to translation services, and in most cases, family members or friends were used as interpreters.
It was further noted in the report that around 20% of women who died from direct4 or indirect5 deaths either first booked for maternity care after 20 weeks gestation, missed over four routine antenatal appointments, or did not seek care3.
Different groups of women from different cultural backgrounds have different cultural beliefs regarding pregnancy, and, thus different views of pregnancy. Some do not view it as “special” and therefore do not seek antenatal care or actively access antenatal care. This is shaped by cultural beliefs and ethnic background4.
Some women who died appear to have been denied access to care because of their cultural beliefs and practices, or where the responsibility for decision-making fell to their husbands or other family members. This was especially true for women who could not speak English. For example:
A pregnant woman who spoke no English had a port of arrival chest x-ray, which was indicative of cardiac disease. Her English-speaking husband was told by the port authorities that she was ill and he should take her to a doctor immediately. They had no means of communicating this directly to the woman who had, in any event, just landed in a strange airport in a distant country. Her husband did not tell her she was ill and she had no antenatal care at all. Her first contact with maternity services was when she was admitted in labour. She died of a post-partum haemorrhage, apparently still unaware of her possible cardiac disease.
For others, the actions of their partner may also have been fatal:
An extremely young, underage bride, who appears to have been brought into the country under false pretences, became pregnant but had no antenatal care. She spoke no English and was not allowed out of her parents’ in-laws’ house. Her ‘husband’ eventually took her to see the GP in mid pregnancy, moribund from tuberculosis. Her in-laws lied about her age and showed no concern for her obvious ill-health or pregnancy and her “husband” told the GP he was not at all interested in obtaining antenatal care, but wanted her treated because she was now too ill for sex. She died, in a caring hospital, alone in a strange country, only a few days later3.
The evidence suggests that it is not only black and ethnic minority women who have an increased rate of maternal and perinatal mortality, but also those women which are more identifiable with vulnerable groups. For example, substance misusers, teenagers, and lower socio-economic groups are also more likely to book after 20 weeks gestation, which is considered as booking late for a pregnancy and seen as negative behaviour by Healthcare Professionals. It has been suggested that the reason why some women do not attend for antenatal care is that they do not know where to go, or some women are worried about their immigration status, and in some extreme cases are embarrassed as they have been kidnapped, raped and/or trafficked into the country to work as a prostitute3. It could be because they find such services difficult to access or understand, they worry about being judged or becoming involved with social services once the child is born. As a consequence, these women may not be informed about potentially harmful lifestyle factors during pregnancy (e.g. drinking, smoking and eating potentially dangerous foods) and warning signs for conditions like pre-eclampsia or gestational diabetes could be missed, putting mother and baby at risk.
A new guideline from the National Institute for Health and Clinical Excellence (NICE)5 aims to reverse this trend. It calls for the re-organisation of NHS services to improve access to and uptake of antenatal care for women with complex social factors, thereby helping to prevent complications and potentially save the lives of these mothers and their babies.
The new guideline, developed by NICE in close collaboration with the Social Care Institute for Excellence (SCIE), calls on antenatal services to become flexible and supportive. This includes the NHS working with social care providers and, in some cases charities and the police, where appropriate, in order to properly care for these vulnerable women and their unborn babies.
The guideline highlights the following groups as examples of women who need particular, tailored support throughout their pregnancies, although it provides guiding principles for care for all women whose pregnancies are complicated by difficult social circumstances;
- Those aged under 20
- Women who misuse substances
- Women who experience domestic abuse
- Pregnant women who are recent migrants, asylum seekers or refugees, or who have difficulty reading or speaking English
The guideline makes a series of recommendations for commissioners to help them shape services according to their local populations, but also includes key information to help Healthcare Professionals engage with these groups of pregnant women and make them feel safer, better understood and reassured.
Feeding practices
By improving the information that we provide to these vulnerable groups of women it may also be possible to improve breastfeeding rates. Although a recent study by Hawkins et al (2008)6, highlights that a reduction in breastfeeding rates is occurring in second generation ethnic minority women and not women who are recent migrants to the country. This is supported by an American study7, which also suggests that immigration status is strongly associated with rates of breastfeeding initiation. It does appear that cultural factors are important when women make a decision to breastfeed and both Midwives and Health Visitors should take this into account when discussing infant feeding with mothers.
A recent qualitative study by Twamley et al (2010)8, explored UK-born ethnic minority women’s breastfeeding experiences. In-depth semistructured interviews were conducted with 34 women of Black African, Black Caribbean, Pakistani, Bangladeshi, Indian and Irish parentage who were born in the UK and 30 Healthcare Professionals. Women in the study were aware of the benefits of breastfeeding, however many chose to give their babies formula milk. The study highlighted that the main barriers to breastfeeding were the perceived difficulties of breastfeeding, a family preference for formula feed and embarrassment about breastfeeding in front of others. This was particularly so for women of a South Asian parentage, particularly those who lived with an extended family. The lack of privacy in these households and grandparental pressure appeared to be key issues. The study identified that the key facilitators to breastfeeding were the self-confidence and determination of women and the supportive role of Healthcare Professionals.
Even though this is a small study it’s results are important and findings can be generalised to other groups of women, including teenage parents. This study highlights that the Midwives and Health Visitors have an important role supporting women to breastfeed. It also highlights the need to involve and include the family where possible, informing of the benefits of breastfeeding to both mother and baby, e.g. for baby reduction in ear infections, asthma, eczema, chest infections obesity, gastro-intestinal infections, childhood diabetes and urine infections. It should be pointed out that it is mixed feeding that causes a reduction in milk supply and it is not that the mother does not have enough milk to feed the baby. Ideally this discussion should be undertaken in the antenatal period and the family should be provided with an interpreter where required, using the points in below to ensure effective communication with the woman and her family, which in turn may help improve breastfeeding rates among these vulnerable women.
There are key points for all Healthcare Professionals to remember when using translation and interpreting services:
- When booking an interpreter give as much notice as possible
- Give precise details about where, when, and how long the interpreter is needed, and that a female interpreter may be required for most women
- Give the address to where the interpreter is to attend
- Specify the language spoken and understood by the woman, not just the nationality
- Briefly explain the consultation
- Book the same interpreter for subsequent visits (if this is a face-to-face translation)
- Talk directly to the woman
- Pause frequently to ensure the woman understands
- Check the woman understands what has been said
- Be attentive when the woman responds
- Book a longer appointment to allow enough time for the woman to ask questions
- Record keeping – make clear notes that an interpreter was used and whether it was a face-to-face or telephone translation
Ways to ensure that women are provided with information which will enable them to maintain contact with services:
- Give all women a telephone number to contact a Healthcare Professional outside of normal working hours at their booking appointment
- Provide women with a private one-to-one consultation on at least one occasion to facilitate discussion of sensitive issues
- Use a variety of methods (e.g. text messages) to remind women who misuse substances of upcoming and missed antenatal appointments
- For women who have difficulty speaking or reading English, provide them with an interpreter (not a member of their family, legal guardian or partner) who can communicate with them in their preferred language
We need to ensure that communication with women is improved:
- Discuss the woman’s fears in a non-judgmental manner, respecting her right to confidentiality.
- Wider range of languages in letters and key documents to pregnant women, including maps with letters inviting women to antenatal checks
- Enhanced website for mothers
- Bilingual maternity support workers
- Maternity help line with direct access to a Midwife
- Produce teenage accessible information on the role of the maternity services and different professionals, including how to access care and what to expect
- Provision of information focused especially for teenage parents
- Use a range of communication methods like text messaging, mobile phones and appointment cards
- The option for all women to access a Midwife as the first point of contact is widely publicised
- Contact details for Midwives are easily accessible to all women in local population
- Translation services for women belonging to ethnic minority groups
Conclusion
There will be inevitable challenges for Midwives and Health Visitors in putting these recommendations into practice, but it is unacceptable that mothers and babies are still dying in this country because of a lack of contact with antenatal care and health services. It is clear that inequalities in health are multifactorial and that they are influenced by issues such as environment, housing, educational achievement, material wealth, discrimination and lifestyle.
We need to do everything we can to help and support these women to ensure they – and
ultimately their babies – survive and are safe and healthy. This can be achieved if we improve access, communication and information provided whilst ensuring ongoing engagement with services.
References
- Bowles C, et al. Choosing health. Born equal? A report on inequalities in infant mortality in London. A technical report. London: The London Health Observatory, 2007. http://www.lho.org.uk/viewResource.aspx?id=12375 [accessed November 2010]
- Office of National Statistics. Review of the National Statistician on births and patterns of family building in England and Wales, 2007. London: Office of Public Sector Information, 2007.
- Lewis, G (ed). The Confidential Enquiry into Maternal and Child Health (CEMACH). Saving Mothers’ Lives: reviewing maternal deaths to make motherhood safer - 2003-2005. The Seventh Report on Confidential Enquiries into Maternal Deaths in the United Kingdom.London: CEMACH, 2007.
- Carolan M, Cassar L. Antenatal care experiences of Pregnant African women attending Maternity services in Melbourne, Australia. Midwifery 2010;26(2):189-201.
- National Institute for Health and Clinical Excellence, Pregnancy and Complex Social Factors: a model for service provision for pregnant women with complex social factors National Collaborating Centre for Women’s Health, 2010 http://guidance.nice.org.uk/CG110/Guidance/pdf/English
- Hawkins S.S, et al. Influence of moving to the UK on maternal health behaviours: prospective cohort study, Br Med J 2008;336:1052-1055.
- Celi, A.C, et al. Immigration, race/ethnicity, and social and economic factors as predictors of breastfeeding initiation. Arch Pediatr Adolesc Med,2005; 159:255-260.
- Twamley K, et al. UK-born ethnic minority women and their experiences of feeding their newborn infant. Midwifery 2010; Oct 28 (Epub ahead of print)
