APPENDIX 2
Memorandum by the Maternity Alliance (MS 3)
1. THE MATERNITY
ALLIANCE
1.1 The Maternity Alliance is a national
organisation that works to end inequality and promote the well-being
of all pregnant women, new parents and their babies. We maintain
contact with a range of maternity service professionals through
our training and outreach programmes and via our second tier advice
line (for employment rights and welfare benefits advice). Our
information service for the public offers employment rights and
welfare benefits advice to 10,000 women per year. We also carry
out small scale research projects with pregnant women and new
families and work with academic institutes on larger research
projects (for example, the Barriers to Care project in partnership
with the National Perinatal Epidemiology Unit).
1.2 We welcome the opportunity to provide
written evidence to the Maternity Services Sub-committee, albeit
at short notice. We believe that the majority of factors affecting
the health of pregnant women and their babies lie beyond the reach
of medical interventions. Health professionals cannot provide
acceptable, effective healthcare unless they have an understanding
of the socio-economic circumstances of their clients. Maternity
services must therefore offer staff training to understand how
their role extends beyond the medical model and how they can positively
influence the broader determinants of health. Examples of the
issues that we feel should be incorporated into health professionals
training and work remit are detailed below.
2. TRAINING ON
HOW TO WORK
EFFECTIVELY AND APPROPRIATELY
WITH MINORITY GROUPS
2.1 Full access to the maternity services
is important for an optimum pregnancy outcome, yet this is not
available to some of the most disadvantaged pregnant women, including
disabled women, women with learning difficulties, teenagers and
women who do not speak English. If and when these women do access
services, they still may not receive the same level of care or
be offered the same choices as other women. Described below are
examples of some of the issues and barriers affecting certain
minority groupsit is not comprehensive.
2.2 In a small qualitative study[1]of
the maternity experiences of asylum seekers, non-English-speaking
Black African women reported being made to comply with procedures
they were unhappy with (in one case by the involvement of the police),
and one women reported that the decision (which she opposed) to
perform a caesarean had been taken by health professionals without
an interpreter. Several asylum seekers reported racial abuse from
NHS maternity staff, although none felt sufficiently empowered to
make a complaint to the NHS. All NHS staff should attend diversity/discrimination
awareness training to help them develop positive attitudes to
diversity and to ensure the implementation of local and national
anti-discrimination/racism policies. 2.3 Parents
and prospective parents with learning difficulties or disabilities
should be able to use maternity services in the community and
in hospitals easily and confidently. They should be cared for
and supported by staff who are sensitive to the capabilities and
potential needs of disabled people and those with learning disabilities,
and who are aware of and will challenge discrimination wherever
it arises. The findings of our learning disability project Right
From the Start[2]suggest that
a large number of community nurses are supporting a growing number
of parents with learning disabilities, in what is often a difficult
and challenging role. However it also found that community nurses
do not feel adequately prepared for their role. Training should
be offered to support health professionals in developing supportive
and empowering practices for clients with learning difficulties
or disabilities. 3. ENSURING
APPROPRIATE AND ACCESSIBLE
SERVICES FOR ALLINTERPRETING
AND TRANSLATION SERVICES
AND ADVOCACY SERVICES
3.1 Women from minority ethnic communities,
and particularly women who do not speak English, are disadvantaged
from full access to services by poor communication with health
professionals, including not only language differences but also
ignorance and intolerance of religious and cultural practices.
[3]As the Changing Childbirth
report noted in 1993, "Women who do not speak English must
be given the means of expressing their wishes and exercising choice."
However this not only requires the setting up of interpreting services,
but also that health professionals are aware of their existence
and understand how to access these services. Our recent series of
"As Good As Your Word" seminars (looking at community
interpreting and translation in public services) highlighted the
fact that health professionals also feel that they need training
in the practicalities of using an interpreter during healthcare
appointments. 4. ENSURING
SUFFICIENT STAFFING
NUMBERS TO ALLOW
OUTREACH WORK/FLEXIBLE
WORKING FOR HARD
TO REACH GROUPS
4.1 Our research[4]into
the experiences of homeless pregnant women and new families found
that they often found it difficult to access maternity services
and had complex needs. It was particularly difficult to maintain
contact with health professionals as women were often housed temporarily
in an area where they were not registered with health services.
Mainstream services need to be adapted to provide high quality care
to those with complex needs and to accommodate a degree of mobility
in their client group to ensure continuous care is provided.
4.2 Teenagers are often very late in
getting their pregnancy confirmed and are therefore delayed in
accessing antenatal care[5]In
order to effectively engage pregnant teenagers in antenatal care,
midwives must be able to work in a flexible structure that offers
a service that meets their needs (for example by setting appointments
in the afternoon not morning) and allows continuity of care[6]Health
professionals working with young women should be trained to understand
the specific needs and approaches needed for working with this group
(such as language, attitude etc). 5. SIGNPOSTING
5.1 Accessing maternity services may
be the first/only contact women and families have with statutory
agencies, and so they have the potential to be a crucial point
for helping them to access other services. Maternity service professionals
are uniquely placed to reach those that traditionally "slip
through the net" and by informing their clients of other
services and organisations in the area, they could potentially
have a huge impact on the health, wellbeing and life circumstances
of those that they reach. For example, homeless women or asylum
seekers could be informed about local projects offering social
support, cheap clothing outlets or local food initiatives offering
cheap and nutritious meals. In the current NHS climate, health
professionals are expected to use their time as efficiently as
possible whilst delivering a high quality and more holistic service.
By training health professionals in the use of signposting tools,
they would be able to point their clients to key sources of further
support and advice, so tackling both the health and personal concerns
of the client in a succinct manner.
6. RIGHTS AND
BENEFITS
6.1 Another element of signposting is
ensuring that women are aware of their employment rights and welfare
benefit entitlements. Given that health inequalities are a high
priority at present and yet are continuing to grow wider, and
given that economic factors are of key importance in affecting
the health divide, the impact that health professionals could
have by ensuring that women are aware of their basic rights, and
how to access further assistance regarding rights and benefits,
is considerable.
7. DOMESTIC VIOLENCE
7.1 Domestic violence is a common occurrence
during pregnancy. Although there are no reliable statistics, figures
from the USA suggest that 1 in 4 pregnant women may be affected.
In some cases it is in reaction to the pregnancy that the violence
begins or worsens. [7]Violence
during pregnancy is associated with premature birth, low birthweight,
injuries to fetal limbs and organs, placental abruption and premature
spontaneous rupture of the membranes[8]
Training on domestic violence for midwives and health visitors,
to encourage disclosure and enable health professionals to provide
appropriate referrals and support, should be rolled out nationally
both pre-registration and as an ongoing area of professional development.
8. BREASTFEEDING
8.1 Despite the known health disadvantages
of artificial feeding and the positive benefits of breastfeeding
for both mother and child, breastfeeding still shows a strong
social class gradient, with the most disadvantaged mothers being
least likely to initiate and sustain breastfeeding. Almost nine
out of 10 women stop breastfeeding before they want to, the highest
proportion before they have even left hospital[9]Effective
education on breastfeeding should be part of the pre-registration
and continuous professional development requirements for midwives,
health visitors, doctors and other relevant health professionals.
9. ENSURE SUFFICIENT
STAFFING LEVELS TO
ALLOW PROFESSIONALS
TO DEVELOP SOCIAL
SUPPORT PRACTICES FOR
THE MOST VULNERABLE
WOMEN
9.1 The transition to parenthood is a
time of great stress for many families, but disadvantaged families
often live in a state of chronic stress and anxiety as a result
of the strain of tight budgeting, debt, poor housing, poor health,
and exclusion from normal social activities. Stress and anxiety
during pregnancy are associated with an increased risk of premature
birth and low birthweight.
[10]
9.2 There is some evidence that one-to-one
support during pregnancy can improve physical and mental health
by assisting disadvantaged women to cope with their difficult
circumstances. Supported women are less likely to feel unhappy
during pregnancy and six weeks after birth they are more likely
to be still breastfeeding, less likely to have introduced solid
food, less likely to be feeling physically unwell, and their babies
are less likely to have had worrying health problems.[11]A
follow-up study found that the improvements in physical and emotional
health of the children were still present seven years later.[12]Support
could also help women vulnerable to postnatal depression [13]We
believe that the NHS should invest in enhanced support by health
professionals for women at risk of isolation, stress and depression.
Investment in "community mother" programmes of trained
lay befrienders, especially for women who do not speak English as
a first language, would also be useful in accessing and supporting
harder to reach groups. 10. SUPPORT
FOR MIDWIVES
10.1 It is important to recognise that
increasing health professionals' understanding of their clients'
wider needs and encouraging them to take a more comprehensive
public health approach may bring emotional challenges for professionals.
They may have to confront sensitive issues that are personal to
them (for example if they themselves are domestic abuse sufferers
or survivors) or they may be distressed by their clients' traumatic
circumstances. It is therefore important to increase the opportunities
for reflective practice and, where necessary, non-clinical support
and debriefing.
February 2003
Foster, K., Lader, D, Cheesbrough, S, Infant Feeding 1995,
ONS. London, The Stationery Office, 1997.
1 McLeish J, Mothers in exile: Maternity
experiences of asylum seekers in England, Maternity Alliance,
2002. Back
2 Right from the Start,
Maternity Alliance, 2002. Back
3 Saunders M, As Good As
Your Word . . . a guide to community interpreting and translation
in public services, Maternity Alliance, 2000. Back
4 Sawtell M, Lives on hold:
homeless families, Maternity Alliance 2002. Back
5 Social Exclusion Unit, Teenage
Pregnancy, The Stationery Office 1999. Back
6 Teenage Pregnancy Unit, Promising
Practice: The Young Mums Midwives, Hammersmith Hospitals NHS Trust,
http://www.info.doh.gov.uk/doh/users.nsf/fss1?readForm 30/01/03. Back
7 Scobie J and McGuire M, (1999)
"The silent enemy: domestic violence in pregnancy", British
Journal of Midwifery vol 4 no 7. Back
8 Growing Up in Britain: Ensuring
a healthy future for our children, BMA, 1999.
Back
9 Foster, K., Lader, D, Cheesebrough, S, Infant
Feeding 1995, ONS. London, The Stationery Office, 1997.
Back
10
ibid. Back
11 Perkin MR et al (1993)
"The effect of anxiety and depression during pregnancy on obstetric
complications" Br J Obstet Gynaecol 100 pp 629-634;
Wadwa PD et al (1993) "The association between prenatal stress
and infant birthweight and gestational age at birth" Am
J Obstet Gynaecol 169 pp 858-865; Lou et al (1994) "Prenatal
stressors of human life affect fetal brain development" Dev
Med Child Neurol 36 pp 826-832.
Back
12 Elbourne et al "Social
and Psychological support during pregnancy" in: ed. Chalmers
et al (1989) Effective Care in Pregnancy and Childbirth,
OUP.
Back
13 Oakley A. et al, (1996)
"Social Support in Pregnancy: does it have long term effects?"
Journal of Reproductive and Infant Psychology vol 14, pp
7-22.
Back
14 Stein A. et al, (1989) "Social
adversity and perinatal complications: their relation t opostnatal
depression" BMJ vol 298 pp 1073-1074.
Back
|