House of Commons - Health - Written Evidence

Select Committee on Health Written Evidence

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 groups—it 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 ALL—INTERPRETING 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.

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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

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ibid. Back