Sharon Trotter RM BSc

Minority ethnic groups: how can midwives bridge the inequality gap?

The full reference for this draft article is: Trotter S (2006). Bridging the inequality gap. The Practising Midwife, 9(11):12-15.

Introduction

Since the 1980s it has been recognized that inequalities in health exist in Britain and that this has had an effect on mortality and morbidity rates’ (Macdonald 2003).
The term ‘ethnic group’ refers to a social group with distinctive language, values, religion, customs and attitudes (Hillier 1991). ‘Minority groups’ further distinguish themselves from the ‘majority’ by, for example, their skin colour, first language or their religion. These groups include immigrants, asylum seekers, travellers and those sharing specific religions and languages, for example Muslim or Hindu. The potential risks associated with these groups are so specific as to be mentioned by name in the most recent Confidential Enquiry into Maternal and Child Health (CEMACH 2004) summary and recommendations.

Effects on pregnancy and childbirth
Legal aspects
Communication
Service provision
Conclusion
Key points for change
References

Effects on pregnancy and childbirth

Statistics tell us that, on average, these particular groups will deliver smaller babies at an earlier gestational age (Schott & Henley 2001). Socio-economic factors may influence these figures. Such factors include: poverty; birth outside marriage; maternal health (physical and mental); uptake of maternity services; psychological and social support (extended family and/or partner); physical (housing and/or overcrowding) and environmental (pollution).
Imagine being introduced to a completely new culture where the language and customs are totally alien to your own. Add to this the natural fears associated with pregnancy, childbirth, breastfeeding and childcare issues, and it is easy to see how complex the picture becomes.
Every couple deserves to be given the most up-to-date, evidence-based information during their transition to parenthood. This allows for informed choice regarding issues surrounding antenatal screening, place of birth, antenatal education, breastfeeding advice, general health education and above all, family involvement. Midwives can greatly enhance this process, which has communication at its heart.
Support during the pre-conception and antenatal period will hopefully serve to increase the chances of an improved postnatal outcome. This support can be optimised by involving family, friends, religious leaders, health professionals and peer support groups. [back to top]

Legal aspects

It is important to understand the framework of legislation that exists to combat potential discrimination faced by these groups.
In 1976, the Race Relations Act (RRA) made it a statutory offence to discriminate against a person on the grounds of race, colour, nationality or ethnic/national origin. The commission for Racial Equality (CRE) was set up as a publicly funded non-government body to tackle racial discrimination and promote equal opportunities, policies and practice. It also campaigns to raise awareness and works closely with the government to make sure all new laws take full account of race relation legislation. The CRE has recently published a ten point plan to help employers promote equality of opportunity in their organisations (CRE 2003) and provide ethnic monitoring. The RRA (amendment) 2000 applies to all public authorities and came into effect in December 2001. The amended Race Relations Act gives public authorities a new statutory duty to promote race equality. The aim is to help public authorities to provide fair and accessible services, and to improve equal opportunities in employment (http://www.cre.gov.uk/duty/index.html). It requires public authorities to eliminate unlawful racial discrimination and to promote equality of opportunity and good relations between persons of different racial groups (Dimond 2002). With regard to maternity services, the Royal College of Midwives (RCM) published a position paper (RCM 2000) suggesting ways in which discrimination could be tackled. This paper also outlines practical ways of implementing appropriate standards to ensure change within maternity services is implemented sensitively and efficiently.
In 2002 the Scottish Executive published its ‘Fair for all’ report (SE 2002). This extensive report sets out a framework for NHS Scotland to follow. It outlines practical steps that can be taken in order to improve health services for ethnic minority communities. [back to top]

Communication

Communication lies at the heart of health care delivery. To be effective it must be a two-way process; the service must give patients the information they need and it must listen and respond to them. It must do this, as far as possible, in a way that is tailored to the individuals…. Unique blend of beliefs, understanding, expectations and ability to communicate’ (Audit commission 1993).
Language barriers present one of the most difficult obstacles to successful communication. This is where the provision of interpreters can make all the difference. In the case of Pakistani women, it is a stark statistic that their babies are twice as likely to die in the first year as their UK counterparts (ONS 2003). Furthermore the high perinatal mortality rate of mothers that had given cause for concern to the Royal College of Obstetricians and Gynaecologists (RCOG) back in 1982, remains the same today, more than 20 years later (Richens 2004).
It is therefore vital to have service provision tailored to the needs of all, irrespective of their background, so that safeguards are in place to effect change (Lamming 2003).
Consequently, translation services should no longer be seen as an ‘optional extra’, but rather part of the ‘core’ requirement for those suffering the effects of a language barrier. ‘As good as your word’ (Sanders 2001) an excellent publication by the Maternity Alliance addresses this issue and should be a required resource within every maternity unit.
Only when effective communication is possible can women hope to receive the level of care they can rightfully expect.
Language, though important, is only one way of imparting knowledge and information. Emphasis should be placed on the many other forms of verbal and non-verbal communication. Such means of communication include: eye contact, touch, volume of voice, gestures, posture, facial expressions and physical distance. A familiar non-verbal elaborate form of communication is sign language for the deaf and hard of hearing.
Another variation of communication was highlighted in a recent paper focusing on the language of touch (Klein 2003). It contrasts the ways in which touch can be used to shape a more positive birth experience for women and their partners. Special note was made about ‘ethnic touch’, peculiar within every culture and race. What is perfectly acceptable to one group of people may well be offensive to others. With this in mind, midwives in a multicultural society should take care to be sympathetic to these specific needs.
Constantly improving technology provides visual and hearing aids, such as video – phones; computer based training; induction loops and website translation software. Having access to such a variety of means of communication may narrow the gap that language barriers create. [back to top]

Service provision

The term ‘Minority Ethnic Group’ underplays the enormity of this issue in the UK. With 1.7 million people affiliated to the Islamic faith alone, this is by no means a ‘minority’ issue. With the recent introduction of the National Service Framework for Childcare (DoH 2004) the main focus is to meet the needs of an individual instead of a ‘one size fits all’ approach.
Projects involving midwifery led care (Sen & Holmes 1996), the introduction of bi-lingual link workers (Baxter 1995), the introduction of an African well women’s clinic (Sosa 2004) and qualitative studies of minority groups (Parvin et al 2004) continue to advance our knowledge and understanding in these areas.
The first project focused on the provision of an enhanced consumer-sensitive midwifery service in a Newcastle Bangladeshi community. A Bengali/English speaking link worker and two full-time midwives provided continuous care throughout the antenatal, labour and postnatal period. The aim to increase awareness and confidence within this ethnic group was achieved and the uptake of health services improved. Alongside an increase in breastfeeding rates, communication skills of the immigrant women were also seen to improve.
The case for bi-lingual link workers involved in a variety of advocacy schemes in the east end of London was investigated. They were found to be highly effective in reducing medical interventions, improving access to health care during the childbearing period and increasing customer satisfaction. Having bi-lingual link workers was found to be a cost-effective way of reducing inequalities associated with black and ethnic minority groups.
The second project consisted highlighted the setting up of an innovative African well women clinic in June 2000. This midwife-led clinic aims to achieve culturally sensitive care for women with Female Genital Mutilation (FGM) and help protect future generations of daughters. This project is not only evidence-based but women-centred. It fulfils a real need to bring about understanding regarding a sensitive and culturally specific ethnic issue. The problem of FGM is not insignificant with 130 million girls and women affected worldwide. Specialist midwives at the Whittington (including a Somalian midwife) run a full day’s clinic once a month. Expert advice is provided during the antenatal and postnatal period. If required, de-infibulation can also be offered antenatally. This has proved popular and more acceptable than waiting until the time of delivery. An ongoing initiative to educate women and prevent genital mutilation to female offspring is also encouraged. In Britain, FGM has been against the law since 1985 when the Female Circumcision Act was introduced. In Scotland, the FGM (Scotland) Act (2004) was re-enacted to extend the protection (making it illegal to organise FGM abroad) and to increase the terms of imprisonment from five to 14 years.
Alliances continue between maternity units in an effort to increase awareness, share information and work towards the eventual eradication of FGM. For more information, The Research Action and Information Network for Bodily Integrity of Women can be accessed online at www.rainbo.org .
An interesting development within recent years has been the proliferation of cosmetic surgery in the pursuit of ‘designer vaginas’. This may actually undermine the battle against FGM by advocating the practice of genital mutilation for purely cosmetic reasons. Dr Ronan Conway (2006) sites this phenomenon and accuses the ‘West’ of double standards. The debate is sure to continue.
The third project concentrated on a qualitative study surrounding the emotional issues of childbearing, and how these relate to the cultural differences of the Bangladeshi women who were interviewed. Once again, language barriers were highlighted, as was the need for advocacy if women were to access the full range of health services. Everyone who took part in this study, whether health professional or patient, gained a better understanding of other participants’ differences and needs. Hopefully this will lead to improved service provision in the future.
These examples show that small changes in practice can have far reaching effects on the quality of care for any disadvantaged group. Equality can only be achieved when health professionals respect the differences and traditions followed by each individual ethnic group. Respect will then be reciprocated and it will be possible to establish a relationship of trust between health professionals and their clients. [back to top]

Conclusion

Every new mother has the right to individualised care. Women from minority ethnic groups are no exception. Good communication within an atmosphere that is free from discrimination and stereotyping, (Kirkham et al 2002) is the key to providing care that is both sensitive and respectful of special needs, whatever they may be. Midwives are well placed to make a real difference to couples during this life changing period.
The opportunity also exists to affect mortality and morbidity rates. This in turn has consequences for public health. However, society as a whole could become the real winner. If greater understanding between races results in a more culturally aware population, tolerant of each other’s beliefs, everyone will ultimately benefit. [back to top]

Key points for change:

• A policy of zero tolerance towards discrimination and stereotyping should be in place for all staff and client groups.
• Parentcraft classes that are culturally acceptable and sensitive to the needs of particular ethnic groups should be available.
• Interpreters must become part of the core service provision and should be appropriate to the individual.
• More patient literature must be translated and readily available for those who do not speak English.
• Staff training must be appropriately targeted.
• Documentation and hand held notes (now policy within Scotland) should indicate relevant details of diet, language, religious or cultural practices.
• During labour, women who wish to be examined by a female attendant for cultural reasons should be given this option.
• Continuity of midwifery care during the labour and birth period is paramount.
• Religious and cultural traditions surrounding the time of birth should be respected and incorporated if at all possible.
• Peer support groups should be encouraged to provide ongoing support for breastfeeding and childcare in the postnatal period.
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References:

Audit Commission (1993). What seems to be the matter: communication between hospitals and patients. National
Health Service Report no.12. HMSO. London.

Baxter C (1995). The case for bi-lingual workers with maternity services. Changing childbirth update no. 4, p5-6.

Confidential Enquiry into Maternal and Child Health (Nov 2004). Why mothers die: midwifery summary and key
recommendations. RCOG Press. London.

Conroy R (2006). Female Genital Mutilation: whose problem, whose solution? British Medical Journal, 333:
106-7.

Commission for Racial Equality (2003). http://www.cre.gov.uk/gdpract/eop.html
(accessed on 01/04/2005)

Dimond B (2002). Race relations and the law. British Journal of Midwifery, 10(9):580-3.

Department of Health (2004). National Service Framework for Children, Young people and Maternity Services. HMSO. London.

Hillier S (1999). The health and health care of ethnic groups. In Sociology as applied to Medicine (ed. G Scambler).
Bailliere Tindall. London.

Kirkham M, Stapleton H, Curtis I & Thomas G (2002). Stereotyping as a professional defence mechanism. British
Journal of Midwifery, 10(9):549-52.

Klein M (2003). The art and culture of touch. The Birthkit, issue 40 (Winter): 8- 10.

Lamming H (2003). The Victoria Climbie Inquiry. Available from www.victoria- climbie-inquiry.org.uk (accessed on
01/04/2005).

Macdonald T H (2003). The Social Significance of Health Promotion. Routledge. New York. p 69.

Office for National Statistics (2003). Available from: http://www.statistics.gov.uk/downloads
/t heme_population/stillbirths_2002_E-
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Parvin A, Jones C E and Hull S A (2004). Experiences and understandings of social and emotional distress in the postnatal period among Bangladeshi women living in Tower Hamlets. MIDIRS Midwifery Digest 14(4):522-6.

Richens Y (2004). Non-English speaking women are at risk. British Journal of Midwifery, 12(2):68-70.

Royal College of Midwives (2000). Position Paper 23: Racism and the Maternity Services. RCM Midwives Journal, 3(11):342-3.

Sanders M (2001). As good as your word. The Maternity Alliance. London.

Schott J & Henley A (2001). Culture, religion and childbearing in a multicultural society. A handbook for health professionals. Butterworth Heinemann. Oxford.

Fair for All (Scottish Executive Department of Health - 2002), found at http://www.show.scot.nhs.uk/sehd/public
ations/ffar/ffar-13.htm Accessed 28/07/06.

Scottish Parliament (2004). Prohibition of female genital mutilation bill [as introduced] session 2. sp Bill 29.
Edinburgh: The Stationery Office.

Sen D M & Holmes C (1996). Newcastle Bangladeshi Midwifery Project. MIDIRS Midwifery Digest, 6(2):225-9.

Sosa G (2004). The African Well Women Clinic at the Whittington Hospital NHS Trust. Midirs Midwifery
Digest, 14(2): 255-60. [back to top]