Chapter 3 The social context of childbirth and motherhood
This chapter provides a brief overview of the social context within which the twenty-first century maternity services are organized and delivered; it highlights the importance of factors such as ethnicity, culture, religion, disability, sexuality and social exclusion which may impact upon the quality of maternity services. Having an understanding of such issues will enable the midwife to work effectively in partnership with women to ensure that the care that is offered meets individual needs of all women, their babies and families.
The journey of having a baby is a profound event. Although this journey may be similar for all women in terms of physiological explanations, its meaning to each woman is individual and unique because the social context of her life and experience is shaped by social, cultural, spiritual, emotional and psychological factors. Therefore, maternity services strive to provide care that is not only safe but is easily accessible and is responsive to women’s individual linguistic, faith and cultural needs, that communicates effectively and provides the information that facilitates informed choices. Correspondingly, government proposals and recommendations reflect these aspirations, advocating that maternity services must be responsive to the individual needs of women and their families, listen to their views and respect their ethnic, cultural, social and family backgrounds (Department of Health (DH) 2004, 2007a,b, NHS Quality Improvement Scotland 2005, Scottish Executive Health Department SEHD (2001), Northern Ireland Department of Health, Social Services and Public Safety NI DHSSPS (2002), Welsh Assembly Government WAG (2005)). The directives reaffirm that women should be the central focus and maternity services should be designed to fit around the woman, her baby and family, with specific emphasis to support normal childbirth and to offer medical intervention only if absolutely necessary. While midwives recognize that meeting individual and unique needs of every woman during childbirth will lead to a fulfilling experience, achieving individualized care remains a challenge particularly when caring for women who are vulnerable or experience disadvantage.
Over the past two decades, a number of policy directives have propelled the NHS to modernize maternity services to meet the needs of women. The policy reforms in the UK have recommended many radical changes in the way maternity services are commissioned and provided (DH 1997, 2000a,b, National Assembly for Wales 2001, 2005, SEHD 2005a,b, DHSSPS 2004, 2005). In particular, they emphasize the need for NHS provider units to be more responsive to the needs of their local population, more sensitive to the needs of all service users, and to offer greater choice, higher standards and better quality of healthcare provision. The need for maternity service re-design is greater than ever before if benefits such as safer care, improving access and outcomes, more choice, promoting normality, local ante- and postnatal services closer to home and home-like birth environment are to be realized (Shribman 2007).
Consequently, the beginnings of the twenty-first century have seen the transformation of the NHS at systems and at organizational level to provide better care, better patient experience and better value for money. The reforms are to deliver a Patient-led NHS (DH 2005), where the services are to be provided through stronger commissioning. The direction of travel is to move away from monolithic provider organizations to that of diversity of providers. More and different providers of maternity services is likely to expand community based provision, creating an opportunity for maternity services to be commissioned from a range of providers such as other NHS providers, voluntary sector, private sector and social enterprise. The expansion of providers will inevitably introduce an environment of contestability with explicit competition. The policy desire is to offer women and their families a greater choice in the services they want and need (DH 2007b), guaranteeing a wider choice of type and place of maternity care and birth by the end of 2009 (DH 2007a).
Simultaneously, the NHS has undergone a major restructuring programme, bringing about dramatic changes to the way health and social care is delivered locally. The White Paper: Our health, Our care, Our say: a new direction for community services (DH 2006a) and The NHS in England: the operating framework for 2006/7 (DH 2006b) have been catalysts for these reforms, proposing a shift of services from hospitals into the community, with the provision of care much closer to home and greater integration with local authority services and having shared responsibilities for public health.
Midwives are the cornerstone of delivering maternity service reforms. Their roles and responsibilities will increasingly focus to deliver greater productivity and best value for money, offering real choice and improvement in women’s maternity experiences. These reforms are creating opportunities for midwives to work in new ways and undertake new and different roles. Midwives are required to be much more oriented towards public health and the reforms provide increased opportunities to work in more diverse teams to provide integrated services. The working environment is changing where midwives are increasingly accountable for the care they provide creating a new form of ownership.
In the twentieth century, childbirth was transformed from a social, domestic event into a highly technological, medical procedure. The 1980s saw a rise in concerns about the way maternity services were organized and delivered; this led to campaigns calling for better access to effective and appropriate obstetric and midwifery care and the need for services to be tailored to meet consumer needs. While women from the middle classes were somewhat reluctant to have intervention imposed on them and called for a less clinical environment for intrapartum care, women from vulnerable and disadvantaged backgrounds complained that they were more likely to receive less favourable treatment, asserting that services failed to take account of their linguistic, religious and cultural needs and some, particularly those from the black and minority ethnic (BME) groups claimed that they experienced additional difficulties owing to stereotypes and discrimination (Cartwright 1979, Larbie 1985, Phoenix 1990). (Note: The use of terminology to describe different groups in the community is an extremely sensitive issue and there is no single acceptable term that embraces all members of the minority ethnic groups. The term ‘black and minority ethnic communities’ has been used here to include all individuals who experience discrimination and disadvantage associated with ‘race’ and ethnicity.) Many of the reasons given by women for dissatisfaction with maternity services include fragmented care, long waiting times, insensitive care, lack of emotional support, inadequate explanations, lack of information, medical control, inflexibility of hospital routines, and dehumanizing aspects of hospitalization and reproductive technologies (Kitzinger 1978, 1990, Oakley 1979, Reid & Garcia 1989).
Universally, there is no agreed definition of vulnerability, however, the term ‘vulnerable groups’ is often used to refer to groups of people who are at risk of being marginalized in accessing maternity services and social exclusion. These groups of people or communities are more likely to experience social marginalization as a result of a number of interrelated factors such as unemployment, poor or limited skills, low income, poor housing, poverty, high crime environment, poor or ill health and family breakdown. Women from these vulnerable groups may experience disadvantage either due to mental or physical impairment, or particular characteristics no longer attributed to mental or physical impairment but that have historically led to individuals experiencing prejudice and discrimination, for example ethnicity or disability. Or it may be concerned with the manner in which individuals or organizations interact with women leading to prejudice and discrimination (Hart et al 2001).
Providing woman-centred care is a complex issue, particularly in a diverse society where individual’s and families’ health needs are varied and not homogenous. Listening and responding to women’s views and respecting their ethnic, cultural, social and family backgrounds is critical to developing responsive maternity services. Persistent concerns have been expressed about the poor neonatal and maternal health outcomes among disadvantaged and socially excluded groups (Lewis 2007, Lewis & Drife 2001, 2004), suggesting not all groups in society enjoy equal access to maternity services (Dixon-Woods 2005, Redshaw et al 2007). The Confidential Enquiry into Maternal and Child Health Report (CEMACH) for the triennium 2003–2005 testified that ‘the link between adverse pregnancy outcomes and vulnerability and social exclusion are nowhere more starkly demonstrated than by this enquiry’. The report goes on to state that ‘those women who need maternity services most use them least’ (Lewis 2007, p 44).
Women may be viewed as disadvantaged not because they have, for example, a disability or are from travelling communities, but because they are more likely to be socially excluded. They are more likely to experience discrimination or be unemployed and it is the detrimental impact of these circumstances on health that is of concern (see Box 3.1). There is strong evidence that disadvantaged groups have poorer health and poorer access to healthcare, with clear links between inequality in social life and inequality in health, demonstrating that inequality exists in both mortality and morbidity (HCHC 2003, Macfarlane & Mugford 2000, Modood et al 1997, Palmer et al 2006). People from these groups have not enjoyed the health gains from wider social and environmental improvements, and are less likely to adopt healthier lifestyles or obtain fair access to services at the same level as the most affluent sectors of the community.
In a broad sense, the government has affirmed its commitment to address issues of inequalities in health, and policy directives are compelling maternity services to readjust themselves and to become conversant with health needs of women from vulnerable and disadvantaged backgrounds. The health of those community groups who are at a higher risk of poorer health outcomes has been given a designated priority area (Acheson 1998, DH 1999, 2000a, 2001). Provider units and healthcare professionals are made responsible for development and delivery of maternity services in such a way that they give an important consideration to the needs of people from vulnerable groups as well as eradicate inequality.
To facilitate care that is responsive to the needs of women, health professionals need to understand women’s social, cultural and historical backgrounds so that care is tailor-made to meet their needs. A number of models of care have been introduced to deliver culturally congruent care, including some examples of midwifery-led case-loading teams developed around the needs of vulnerable groups, e.g. Blackburn Midwifery Group Practice (Byrom 2006), however the philosophy of ‘woman-centred care’ is that used to meet individual needs of the women who experience disadvantage.
Britain has the highest rate of teenage pregnancy and teenage parenthood in Europe. Some 90 000 teenagers in England become pregnant every year; of these, nearly 8000 are under the age of 16 years. Approximately three-fifths of teenage conceptions will result in live births (Social Exclusion Unit 1999). Many young mothers do achieve a successful outcome to their pregnancy and parenting; it should, however, also be recognized that mortality and morbidity among babies born to these mothers is increased and that the mothers show a higher risk of developing complications, such as hypertensive disorders and intrapartum complications (Lewis & Drife 2004). Young teenage mothers tend to present late for antenatal care and are disproportionately likely to have some risk factors associated with poor antenatal health (e.g. poverty and smoking).
For many young mothers, pregnancy and parenthood means an early conclusion to their education with consequent reduced career opportunities and increased likelihood that they will find themselves socially excluded and living in poverty. The Government’s Social Exclusion Unit report on teenage pregnancy (1999) set two major targets: (1) to halve the pregnancy rate in under 18-year-old teenagers by the year 2010 and (2) to achieve a reduction in the risk of long term exclusion for teenage parents and their children. Midwives have a role to play in the achievement of both these targets through their public health role and the provision of appropriate, accessible services. The Government Action Plan on Social Exclusion describes a ‘cycle of disadvantage’ with deprivation passing down from one generation to the next; it goes on to suggest that the daughter of a teenage mother is twice as likely as the daughter of an older mother to become pregnant in her teen years (HM Government 2006, p 8).
With appropriate support, young mothers can make an effective transition to parenthood. They can be assisted to develop good parenting and life skills and be helped out of this potential downward spiral. MacKeith & Phillipson (1997), writing about young mothers, argue that being judgemental achieves nothing positive but it reduces self-esteem, engenders resentment and destroys the relationship between the midwife and her client. While some progress has been made towards achieving the 2010 targets, there is still much to do; ‘A guide to commissioning and delivering maternity services’ offers assistance in developing local strategies (Teenage Pregnancy Unit et al 2004).
Women with disability are increasingly becoming users of the maternity services as they seek to live full and autonomous lives. The midwife needs to allow sufficient time to assess how the disability may impact on the woman’s experience of childbirth and parenting and to work with her in identifying any resources that may alleviate perceived difficulties. Assumptions should not be made on visual observation alone. Where possible, the woman should have a named midwife with whom she can build a trusting relationship and have continuity of care. An introduction to other professionals who may be involved in the care should be considered early in pregnancy. Comprehensive record-keeping will reduce the likelihood of repetitive questioning.
The woman will probably be well informed about her disability but may need the midwife to provide advice on the impact that the physiological changes of pregnancy and labour may have on her, for example the increased weight and change in posture. Some women and their partners may raise concerns regarding a genetic condition that could be passed on to their baby and need referral to specialist services such as a genetic counsellor. Midwives and other healthcare professionals should recognize the need to approach antenatal screening in a sensitive manner (see Ch.18). Midwives need to be aware of local information pertaining to professional and voluntary organizations and networks and adopt a multidisciplinary approach to planning and provision of services. The Common Assessment Framework may be an appropriate tool for the midwife to use to ensure a coordinated multi-agency approach to care (DfES 2006).
A birth plan will help the woman to identify her specific needs alongside the issues that most pregnant women are concerned with, such as choice of pain relief and views on interventions. Midwives should empower women with a disability to make informed choices about all aspects of their antenatal, intrapartum and postnatal care (RCM 2000a). If the woman is to give birth in hospital it may be helpful for her to visit the unit, meet some of the staff and assess the environment and resources in relation to her special needs. A single room should be offered to her to facilitate the woman’s control over her immediate environment and, where appropriate, to adapt it to accommodate any equipment that she may wish to bring with her. A woman who is blind or partially sighted may prefer to give birth at home where she is familiar with the environment. If she has a guide dog then consideration needs to be given to its presence in the hospital environment.
Women with learning difficulties may need a friend or carer to help with the birth plan but the midwife should not overlook who is the client; she must involve her as much as possible and recognize that she may have feelings and anxieties that she is less able to articulate.
Midwives need to understand the worldview of women with disabilities in order to shape the maternity services to meet the individual needs of these women. They need to value key principles of rights, independence, choice and inclusion. Many women with disability may have been educationally disadvantaged, as they may have had to miss compulsory education in school years because of receiving medical treatment. The disability may have led to social isolation, which in turn could have restricted the woman’s awareness of available services. Midwives also need to have knowledge of the potential effect that disability may have on the individual woman as a recipient of maternity care.
It is well documented that women living in poverty are more likely to suffer health inequalities and have a higher rate of maternal and perinatal mortality (Lewis 2007, Lewis & Drife 2004, Townsend & Davidson 1982, Whitehead 1987).
Tackling inequality is high on the public health agenda and the midwife has an important role in targeting women in need. Sure Start and Sure Start Plus schemes have contributed to bringing services together and addressing the needs of disadvantaged parents; see Box 3.2, Karen’s story.
‘Karen’ escaped domestic abuse with her son – so serious that she had to change her name so that she could not be traced. She also has a criminal record for fraud (she forged a name to obtain goods when she was desperate for money). She has now met a new partner and has had a baby. Her life is really improving, they are buying a house through a council partnership scheme and she now has a part-time job. Karen believes her ‘success’ has been greatly helped by support from Sure Start.
‘Hello, my name is Karen, mum to Ethan, 7 years and Chloe, 6 months. We are regular users of the Sure Start services. My son, Ethan has some special needs and has one-to-one support from Claire who gives him the understanding that he needs; she also helps me with trying to help Ethan and it has made a fantastic difference. While I was pregnant with Chloe, I used Maria, the midwife, who came to me as I found it hard to get around; she checked my baby’s heartbeat – that was lovely to hear. She also gave me her mobile number and if I ever needed her I could just call and when you have a high risk pregnancy it is such a reassuring feeling to know someone is there for you. On a Friday I go to an art and craft group, we learn new skills, from making purses to painting. I have also run a group on a Monday for mums over 24, as I felt this service was lacking, but without the support of Megan and Nasreen to do this I would not have done it. I moved to this city about three and a half years ago and was very lonely and isolated, but joining the groups at Sure Start I now have a good circle of friends and I have my confidence back. All of the workers at Sure Start do a great job and a lot of people don’t realize how much work they do with individuals and in the community. I would like to say a big thank you to you all.’
Salmon & Powell (1998) recognize that midwives should be sensitive to the financial difficulties that some women face and should not give inappropriate advice that may reinforce an already vulnerable situation. They also recognize that concepts such as continuity and choice may be viewed as secondary for women struggling with the daily reality of managing poverty.
The UK has continued to see major demographic changes in the profile of its population and is more ethnically diverse now than ever before (Office for National Statistics, ONS 2001). According to the 2001 census, there are approximately 4.6 million people from a BME origin residing in UK, constituting 7.9% of the total population, having risen from a figure of 3 million (or 5.5%) in 1991. Of these, nearly 50% of the population account for South-Asian origin (people of Indian, Pakistani, and Bangladeshi backgrounds) and approximately 2% of the people are from Black backgrounds, that is, Black Caribbean, Black Africans and Black other and 0.4% each of Chinese and of various origins including Arabs and ‘mixed’ backgrounds.
However, there is considerable variation in the distribution of the BME population within the UK countries and within the regions. The BME population is principally located in England, where the BME population is approximately 9%; in Scotland and Wales the BME composition is of approximately 2% each and in Northern Ireland it is less than 1%. These statistics are important for maternity services, so that they can respond to the demographic composition and diversity of BME populations. However, Britain’s BME population not only differs from the majority of the population but also has sub-groups which differ from each other in terms of culture, lifestyle, language and religion.
When referring to multi-ethnic societies, a basic understanding of the culture is often assumed to mean the way of life of a society or a group of people and is used to express social life, food, clothing, music and behaviours. The concept of culture has been defined by many (Helman 1994, Leininger 1978, Lewis 1976), providing a variety of insights into the concept. However, the commonalities are that culture is learned, it is shared and it is passed on from generation to generation. Members of the society learn a set of guidelines through which they attain concepts of role expectancies, values and attitudes of society; it is therefore not genetically inherited but is socially constructed and the behaviour of individuals is shaped by the values and attitudes they hold as well as the physical and geographical surroundings in which they interact. Individuals perceive and respond to stimuli from economic, social and political factors in different ways and they will be affected differently according to age, gender, social class, occupation and many other factors. Culture is very much a dynamic state, it is not a group phenomenon and to treat it as homogeneous can be quite dangerous as it can lead to generalizations. Some aspects can be true for some and not for others belonging to the same cultural group.
An understanding of some of the cultural differences between social groups is essential in ensuring that professional practice is closely matched to meet the needs of individual clients, promoting the delivery of culturally congruent care. An understanding of the role culture plays in determining health, health behaviours and illness is essential when planning and delivering services that meet the health needs of the local population. However, some caution the role of culture in explaining patterns of health and health-related behaviour, arguing that emphasis on culture diverts attention away from the role of broad structural process in discrimination and the role that racism plays in health status (Ahmad 1993, 1996, Stubbs 1993). In practice then, emphasis on culture could lead to attributing inequalities entirely in cultural differences, diverting attention from the real causes of discrimination and racism often faced by women from diverse backgrounds.
Ethnic diversity in the UK has created major challenges for maternity services. In the triennium 2003–2005, more than 20% of births in the UK were to mothers who themselves were born elsewhere (Lewis 2007). CEMACH reports have demonstrated that the inability to respond appropriately to the individual needs of women from different backgrounds is reflected in persistent poor health outcomes for both mother and baby (Lewis 2007, Lewis & Drife 2001, 2004). The last two decades have seen a much more consistent approach to health policy to redress this discrepancy and, coupled with the Race Relations (Amendment) Act of 2000, has propelled widespread transformation underpinned by the duty to promote racial equality, firmly placing the responsibility for responding to ethnic diversity on provider organizations and healthcare professionals (DH 1997, 2000a).
Gerrish et al (1996) found that midwives lacked knowledge of many issues when providing care to women from BME groups but were concerned to learn more. Healthcare professionals who are not equipped with basic information about ethnic groups are more likely to make assumptions about the needs and preferences of women based on inaccurate stereotypes. It is critical that midwives should be equipped with knowledge, enabling them to provide high quality, anti-discriminatory care that is appropriate and responsive to the varied health needs of the diverse population.
Women from the BME population experience disadvantage and are socially excluded for two main reasons. First, some women are more likely to be categorized into lower socioeconomic status; they are predominantly residents of deprived inner city areas, have poor housing, are at risk of high unemployment, and have low paid occupations, poor working conditions, poor social security rights, and low income, all of which lead to poverty. Often factors, such as lifestyle, environmental factors and genetic determinants are cited as indicators of poor health outcomes dismissing key social determinants of poverty, poor housing and poor education (Nazroo 1997, Platt 2007).
Second, because their skin colour and ethnic origin make them visible minorities, they are more likely to experience racial harassment, discrimination and social inequalities (Nazroo 2001). Institutionalized racism and general reluctance by organizations and individuals to address the sensitive issue of ethnicity are likely contributors to inequalities of health and access to maternity services (RCM 2003). It is important to understand concepts of discrimination and racism and how this can marginalize women.
Discrimination is a process whereby one person is treated less favourably than another and occurs when prejudice is brought into action, often to the disadvantage of particular groups or individuals. Discrimination can operate in two forms: (a) Direct discrimination operates at an individual level and (b) indirect discrimination is usually at an institutional level. Direct discrimination arises where an individual is treated less favourably, on the grounds of gender, ‘race’, disability, sexual orientation, religion, culture or age, than another person would be treated in the same or similar circumstances. An example from the Commission for Racial Equality follows (CRE 1994, p 22):
A receptionist at a community health clinic tells a black woman that there are no appointments available for at least 2 weeks. She then proceeds to offer a white woman an appointment for the next day.
Indirect discrimination occurs when a requirement or condition that applies to everyone has the effect of excluding a significantly greater proportion of people from a particular group than others. An example adapted from the CRE (1994) is:
An antenatal clinic offers classes on breathing and relaxation techniques for expectant mothers. These classes are also open to their partners. Women from some ethnic groups who experience difficulty in discussing childbirth issues in male company often drop out or do not attend. They miss out on these facilities, as there are no classes for women only.
Racism on the other hand, is a doctrine or ideology or dogma that is underpinned by the assumption that some groups are superior to others, and is interpreted as the systematic oppression of individuals or groups based on their skin colour or ethnic origin (Fernando 1991). Racism is associated with power that enables individuals, or institutions to make things happen or prevent them from happening. It is the enactment of prejudice and discrimination, either at an individual or institutional level, by those who are in power either by an act of deliberation or unintentionally.
Racism can operate at an individual and/or institutional level. Individual racism operates through the behaviour of people at a personal level, leading to discrimination. An example of individual racism is where a healthcare practitioner does not offer translating or interpreting services because she believes that while in England, everyone should speak English. This in fact will lead to a poorer quality of service.
Institutional racism, on the other hand, is ‘the collective failure of an organization to provide an appropriate and professional service to people because of their colour, culture or ethnic origin. It can be seen or detected in processes, attitudes and behaviour which amount to discrimination, through unwitting prejudice, ignorance, thoughtlessness and racist stereotyping, which disadvantages ethnic minority people’ (Macpherson 1999, p 28). This suggests that institutional racism is essentially a situation when racial prejudice becomes part and parcel of institutions and is set in the structures of the society, so that long-standing practices can cause organizations to discriminate unintentionally.
Often the term ‘race’ is used to refer to people from the BME communities. This term is underpinned by the premise that people are differentiated by specific genetic and physical characteristics (e.g. Caucasian, Negroid, etc.) and are connected by common descent and origin. However, the scientific explanations reject the notion that there is a biological difference in the ‘races’, arguing that there is little genetic difference between different ‘races’ and, more so, that genetic differences within ‘races’ are greater than the differences between ‘races’ (Rose & Rose 1986). Notwithstanding this, ‘race’ is widely used in the social and political context and is associated with concepts, such as discrimination and racism.
Ethnicity has largely replaced the term ‘race’, encompassing all of the ways in which people from one group seek to differentiate themselves from other groups. ‘Ethnicity is an indicator of the process by which people create and maintain a sense of group identity and solidarity which they use to distinguish themselves from “others”’ (Smaje 1995, p 16). Ethnicity is a self-claimed identity and is socially constructed; people of a particular group have a common sense of belonging, and have shared beliefs, values and cultural traditions as well as biological characteristics. In general, people use these terms to identify the ‘other’ groups but it must be remembered that all people have a culture and ethnicity.
When people value their own culture more highly, perceiving their cultural ways to be the best, they devalue and belittle other ethnic groups, perceiving ‘others’ culture as bizarre and strange; this is referred to as ethnocentrism. Ethnocentric behaviour, in particular when other individuals’ cultural requirements may be ignored or dismissed as unimportant, would do very little to meet the tenets of woman-centred care and hinders the delivery of responsive care. Many maternity services are still based on an ethnocentric model, e.g. education for parenthood is not culturally sensitive where women and their partners are positively encouraged to attend jointly (Katbamna 2000).
BME groups as users of the maternity service: The majority of women from BME groups express satisfaction with maternity services. While some argue that ethnicity is not a marker for good or poor quality (Hirst & Hewison 2001, 2002), others have reported a plausible relationship between ethnicity and women’s proficiency in speaking and reading English with poor quality of care (Bharj 2007, Bowes & Domokos 1996a, 2003). Many women assert that their ability to access maternity services is impaired because they are offered little or no information regarding options of care during pregnancy, childbirth and postnatal period (Bharj 2007, Katbamna 2000). Women are therefore not aware of the range of maternity services and choices available to them. For example, a video plus leaflet on hospital delivery in Bengali will tell only half the story with respect to birth options if the leaflet on home birth is available only in English (CRE 1994). Women who do not have full and appropriate information cannot easily access health services and the consequence is poor uptake of maternity and other preventative services.
Extensive evidence indicates that lack of proficiency to speak and read English adversely impacts on women’s experience and their ability to access and utilize maternity services (Bowes & Domokos 1996a, Chan 2000, Katbamna 2000, Woollett & Dosanjh-Matwala 1990a,b), impacting adversely on the quality of maternity services and maternity outcomes (Lewis & Drife 2004). Often lack of interventions to overcome communication and language barriers, such as qualified interpreters is cited as a major challenge in accessing maternity services (Harper-Bulman & McCourt 2002). Use of relatives or friends as interpreters during sensitive consultations is viewed by women to be inappropriate. In some studies, women reported that their requests to see a female doctor were dismissed and they were distressed when treated by a male doctor, particularly when they observed purdah (Sivagnanam 2004).
Some women from the BME communities have reported that midwives are unable to develop positive relationships with them, marring their childbirth experiences (Ellis 2004, Woollett & Dosanjh-Matwala 1990a,b). Midwifery care based on discriminatory attitudes and institutional racism has not only tarnished women’s maternity experience but has led to substandard care (Bharj 2007, Bowler 1993a,b, Richens 2003, Sivagnanam 2004).
Consequently, women in such environments feel that the reception and handling they receive is less than adequate and they are left feeling humiliated. Those women who have poor experiences of maternity services are less likely to access maternity and preventative services readily. Often, service provision is inappropriate and insensitive with claims that stereotyping and discrimination within the NHS remain major issues that underpin their experiences of maternity services. The following two key elements can assist in the provision of equitable maternity services:
Midwives need to be aware of the complex needs of this group of vulnerable women who, in addition to the problems described above, have often experienced traumatic events in their home country, may be isolated from their family and friends and face uncertainty regarding their future domicile.
It would be wrong to categorize travelling families as a homogeneous group. This umbrella term merely serves to describe the nomadic nature of their lifestyle but fails to recognize their origins or the social context of their lives. Travellers may belong to a distinct social group such as the Romanies, their origins may lie in this country or elsewhere such as Ireland or Eastern Europe, or they may be part of the social grouping loosely termed ‘New Age’ travellers or part of the Showman’s Guild travelling community. As with all social groups, their cultural background will influence their beliefs about and experience of health and childbearing.
A common factor, which may apply to all, is the likelihood of prejudice and marginalization. Midwives need to examine their own beliefs and values and develop their knowledge to address the needs of travelling families with respect and provide a service which is non-judgemental. An informed approach to lifestyle interpretation may stop the midwife identifying the woman as an antenatal defaulter with the negative connotations that accompany that label. Moving on may be through choice related to lifestyle, but equally it may be the result of eviction from unofficial sites.
Some health authorities have designated services for travelling families that contribute to uptake and continuity of care. These carers understand the culture and are aware of specific health needs; they can also access appropriate resources, for example a general practitioner (GP) who is receptive to travellers’ needs. A trusting relationship is important to people who are frequently subjected to discrimination. Handheld records contribute to continuity of care and communication between care providers, but the maternity service also needs to address communication challenges for individuals who do not have a postal address or who have low levels of literacy.
Evidence suggests that an increasing number of women are seeking motherhood within a lesbian relationship. The exact numbers are unclear as it is the woman’s choice as to whether she makes her sexual orientation known. The midwife can, however, create an environment in which she feels safe to do so. Communication and careful framing of questions can reduce the risk of causing offence and assist the midwife in the provision of woman-centred care.
Wilton & Kaufmann (2001) identify the booking interview as the first time, as a user of the maternity service, that the woman must consider how she will respond to questions such as ‘when did you last have sex?’ or ‘what is the father’s name?’ Issues such as parenting, sex and contraception may have different meanings for the midwife and the woman and therefore careful use of non-heterosexist language by the midwife will help to promote a climate for open communication (Hastie 2000, p 65). Hastie argues that the ‘realities of lesbian experiences are hidden from the mainstream heterosexist society and so stereotypes are rife among health practitioners’; she goes on to say that oppression and invisibility damage health. The RCM (2000b) Position Paper 22 on maternity care for lesbian mothers, states that midwives should take a lead in challenging discriminatory language and behaviour, both positively and constructively. Wilton & Kaufmann (2001) suggest that this can be achieved by developing awareness and understanding, signaling acceptance and improving service delivery.
Midwives are in a unique position to exploit the opportunities created by the NHS reforms to deliver equitable services, and to create responsive organizations and practices. They have a moral, ethical, legal and professional responsibility to provide individualized care and to develop equitable service provision and delivery (NMC 2008).
The Race Relations (Amendment) Act 2000, the Disability Discrimination Act (DDA) 2005 and the Equality Act 2006 require all organizations to produce schemes that promote race, disability and gender equality in employment and service provision and delivery.
Midwives have a statutory obligation to provide relevant and responsive maternity services for all women and their families. Organizations and individuals are charged to develop and deliver maternity services in such a way that they give an important consideration to the needs of women from disadvantaged groups as well as reducing inequalities of health.
Midwives play a key role in bringing about change. They have a responsibility to facilitate an environment that provides all women and their families with appropriate information and encourages more active participation in the decision-making process, including ensuring ‘informed consent’.
Midwives need to be knowledgeable and understand their own values, attitudes, norms and expectations that affect their professional practice. They must understand the backgrounds of the clients, enabling them to respond equitably and appropriately. Midwives also need to be aware of issues of prejudice, discrimination and racism and how these manifest themselves in the provision and delivery of healthcare and may act as a barrier to seeking healthcare.
Midwives need to be equipped with knowledge and understanding of cultures and lifestyles of the women for whom they care. It is only then that they can feel confident to plan the services that the women require and deserve. Several texts provide essential background knowledge concerning women who experience disadvantage; although such background information is helpful, midwives should adopt a critical approach to reading such material and applying it to individual women in order to avoid generalizations and stereotypical responses. It is evident that prior knowledge is helpful, however midwives should develop sensitive approaches through which they can ascertain this information from the women which will assist with delivery of responsive care as well as assist the development of relationships between women and midwives.
Women from disadvantaged backgrounds often lack knowledge and understanding of the maternity services. They are not always given adequate information about the full range of maternity services and options of care available to them during pregnancy, labour and postnatal period. Often information is not available in appropriate formats to reach women who have visual or hearing impairment or who lack proficiency in speaking and reading English. Therefore, they are unaware of the range of maternity services and choices available to them.
Many women, for example those from lower socioeconomic groups or from the BME groups, feel less confident than others in actively participating in making decisions about the care they receive and indeed are less able to make informed choices. They are unable to give informed consent. These factors leave the women feeling frustrated and isolated, marring their experience of maternity services as well as their relationships with midwives.
Midwives should take account of the difficulties encountered by women who are less familiar with the health services and less confident, and ensure that they create an environment that empowers the woman to explain her views and wishes regarding her maternity care.
Consideration should be given to other service users of maternity services, for example, fathers who are the sole carers for their babies have reported that the majority of information on pregnancy and childbirth is aimed at women and their informational needs are not addressed.
Communication is a bedrock on which to promote access and woman-centred services, for two reasons. First, women can access and use services only if they are aware of their existence. Midwives can overcome this issue by communicating appropriately and giving timely information to enable women to access maternity services. Second, many women from disadvantaged backgrounds are not confident and are unable to express their needs and preferences to the midwives and so fail to utilize services effectively (Davies & Bath 2001, Hart et al 2001). Consequently, exercising choice and control over the care they receive becomes a challenge and women-centred care will remain a myth for them (Hunt & Symonds 1995, Neile 1997, Stapleton 1997). Midwives can play an important role in facilitating two-way communication to enable women to participate in making decisions about the care they want, need and receive.
Communication difficulty, due either to linguistic limitations or to other forms of disability remains problematic (Baxter 1997, Bowes and Domokos 1996a, Hart et al 2001, Woollett & Dosanjh-Matwala 1990a). Midwives claim that communication and language difficulties hinder the delivery of effective maternity services and have expressed dissatisfaction with the care they provide when they cannot effectively communicate with women who lack proficiency in speaking English, or women with hearing or visual impairment. They state that inability to understand the women as well as explain themselves leaves them frustrated (Audit Commission 1995). Often midwives unintentionally exhibit these frustrations in their behaviour and attitude, which are negatively perceived by the women, marring their experience of maternity services. Consequently, women are less likely to access maternity and preventative services readily.
Midwives recognize that communication and language difficulties may be addressed by making use of professional qualified interpreters or liaison workers or signers (Hayes 1989). However, despite recognition of the value of qualified interpreters in improving service provision and satisfaction, interpreting services are not adequately meeting the demand (Baxter 1997). In practice, the use of qualified interpreters is intermittent and fragmented. Financial resources, midwives beliefs and attitudes, time constraints and the nature of employment of qualified interpreters determine the availability of qualified interpreters (Bharj 2007).
To overcome communication and language difficulties, often women are encouraged to bring their own interpreters (e.g. adults, family members, neighbours and children) (Katbamna 2000). Relying on such measures leads to ‘making do’ and ‘making the best of the situation’. Five women out of a total of 19 who died as a result of domestic violence could not speak English and in all cases the husband acted as interpreter (Lewis 2007). Although interpreter or translator contributions can be useful in overcoming communication difficulties, they can be major barriers during the consultation process, especially when discussing sensitive and personal issues. Voluntary interpreters or relatives and friends are often untrained in the art of interpreting, have little or no knowledge of the NHS and are often confused themselves by medical terminology.
For many, the use of interpreters will be fundamental in the communication process. To this end, midwives should be adequately prepared to use them effectively, taking into account the need for privacy and dignity. Midwives should also utilize interpersonal skills effectively and be sensitive to the communication process between themselves and women who experience communication difficulties so as to create an opportunity for effective and efficient exchange of information. This would serve to provide women with clear, balanced and evidence-based information that they can understand, enabling them to make appropriate informed choices and exercise control over the care they receive.
In circumstances where women cannot effectively communicate with their midwives, they are unable to fully participate in decisions made about their care. These women feel that professionals and hospitals ‘take over’ and make decisions about them without first discussing all the options, or informing them of their rights. Box 3.3 provides suggestions for developing a communication and information strategy.
Box 3.3 Communication and information strategy
Midwives play a key role in bringing about change. As advocates of women, they should ensure that the needs and wishes of women, in particular those who may not be able to communicate effectively, are taken into consideration during the planning and delivery of services. As change agents, they will need to utilize skills of adaptability, flexibility and political awareness in the development and implementation of innovatory practices to ensure that they are available equitably to all women. Midwives should actively participate in raising awareness of the available services among all women.
For midwives to work in partnership with women, they need to develop a meaningful relationship with women. Partnership working and its impact in promoting woman-centred care has been discussed in detail, identifying issues such as trust, power and empowerment need due consideration (Calvert 2002, Kirkham 2000). Issues of trust and confidence between women and midwives contribute to meaningful relationships, facilitating an environment where the midwife can ascertain the needs and preferences of the women as well as providing appropriate information so that the woman can make informed choices and be involved in decision-making about her care. Midwives, however, acknowledge that they have difficulty in developing positive relationships with some women, in particular those from a disadvantaged background (Hart et al 2001). Midwives provide the necessary physical care but not appropriate emotional and psychological care and as a result do not really get to know them (Bowes & Domokos 1996a). Often when there is no feedback from these women, midwives get frustrated and angry.
Stereotyping and discrimination play a major role in hindering the development of meaningful relationships. There is well-documented evidence illustrating the detrimental effect of discrimination and racism on people’s health (Virdee 1997). Several studies confirm that midwives commonly use stereotypes of women in determining their needs and preferences and utilize these to make judgements about the kind of care women deserve, as well as what a particular woman is likely to want during labour and birth (Bowler 1993a,b, Green et al 1990, Pope et al 2001). Often these stereotypes and prejudices have detrimental effect on women’s maternity experiences (HCHC 2003, Redshaw et al 2007).
Women who are ‘more visible’ are more likely to be negatively stereotyped and negative experiences may be significant factors in reducing women’s confidence and prevent them from exercising choice and control over the care they receive. For example, women with disabilities are cared for in a paternalistic manner, which hinders their empowerment; women from travelling families are viewed by society as a threat, dishonest scroungers and dirty; women from South Asian backgrounds are seen as stupid, smelly, attention-seeking, making too much noise during labour and having low pain threshold (Bowler 1993a,b). When professional practices are based on these stereotypes there can be harrowing consequences, for example, in Bowler’s study (1993a,b), based on the assumption that Asian women have low pain threshold it was found that midwives often withheld pain relief from them as they considered they were not in real need nor deserving of such care.
Many organizations and midwives claim that they treat everyone the same; care delivery is based upon individualized practices, informed by normal policies and routine practices and women’s backgrounds make no difference. This approach is possibly based upon the premise that equal provision is made for all women and the women are expected to integrate and make use of the pre-existing services. This approach in itself can lead to discriminatory practices, where universal provisions fail to meet specific health requirements of women from disadvantaged groups.
Women from socially excluded groups are often seen to have ‘special needs’, making extra demands on the service. Emphasis on cultural differences that account for ill health, for example tuberculosis, rickets, hepatitis, has contributed towards pathologizing culture. Hence, government initiatives such as the ‘stop the rickets’ and the ‘Asian mother and baby’ campaigns have been criticized by many from the BME who claim their communities are singled out, with the blame on their cultural dietary habits or lifestyles, or even their inability to care for their children (Rocheron 1988, Torkington 1984). These approaches focus on cultural idiosyncrasies with particular emphasis on linguistic or cultural differences and quite effectively obscure power differentials between minority ethnic groups and the majority.
Discriminatory attitudes and hostility coupled with their adverse impact on women will do little towards the development of a meaningful relationship. Consequently, partnership working will be rhetoric for women from disadvantaged background as will issues of continuity, choice and control. Midwives need to consider such issues and where possible draw upon transcultural models to provide anti-oppressive care promoting the tenets of woman-centred care for women from disadvantaged groups.
This chapter has focused on a number of issues that require consideration by organizations and midwives when providing and delivering maternity services to all women and their families, in particular those who are most at risk of being excluded. The NHS reforms coupled with government proposals to modernize maternity services to respond effectively to the contemporary population have created exciting opportunities for healthcare practitioners to develop and implement equitable services. However, midwives cannot achieve this huge agenda on their own; organizations have to create an environment to drive some of these changes at a strategic level. The needs and preferences of women from disadvantaged backgrounds must be brought into the mainstream and integrated into the planning and commissioning processes through effective meaningful engagement. The voices of the members who are most at risk of exclusion should be listened to at every point of the planning and commissioning cycle. It is only then that we can provide responsive and appropriate services to meet the needs of all women and their families.
Acheson SD. Independent Inquiry into Inequalities and Health. London: The Acheson Report. The Stationery Office, 1998.
Ahmad WIU, editor. ‘Race’ and health in contemporary Britain. Buckingham: Open University Press, 1993.
Ahmad WIU. The trouble with culture. In: Kelleher D, Hillier S, editors. Researching cultural differences in health. London: Routledge; 1996:190-219.
Audit Commission. What seems to be the matter: communication between hospitals and patients. London: Audit Commission for Local Authorities and National Health Service for England and Wales, 1995.
Baxter C. The case for bilingual workers within the maternity services. British Journal of Midwifery. 1997;5(9):568-572.
Bharj KK. Pakistani Muslim women birthing in northern England; exploration of experiences and context. Sheffield: Sheffield Hallam University, 2007. Doctoral Thesis
Bowes AM, Domokos TM. Race, gender and culture in South Asian women’s health: a study in Glasgow. In: McKie L, editor. Researching women’s health: methods and process. Dinton: Quay Books, 1996.
Bowes A, Domokos TM. Your dignity is hung up at the door: Pakistani and White women’s experiences of childbirth. In: Earle S, Letherby G, editors. Gender, identity and reproduction. Basingstoke: Palgrave Macmillan, 2003.
Bowler I. They’re not the same as us: midwives’ stereotypes of south Asian descent maternity patients. Sociology of Health and Illness. 1993;15(2):157-178.
Bowler I. Stereotype of women of Asian descent in midwifery, some evidence. Midwifery. 1993;9:7-16.
Byrom S. Antenatal care in children’s centres – making it happen. Midwives. 2006;9(11):446-447.
Calvert S. Being with women: the midwife–woman relationship. In: Mander R, Fleming V, editors. Failure to progress, the contraction of the midwifery profession. London: Routledge, 2002.
Cartwright A. The dignity of labour? London: Tavistock, 1979.
Chan C. A study of health services for the Chinese minority in Manchester. British Journal of Community Nursing. 2000;5:140-147.
CRE (Commission for Racial Equality). Race relations code of practice in primary healthcare services. London: CRE, 1994;22.
Davies MM, Bath PA. The maternity information concerns of Somali women in the United Kingdom. Journal of Advanced Nursing. 2001;36(2):237-245.
DfES (Department for Education and Skills). Working together to safeguard children. London: HMSO, 2006.
DH (Department of Health). The new NHS: modern, dependable. London: DoH, 1997.
DH (Department of Health). Saving lives: our healthier nation. White Paper. London: HMSO, 1999.
DH (Department of Health). The NHS plan. A plan for investment, a plan for reform. London: Stationery Office, 2000.
DH (Department of Health). The vital connections: an equalities framework for the NHS. London: DH, 2000.
DH (Department of Health). Shifting the balance of power within the NHS: securing delivery. London: DH, 2001.
DH (Department of Health). National service framework for children, young people and maternity services. London: DH, 2004.
DH (Department of Health). Creating a patient-led NHS, delivering the NHS Improvement Plan. London: DH, 2005.
DH (Department of Health). Our health, our care, our say: a new direction for community services. London: The Stationery Office, 2006. White Paper. Cm 6737
DH (Department of Health). The NHS in England: the operating framework for 2006/7. London: HMSO, 2006.
DH (Department of Health). Maternity matters: choice, access and continuity of care in a safe service. London: DH, 2007.
DH (Department of Health). Choice matters: 2007–8, putting patients in control. London: DH, 2007.
DHSSPS (Department of Health, Social Services and Public Safety). A healthier future. A twenty year vision for health and wellbeing in Northern Ireland. DHSSPS, Belfast, 2004.
DHSSPS (Department of Health, Social Services and Public Safety). It’s what matters to patients. Northern Ireland Essence of Care Project. Belfast: DHSSPS, 2005.
Dixon-Woods M. Vulnerable groups and access to healthcare: a critical interpretive review. Report for the National Co-ordinating Centre for NHS Service Delivery and Organization R & D (NCCSDO). Leicester: University of Leicester, 2005.
Ellis N. Birth experiences of South Asian Muslim women: marginalized choice within the maternity services. In: Kirkham M, editor. Informed choice in maternity care. Basingstoke: Palgrave Macmillan, 2004.
Fernando S. Mental health, race and culture. London: Macmillan/MIND, 1991;24.
Gerrish K, Husband C, MacKenzie J. Nursing for a multi-ethnic society. Buckingham: Open University Press, 1996.
Green JM, Kitzinger JV, Coupland VA. Stereotype of childbearing women. Midwifery. 1990;6(3):125-132.
Hastie N. Cultural conceptions. In: Fraser D, editor. Professional studies for midwifery practice. Edinburgh: Churchill Livingstone; 2000:63-75.
Harper-Bulman K, McCourt C. Somali refugee women’s experiences of maternity care in west London: a case study. Critical Public Health. 2002;12(4):365-379.
Hart A, Lockey R, Henwood F, et al. Addressing inequalities in health: new directions in midwifery education and practice. London: English National Board for Nursing, Midwifery and Health Visiting, 2001. Research report No. 20
Hayes L. The role of the interpreter/linkworker in the maternity service. Coventry: University of Warwick, 1989. Unpublished MA thesis
HCHC (House of Commons Health Committee). Inequalities in access to maternity services. London: The Stationery Office, 2003. Eighth report of Session 2002–03
Helman CG. Culture, health and illness, 3rd edn. Oxford: Butterworth-Heinemann, 1994.
Hirst J, Hewison J. Pakistani and indigenous ‘white’ women’s views and the Donabedian–Maxwell grid: a consumer-focused template for assessing the quality of maternity care. International Journal of Healthcare Quality Assurance. 2001;14(7):308-316.
Hirst J, Hewison J. Hospital postnatal care: obtaining the views of Pakistani and indigenous ‘white’ women. Clinical Effectiveness in Nursing. 2002;6(1):10-18.
HM Government. Reaching out: an action plan on social exclusion. London: Cabinet Office, 2006.
Hunt S, Symonds A. The social meaning of midwifery. Basingstoke: MacMillan, 1995.
Katbamna S. ‘Race’ and childbirth. Buckingham: Open University Press, 2000.
Kirkham M, editor. The midwife–mother relationship. Basingstoke: MacMillan, 2000.
Kitzinger J. Strategies of the early childbirth movement: a case study of the National Childbirth Trust. In: Garcia J, Kilpatrick R, Richards M, editors. The politics of maternity care. New York: Oxford University Press; 1990:92-115. Ch 5
Kitzinger S. Women as mothers. London: Fontana, 1978.
Larbie J. Black women and the maternity services. London: Health Education Council and the National Extension College for Training in Health and Race, 1985.
Leininger MM. Trans-cultural nursing: concepts, theories and practice. New York: John Wiley, 1978.
Lewis G, editor. 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.
Lewis G, Drife J, editors. Why mothers die. The Sixth Report of the Confidential Enquiries into Maternal Deaths in United Kingdom 2000–2002.The Confidential Enquiries into Maternal and Child Health. London: RCOG Press, 2004.
Lewis G, Drife J, editors. Why mothers die. The Fifth Report of the Confidential Enquiries into Maternal Deaths in the United Kingdom 1997–1999. The National Institute of Clinical Excellence. London: RCOG Press, 2001.
Lewis IM, editor. Social anthropology. Harmondsworth: Penguin, 1976.
Macfarlane A, Mugford M. Birth counts: statistics of pregnancy and childbirth. London: The Stationery Office, 2000.
MacKeith P, Phillipson R. Young mothers. In: Kargar I, Hunt SC, editors. Challenges in maternity care. Basingstoke: Macmillan, 1997.
Macpherson W. The Stephen Lawrence inquiry: report of an inquiry. London: Home Office, 1999.
Modood T, Berthoud R, Lakey J, et al. Ethnic minorities in Britain: diversity and disadvantage. London: The Fourth National Survey of Ethnic Minorities. Policies Studies Institute, 1997.
National Assembly for Wales. Improving Health in Wales: A Plan for the NHS and its partners. Cardiff: National Assembly for Wales, 2001.
National Assembly for Wales. Designed for life – a world class health service for Wales. Cardiff: National Assembly for Wales, 2005.
Nazroo J. The health of Britain’s ethnic minorities: findings from a national survey. London: Policies Studies Institute, 1997.
Nazroo J. Ethnicity, class and health. London: Policy Studies Institute, 2001.
Neile E. Control for black and ethnic minority women: a meaningless pursuit. In: Kirkham MJ, Perkins ER, editors. Reflections on midwifery. London: Baillière Tindall; 1997:114-134. Ch 6
NHS Quality Improvement Scotland. Clinical standards – maternity services. Edinburgh: NHS Quality Improvement Scotland, 2005.
NI DHSSPS (Northern Ireland Department of Health, Social Services and Public Safety). Developing better services: modernizing hospitals and reforming structures. Belfast: NI DHSSPS, 2002.
NMC (Nursing and Midwifery Council). The Code: Standards of conduct, performance and ethics for nurses and midwives. London: NMC, 2008.
Oakley A. Becoming a mother. Oxford: Martin Robertson, 1979.
ONS (Office for National Statistics). Social trends 31. London: ONS, 2001.
Palmer G, MacInnes T, Kenway P. Monitoring poverty and social exclusion 2006. York: Joseph Rowntree Foundation, 2006.
Phoenix A. Black women and the maternity services. In: Garcia J, Kilpatrick R, Richards M, editors. The politics of maternity care. New York: Oxford University Press; 1990:274-299. Ch 15
Platt L. Poverty and ethnicity in the UK. Bristol: The Policy Press, 2007.
Pope R, Graham L, Patel S. Woman-centred care. International Journal of Nursing Studies. 2001;38:227-238.
RCM (Royal College of Midwives). Position Paper 4a: woman-centred care. Reprinted in RCM Midwives Journal 2001. 2000;4(2):46-47.
RCM (Royal College of Midwives). Maternity care for lesbian mothers. London: RCM, 2000. Position Paper No. 22
RCM. Evidence provided for the House of Commons Health Committee (2003) Inequalities in Access to Maternity Services, Eighth Report of Session 2002–03. London: The Stationery Office, 2003;17.
Redshaw M, Rowe R, Hockley C, et al. Recorded delivery: a national survey of women’s experience of maternity care 2006. Oxford: National Perinatal Epidemiology Unit, 2007.
Reid M, Garcia J. Women’s views of care during pregnancy and childbirth. In: Chalmers I, Enkin M, Keirse MJNC, editors. Effective care in pregnancy and childbirth. Oxford: Clarendon Press; 1989:131-142.
Richens Y. Exploring the experiences of women of Pakistani origin of UK maternity services. 2003. Report prepared for the 8th Mary Seacole. Online. Available: www.yanarichens.com.
Rocheron Y. The Asian mother and baby campaign: the construction of ethnic minorities ‘health needs’. Critical Social Policy. 1988;22:4-23.
Rose S, Rose H. Less than human nature. Race and Class. 1986;27(3):47-66.
Salmon D, Powell J. Caring for women in poverty: a critical review. British Journal of Midwifery. 1998;6(2):108-111.
Scottish Executive Health Department (SEHD). A framework for maternity services in Scotland. Scotland: Scottish Executive, 2001.
Scottish Executive Health Department (SEHD). Delivering for health. Edinburgh: Scottish Executive, 2005.
Scottish Executive Health Department (SEHD). Building a health service fit for the future. Edinburgh: Scottish Executive, 2005.
Shribman S. Making it better: for mother and baby. London: Clinical case for change. Department of Health, 2007.
Sivagnanam R, editor. Experiences of maternity services: Muslim women’s perspectives. London: The Maternity Alliance, 2004.
Smaje C. Health, race and ethnicity: making sense of the evidence. London: King’s Fund Institute, 1995;16.
Social Exclusion Unit. Teenage pregnancy. London: Stationery Office, 1999.
Stapleton H. Choice in the face of uncertainty. In: Kirkham MJ, Perkins ER, editors. Reflections on midwifery. London: Baillière Tindall; 1997:47-69. Ch 3
Stubbs P. ‘Ethnically sensitive’ or ‘anti-racist’? Models for health research and service delivery. In: Ahmad WIU, editor. Race and health in contemporary Britain. Buckingham: Open University Press; 1993:34-47. Ch 3
Teenage Pregnancy Unit. DH Nursing and midwifery policy, Royal College of Midwives. London: RCM, 2004.
Torkington P. Blaming black women – rickets and racism. In: O’Sullivan S, editor. 1987 Women’s health, a spare rib reader. London: Pandora; 1984:82-85. Ch 2
Townsend P, Davidson N. Inequalities in health: the Black report. Harmondsworth: Penguin, 1982.
Virdee S. Racial harassment. In: Modood T, Berthoud R, Lakey J, et al, editors. 1997 Ethnic minorities in Britain: diversity and disadvantage; Fourth National Survey of Ethnic Minorities. London: Policies Studies Institute; 1997:259-289. Ch 8
WAG (Welsh Assembly Government). NSF for Children, Young People and Maternity Services in Wales. Cardiff: Welsh Assembly Government, 2005.
Wilton T, Kaufmann T. Lesbian mothers’ experiences of maternity care in the UK. Midwifery. 2001;17:203-211.
Woollett A, Dosanjh-Matwala N. Pregnancy and antenatal care: the attitudes and experiences of Asian women. Child Care, Health and Development. 1990;16(1):63-78.
Woollett A, Dosanjh-Matwala N. Postnatal care: the attitudes and experiences of Asian women in east London. Midwifery. 1990;6:178-184.
Whitehead M. The health divide: inequalities in health in the 1980s. London: Health Education Council, 1987.