Clinical Practice Guidelines Antenatal Care — Module II
Part A — Optimising antenatal care
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- Navigate this page:
- References
- 1 2Antenatal care for migrant and refugee women 3
- 2.1Background to culturally safe antenatal care
- Factors affecting uptake of antenatal care
- Issues affecting women from particular groups
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Care for women with a normal pregnancy and birth should be demedicalised |
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Pregnancy and birth should be viewed as a natural process in life and essential care should be provided to women with the minimum set of interventions necessary. |
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Care should be based on the use of appropriate technology |
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Sophisticated or complex technology should not be applied when simpler procedures may suffice or be superior. |
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Care should be evidence-based |
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Care should be supported by the best available research, and by randomised controlled trials where possible and appropriate. |
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Care should be local |
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Care should be available as close to the woman’s home as possible and based on an efficient system of referral from primary care to tertiary levels of care. |
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Care should be multidisciplinary |
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Effective care may involve contributions from a wide range of health professionals, including midwives, general practitioners, obstetricians, neonatologists, nurses, childbirth and parenthood educators. |
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Care should be holistic |
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Care should include consideration of the intellectual, emotional, social and cultural needs of women, their babies and families, and not only their physical care. |
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Care should be woman-centred |
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The focus of care should be meeting the needs of the woman and her baby. Each woman should negotiate the way that her partner and significant family or friends are involved. Care should be tailored to any special needs a woman may have. |
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Care should be culturally appropriate and culturally safe |
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Care should consider and allow for cultural variations in meeting these expectations. |
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Care should provide women with information and support so they can make decisions |
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Women should be given evidence-based information that enables them to make decisions about care. This should be provided in a format that the woman finds acceptable and can understand. |
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Care should respect the privacy, dignity and confidentiality of women |
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All women have the right to be treated with respect and dignity, have their privacy respected, and be assured that all their health information is confidential. |
References
Chalmers B, Mangiaterra V, Porter R (2001) WHO principles of perinatal care: the essential antenatal, perinatal, and postpartum care course. Birth 28: 202–07.
WHO (1998) Workshop on Perinatal Care. Report on a WHO Expert Meeting. Venice 16–18 April 1998. Copenhagen: World Health Organization Regional Office for Europe.
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2Antenatal care for migrant and refugee women3
While many migrant and refugee women experience healthy pregnancies, issues associated with resettlement can contribute to poorer perinatal outcomes than those experienced by women in general. While the diversity of circumstances and experiences is acknowledged, this chapter highlights general considerations in improving the experience of antenatal care for migrant and refugee women.
The term ‘migrant and refugee’ is used in these Guidelines to refer both to women who are voluntary migrants and women who come to Australia as refugees, humanitarian entrants or asylum seekers. Migrants and refugees are also often referred to as people of culturally and linguistically diverse background, people from non-English–speaking backgrounds or people who speak a language other than English.
2.1Background to culturally safe antenatal care
“Caring for individuals from diverse backgrounds is a daily reality for nurses and midwives, who are expected to provide care which is both clinically safe and culturally sensitive.” (Williamson & Harrison 2010)
Although more than a quarter of women who gave birth in Australia in 2010 were not born in Australia (Li et al 2012), there is little specific information on the pregnancy outcomes of migrant and refugee women. National data suggest similar rates of perinatal death among babies of women born in Australia and those born overseas (Li et al 2012). However, retrospective studies suggest that outcomes vary with country of birth (Drysdale et al 2012) and use of interpreters, but not refugee status (Thomas et al 2010).
There is significant heterogeneity among migrant and refugee women and their experience of antenatal care. Women bring with them the knowledge and practices from their home countries. Expectations of early antenatal attendance vary between countries. For example, more than half (57%) of women giving birth in NSW in 2004 who were originally from a developing country first attended for antenatal care later than 12 weeks in the pregnancy (Trinh & Rubin 2006). In NSW in 2006, 64.9% of mothers born in Melanesia, Micronesia and Polynesia and 72.8% of mothers born in the Middle East and Africa commenced antenatal care before 20 weeks gestation, compared with 89.6% of mothers born in English-speaking countries (CER 2007). Expectations of the birth experience are also strongly influenced by cultural views and practices (Hoang et al 2009).
Over the past 10 years, an increasing proportion of refugee and humanitarian entrants to Australia has come from Africa, the Middle East and Southeast Asia; about 30% are women aged 12–44 years (Correa-Velez & Ryan 2012). Refugee women are more likely than other women to have complex medical and psychosocial problems and may face additional barriers in accessing antenatal care (Correa-Velez & Ryan 2012).
Factors affecting uptake of antenatal care
Migrant and refugee women are diverse, and have differing issues and outcomes. As well as cultural background, women’s experiences differ with migration status, educational level and prior experience of pregnancy and birth. However, there are some common issues that can affect uptake of antenatal care by migrant and refugee women. These include (McCarthy & Barnett 1996; Carolan & Cassart 2010; Phiri et al 2010; Murray et al 2011; Boerleider et al 2013):
migration factors: lack of knowledge of or information about the Western healthcare system (including rights in relation to tests and treatments); arriving in the new country late in pregnancy; history of grief, loss and/or trauma in addition to migration;
cultural factors: adherence to cultural and religious practices, poor language proficiency, lack of assertiveness, partner/family perception of antenatal care, perceiving pregnancy as not requiring health professional involvement, belief that antenatal care is more a burden than a benefit, belief that antenatal classes are not necessary;
position in host country: financial problems, unemployment, low or intermediate educational level, social inequality (education, economic resources and residence [rural or urban]), lack of time, lack of childcare, no medical leave from work;
social network: lack of usual female family and community support systems, isolated community;
accessibility: inappropriate timing and incompatible opening hours, transport and mobility problems, indirect discrimination, lack of suitable resources (eg female interpreters);
expertise: health professional lacking knowledge of cultural practices; and
personal treatment and communication: poor communication, perception of having been badly treated by a health professional.
Health care costs and access to health services can be an issue for some women. Women who are asylum seekers may be ineligible for either Medicare or Centrelink Health Care Cards. Women who are skilled migrants and international students may also have restricted health care access because they don't have Medicare entitlements. While overseas students are required to maintain Overseas Student Health Cover for the duration of their time in Australia, pregnancy-related services may not be covered in the first 12 months of membership.
Even when care can be accessed, women who have no previous experience with a western health care system may have limited understanding of reasons for antenatal visits, medical procedures and use of technology. They may not feel confident to ask questions or participate in discussions about their care plan or birth options. Different cultural beliefs may also influence aspects of antenatal care such as involvement of the father in pregnancy and childbirth, acceptance of tests and interventions, willingness to be cared for by a midwife rather than a doctor or a woman rather than a man, understanding of dates and times of appointments, and knowledge about medical aspects of pregnancy.
Issues affecting women from particular groups
Different groups of migrant and refugee women face specific issues that may affect their experience of pregnancy and birth. Increased awareness of such issues and the differences between groups will help to promote better antenatal care of women from migrant and refugee backgrounds.
Women who arrive in Australia as refugees: Prior to migration, many refugees experience poor health (including oral health, co-existing health issues and inadequate nutrition) and experience poverty, discrimination, trauma and violence in their countries of origin and in countries of displacement. These experiences cause significant psychological distress, manifesting in symptoms of anxiety, depression, post-traumatic stress, poor sleep and concentration. These symptoms can continue to affect women’s lives as they face further emotional challenges in the resettlement period. Early intervention and referral to appropriate counselling services should always be offered and assistance in accessing services provided. Refugee women may fear authority figures, including health professionals, due to past experiences and may also have financial, employment and housing issues. Women in this situation will require reassurance and explanation of the care offered to them, including tests, procedures and pregnancy risks. More time may be needed, and specific strategies used (often in collaboration with other services and migrant agencies) to build necessary confidence and trust.
Women affected by Female Genital Mutilation/Cutting (FGM/C): FGM/C is the collective term used to describe the cultural practice of cutting or removal of either a part, or the whole external female genitalia. Some of these procedures are minor, while others involve significant change and have an impact during the antenatal period. Depending on the degree of FGM/C, women may require referral to services offering specialised care and support. Some women may need to be deinfibulated to enable ongoing clinical assessment and avoid complications; this is usually performed in the second trimester but the first trimester is the optimum time to discuss the procedure.
Women in higher risk groups: Some migrant and refugee groups have higher rates of risk factors such as gestational diabetes, smoking in pregnancy and vitamin D deficiency. Lifestyle advice should take cultural issues into account (eg giving culturally relevant nutritional advice on managing gestational diabetes and educating both women and men about passive smoking, as it may be men rather than women who smoke). Domestic violence is high among some communities, and may be hidden within the family structure and/or the community. Screening for conditions endemic in the woman’s country of origin may also be a consideration.
Health professionals are encouraged to develop an understanding of the issues facing families from the migrant and refugee groups that they regularly work with and to use this information to improve the care they provide.
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