Handbooks for Health Professionals
Excerpts
from
Chapter 19: Pregnancy and Antenatal Care
Antenatal Care
A great deal of time, money and energy are invested in antenatal care
in the West. Most women have been socialized and educated into regular
clinic attendance, which is considered to be extremely important despite
the fact that many components of routine antenatal care have no proven
benefits (Enkin, Keirse and Chalmers, 1990; Steer, 1993).
It has been known for some time that many women find antenatal clinics tiresome and unrewarding and that they do not meet their needs (Gladman, 1994). Too often women have been passive targets, expected to turn up, wait for hours and then accept 'care' which does not always address their concerns (Thorley and Rouse, 1993). The social, emotional and spiritual aspects of pregnancy important to many may be ignored (Vincent Priya, 1992). Some women are subjected to unexplained procedures and investigations (Smith and Marteau, 1995). Childcare facilities are rare, and mothers are often distracted and stressed by the demands of their other children, both in the waiting area and during the consultation. Journeys may be long and difficult. Nevertheless, most women spend large amounts of time, energy and money travelling to and attending clinics.
Women of minority groups may encounter a range of additional disincentives to antenatal attendance. For example:
| • | being in an alien environment, feeling conspicuous and out of place | |
| • | unwelcoming or racist attitudes and behaviour | |
| • | appointment times that disregard religious festivals or family commitments | |
| • | health professionals who do not understand or respect their needs and preferences | |
| • | being addressed incorrectly because staff do not understand their naming systems | |
| • | language barriers (Narang and Murphy, 1994). |
For some women the whole concept of antenatal care as organised in the West is new and they have to adapt to unfamiliar systems and values. Medicalized antenatal care, blood tests, ultrasound, urine tests and amniocentesis may be completely new concepts. Women who do not understand the purpose of antenatal care and the various checks, or who feel threatened and uncomfortable at clinics may see little point in attending.
| 'We had a lot of trouble persuading some women from rural areas of Africa to bring urine samples to the clinic. They always smiled but said they had forgotten. Eventually I realized that they could not see the point and what is more they thought we were extremely odd to ask for their urine. To them it seemed as crazy as we would think a request to bring in our toe-nail clippings. Once we explained, there was no problem.' |
| Obstetric registrar |
| 'Bangladeshi women who have had several babies back home may not see the relevance of antenatal care. They managed quite well without it before. They may also be wary of having investigations or treatment imposed on them.' |
|
Midwife teacher |
| 'I felt grateful for so much attention from the doctors. But I was afraid that some of the tests would harm my baby. And often I did not understand why they were doing them. I had two babies in Bangladesh without all these tests and everything was OK. I did not worry so much there.' |
| Mother of three |
In addition, some women worry about the 'policing' and monitoring role of health professionals, and fear that they may get into trouble if they do not conform or if they inadvertently reveal some practice or aspect of behaviour that health professionals might disapprove of.
The impact of reputation
Once they are in the system many women feel powerless. Women of
minority groups may have reason to feel even more so. Reports of poor
care, abuse or rudeness travel fast. Women who book late or 'default'
on appointments are usually seen as irresponsible and unco-operative,
but some may have good reasons. Those who have experienced or fear unsympathetic
or inappropriate treatment may vote with their feet.
|
'In the late 1980s, Asian women who were going to have their
babies at the local district general hospital started to delay booking
until they were 24 weeks pregnant. They had heard through the community
grapevine that a consultant obstetrician there had decided that
all women over 40 should have amniocentesis. |
| Midwife teacher |
| 'In the clinic where I worked, women undergoing pre-natal diagnosis came in expecting abdominal ultrasound. Many of the Asian women, who had less explanation than the others, and were not asked for their consent, were particularly horrified and humiliated to find they were expected to submit to trans-vaginal ultrasound performed by a male doctor using a transducer covered with a condom. One woman who spoke little English became extremely distressed when the doctor continued against her obvious resistance.' |
| Student midwife |
What kind of care does your antenatal clinic offer?
Take a fresh look at your antenatal clinic. One way of reviewing
some aspects of your service is to sit quietly and unobtrusively in the
reception or waiting area and to fade into the background and watch.
Consider the following questions:
| • | What is going well? What concrete evidence do I have for my conclusions? | |
| • | What needs improving? How can these improvements be achieved? | |
| • | Is everyone, including clerks and receptionists, friendly, respectful and welcoming? | |
| • | Is bureaucracy kept to a minimum? | |
| • | Are people addressed correctly? Are there mechanisms for recording names of women and their partners or husbands correctly (see Chapter 14). | |
| • | Are women put at ease? Do they know what to do next at each stage and where to go? | |
| • | Are appointment procedures sufficiently flexible to take account of different religious festivals and of each woman's work, family and childcare commitments? | |
| • | Do the posters and leaflets reflect the variety of cultures and groups in your community? | |
| • | Are there crèche facilities? | |
| • | Are interpreters readily available for all the main local languages? Is there a system for getting hold of an interpreter for a client who speaks a language that is not normally catered for? | |
| • | Whose agenda is being met? Are women's concerns being addressed? |
ANTENATAL SCREENING
The way a women reacts to antenatal screening and the decisions she
makes will be influenced by her attitude to her pregnancy and her feelings
about becoming a mother. She will also be influenced by her own and her
community's attitudes towards normality and disability, by economic factors
and by religious and moral beliefs.
Many parents want screening and see it as a positive advance which widens their choices. However they may be unclear about what these choices involve. They may not understand the purpose and scope of the tests that are offered, or that the potential end result of many tests is the termination of a pregnancy.
| 'I had no idea during my first two pregnancies what the tests I had might lead to. I assumed that if they found something wrong they could put it right. I was horrified to discover during my third pregnancy, that the only option I would have had was a decision to get rid of the baby.' |
| Professional woman |
Some parents may feel that it would be irresponsible to refuse the tests they are offered. Others may accept certain tests and refuse others for 'non-medical' reasons.
| 'Well, they offered me blood test and a scan to see if the baby was alright, so I had the scan because I can't stand needles.' |
| Mother of three |
Some parents may be confused about the distinction between screening, which assesses how likely they are to be carrying a baby with a specific condition, and diagnostic tests, which can tell 'with reasonable certainty' whether or not the baby is affected. (Green and Statham, 1993). They may accept testing without realizing the psychological risks and benefits and that their anxiety may in fact be increased rather than diminished (Van den Akker, 1993). They may also assume that if the results of all the tests are negative, their baby will definitely be healthy.
Ultrasound is generally considered a positive psychological experience for pregnant women and many parents welcome a routine scan as an opportunity to see their baby. But because women are often given far less information about the purpose of scans than about serum screening tests they may be unaware that their baby is being screened for anomalies (Smith and Marteau, 1995). If even a minor problem is found, anxieties are raised and their relationship and attitude to their baby during the rest of the pregnancy is likely to be altered (Boyle, 1994).
| 'My sister-in-law had a scan and they told her they'd found placental lakes and she was to come back in a month for another scan. At that scan they found them again, so they sent her away for another month. She was worried sick. When she want back the third time they told her cheerfully that the lakes had disappeared. She plucked up the courage to ask what it all meant and they told her they didn't really know, but placental lakes were quite common and usually went away. Her pregnancy had been ruined by three months worry.' |
| Postnatal support worker |
Women who accept screening such as the 'triple test' may not realize that dealing with the results and deciding what action to take is sometimes far from simple.
| 'There's a lot more anguish about. Every week I listen to women trying to make decisions on the basis of numerical probabilities. Probabilities aren't tremendously helpful when you are trying to decide whether or not accept diagnostic procedures which carry their own risks and may lead to a decision about whether or not to abort a baby.' |
| NCT teacher/tutor |
Some professionals assume that women make a positive choice to undergo screening and diagnostic testing in order to abort the fetus if it is abnormal, but this is not necessarily so (Van den Akker, 1993). They are far more likely to be seeking reassurance that their baby is all right (Gladman, 1994). For some women, termination, however distressing, may be preferable to giving birth to a child with a disability or life-threatening disease. But for others, termination is unacceptable on personal, moral or religious grounds. Some parents who, before testing, thought they would have a termination if the result was positive, may change their minds when faced with the decision. Others may never consider a termination but may want to know if their baby is abnormal so that they can begin the process of adaptation and acceptance before he or she is born.
'Pregnant women now have to search their own souls and make a positive moral decision whether they would want to continue with the pregnancy or have a termination.....And that day that they take the decision will have changed them' (From Nicolaides, 1994, by permission).
Religious and cultural issues
The amount of screening offered during a normal pregnancy may
particularly surprise or worry women who have strong religious views on
interventions and/or on the termination of pregnancy, or who are unfamiliar
with British antenatal care. Some may feel threatened, frightened, confused
or assaulted. Some may not have the confidence to ask questions or to
challenge routine practice. As always, language barriers increase any
difficulties:
| • | It is important not to assume that quiet acceptance equals consent and to ensure that all women, whatever their background, are informed of the purpose, scope, risks and benefits and limitations of the various tests, and that they understand that they have choices. | |
| • | The cultural, religious, spiritual, social and emotional implications of testing should be taken into account. At the same time it is important not to assume, for example, on the basis of a client's religion, what she is going to decide. Women who make decisions contrary to the teaching of their religion may be in particular need of understanding and comfort. Scrupulous confidentiality must be maintained. | |
| • | Some women may have concerns in relation to specific procedures. Some may be unwilling to have blood taken during pregnancy in case it weakens them. Muslim women who are fasting during Ramadan may be unwilling to give blood and may refuse glucose tolerance tests. Some Orthodox Jewish women, who are usually certain about the date of their last period, may see no point in having a scan to date their pregnancy. The physical exposure required to carry out a scan may present problems for some women. | |
| • | Women who normally make major decisions jointly, or whose husbands or older female relatives normally make such decisions, may want the consent and support of other family members before deciding whether to accept screening or diagnostic tests. Information and counselling about screening and diagnostic testing should therefore be available to husbands or partners and other family members. However, care should always be taken to ensure that the woman gives consent or refuses on her own behalf. | |
| • | Appropriate counselling and screening should be offered to people known to be possible carriers of genetic diseases such as the haemoglobinopathies and Tay Sachs disease (see chapters 25 and 29). However questions about people's origins and family histories should be broached sensitively and with clear explanations of the reasons for asking. | |
| • | In some parts of the world there are enormous cultural, social and economic pressure to have sons, especially if a couple only has daughters (Booth, Verma and Singh Beri, 1994; Imam, 1994). Health professionals may be concerned about telling some parents the sex of their unborn child in case they decide to terminate the pregnancy if the baby is a girl. Termination on these grounds is illegal and is abhorrent to most people. But before making judgements about others, it may be useful to remember that many parents' decision to abort an 'abnormal' fetus in the UK is influenced by the knowledge that our society does not provide adequate resources for the disabled, and that able-bodied people are ignorant and prejudiced about disability. Similar social and economic constraints are at work when women in India choose to abort girl fetuses (Grant, 1993). |
| Back to top |
Link
to Judith Schott's training courses
Back
to information on the book
[
Childbearing ] [ Patient
Care ] [ When a Baby Dies
]
[ About Alix Henley ]
site created by The Word Pool