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Supporting an ethnic minority woman's choice for pain relief in labour: A reflection

02 June 2016
Volume 24 · Issue 5

Abstract

Despite professional expectations for midwives to provide care to women that is founded in equality and recognises diversity (Nursing and Midwifery Council, 2015), women from ethnic minority populations consistently suggest that they are not heard (Briscoe and Lavender, 2009; Tobin et al, 2014). This article reflects on a situation where a Portuguese woman with limited English-speaking ability was denied access to epidural anaesthesia as the midwife felt that the woman could not give valid consent to the procedure without the presence of an interpreter. The midwife's role in this situation is reflected on, and implications for midwifery practice identified.

Communication is seldom thought of as a high-priority instrument in improving maternal outcomes; however, when it is timely, fitting to the situation and meets the individual needs of the woman and the health-care team, it can make a significant difference (Bick, 2010). Effective communication between women and health professionals is fundamental to the provision of safe, optimised care (Hayes et al, 2011). It is the origin of best practice, not only in midwifery but in all disciplines (Price, 2013). When providing individualised, holistic care to women, it is imperative to consider their cultural identity and needs (McCarthy et al, 2013). Inadequate or poorly organised maternity services, complicated by a lack of education in cultural understanding and inconsistent access to interpreter services, often have a detrimental effect on care provision (Tobin et al, 2014).

This article reflects on a clinical situation in which a midwife was caring for a Portuguese primigravid woman in established labour. The woman had a poor grasp of the English language. The midwife attempted to contact interpreter services to assist her during her labour, but to no avail. Visibly distressed, the woman appeared to be signalling that she wished to have an epidural. The midwife caring for her declined access to an epidural as she believed the woman would be unable to consent in the absence of an interpreter. Following birth, once the interpreter was available, it was confirmed that the woman had been attempting to request an epidural. The reasons for her request not being granted were explained to her, and she accepted the rationale behind the midwife's decision. The woman's acceptance of the situation may have been because she had progressed quickly to a normal vaginal birth rather than a prolonged situation; however, the implications in this situation warrant consideration to establish the evidence behind the midwife's decision-making and to explore care of women from minority ethnic groups in maternity services.

With one quarter of UK births attributed to women from outside the UK, there are very real implications for midwives in relation to promoting and developing supportive maternity service relationships with ethnic-minority women (Office for National Statistics, 2015). Reports from the Confidential Enquiries into Maternal Deaths have identified disproportionately higher mortality rates in the ethnic-minority population (Hayes et al, 2011). There are consistent messages that suggest women from minority ethnic groups do not receive optimal care and, therefore, have a high risk of morbidity and death (Ameh and van de Broek, 2008).

The care provided during pregnancy and childbirth is of great value in every culture, yet people of migrant origin often experience barriers to obtaining accessible, good-quality health care, in contrast to people of the host society (Lakhani, 2008; Malin and Gissler, 2009). Becoming a mother, while attempting to adjust and settle into a new culture, can be a major challenge (Benza and Liamputtong, 2014). The majority of childbearing women desire a midwife who will listen to them, offer compassionate understanding, be genuine and not judge them (England and Morgan, 2012). All NHS service users—regardless of where they live, the country of their birth or their ethnic origin—have the right to expect equal and fair access to primary health-care services that are responsive to their needs (Lakhani, 2008).

What is the purpose of informed consent?

In this case, the midwife declined to permit the woman to receive epidural analgesia on the grounds that the woman was unable to give informed consent to the procedure. The purpose of informed consent is to provide protection of the individual's autonomy and integrity (Marshall, 2000). Morally, consent enables an autonomous person to choose what treatment he or she will agree to or refuse (White and Seery, 2009). The National Institute for Health and Care Excellence (NICE, 2014) proposes that, if a woman does not have the capacity to make decisions, health professionals ought to follow the Department of Health (2009) reference guide to consent. These guidelines identify a legal and ethical standard that valid consent ought to be achieved prior to commencing treatment for a person. The guidelines go on to state that if health professionals do not obtain consent and the client goes on to suffer harm as a result of the intervention, this may result in a claim of negligence against the health professional involved (Department of Health, 2009).

Midwifery 2020 acknowledged migrant women who do not speak English as a first language to be a vulnerable group with complex needs (Chief Nursing Officers of England, Northern Ireland, Scotland and Wales, 2010). Obstetric care to the migrant population gives rise to numerous challenges for the health system (Hayes at al, 2011). McCourt and Pearce (2000) suggest that a lack of high-quality maternity care for ethnic-minority women is a result of the institutional organisation of care, and recommend that alternatives such as the caseload model of care are made available as a choice to facilitate more women-centred care. Beake et al (2013) found that caseload midwifery in a multi-ethnic community has the potential not only for improved quality of care but also improved safety.

The word ‘midwife’ literally translates as ‘with woman’. Working within this literal translation, most women welcome having active participation in the process of their care, the possibility of choice and feeling in control during their childbearing event (Borrelli, 2014). The capacity to make decisions is based on a woman understanding and using information about treatment when making a decision (Griffith, 2011). However, no individual has the right to accept or decline medical treatment on behalf of another, unless they have specific legal authority to do so (Hayes et al, 2011). Working in accordance with the Nursing and Midwifery Council (NMC, 2015) Code, midwives must be able to demonstrate that they have acted in the best interests of the woman when providing care in an emergency.

Helping ethnic-minority women to have a voice

Despite an expectation in the Code (NMC, 2015) in relation to promoting equality and diversity, ethnic-minority women consistently suggest that they are not heard or believed, identifying control to be a major factor as they feel that the midwife attempts to control their knowledge, choice and even ability to give birth (Cross-Sudworth, 2007; Briscoe and Lavender, 2009). People from minority ethnic groups are often fearful of health professionals because they are not confident in speaking assertively and with authority in the native language (van Servellen, 2009). Compassion, empathy and kindness are as important in intrapartum care as the ability to manage physical skills such as epidural analgesia (Curtin, 2014). Midwives must become politically and socially aware to make equality in health care a reality for vulnerable women (Ukoko, 2005). It has been suggested that ethnic-minority representation on Maternity Services Liaison Committees is imperative in ensuring the needs of these groups are taken into consideration when providing services (Schott and Henley, 1996).

A recent enquiry into maternal deaths recommended that professional interpretation services be provided for all pregnant women who do not speak English, and highlighted the lack of availability of suitable interpreters as a factor in poor outcomes (Cantwell et al, 2011). Securing interpreter services for women in labour is challenging due to the unpredictable timing of the onset and duration of labour, as was the case in this situation (Fetters et al, 2007). Health-care providers are often influenced by hectic working conditions when deciding whether professional language assistance is needed (Kale and Syed, 2010). Although communication and language barriers between clients and health-care workers are prevalent, few studies have documented what health-care workers do when they encounter language obstacles (Kale and Syed, 2010). Tobin et al (2014) carried out a study to explore the childbirth experience of ethnic-minority women in Ireland and found that, while women commented positively on the kindness and care they received from health-care providers, there was an evident lack of education and awareness among staff, which was at times complicated by ignorance.

Opportunities to discuss advance care directives for labour and birth

Marshall (2000) recommended that discussions with women about the advantages and disadvantages of intrapartum procedures should take place during the antenatal period. This is supported by Sonwalkar and Hawthorne (2002), who state that women ought to receive sufficient information to make an informed decision irrespective of race or language, and go on to question whether anaesthetists should have contact with women during antenatal appointments before the request for an epidural is made. There is little research into how UK maternity services are organised and delivered, or how these services can be changed to improve outcomes for disadvantaged women (Mastracola and Nwabineli, 2009). Fetters et al (2007) used a mixed-methods approach to seek the opinions of Japanese-speaking women living in the USA, who had given advance consent during the antenatal period for epidural analgesia in labour, the purpose of which was to help women who desired epidural analgesia during labour to receive it. The survey was carried out following concerns from maternity staff that Japanese-speaking women could not communicate effectively enough to offer valid consent. The study outcomes suggested the majority of women found advance consent helpful; the authors highlighted that women from other cultural groups who are isolated by language barriers may benefit from this process (Fetters et al, 2007). Women are no less autonomous when they are pregnant, and birth plans created in the antenatal period should be treated as advanced directives (White and Seery, 2009). The key skill in working with women from minority groups is based on the midwife's ability to view each woman in her own right and not as someone ethnically distant (England and Morgan, 2012). Working in partnership and using a multidisciplinary approach is likely to improve access to maternity services, and consequently obstetric outcomes, for ethnic-minority women (Ameh and van de Broek, 2008).

For almost all pregnant women, the midwife is the main coordinator of care throughout pregnancy to the postnatal period, and the centre of communication in the multidisciplinary team to suitably coordinate the care of women who require input from other services (Chief Nursing Officers of England, Northern Ireland, Scotland and Wales, 2010; Price, 2013). Midwives should ensure they can publicly display good decision-making, as well as demonstrating client involvement, in order to comply with national standards and guarantee the provision of quality care (Barber, 2012). They have a duty of care to women to ensure optimal analgesia is provided during labour (McGrady and Litchfield, 2004).

Conclusion

Women from immigrant backgrounds have the right to sensitive and adequate health care during the childbearing process, regardless of their migrant status (Benza and Liamputtong, 2014). However, there is evidence that good communication and care are currently not being provided for these women in conventional services. This is compounded by the fact that suboptimal obstetric outcomes are more common among migrant women than the native UK population (Hayes et al, 2011).

Midwives must act as advocates for women in their care and are required by the NMC (2015)Code to make arrangements to meet women's language and communication needs to ensure information is accurate and comprehensible. Ethnic-minority women should be actively encouraged to participate in local Maternity Services Liaison Committees, and more consideration should be given to advance care directives in the antenatal period to ensure every woman's unique needs are attended to. Further continuing education and support for midwives is required to promote culturally appropriate care.

Key Points

  • Evidence suggests that ethnic minority women often feel as though they do not have a voice in the UK maternity system
  • Midwives have a pivotal role to help women whose first language is not English to be educated sufficiently to make informed choices about their care management during labour and birth
  • Antenatal opportunities should be provided to discuss issues such as epidural anaesthesia and consideration of advance directives for care should be considered in case the situation arises where interpreter services are not available
  • Ethnic minority women should be actively invited and encouraged to participate in Maternity Service Liaison Committees
  • Midwifery models of care, such as caseload midwifery, should be considered for ethnic minority women, to enhance the trusting relationship between the woman and her midwife