Aims

This article describes a study of the maternity care experiences of Somali refugee women in West London. It is part of a larger study investigating the implementation of a new model of maternity care called ‘caseload maternity'. The aim of study was to develop an understanding of the reality that Somali refugee women face in their contacts with maternity services in the UK. It also aimed to ensure that maternity service developments are informed by women's perspectives including those who have been described as ‘muted'.

Methodology

The research was qualitative in nature. Semi-structured interviews were conducted with 12 Somali women during six individual interviews and two focus groups. Interviews were conducted in Somali with an experienced Somali interpreter who had knowledge and an interest in health issues. Open prompts were used to elicit information about the different stages in maternity care. At the end of each stage, closing questions asked the woman to sum up what was most helpful about the care and what she would have like to have changed. Interviews were recorded with the women's consent and transcribed by the author. Somali participants were found using the snowball sampling method. Two women were receiving caseload midwifery care and the remainder received conventional shared maternity care. Interviews were also carried out with health professionals involved in providing care and improving access to services for ethnic minorities. Two focus groups were carried out with midwives, one with hospital-based midwives and one with those working with personal caseloads. In addition, individual interviews were carried out with a Somali health-link worker, a woman who worked in hospital management and an obstetric registrar. These semi-structured interviews sought to explore professionals' perceptions about Somali women and their maternity care needs. Interview texts were coded in order to generate themes and issues set out in the findings. At a follow-up group discussion, the findings were told to the participants so that they could confirm whether the analysis reflected their perspective. The women also volunteered to form a panel for future user consultation and proposed to the local authority that a community-based peer interpreting scheme could be developed.

Key Findings

Most findings relate to the language barrier since this issue underpinned other problems the women experienced in their contacts with maternity services. All women thought a fully integrated interpreting service was vital to improved experience of maternity services. Despite the fact that the local provider trust had contacts with two official interpreting services, the women said that these services were rarely used. Most women felt they had no choice other than to provide their own translator and were not satisfied with the level of skill or appropriateness of the interpreters they could find. All but one woman who discussed their female genital mutilation [FGM] were unhappy with how FGM was dealt with. The women who had little or no continuity of care experienced the most severe communication difficulties. Somali women who received caseload care and those who received more continuity of care from hospital-based midwives discussed the fact that these midwives made an effort to overcome the language barriers. The midwives interviewed said that interpreting services had improved over the past couple of years but they did not routinely order services. Practical and attitudinal factors prevented staff from using language services more fully. A key factor was the gap between the degree to which the midwives and Somali women considered the language barrier to be a problem. As a practical matter, midwives rarely know which women they will see during visits. Communication between different care providers is limited and hospital midwives relied on general practitioners to give information on language needs in advance. Caseload midwives who were in a better position to plan care with individual women preferred to rely on informal sources when this was acceptable to the women. Attitudinal barriers were apparent amongst hospital midwives who displayed stereotyped assumptions about Somali women: that they are naturally good mothers, that they do not use pain relief and that they prefer to be instructed rather than receive information and choices about their care.

Conclusions

Communication is a matter of concern for all women that may be underestimated by staff and may limit access to health services for women whose first language is not English. Women who are able unable to communicate with health professionals find services remote, confusing and frightening while midwives who cannot effectively communicate with the women fall back on the use of cultural stereotypes and distancing behaviour. This is compounded by the professional lack of awareness about the needs and preferences of women from minority ethnic groups. As refugees who have lost social support through the disruptions of forced migration, the Somali women's lack of familiarity with UK health services reinforced a sense of fear and isolation engendered by the language barrier. There is a growing recognition that language support must be incorporated into health services. However, the lack of commitment to providing services for ethnic minorities appears to be a form of instituionalised racism. In order for ethnic minorities to gain equal access to health services, there needs to be an overall strategy with provision incorporated into the health care system.

Recommendations

The article concludes with the following recommendations:

• language services must be better integrated into the health service allowing for continuity and longer-term provision of support;

• GPs have a potentially important role to play in better organising referrals and care arrangements which can facilitate appropriate interpreting services;

• language services for pregnant women should enable greater continuity linking particular interpreters to particular women;

• schemes promoting continuity of care and more personalised care should be prioritised for minority ethnic users;

• planned education for health professionals is needed for work in a multicultural society.