Antenatal care perceptions of pregnant African women attending maternity services in Melbourne, Australia

ARTICLE IN PRESS Midwifery (2010) 26, 189–201

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Antenatal care perceptions of pregnant African women attending maternity services in Melbourne, Australia Mary Carolan, PhD (Director of Midwifery)a,, Loris Cassar, BNsg, G.Dip Midwifery (Midwife)b a

School of Nursing and Midwifery, St. Alban’s Campus, Victoria University, PO Box 14428, Melbourne 8001, Australia b Western Health (Sunshine Hospital), 176 Furlong Road, St. Albans 3021, Australia Corresponding author.

E-mail address: [email protected] (M. Carolan).

Received 6 November 2007; received in revised form 5 February 2008; accepted 22 March 2008

Abstract Objective: to explore the experiences and concerns of an African-born sample of pregnant women receiving antenatal care in Melbourne, Australia. Design: qualitative in-depth interviews. Setting: the African Women’s Clinic located in Melbourne’s western suburbs, an area known for social deprivation and high numbers of recently arrived African migrants. Participants: 18 pregnant African-born women were interviewed. Findings: African women receiving pregnancy care in Australia undergo a process of adjustment as they travel from a view of pregnancy as not ‘special’ to valuing continuous antenatal care. Five themes were identified along the trajectory: pregnancy is not special; resettlement is a priority; childbearing is a normal process; coming to value continuous pregnancy care; and cultural sensitivity is important. Throughout each stage, valuing and acceptance of Australian pregnancy care were mediated by the women’s cultural beliefs. Conclusion: the African population in Melbourne is not homogenous, and women’s experiences differ with cultural background, residential status, educational level and prior experience. All, however, seem to progress through phases of adjustment to value continuous antenatal care. In this climate of change, the provision of a supportive sensitive service appears to promote acceptance of services and attendance at appointments. & 2008 Elsevier Ltd. All rights reserved. Keywords Midwifery; Migrants; African; Prenatal care

Introduction Childbearing is a life event of critical importance (Davis Floyd, 1988) that is experienced within a cultural and social context (Davis Floyd, 1988; Callister, 1995; Simkin, 1996; Cheung, 2002; Schneider, 2002). As such, the practices that surround childbirth are underpinned and shaped

by local beliefs and social context (Jordan, 1993; Cheung, 2002), and this occurs in all societies. Moreover, in more traditional societies, childbearing may be the most important role in a woman’s life (Jeng, 1997; Callister et al., 1999; Lee and Kuo, 2000; Kridli, 2002; Sperstad and Werner, 2005), and a variety of practices and rituals exist to protect and support the new mother and the fetus/baby.

0266-6138/$ - see front matter & 2008 Elsevier Ltd. All rights reserved. doi:10.1016/j.midw.2008.03.005

ARTICLE IN PRESS 190 Some examples include warding off the ‘evil eye’ in Middle Eastern cultures and the avoidance of ‘cold’ foods for 40 days post partum in many Asian cultures. Religious influences may also be very important and women may subscribe to a variety of religious determinants of pregnancy outcome, such as God and moral behaviour (Granot and Spitzer, 1996; Kridli, 2002). All of these factors influence a woman’s understanding of appropriate maternal behaviour and attention to the pregnancy (Schneider, 2002). In this way, women from diverse backgrounds may use different frames of reference to make sense of pregnancy events (Jordan, 1993; Wiklund et al., 2000), and may behave in ways contrary to Western beliefs. Moreover, against this background of recognised cultural meaning, childbearing can pose real challenges for the new immigrant, who no longer has access to traditional support and practices, and whose beliefs may hold no currency in their new country (Wiklund et al., 2000). Such challenges may be compounded by language barriers (Marshall and While, 1994; Bentham, 2003), different understandings of antenatal care and competing interests, such as resettlement (Baker et al., 1994). Increasing trends of African migration and refugee resettlement mean that Western societies are becoming more culturally diverse. In Australia, for example, approximately 12,000 asylum seekers are accepted annually (DIMIA, 2005) and, in recent years, almost 70% have come from countries in subSaharan Africa (DIMIA, 2005; Smith, 2006), including Eritrea, Somalia, Sudan, Ethiopia and Kenya. Similar trends are seen in the UK, North America and selected European countries (DIMIA, 2005). Nonetheless, despite this increasing trend, to date, there is limited research about African women giving birth in host countries (countries accepting African refugees for resettlement). Existing literature indicates that pregnancy care is fraught with difficulty for this population and also that inadequate access to care is common (Bulman and McCourt, 2002; Burnett and Fassill, 2002; Harris et al., 2006). Access to care appears to be hampered by unsympathetic services, racism and racial stereotyping (Granot and Spitzer, 1996; Bulman and McCourt, 2002; McLeish, 2002; Herrel et al., 2004). The cultural context of care is also identified as important (Wiklund et al., 2000), and this is especially the case for women with limited access to family or cultural support. Efforts to promote culturally sensitive care are discussed in the literature, and are generally associated with improved attendance at antenatal appointments (Beine et al., 1995; Carolan and Cassar, 2007). Authors suggest that African women prefer to be

M. Carolan, L. Cassar cared for by a female caregiver, and this is particularly true of women who have experienced female genital mutilation (FGM) (Beine et al., 1995; Wiklund et al., 2000). Further studies evaluating pregnancy care in host countries indicate that circumcised women often perceive their care to be harsh and offensive to cultural values (Chalmers and Hashi, 2000; Bulman and McCourt, 2002). There is a general impression that the needs and wants of childbearing African women are not well understood. Moreover, the extant literature explores the experiences of African-born women receiving pregnancy care principally in the UK, North America and Europe (Beine et al., 1995; Chalmers and Hashi, 2000; Bulman and McCourt, 2002; Herrel et al., 2004; Ukoko, 2005; Lundberg and Gerezgiher, 2007). The Australian literature is noticeably sparse and, despite exhaustive searching of electronic databases such as CINAHL, Medline, and Maternity and Infant Care, and hand searching of the Australian literature, no documented studies have been found that report on the experiences of African women giving birth in Australia. Thus, this exploratory study aimed to address this gap by examining the experiences of a group of African women receiving pregnancy care in Melbourne, Australia. In this way, it is hoped to initiate some debate around the experiences and concerns of this growing population of birthing women.

Background to the study In Australia, maternity care is provided via two principal models. Public care, which is Medicare funded, incurs no additional cost for women and is generally provided by general practitioners (GPs) in the community and midwives in public hospitals. Low-risk women attend antenatal clinics and have most care provided by midwives but are reviewed, at selected intervals, by a doctor. Care during labour, birth and post partum is mainly provided by midwives in consultation with hospital doctors, and women return to their GP for review at six weeks post partum. Alternately, a percentage of women, with private health insurance, elect to see a private obstetrician and attend for antenatal appointments in the obstetrician’s rooms. Most of these women attend a private hospital for labour and birth. Care is provided by midwives in consultation with the private obstetrician, who will aim to be present for the birth. Within the public model of care, some dedicated antenatal clinics are offered for particular segments

ARTICLE IN PRESS Antenatal care perceptions of pregnant African women in Australia of the population, e.g. teenage, refugee or aboriginal women (DHS, 2006).

Methods A qualitative method was considered most appropriate for this study. It aimed to explore the phenomenon of African women’s experiences of Australian antenatal care, about which little is known, from an ‘emic’ perspective (Patton, 1990; Creswell, 2007). This methodology permitted reporting of participants’ views and valuing of the women’s experiences, both important considerations for the current study. The particular inductive approach used was based on Ezzy’s (2002) thematic analysis methodology. A significant strength of this approach is that it allows the researcher to be particularly sensitive to emergent categories and interpretations without recourse to predetermined beliefs or presumptions (Ezzy, 2002). Following approval by university and hospital ethics committees, a purposive sample of women was recruited from the African Woman’s Clinic, situated in Melbourne’s western suburbs. Purposive sampling was considered to be particularly useful for this study, in line with Patton’s (2002) suggestion of purposive sampling as appropriate when participants constitute a select population. The group of interest, pregnant African women, is a discrete group and recruitment at a targeted clinic was considered to be effective. As recruitment commenced, women were invited to participate by a midwife who was not involved in the study. The following inclusion criteria were used:

  

born in an African country; pregnant at the time of recruitment; and attending the African Women’s Clinic for antenatal care.

Sample size was not predetermined and recruitment continued until no new information was forthcoming (Patton, 1990; Rice and Ezzy, 1999). Data saturation was achieved after 15 interviews, but a further three participants were recruited in the event that some new material might still emerge. In-depth interviews were conducted with 18 pregnant African women in 2006–2007. Women were offered a choice of interview venue, and all but one participant elected to be interviewed at the clinic. This participant chose to be interviewed at home. Interviews were mediated by an interpreter in all but two cases. The interpreters used were from the same pool of interpreters used by

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the clinic and associated hospital. All were female and approved by the National Accreditation Authority for Translators and Interpreters, and thus were well versed in issues of privacy and cultural sensitivity. An interview guide was used and as an opening, participants were asked to discuss their experience of having a baby in Australia. Thereafter, women were asked:

  

What do you like/dislike about pregnancy care in Australia? What concerns, if any, do you have for yourself or your baby? What, if anything, could be done to improve your experience?

These open-ended questions were intended as prompts and were developed in consultation with the clinic’s midwives. They served as a guide but were not adhered to rigorously as the researcher felt it was important to allow a spontaneous generation of questions in pursuit of interesting material that emerged. Patton (1990) proposed similar measures. An unexpected difficulty that emerged during interviews was related to the women’s reluctance to permit audio-recording of data. Only one participant consented to having her interview taped, and refusal related primarily to suspicion and cultural concerns. Several women had spent time in refugee camps and had experience of being questioned by authorities. These women were upset and suspicious about the researcher’s need to record their conversations. Therefore, notes were taken during the interview and a summary of the interview was transcribed immediately after, when the content was still clear in the researcher’s mind. These interviews were generally longer than the expected one-hour duration, related to lengthy note taking and the jotting down of verbatim comments. Although it is recognised that some data were lost by sanctions on audio-taping, the researcher’s skills of note-taking during interview and transcription immediately thereafter improved as data collection progressed.

Data analysis Thematic analysis aims to identify themes within the data and each theme is determined by emergent categories. Categories, in turn, consist of significant phrases, sentences and paragraphs that contribute to a particular concept. In this

ARTICLE IN PRESS 192 study, data were analysed, consistent with Ezzy’s (2002, pp. 86–90) understanding of thematic analysis, in the following manner:

         

summaries of the interview were made immediately following the interview; notes and summaries were read repeatedly to obtain a sense of the content; notes and memos were made on general findings; open coding was employed and a large number of categories were outlined; categories were grouped together under higher order headings; similar headings were removed and categories were collapsed to produce a final theme list; trustworthiness of data analysis was addressed by asking a colleague to generate a theme list independently; transcripts were reviewed again and alternate explanations were sought; each transcript was coded according to the list of themes; and each coded section was moved to the theme where it belonged.

Findings Most participants came from the Horn of Africa and were principally from Dinka and Amharic cultural and linguistic backgrounds. All but one participant had a refugee or family reunification visa. Length of stay in Australia varied from three weeks to two years. Only two participants were fluent in English, although most were literate in their spoken language. Four were not literate in any language and three were marginally literate in that they could understand very basic writing in their spoken African language. Religious background varied. Amharic-speaking women were Muslim, and large families were highly valued among this group. The birth of a son, in particular, was an occasion for celebration and source of status for the mother. Most women spoke of pregnancy as a woman’s purpose and responsibility. In comparison, most Dinka women belonged to Nilotic religious groups, wherein members believe in one God, Nhialic. This God speaks through spirits which take temporary possession of individuals in order to speak through them. Dinkas ordinarily live within a cattle-based economy and large families are the norm. Dowries are paid in cattle, and girls are generally well regarded as the future wealth of the family. FGM was common among women of Amharic backgrounds and varied in extent. Dinka or Christian women tended not to

M. Carolan, L. Cassar be circumcised or to have the least radical form of circumcision. Socio-economic status was generally low, by Australian standards, among participants and most lived in transient housing or moved between several addresses. Telephone numbers were frequently unavailable or unreliable. The majority of women had had at least two children previously. All but one of the participants were experiencing antenatal care for the first time in Australia (Table 1).

Themes During analysis, a unifying theme of ‘adjustment to continuous pregnancy care’ was found (Fig. 1). Women entered pregnancy care with the view that pregnancy was such a normal and expected event in a woman’s life that it was scarcely worth a mention. Most had had babies before; some as many as eight or nine children, and one woman presented with her 13th pregnancy. These women were confused by the attention that childbearing received in Australia, and they struggled to understand the importance of early antenatal care. However, once registered for care, most women travelled through a gradual trajectory of adjustment to arrive at a valuing of continuous antenatal care. Five stages of incremental change are described: (1) pregnancy is not special; (2) resettlement is a priority; (3) childbirth is a normal process; (4) valuing continuous pregnancy care; and (5) cultural sensitivity is important. Throughout each stage, the woman’s accommodation of pregnancy care was mediated by her sensemaking efforts, which, in turn, were influenced by cultural beliefs. The provision of a supportive sensitive service aided the process of adjustment and allowed the women to make sense of events in a non-threatening environment.

Culturally sensitive care Culturally sensitive care is defined here as care based on the following set of assumptions outlined by the College of Nurses of Ontario (2005, p. 3). The final points are modified to include ‘midwife’ rather than ‘nurse’:

 



Everyone has a culture. Culture is individual. Individual assessments are necessary to identify relevant cultural factors within the context of each situation for each client. An individual’s culture is influenced by many factors, such as race, gender, religion, place of

ARTICLE IN PRESS Antenatal care perceptions of pregnant African women in Australia Table 1 Sample

  

193

Participant characteristics. Age Country (years) of origin

Residential status in Australia

Cultural background

Literacy

Fluent in English

Parity

No, attending language school No, attending literacy classes No, attending language school No, attending language school

5

W1

32

Ethiopia

Refugee visa

Dinka

W2

37

Sudan

Refugee visa

Dinka

W3

20

Sudan

Refugee visa

Amharic

Not literate in any language Marginally literate in Dinka Literate in Amharic

W4

21

Sudan

Amharic

Literate in Amharic

W5

35

Sudan

Family reunification visa (fiance´e) Refugee visa

Amharic

Not literate in any language

W6

21

Sudan

Refugee visa

Amharic

Literate in Amharic

W7

20

Sudan

Amharic

Literate in Amharic

W8

26

Eritrea

Family reunification visa Refugee visa

Christian

W9

23

Sudan

Literate in African language Literate in African language

W10

24

W11

Christian

Sudan

Family reunification visa (fiance´e) Refugee visa

38

Somalia

Refugee visa

Dinka

W12

30

Kenya

Christian

W13

28

Eritrea

Permanent residency Refugee visa

Christian

W14

35

Somalia

Refugee visa

Dinka

W15

22

Sudan

Dinka

W16

34

Sudan

Family reunification visa (fiance´e) Refugee visa

Amharic

W17

42

Sudan

Refugee visa

Dinka

W18

36

Sudan

Refugee visa

Amharic

Dinka

birth, ethnicity, socio-economic status, sexual orientation and life experience. The extent to which particular factors influence a person will vary. Reactions to cultural differences are automatic and often subconscious. The midwife’s culture is influenced by personal beliefs as well as by professional values.

Literate in Dinka and English, two other African languages Literate in African language Literate in three African language and English Not literate in any language Not literate in any language Marginally literate in African language

No, not attending literacy classes No, attending language school No, attending language school No, attending language school Improving, attending language school Fluent

7 0 0

8

3 0 4 0

2

No, attending language school Fluent

9

No, attending language school No, attending language school No, attending language school

3

3

7 1

8 No, not attending literacy classes Marginally literate in No, attending 13, spoken African language language school uncertain Literate in spoken African No, not 9, language attending uncertain literacy classes

Literate in spoken African language



The midwife is responsible for assessing and responding appropriately to the client’s cultural expectations and needs.

Pregnancy is not special For the most part, participants understood childbearing as something women did simply because

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M. Carolan, L. Cassar Cultural beliefs and understandings Pregnancy is not special

Resettlement is a priority

Childbirth is a normal process

Valuing pregnancy care

Pregnancy is a woman’s responsibility

Life is good here

Intervention is frightening/ unexpected

The benefits of antenatal care

Difficulties understanding the complexities of care

But there are lots of challenges

Expect to have pain

We learn many useful things It is good to be prepared Learning from the experts

Confused by the fuss

Availability of medical care

Cultural sensitivity facilitates adjustment Cultural beliefs inform decisions Shocked at Australian approaches to care Cultural sensitivity promotes attendance at appointments

The provision of culturally sensitive care

Figure 1 Adjustment to continuous pregnancy care.

they were women. They approached childbearing in a fatalistic and pragmatic way, accepting it as God’s will and their natural purpose in life. As such, pregnancy was not considered special or as needing special consideration. Indeed, failure to produce children was more of a problem, and women who had not given birth were often divorced by their husbands. In Africa, there were also economic imperatives for wishing to have many children. Reasons included dependence on offspring to work for the family, the need to have many children to have some survive, and the desire to improve the family’s income by commanding marriage dowries for offspring. Additionally, there was an expectation that women would bear many children to compensate for their own dowries. For most, status was associated with the number of children, particularly male, born into the family. Pregnancy is not problem for us (Sudanese) it is what women have to do y In my country, it is problem if you don’t have baby, then your husband can take another wife. (W6) In Sudan, when you get married a man can pay 50 cows, so you must produce a lot of children to get cows for dowry, to get it back for him y it is your responsibility to have lots of children, up to eight children y (W10) When entering antenatal care for the first time in Australia, the women had difficulties understanding the different approach and were confused by the attention. Most participants had had babies in Africa and had received minimal antenatal care.

Babies had been born at home or in refugee camps, usually attended by other women, family members and occasionally a midwife or doctor. Although the women all had experience of fetal or baby loss, either directly or indirectly, they had little understanding of the purpose of screening tests or the need to monitor early pregnancy. I don’t see the point to look inside with the machine [ultrasound] y . Maybe it will kill the child y (W1) In my country, we don’t have this thing (Down’s syndrome). Maybe it is just in Australia y (W2)

Resettlement is a priority Resettlement was an overwhelming priority for participants, many of whom were very recent arrivals in Australia. Their arrival in Australia represented a sudden immersion in a new culture about which little was known. This immersion was sometimes overwhelming, and participants struggled to get a foothold, to learn English and to make sense of their new homeland. For most, the experience had both positive and negative aspects. On the one hand, resettlement brought about an improvement in quality of life and participants were happy to live in a safe society where food was plentiful. On the other hand, most had left behind family, friends and a culture where they were understood. As they struggled to reestablish themselves in Australia, the current pregnancy was considered low on their list of priorities.

ARTICLE IN PRESS Antenatal care perceptions of pregnant African women in Australia I like living here y the food is available, the medicine is available. I have nothing to worry about. You can get education y no one will come into your house and kill you. (W10) I came as fiance ´e y I got pregnant first time y I was shocked y I had no family y there was a problem with Medicare (waiting period) and we had to pay $35 to see the doctor y we have no money y I don’t speak (English). We can’t have house (not eligible for public housing) y (W9)

Childbirth is a normal process For the most part, participants understood childbearing as a normal process and had confidence in their capacity to give birth. This was particularly the case for multigravid women, although first-time mothers were also confident that there would be assistance at the hospital should they experience difficulties. Although multiparous women used terms of reference unfamiliar to Western ideology, most felt that they knew when their babies would arrive and distrusted information that indicated otherwise. I am fine, everything is ok. I don’t need an operation. I should have a natural birth y I don’t need medicine (induction). (W6) For the boy, the pain lasts 2 hours but with the girls it was very quickly. This time I think the baby will come out in 30 or 45 min y (W16) Labour pain was viewed as an integral part of childbirth and participants were generally surprised to be offered pain relief or to be asked about pain relief preferences. Some women had been present at many births in Africa, and understood severe labour pain to be associated with imminent birth. There is big pain before (the birth) y when the pain goes down the baby won’t come. (W14) I don’t need medicine for pain y . Why not lie down when the pain is bad? (W12) Participants were similarly surprised and reluctant to submit to induction of labour, and most struggled to understand why such an intervention was necessary. This attitude seemed to relate to a view of labour as being initiated by the baby when it was ‘ready to come out’. Induction was viewed as a disruption to this normal event and as something to be feared. I don’t see the reason for taking medicine to bring the baby out y better to wait till it comes

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out itself y . With the medicine, will the baby come out alive? (W11) One consequence of being induced was that women were left fearful for their next birth. I had a terrible pain y I had medicine (induction) to make the baby come y . Now I am very scared y the first three [babies] I wasn’t scared y now I am very scared because of last time in the hospital. (W8)

Valuing pregnancy care While participants initially did not see the value of attending regular appointments in early pregnancy, most described a later valuing of the information and advice they received at the antenatal clinic. There was a shift away from the view of pregnancy as ‘not special’, and women came to understand their health and the health of their baby as important. Most became interested in attending clinic education sessions and received basic education on pregnancy, self-care through the discomforts of pregnancy, and information on practical issues such as clothing for the baby. Information on diet, breast feeding and contraception were particularly well received. I come because I want to know about my health and the baby’s health y it is good to come regularly to the clinic to see if everything is in good condition. (W3) This change was accompanied by a comparison of the care participants might receive as pregnant women in Africa against the care provided in Australia. When Australian care was judged acceptable or preferable by comparison, women assimilated continuous pregnancy care into their understanding of how things should be during pregnancy. Most women seemed to assimilate new beliefs by making sense of them compared with what they already understood. Very often, the new belief did not replace the old belief but co-existed with it. This stage of comparison seems to be integral to the process of adjustment. By comparing Australian care with their previous experiences, participants came to accept the model and express a willingness to attend appointments and to promote attendance among peers. Only one participant (W12), who came from a privileged position in Africa, judged Australian care as inferior to the care she had received in Africa. Nonetheless, she also endorsed a model of continuous care as important for all pregnant women. At this stage, most participants considered Australian care

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M. Carolan, L. Cassar

providers as experts compared with traditional (African) sources of pregnancy knowledge.

me, she doesn’t see me like problem y always smiling. (W3)

In Sudan, people don’t know a lot about pregnancy. Here I learn many things from doctors and midwives not just people who know nothing. (W5)

y She (midwife) will give us a chance if we make a mistake and come to the wrong clinic y she phones if we forget or if we don’t come y (W8)

At this stage, most participants had developed confidence with the Australian hospital system, which they compared favourably with African health services.

At this stage, participants often made reference to their lack of familiarity with pregnancy interventions and routine procedures performed in Australia. Some expressed their shock and surprise at what they were asked to do, e.g. vaginal swabbing for group B streptococcus. Many women had never contemplated such an idea but were tolerant of procedures once they were explained to them.

In Africa, the midwives are rough, they don’t have the machine to listen to the baby, they just use something to push onto your stomach. (W5) No good doctors in Somalia, they just stick it (needle) in anywhere (in your arm) to take blood test. (W14) In contrast to the majority of participants, W12 had this to say.

We don’t use tampon in my culture, I scare to put something inside there y maybe it will make problem for the baby if I do it. Better midwife do it. (W6)

On the day of booking in pregnancy, they are supposed to do a basic check-up y on my first time, they didn’t even do my weight y they only checked my weight twice in the whole pregnancy. Not even once testing my urine y They just check the blood pressure and measure this (tummy) y nothing else y In Africa, if you go to a good centre they take proper care of you y check everything y

It was clear that women struggled to comply when the request was in contravention of cultural beliefs. This struggle seemed to relate to wanting to do what was asked and to conform to Australian expectations, while also being concerned about attracting danger for the fetus they carried. Contravening their own social and cultural rules was problematic and led to confusion regarding which direction to follow.

Cultural sensitivity facilitates adjustment When participants were asked to comment on the pregnancy care they received in Australia, almost unanimously, they discussed the importance of feeling accepted and comfortable when attending for appointments. For some, this meant being with other African women and not feeling different as they might in mainstream services. For most, it meant having a caregiver who was sensitive to their lack of local knowledge and who was accommodating and tolerant of the mistakes they sometimes made. Almost all participants remarked that the friendly and accepting atmosphere at the pregnancy clinic facilitated attendance, and helped them to understand that it was important to attend. Interpreters were prebooked for women’s appointments and were present at education sessions, and this measure greatly facilitated attendance. When I come here, I see my language, my culture, I meet many friends y here we are people (not a nuisance), Leanne is happy to see

In my culture, it is rude to breast feed a baby when you are pregnant with another one but in Australia you should continue y I didn’t know y maybe it is bad for the baby y (W14) Sometimes magic goes into the woman’s stomach where the baby is sleeping y so it is dangerous to see the baby before it comes out. I don’t see why the doctor wants to look inside (ultrasound) y (W17) Throughout the women’s accounts, it was clear that cultural acceptance and sensitivity promoted attendance at antenatal appointments. It also made it easier for women to negotiate a compromise when they did not like the measure proposed. I like to come here y they are happy to see me y. When I go to the hospital I am the only one not Aussie y I am problem for them (staff). I am scared y the doctor is very busy y (W16) When the baby did not come on March 22nd, I was very scared about the medicine to make the baby come y Leanne tells me to try natural way y (laughing) maybe better y (W5)

ARTICLE IN PRESS Antenatal care perceptions of pregnant African women in Australia

Discussion A strength of this research is that it has utilised a methodological approach in which themes are permitted to emerge from participants’ accounts rather than fitting into predetermined categories, as in other qualitative methods (Ezzy, 2002). However, interviews were conducted in English, by an Australian individual, and were mediated by an interpreter. Therefore, interviews may have been prone to cultural and communication difficulties (Wallin and Ahlstrom, 2006). The researcher aimed to minimise these concerns by researching Dinka and Amharic culture. This approach involved reading widely about the Horn of Africa and its people (Deng, 1972; Lienhardt, 1988; Taddese, 1994; Jabir, 1996; Victorian Co-operative on Children’s Services for Ethnic Groups, 1997; Pankhurst and Pankhurst, 2000; Beswick, 2004; Abegaz, 2005; Collins and Burns, 2007), and researching a variety of websites and documents on line (http:// www.africanholocaust.net/peopleofafrica.htm#a; http://www.iowaprojectexport.org/documents/ somalissudanese.pdf; http://www.madingbor.com/ page/page/2064097.htm). Several weeks were also spent at the African Woman’s Clinic prior to recruitment, in a bid to better understand potential communication limitations. During this time, the researcher spoke to interpreters and clinic staff about the needs and particular issues of attending women. Difficulties associated with data collection and recall are also acknowledged as limitations of this study. However, the researcher employed a range of strategies to minimise the effect of these conditions, such as noting interesting comments made by participants. Many of these verbatim quotes are used as exemplars in the text. Findings in this study indicate that African women receiving pregnancy care in Australia undergo a process of adjustment as they travel from a traditional, cultural view of pregnancy as not ‘special’ and as not requiring particular attention, to a view of continuous antenatal care as important and desirable. This journey is largely facilitated by culturally sensitive and supportive services, and many study participants volunteered that they initially returned for appointments simply because the atmosphere at the clinic was friendly and accepting. In receipt of supportive services, participants attended antenatal appointments and, over the course of several visits, came to value the care offered. This finding, of culturally sensitive services as important, has also been reported in the literature around immigrant women (Beine et al., 1995; Downs et al., 1997; Chalmers and Hashi, 2000). For example, Beine et al. (1995), who

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researched perceptions of antenatal care among Somali women resident in San Diego, USA, found that sensitive care improved participants’ access to and utilisation of services. In the broader literature, there is general recognition of cultural beliefs and the observance of cultural practices as important to childbearing women everywhere (Jordan, 1993; Jeng, 1997; Callister et al., 1999; Cheung, 2002; Kridli, 2002). African women are similarly affected (Wiklund et al., 2000; Herrel et al., 2004; Mathole et al., 2004; Byaruhanga et al., 2006; Lundberg and Gerezgiher, 2007), and it is evident that most women continue with traditional birthing practices and beliefs when they emigrate (Granot and Spitzer, 1996; Rice, 2000). As such, women require access to services that are sensitive and accommodating of their cultural beliefs and practices. Very often, existing services do not demonstrate this level of sensitivity (Granot and Spitzer, 1996; Chalmers and Hashi, 2000; Bulman and McCourt, 2002), and it seems likely that cultural awareness and acceptance facilitate greater access to care among immigrant women. Improved sensitivity may also impact positively on women’s satisfaction with services. Other factors that improved attendance at antenatal appointments in the current study included the availability of interpreters and the provision of interpreter-mediated education services. Participants generally described a lack of English language skills as the most significant difficulty they faced in Australia, and similar findings have been reported elsewhere (Davies and Bath, 2001; Bulman and McCourt, 2002; Bentham, 2003; Ukoko, 2005; Straus et al., 2007). Attention to communication and language support is thus prominently advised in the literature (Davies and Bath, 2001; Bulman and McCourt, 2002; Elise and Johansen, 2006; Straus et al., 2007). For example, Elise and Johansen (2006) caution that clarifying events through interpretation and communication is important if staff are to avoid imposing ‘imagined’ cultural values on immigrant women (p. 516). Women in this study invariably expected to have a normal birth and were keen to avoid interventions such as induction of labour and caesarean section. Most held the view that labour would be initiated by the baby when it was ready to be born, and they were nervous of any interference. Australian maternity care is based on Western models of care and generally involves a good deal of surveillance and testing. This approach is often thought to be essential for refugee African women, who are regarded as a high-risk population in terms of poor

ARTICLE IN PRESS 198 prior health and unusual disease. However, this may not be the best approach to care for African women and, in this study, the interventionist aspect of care was probably the factor least acceptable to participants. Although it is driven by perceptions of risk, it is unclear what risk actually constitutes for this population, and further research is needed to establish their real risks. Interventions, such as post-term induction of labour, were particularly feared by participants and warrant further investigation. Similarly, in the wider literature, many studies reveal a strong preference among African women for natural birth and a declared apprehension of caesarean births (Beine et al., 1995; Chalmers and Hashi, 2000; Essen et al., 2000; Herrel et al., 2004), although there is little mention of induction of labour as problematic. Women with FGM, particularly infindibulation, appear to be particularly concerned about caesarean section (Chalmers and Hashi, 2000; Essen et al., 2000), and Essen et al. (2000) discuss such women as voluntarily reducing their food intake in a bid to have a smaller baby and thus avoid intervention. Interestingly, although the majority of women in this study had experienced FGM types 1 or 2, FGM was seldom raised as a concern during interview. This may be because none had experienced the more radical form of FGM. It may also relate to the women’s cultural acceptance of FGM as a normal transition to womanhood. In general, women in this study were satisfied with their care and felt privileged to avail of Western services, but they nonetheless held strong beliefs about certain aspects of childbearing. For these women, their journey to seeing antenatal care as valuable and desirable was marked by a series of sense-making endeavours and internal struggles. Most struggled to understand the need to attend for appointments early in pregnancy, and to see the utility of screening tests. Induction of labour was a particularly troubling concept and one that the women had not encountered previously. Many were afraid of technology, such as ultrasound, and were confused when advised to behave in a way contrary to their traditional practices. These struggles were juxtaposed against a valuing of care and the desire to give birth in a clean, safe and expert environment and to conform with Australian expectations. This experience is not unique to Australian migrants, and parallels are to be found in other studies. For example, Granot and Spitzer (1996), who examined the pregnancy practices and beliefs of Ethiopian immigrant women in Israel, found that participants considered it worth enduring ‘negative Israeli health-care practices in order to have access to clean, safe and expert care’

M. Carolan, L. Cassar (p. 299). Meanwhile, Kridli (2002), who examined the experiences of Arab immigrant women in America, found that participants valued Western medicine and generally respected and trusted American health-care providers, but nonetheless held strong traditional beliefs that affected their attendance at services. For the participants of this study, feeling welcome and accepted at the antenatal clinic was very important, and most found it easy to attend knowing that they would not be judged harshly, even if they inadvertently behaved inappropriately. Knowing the midwife and other staff was positively linked to attendance, and other studies have similarly identified continuity of care as important for ethnic-minority groups (McCourt and Pearce, 2000; Carolan and Cassar, 2007). Several sources suggest that African women often face disrespect, prejudice and racial stereotyping within maternity services (Davies and Bath, 2001; Bulman and McCourt, 2002; McLeish, 2002; Herrel et al., 2004; Straus et al., 2007), and also that this treatment has negative implications for the women in terms of addressing their information needs and providing an accessible service (Davies and Bath, 2001; Straus et al., 2007). Many writings advocate the provision of sensitive antenatal services as likely to improve attendance among immigrant women in general (Beine et al., 1995; Downs et al., 1997; Small et al., 1999; Chalmers and Hashi, 2000; Rice, 2000). Small et al. (1999), who explored the experiences of Turkish, Vietnamese and Fillipino immigrant women receiving pregnancy services in Melbourne, found that women were ‘less concerned that caregivers knew little about their cultural practices than they were about care they experienced as unkind, rushed, and unsupportive’ (p. 77). Finally, it is very likely that attendance at a dedicated African Women’s Clinic aided assimilation for the participants of this study. Mainstream maternity services are often associated with unsympathetic services, racism and racial stereotyping, and it is clear that these difficulties impact on attendance and assimilation (Granot and Spitzer, 1996; Bulman and McCourt, 2002; McLeish, 2002; Herrel et al., 2004). By offering an opportunity for African women to attend services at community level, together with other African women, at a clinic interested in and sympathetic to their needs, this service most likely facilitated easier and earlier assimilation into Australian society. However, the provision of centralised services remains contested in Australia in terms of isolating services and further marginalising refugee groups (Finney Lamb and Cunningham, 2003; Smith, 2006).

ARTICLE IN PRESS Antenatal care perceptions of pregnant African women in Australia The provision of such services may also be limited by location, numbers of refugees and funding. Therefore, it is important that mainstream healthcare services are capable of providing sufficient and culturally appropriate care to refugee groups (Smith, 2006; Carroll et al., 2007).

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provision are of limited utility for this population. Further research is required to identify the information needs of these women, and also the best medium in which to educate new migrants with limited literacy.

Conclusion Implications for practice This paper highlights increasing trends of African migration and refugee resettlement in Australia, and the consequent increase in numbers of African women receiving pregnancy care. Although findings are limited by the sample size, this study offers some original insights into the concerns of this growing group of childbearing women. Findings suggest that African migrants take some time to adjust to the notion of continuous antenatal care, which is generally a new concept. Attendance at appointments is positively encouraged through the provision of supportive and respectful care and, with this level of support, most women come to value the care they receive as important and desirable. In possession of this knowledge, midwives and other health-care providers may strive to provide care that accommodates cross-cultural beliefs and practices, and supports African women during this period of change. One of the arguments, most frequently countered in discussions of culturally competent care, is the virtual impossibility of knowing something about every culture one is likely to encounter in socially diverse societies such as Australia. In the face of this overwhelming task, the researcher would suggest that midwives and others are mindful of Small et al.’s (1999) finding above and aim to provide services that are kind and unrushed. The provision of sensitive antenatal services would likely do much to improve attendance among African women. To facilitate such services, midwives themselves need information and support. Information on cultural background and likely antecedent health may contribute to a greater understanding of this population, and may diminish midwifery concerns about providing care for African women. Findings in this study also suggest important areas for continuing research. For example, many participants in this study had a limited understanding of the normal physiology of pregnancy. Most had little idea of pregnancy care in developed countries, and had not previously encountered the notion of antenatal screening or ultrasound. Several had limited literacy and language skills. Therefore, standard approaches to information

In conclusion, the African population in Melbourne is diverse and includes migrants from a range of African countries. As such, cultural and religious backgrounds differ among this population, as do prior education and experience. Traditional birthing practices and beliefs are as varied as the women themselves. All, however, seem to progress through sequential phases of adjustment before arriving at an understanding of continuous antenatal care as important. This process appears to be facilitated through the provision of a supportive sensitive service. The provision of a sensitive welcoming service appears to promote acceptance of antenatal care and encourage attendance at antenatal appointments.

Acknowledgements The authors wish to thank Ms. Adrienne White, Sunshine Hospital, Melbourne, for her assistance and facilitation of the study, and the women and staff at the African Women’s Clinic. This study was made possible through a grant from the Victoria University School of Nursing.

References Abegaz, B., 2005. Ethiopia: A Model Nation of Minorities, Ethiopia News, Addis Ababa. /http://www.ethiomedia. com/newpress/census_portrait.pdfS. (last accessed 12 March 2007) Baker, C., Arseneault, A.M., Gallant, G., 1994. Resettlement without the support of an ethnocultural community. Journal of Advanced Nursing 20, 1064–1072. Beine, K., Fullerton, J., Palinkas, L., et al., 1995. Conceptions of prenatal care among Somali women in San Diego. Journal of Nurse-Midwifery 40, 376–381. Bentham, K., 2003. Maternity care for asylum seekers. British Journal of Midwifery 12, 73–77. Beswick, S., 2004. Sudan’s Blood Memory: the Legacy of War, Ethnicity, and Slavery in Early South Sudan. University of Rochester Press, Rochester, NY. Bulman, K.H., McCourt, C., 2002. Somali refugee women’s experiences of maternity care in west London: a case study. Critical Public Health 12, 365–380. Burnett, A., Fassill, Y., 2002. Meeting the Health Needs of Refugee and Asylum Seekers in the UK. Department of Health and National Health Service, London.

ARTICLE IN PRESS 200 Byaruhanga, R.N., Bergstorm, A., Tibemanya, J., Nakitto, C., Okong, P., 2006. Perceptions among post-delivery mothers of skin-to-skin contact and newborn baby care in a periurban hospital in Uganda. Midwifery, in press, doi:10.1016/j.midw. 2006.09.002. Callister, L.C., 1995. Cultural meanings of childbirth. Journal of Obstetric, Gynecologic, and Neonatal Nursing 24, 327–331. Callister, L.C., Semenic, S., Foster, J.C., 1999. Cultural and spiritual meanings of childbirth: orthodox Jewish and Mormon women. Journal of Holistic Nursing 17, 280–295. Carolan, M., Cassar, L., 2007. Pregnancy care for African refugee women in Australia: attendance at prenatal appointments. Evidence Based Midwifery 5, 54–59. Carroll, J., Epstein, R., Fiscella, K., Gipson, T., Volpe, E., JeanPierre, P., 2007. Caring for Somali women: implications for clinician–patient communication. Patient Education and Counseling 66, 337–345. Chalmers, B., Hashi, K.O., 2000. 432 Somali women’s birth experiences in Canada after earlier female genital mutilation. Birth 27, 227–234. Cheung, N.F., 2002. The cultural and social meanings of childbearing for Chinese and Scottish women in Scotland. Journal of Midwifery 18, 279–295. College of Nurses of Ontario, 2005. Culturally Sensitive Care. Publication No. 41040. College of Nurses of Ontario, Toronto. Collins, R.O., Burns, J.M., 2007. A History of Sub-Saharan Africa. Cambridge University Press, Cambridge. Creswell, J.W., 2007. Qualitative Inquiry and Research Design: Choosing Among Five Traditions, second edn. Sage, Thousand Oaks. Davis Floyd, R.E., 1988. Birth as an American rite of passage. In: Michaelson, K. (Ed.), Childbirth in America. Anthropological Perspectives. Bergin and Garvey, Beacon Hill, MA. Davies, M., Bath, P., 2001. The maternity information concerns of Somali women in the United Kingdom. Journal of Advanced Nursing 36, 237–245. Deng, F.M., 1972. The Dinka of the Sudan. Holt, Rinehart & Wilson, New York. DHS, 2006. Having a Baby in Victoria. Department of Human Services, Victorian State Government, Melbourne. DIMIA, 2005. Refugee and Humanitarian Issues: Australia’s Response. Department of Immigration and Multicultural and Indigenous Affairs, Canberra. Downs, K., Bernstein, J., Marchese, T., 1997. Providing culturally competent primary care for immigrant and refugee women: a Cambodian case study. Journal of Nurse-Midwifery 42, 499–508. Elise, R., Johansen, B., 2006. Care for infibulated women giving birth in Norway: an anthropological analysis of health workers’ management of a medically and culturally unfamiliar issue. Medical Anthropology Quarterly 20, 516–544. Essen, B., Hanson, B.S., Ostergren, P.O., Lindquist, P.G., Gudmundsson, S., 2000. Increased perinatal mortality among sub-Saharan immigrants in a city-population in Sweden. Acta Obstetricia et Gynecologica Scandinavica 79, 737–743. Ezzy, D., 2002. Qualitative Analysis: Practice and Innovation. Allen & Unwin, Crows Nest, NSW. Finney Lamb, C., Cunningham, M., 2003. Dichotomy or decisionmaking: specialization and mainstreaming in health service design for refugees. In: Allotey, P. (Ed.), The Health of Refugees. Public Health Perspectives from Crisis to Settlement. Oxford University Press, Melbourne. Granot, M., Spitzer, A., 1996. Pregnancy and delivery practices and beliefs of Ethiopian immigrant women in Israel. Western Journal of Nursing Research 18, 299–313.

M. Carolan, L. Cassar Harris, M., Humphries, K., Nabb, J., 2006. Asylum seekers: delivering care for women seeking refuge. RCM Midwives Journal 9, 190–192. Herrel, N., Olevitch, L., Dubois, D.K., Terry, P., Thorp, D., Kind, E., Said, A., 2004. Somali refugee women speak out about their needs for care during pregnancy and delivery. Journal of Midwifery and Women’s Health 49, 345–349. Jabir, O., 1996. Eritrea: Land of the Sea. Notes on Eritrean Background and Culture, Especially Beliefs and Customs. Victorian Co-operative on Children’s Services for Ethnic Groups, North Carlton, Melbourne. Jeng, S.J., 1997. Chinese traditional childbearing culture. Chinese Culture Monthly 212, 1–26. Jordan, B., 1993. Birth in Four Cultures: a Crosscultural Investigation of Childbirth in Yucatan, Holland, Sweden, and the United States. Revised and expanded by Davis-Floyd, R. Waveland Press, Prospect Heights. Kridli, S.A., 2002. Health beliefs and practices among Arab women. American Journal of Maternal/Child Nursing 27, 178–182. Lee, S.H., Kuo, B.J., 2000. Chinese traditional childbearing attitudes infertile couples in Taiwan. Journal of Nursing Scholarship 32, 54. Lienhardt, G., 1988. Divinity and Experience: the Religion of the Dinka. Oxford University Press, Oxford. Lundberg, P.C., Gerezgiher, A., 2007. Experiences from pregnancy and childbirth related to female genital mutilation among Eritrean immigrant women in Sweden. Midwifery, in press, doi:10.1016/j.midw.2006.10.003. Marshall, S., While, A.E., 1994. Interviewing respondents who have English as a second language: challenges encountered and suggestions for other researchers. Journal of Advanced Nursing 19, 566–571. Mathole, T., Lindmark, G., Majoko, F., Mania Ahlberg, B., 2004. A qualitative study of women’s perspectives of antenatal care in a rural area of Zimbabwe. Midwifery 20, 122–132. McCourt, C., Pearce, A., 2000. Does continuity of carer matter to women from minority ethnic groups? Midwifery 16, 145–154. McLeish, J., 2002. Mothers in Exile: Maternity Experiences of Asylum Seekers in England. Maternity Alliance, London. Pankhurst, R., Pankhurst, B., 2000. The Ethiopians: a History. Blackwell, Oxford. Patton, M.Q., 1990. Qualitative Evaluation and Research Methods. Sage, Newbury Park, CA. Patton, M.Q., 2002. Qualitative Research and Evaluation Methods. Sage, Thousand Oaks. Rice, P.L., 2000. Nyo dua hli—30 days confinement: traditions and changed childbearing beliefs and practices among Hmong women in Australia. Midwifery 16, 22–34. Rice, P.L., Ezzy, D., 1999. Qualitative Research Methods, a Health Focus. Oxford University Press, Melbourne. Schneider, Z., 2002. An Australian study of women’s experiences of their first pregnancy. Midwifery 18, 238–249. Simkin, P., 1996. The experience of maternity in a woman’s life. Journal of Obstetrics, Gynecology, and Neonatal Nursing 25, 247–252. Small, R., Rice, P.L., Yelland, J., Lumley, J., 1999. Mothers in a new country: the role of culture and communication in Vietnamese, Turkish and Filipino women’s experiences of giving birth in Australia. Women and Health 28, 77–101. Smith, M.M., 2006. Refugees in Australia: changing faces, changing needs. Medical Journal of Australia 185, 587–588. Sperstad, R.A., Werner, J.S., 2005. Coming to the cultural: nursing insights from a Hmong birth case study. Journal of Obstetrics, Gynecology, and Neonatal Nursing 34, 682–688.

ARTICLE IN PRESS Antenatal care perceptions of pregnant African women in Australia Straus, L., McEwen, S., Hussein, F.M., 2007. Somali women’s experience of childbirth in the UK: perspectives from Somali health workers. Midwifery, in press, doi:10.1016/j.midw. 2007.02.002. Taddese, T., 1994. Do the Amhara exist as a distinct ethnic group? In: Marcus, H.G. (Ed.), Proceedings from the 12th International Conference of Institute of Ethiopian Studies, Addis Ababa, Ethiopia. Conference held at Lawrenceville NJ, The Red Sea Press. Ukoko, F., 2005. Sure start midwife: giving a voice to the voiceless. British Journal of Midwifery 13, 776–780.

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Victorian Co-operative on Children’s Services for Ethnic Groups, 1997. Somalia and the Somalis: Notes on their Background and Culture, Especially Beliefs and Customs Relating to Children and Family Life. Victorian Co-operative on Children’s Services for Ethnic Groups, North Carlton, Melbourne. Wallin, A., Ahlstrom, G., 2006. Cross-cultural interview studies using interpreters: systematic literature review. Journal of Advanced Nursing 55, 723–735. Wiklund, H., Aden, A.S., Hogberg, U., Wikmun, M., Dahlgren, L., 2000. Somalis giving birth in Sweden: a challenge to culture and gender specific values and behaviours. Midwifery 16, 105–115.