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Shifting boundaries
Pergamon
Women’s Studies InternationalForum.Vol. 18. No. 3, pp. 2%309. 19% CopyrightQ 1995 Elsevier Science Ltd Printedin the USA. All tights reserved 0277~5395/95$9.50 + .oO
SHIFTING BOUNDARIES Exploring the Influence of Cultural Traditions and Religious Beliefs of Bangladeshi Women on Antenatal Interactions TINA MILLER School of Social Sciences, Oxford Brookes University, Gipsy Lane Campus, Headington, Oxford OX3 OBP, UK
Synopsis - For the majority of women living in Bangladesh there is no formalised system of antenatal care. Bangladeshi women coming to live in the United Kingdom are confronted with a highly developed system of preventative antenatal care, alien in many respects to their previous experiences. In this study the religious beliefs and cultural practices of Bangladeshi women were explored to see how they may influence take up of antenatal services. In turn, the boundaries between traditionally “private” (domestic and female) and “‘public” (wider, professionally defined) spheres were considered, and the implications of this for “control” in pregnancy and childbearing were explored. The difftculty of locating and accessing a “hidden” group was a major methodological consideration. The data collected showed that the women interviewed had attended antenatal clinics, and that whilst some shifts in the boundaries between “private” and “public” spheres were accepted, others had been rejected, and “control” retained.
During the early 1980s I lived in Dhaka, the capital of Bangladesh, for 2 l/2 years. I worked at a children’s hospital and spent time in the “bustees” the urban slums, tracing former inpatients of the hospital in order to assess their nutritional status. I returned from Bangladesh midway through my stay for the birth of my frost child. The morning after my daughter was born I was aware of a commotion in the next bed. The new mother, a Bangladeshi, was in a state of bewilderment, and the two auxiliary nurses she was appealing to had failed with sign language and were looking slightly bemused. I was able to interpret for her; she was in pain and was thirsty. The sense of her bewilderment at being in alien surroundings with no means of communication remained with me. By the time my third daughter was born I was studying for an M.Sc. and able to pursue my interest in the delivery of maternity services to women from minority ethnic groups living in Britain. The following is an account of a pilot study which set out to explore how cultural and
religious beliefs might affect the use of maternity services by a small group of Bangladeshi women living in Britain, and how boundaries between traditionally “private” and “public” spheres may be changing. “Private” being the domestic and female domain and “public” the wider context of professional definitions and domination. The methodological implications involved in accessing a largely “hidden” group and undertaking a piece of cross-cultural research were also considered. Between the years 1975 and 1987 perinatal mortality rates in Britain, that is “all stillbirths and all deaths in the first week of life per one thousand registered total births” (Mayes, 1988) were halved. Despite this, a report on Maternity Services published in 1990 (National Audit Office, 1990) confirmed that certain minority ethnic groups showed an unacceptably high incidence of perinatal mortality, which could not be explained by socioeconomic factors alone. These findings are supported by other studies (Lumb, Congdon, & Lealman, 1981; Short Committee Report, 1980) which in recent years have focused on the “problems” of minority ethnic groups and access to health
With thanks to the women who allowed the author to join their group and who shared their experiences. 299
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services. Other research has suggested that higher perinatal mortality and congenital malformation rates occur in Asian mothers when compared with British born mothers (Clarke & Clayton, 1983; Lumb et al., 1981). Mothers of Asian origin have also been found to be more susceptible to dietary deficiencies during pregnancy, premature labour, and to be delivered of small-for-dates babies (Charles, 1983; Lumb et al., 1981). In recent years interest has grown in antenatal care provision and take up of services by women from minority ethnic groups; underutilisation of antenatal services has been associated with higher perinatal mortality rates (Firdous & Bhopal, 1989). Yet the extent to which lower perinatal mortality rates can be attributed to “better” maternity care is a matter of some debate. Campbell and Macfarlane (1990. p. 221) have confirmed that “. . . the results of a number of studies had been published which did tend to suggest that the relationship between the hospital delivery rate and the decline in perinatal mortality was spurious.” Oakley has also argued that despite a more healthy population in which women have fewer children, the “tendency is to attribute greater safety in childbirth wholly to better medical care” (Oakley, 1979. p. 15). In a society where the process of pregnancy and childbearing have become medicalised, and a “cultural dependence on professional health care” exists (Oakley, 1979), women from minority ethnic groups have been identified as presenting “special problems,” and not using the maternity services in an “appropriate” way. Research into the use of maternity services by women from minority ethnic groups has also tended to identify and label service users in terms of broadly defined racial groupings. Asian women have been studied as an homogeneous group which has led to different cultural norms and religious beliefs being masked. As Phoenix (1990, p. 288) has pointed out, “the propensity to see black women as being ‘all the same’ is not only inaccurate, but also racially discriminatory, in that it can mask individual needs.” By focusing on a small group of Bangladeshi women and their childbearing experiences, I hoped that individual voices would be heard. Bangladeshi women coming to live in Britain are confronted with a highly developed system of preventative antenatal care. In Bangladesh, pregnancy and childbirth have for centuries been shrouded in the mystery of “Purdah,” the
associated concept of “pollution” and in many areas the belief in evil spirits or “bhuts” who are believed to be particularly attracted to pregnant and breast feeding women (Islam, 1980; McConville, 1988). Any knowledge a woman may possess about childbearing will usually have been gained in the private domain, passed on by her mother-in-law or another female relative. But activities and diet during the preand postnatal periods may be strongly influenced by traditional practices and religious beliefs. The religious teachings of the Koran are followed fervently by the majority of Bangladeshis who are Muslim; their belief is that their destiny is God’s will. Only those women from wealthy families can afford to pay for medical “check ups” during pregnancy, and only l-2% of Bangladeshi women deliver their babies in clinics or hospitals (McConville, 1988). For the vast majority there is no system of “professionalised” antenatal care; delivery occurs at home either alone or with the assistance of female relatives or women experienced in delivering babies but having no formal training or qualification, known as “dais” or “dhorunis” (Islam, 1980). Pregnancy and childbearing in Bangladesh are part of a “natural,” nonmedicalised process from which men are largely excluded, and in which women have control. In contrast, in Britain the move away from domicilliary midwife care to hospital based, male-dominated care that has occurred over the last 40 years has served to reinforce the illness view of pregnancy and childbearing “the health care system usually operates from the . , . assumption that all pregnancies are pathological until their normality is demonstrated after the event” (Garcia, Kilpatrick, & Richards, 1990, p. 4). Whilst pregnancy and childbearing in Bangladesh have remained within the private domain, and largely under the control of women, boundaries have shifted in Britain. A difference in the perception of need for medicalised antenatal care may then exist. METHODOLOGICAL
CONSIDERATIONS
The aim of the study was to examine how cultural and religious beliefs may influence use of maternity services amongst Bangladeshi women living in Britain, and the impact of a highly developed system of antenatal care on the “private” and “public” spheres of the women’s
Bangladeshi Women on Antenatal Interactions
lives. I proposed to interview Bangladeshi women to find out how they perceived antenatal services and their need for them. There were some obvious obstacles to be considered in the data collection process. These included: language difficulties, the difftculty of talking to Bangladeshi women on their own, the sensitive nature of potential data, and possible reactivity to a White researcher. As I had lived, worked, and travelled in Bangladesh and was sensitive to the religious beliefs and cultural traditions, some potential difficulties were avoided. As a woman and a mother I also hoped that a sense of shared sisterhood would exist/be achieved. But it was my research question being pursued, and I was aware of the power imbalance that might exist. As researcher and interviewer I would be an integral part of the research process, and although aware of the potential for reactivity, I was also aware that I could “never be a de-personal&d data collecting instrument purified of ‘bias”’ (Edwards, 1993, p. 16). It was after all because of who I was, my own experiences, that I had set out to explore this particular topic. I would also be in a position to interprete, include, or disregard the data collected as I chose, as Rhodes (1994, p. 555) has commented “. . . no matter how egalitarian the terms of the encounter and how much room the informants have to express themselves in their own terms, the interpretation usually remains that of the researcher.” By presenting as much of the transcribed data in the main text of the resulting research paper, I hoped to enable the women’s voices to be heard. Language difficulties have resulted in the common practice of women attending antenatal clinics accompanied by their husbands or a child who can translate for them. Attempts to collect data under such circumstances may result in inhibited responses; matters conceming pregnancy and childbirth have traditionally been located within the private sphere and the domain of women alone. Employing an interpreter to help overcome language difficulties could itself present problems (Edwards, 1993). The interpreter may interpret selectively, interpreting only that data she feels to be relevant or appropriate. Access to Bangladeshi women on their own is not only affected by the practice of using a husband or child as a translator. The behaviour of women in public and private is governed according to Islamic law by a strict code and by “purdah,” the physical exclusion
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from the outside world. For this reason women may be chaperoned by their husband or a male relative. Yet given the sensitive nature of the data sought it was considered preferable to interview women on their own, although this might prove difficult. The potential reaction to a White researcher was another factor to be considered. Although pregnancy and childbearing may be openly discussed amongst Bangladeshi women, I, as an ethnically different woman might have difficulty gaining their confidence. It was possible that I would be regarded with suspicion, perceived as an official figure, resulting in potential data being withheld. The anonymity that could be achieved through the use of a questionnaire was rejected, the advantages of an exploratory approach being favoured. Although the data collection process could be protracted, negotiating access and establishing rapport could take weeks or months; the potential richness of the women’s own accounts, collected in this way, far outweighed any time saving that might result from using quantitative methods of data collection. It was also decided to opt for a nonmedical setting. Interviewing respondents in a clinical stetting might give the study an official appearance and affect the data collected. The use of informal, in-depth interviewing would, it was hoped, enable data of a possibly sensitive nature to be collected, the setting and informality of the interview and the establishment of rapport enabling the respondent to feel relaxed and respond accordingly. As this was a pilot study, the data collection process would be constantly under review. NEGOTIATING INITIAL ACCESS Bangladeshi women living in Britain are a largely “hidden” group; their position is compounded by language difficulties and competing cultural traditions and religious beliefs. In order to talk to Bangladeshi women about their experiences of maternity services in Britain I had first to locate willing respondents. I had not anticipated just how difficult this would be, or appreciated the extent to which Bangladeshi women were a “hidden” group. The initial plan was that three interviews should be conducted with pregnant Bangladeshi women. The first would be carried out by myself and an interpreter, the second by the interpreter alone, and the third by myself and an interpreter interviewing a Bangladeshi
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woman who had been born in the United Kingdom and so might have been more exposed to “western” ideas of childbearing behaviour. Eventually these proposals were modified, but in any exploratory research the process of design is an ongoing part of the fieldwork. I hoped that initial access to potential respondents might be through a health visitor contact. Although I realised that this might result in a “biased” sample, that is, women who had attended antenatal clinics, I felt that by using snowball sampling to locate subsequent respondents the risk of “bias” would be reduced. A health visitor working in the locality was contacted, through a mutual friend, and the proposed area of research discussed. Although interested, she felt unable to act as a potential link to Bangladeshi women in her care. She thought that her involvement might make the women feel obliged to participate, her interest giving the research official sanction. She was able to suggest a Bangladeshi community worker who she felt might be able to help. Several attempts were made to contact the Bangladeshi community worker by telephone. Finally contact was made and I was able to explain my research interests. The community worker listened patiently and then explained that she was not in fact Bangladeshi but Indian. However, she was able to give me the name of a Bangladeshi lady who worked in the language organ&s office. Contact was eventually made with J. after telephone calls to her office and home. Once again I explained who I was and what I was doing. We arranged to meet to discuss my proposed area of research. At the meeting it transpired that J. had migrated from Bangladesh when a young child. She was married to a White British man, able to speak only limited Bengali but continued to observe the Muslim faith and dressed traditionally in a sari. She was interested in the research I was trying to carry out and shared some of her own experiences. It transpired that a Bangladeshi women’s group had been set up a few weeks previously. The group had been established through the language centre where J. worked, to encourage Bangladeshi women to venture outside their homes, to socialise with other Bangladeshi women, to sew and to learn English if they wished. The group met on a weekly basis in rooms above the language centre. I was invited to attend the next meeting when I would be able to discuss my research interests with the
women. The difficulty of accessing Bangladeshi women had been highlighted by my attempts to locate even a “gatekeeper.” NEGOTIATING A ROLE IN THE SElTlNG The process of gaining access had been initiated
with the invitation to the women’s group; however, the role I was to adopt there was not yet clear. I did not want to present myself as just a researcher, although that was primarily why I was joining the group, and determined to try to avoid such an overt role at the initial meeting. I felt that it would be counterproductive, casting me in an “offtcial” role and disturbing the “natural” setting of the group. In fact, at the first meeting J. introduced me to the women as a researcher, interested in antenatal care and Bangladeshi women, the very role I had hoped to avoid! The reaction of the women to this introduction was to look embarrassed, and murmur amongst themselves. I was aware that, in some ways, the information that I sought would involve the women sharing with me aspects of their lives traditionally bound within the private sphere. As Bangladeshi women they represented a collection of voices not often heard: “muted voices.” I hoped that through friendship and trust being established their voices might be heard, but I also recognised that the women might not be prepared to share their experiences with me, might remain suspicious of me, and that “self-muting” might occur. Over the course of the next three meetings I sought to minimise my appearance as a researcher and to negotiate a role of participant in the group, taking my children with me to join the others in the creche and taking my sewing along to the sewing group. The way in which I was perceived by the women would ultimately affect the data collected. During these meetings, which were usually attended by up to 10 women, I was quizzed about the time I had spent in Bangladesh and invited to speak Bengali. The women were keen to know whether I had visited Sylhet, the north eastern area of Bangladesh from which most of them came and what I had thought of it. It was this shared knowledge and appreciation of Bangladesh (“Bangla” - beautiful, “desh” - country), its religion, customs, and language, which united me with the other women in the group. Without this first-hand knowledge, I could not have presumed to undertake the research I was now embarking on.
Bangladeshi Women on Antenatal Interactions
I avoided talking about pregnancy and childbirth and usually spoke to the women individually, despite attempts by J. to get me to talk to the women as a group. I had judged by their initial reaction to my introduction that to address the women as a group would not be conducive to collecting data of a potentially sensitive nature, which on an individual basis I hoped to be able to gather. Throughout the process of gaining access and negotiating roles the contact who had enabled me to join the group used her authority to act as a “gatekeeper.” She appeared at times to be concerned about the time the interview sessions might take and that I was not actually giving the whole group a lecture on antenatal care. Eventually a research bargain, in a very real sense, was struck when I agreed to help organise the group creche once the interviews had been completed. The Bangladeshi women’s group had been set up with the help of a grant from the City Council. The women were brought to the meetings and taken home by mini-bus. An indication of how aware I was of the possibility of my presence disturbing the group, which had not been long established, was apparent when I attended my second meeting. Only three women were in the classroom and J. was looking very cross. She asked me to sit down and then left the room. By the time she returned I had convinced myself that the reason for the poor attendance was because the women did not want a “bideshi,” a White woman, joining their group. I was ready to apologise and leave when J. explained that the bus driver had failed to collect all the women, J. was especially cross because the driver was a Pakistani and had completely disregarded her instructions seeming to think he knew better than any woman. THE INTERVIEWS Three interviews were carried out during the course of my attendance at the Bangladeshi group meetings. The fitst interview lasted for approximately 2 hours and produced some interesting data. M. quickly relaxed as the interview progressed, and it was M. who raised issues of a potentially sensitive nature, for example, the 40 day period after birth in which a Muslim woman must abstain from any physical relationships with her husband and is not allowed to pray. Rapport had been established
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before the interview when we had spoken informally, we had found we had similar aged children and were closer in age ourselves than most of the other women. This respondent was unusual because she had worked as a checkout assistant in a supermarket whilst her husband was in Bangladesh, although she confided that to do so was “actually completely against our religion.” M. had been educated in Britain and was able to speak English fluently. The second interview was carried out during the course of the weekly meetings. This interview was set up as a result of time having become a major consideration in the research process and the failure of an interpreter to appear. (M., whom I had interviewed first, had agreed to act as an interpreter in subsequent interviews, but was by now heavily pregnant and waiting for the birth of her child before resuming attendance at the group). In the second interview I spoke to J., the group organiser and the person with whom I had first had contact. Although J. had come to live in Britain when she was 6 years of age and was now married to a White British man, she had continued to be a practising Muslim. She had also had contact, through her language teaching, with many Bangladeshi women living in both London and Oxford. Our relationship had passed through several stages. I felt that some rapport had been established when, having attended the group for 3 months, J. telephoned me to let me know that the meeting had been cancelled. Previously I had always to telephone her, or turn up to find out. As J. had introduced me to the group and was well aware of my research interests I felt able to ask more direct questions. However, I felt unable to ask what may have been perceived as questions of a sensitive nature, possibly because J. was older than me. Although J. did not think she would be a useful respondent, the interview produced some unexpectedly useful data. The third interview was carried out in a group. Three women were present and a younger Bangladeshi woman acted as an interpreter. This was the least “successful” interview. The women were all originally from rural Bangladesh and did not speak English. They were all older than me and, although they were used to me sitting in the sewing room alongside them and had asked me questions about my time in Bangladesh, our age differences and the language difficulties that existed had
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made it difftcult to establish any degree of rapport. I was aware that they had continued to be slightly reserved in their behaviour and chatter when I was present. The problems of using interpreters in research were highlighted by this interview. The only available interpreter from within the group was not really acceptable to the group. She was much younger than they were, unmarried, and had no personal experience of pregnancy and childbirth. The interpreter felt embarrassed, and so did the women. This interview lasted only 30 minutes, and, although I used the same agenda as in the other interviews, I felt restricted in the questions I could ask. The interview was not only dominated by the oldest woman present, but termlnated when she decreed. Their short responses may have been a result of not wishing to appear to be complaining about services in a country to which they had immigrated. They may have continued to regard me in an offrcial light and have been worried that their responses would become public. The process of “self-muting” was apparent amongst the women; the eldest, and possibly the most “powerful” within the group dictating to the other women present how the interview should “progress.” The disadvantages of using an interpreter were all too apparent from this exercise. I had very little control over the proceedings, and the ascribed attributes of the interpreter clearly affected the sort of data that could be collected. Interviewing the women in a group would, I had hoped, enable them to feel more relaxed. Clearly in this instance this was not the case. The fact that I could speak some Bengali and understand a lot more enabled me to follow the limited “progress*’ of the interview. Once the data had been collected the two taped interviews were transcribed and notes from the group interview written up. Throughout my attendance at the weekly meetings I had also kept a diary. The data was then segmented into different areas and analysed for recurrent themes. FINDINGS Practice of the Muslim religion To the non-Muslim it is difficult to appreciate how all-embracing the Muslim faith is. To the practising Muslim it is a way of life; every act has religious significance, and people judge themselves and others accordingly. However,
living in a non-Muslim society it appears that some adaptation may have to be made, boundaries between private and public spheres shift. How far this occurs varies from family to family. During our interview, M. commented Actually when we are living in England we can’t keep everything like we would in Bangladesh . . . when you step out from your home everything is different. It depends on the family actually . . . my friends their parents were not so strict and they did a lot of things the western way . . . all sorts of things I couldn’t do. The extent to which Muslims coming from Bangladesh adapt their traditional practices to fit in with the predominant traditions of British society may depend on whether they migrated from the rural areas of Bangladesh or from Dhaka, the capital city. The first respondent drew a distinction between rural women and those like herself who had lived in Dhaka. Interestingly, it was only in the group interview that it was necessary to use an interpreter; although the women had lived in Britain for at least 10 years, they had not learnt to speak English. The women in the group interview were all originally from rural Bangladesh. J. also made a distinction between women from rural Bangladesh and the city dweller, who was more likely to be educated. When I had asked her whether she would fast during ran&an (a month of fasting during daylight hours) she had replied, Yes, but not during pregnancy as most of these women would. The women she was referring to were those in the group from rural Bangladesh. Attendance at antenatal clinics All the women interviewed had attended antenatal clinics during their pregnancies in Britain. Of the five women interviewed only three had also had children whilst in Bangladesh. These women were the respondents in the group interview. I was able to ascertain that in Bangladesh they had not had any formalised antenatal care when pregnant, but the limitations imposed by the use of the interpreter, and
BangladeshiWomen on Antenatal Interactions
self-muting on the part of the women, meant that I was unable to gather any detailed information about this. The women in this group said that they had attended the antenatal clinic because they thought they had to. J. and M. had also regularly attended antenatal clinic sessions. This appeared to represent a partial acceptance of the dominant culture, an acceptance of one aspect of pregnancy and childbearing which had traditionally been located within the private domain shifting into the public domain. In turn, this had involved an erosion of the power that women had traditionally held in all matters relating to pregnancy and childbearing. The procedures followed during regular antenatal check-ups may involve practices that are contrary to the teachings of the Koran and Islamic law, for example, internal examinations by male doctors. On this matter M. had commented that this practice was . . . totally against our religion you see and that’s why we do prefer a lady doctor . . . I feel shame actually.
On the subject of recently arrived Bangladeshi women, M. went on to say, I’ve heard people talking, like you know they are embarrassed and feel shamed the way they check you out, especially with your first baby . . . it’s because they’re so different they’ve never seen these sort of things before. Four of the women interviewed had been able to register with female doctors and were happy with this arrangement. The other, who was registered with a male doctor was not so satisfied. Despite these reservations all the women had attended antenatal clinics. Language di#iculties and use of antenatal services Language difficulties, combined in some cases with the break up of extended family units, have led to changes in traditional practices amongst some Bangladeshis living in Britain. Because many women do not speak English they must take a relative with them to the antenatal clinic to translate for them. In Bangladesh all matters relating to pregnancy
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and childbirth are the domain of women alone; mothers, or more commonly mothers-in-law, would give any advice thought necessary. Migration to Britain has led to the break up of large extended family units. In many cases there is no mother or mother-in-law living in Britain and so increasingly husbands are becoming in-volved in this traditionally female area. In our discussion, M commented that The husband goes because they (the women) feel scared to death, they don’t speak the language and everything is so strange. For a woman from the village they feel really strange. J., the woman married to the White Briton, acknowledged that language problems had led to the practice of husbands acting as interpreters and that this was forcing them into a new role. It was also possible that the women’s needs were remaining unvoiced. J. went on to comment . . . the GP has complained to us (the language organisers) that husbands and wives never seem to have discussed anything before they come to the clinic. Once again the shifting of boundaries between private and public are apparent. Men may now chaperone their wives and become involved as interpreters, and appear to conform to a model of marital relationship expected by, in this instance, a GP. But within the private domain of the home it is apparent that matters relating to pregnancy and childbirth remain within the control of women and are not openly discussed with men. Although there may have been a shift in traditional practices in some families, not all are ready to accept change, as M. explained Some people they don’t understand and said “oh, it’s shame for boy to go.” The attitudes of other Bangladeshis living in the community also appeared important. When M. told me that she did not intend observing the fasting period of Ramadan as she was pregnant she added . . . but I know it will be awkward for me because people don’t think it’s a reasonable excuse.
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The influence of the Imam
Attitudes of other Bangladeshis may be more influential than those of the health professional. The attitudes of the Imam, the Muslim prayer leader, may be particularly influential. Decisions about whether to observe the period of ramadan when pregnant must be made by Bangladeshi women. Advice given by the Imam and the health professional may be contradictory. When interviewing M., she had said that although she had not observed ramadan when pregnant with her second child, she intended to in this her third pregnancy I did not fast (then) . . . but I wasn’t scared of religion so much then . . . But now to our religion it is quite a sin. She also expected her GP to advise her not to fast as ramadan would occur during the eighth month of her pregnancy, but she said she would disregard this advice. But not all Bangladeshi women would follow the advice of their religious teachers . . . some women you know they are not so religious, they actually prefer their doctor to tell them not to fast, so they enjoy not fasting.
The issue of ramadan highlights the potential conflict which can arise between the teachings of the Muslim religion and the practices of antenatal care. Interestingly, the teachings of the Muslim religion may also vary according to the Imam and his interpretation of the Koran, the Muslim holy book. M. explained . . . they just learn it (the Koran) by heart without having much idea of the meaning. They only get an idea of these meanings from the lrnam.. . that’s why a lot of people fast when theyarepmgnant... the Koran does say that you needn’t if it is going to make your baby ill . . . but they were sure they had to. The perception by health professionals of the significance of some Muslim practices to some Bangladeshi women may affect interactions in antenatal services. Health professionals may consider some religious practices such as the observance of ramadan as feckless behaviour during pregnancy. Yet the Bangladeshi mother may consider it feckless not to observe
ramadan, highlighting competing views of what is “feckless.” Cultural stereotyping and cultural change
Cultural perceptions and cultural stereotyping by health professionals may also influence use of antenatal services. J., who had lived in Britain since she was 6 years of age, spoke of her treatment at the antenatal clinic and her experiences of stereotyping by health workers Well, I think I give the image of being an Asian woman and people have their barriers . . . It’s difficult to be assertive even when you have the language, I feel I was bossed around and I feel quite resentful about that . . . and then the health visitor who came to see me before my child was born was making all sorts of wild assumptions too. She was alright once she got to know me, but she was being patronising at first. There is a danger of considering all Asian women to be the same. Yet clearly cultural differences and expectations exist, and these may independently affect an individual’s take up of antenatal services. There has been a tendency for health services and health workers to reflect a commonly held belief that all women from the Asian subcontinent are culturally homogeneous. Cultures are dynamic and, amongst the Bangladeshi women who attended the meetings, certain traditions appear to have changed, and boundaries shifted. The gradual involvement of men within what has previously been a woman’s domain has been described earlier. When interviewed and asked whether women would find it embarrassing to talk abouj. matters relating to pregnancy and childbirth m the presence of their husbands, M. commented No, nowadays it isn’t to be honest. It was (in) my Mums day when everything was so different, nowadays I think they don’t feel that shame . . . It’s nothing harmful or shameful to talk to one’s husband, it’s not, and this is what we are learning. Changes have occurred then over a generation.‘It is possible that these changes in behaviour and expectations may, in part, be as a
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result of migration to Britain. M. and J. had both been educated in the British school system and appeared more open to change even in the face of parental opposition. M. had even worked in a supermarket . . . the job I did is actually completely against our religion because Muslim women mustn’t show their hair, they mustn’t serve men . . . my Dad was very, very upset actually.
J. worked full time as a language teacher. The three women who had been interviewed in a group were all older and had migrated to Britain as married women. None of them had worked outside the home or learnt to speak English. Take up of parentcrafi classes
All the women interviewed had attended antenatal clinics when pregnant in Britain. An aspect of antenatal care which has been the focus of many initiatives by health authorities has been the promotion of Parentcraft classes (Munro, 1988). Only one of the five women interviewed had attended parentcraft classes. When the subject of parentcraft classes was raised in the group interview the interpreter did not at first understand what I meant. I explained what these classes were and went on to say that these classes were sometimes held in the evening, at which point she looked horrified and said “these women would not go out in the evening.” In the first interview it was M. who raised the subject of parentcraft classes. Toward the end of our interview I asked M. what she liked or did not like about antenatal care and was surprised to hear her warm to the subject of parentcraft classes. This was something she clearly had thought about and spoken to friends about. She went on to say That is what most mothers-in-law doesn’t like, they said “why so much bothering?’ . . . you have to go and practice . . . I think that’s not necessary, because our culture is so different, we do learn so much from our Mum. A lot of like English girls they’re away from their Mum, and I think for them it’s good. But for us it’s not because we do listen to our mum . . . our culture is totally different.
This suggests that some Bangladeshi women may be selective in the antenatal care they take up. It also highlights a difference in the perception of the need for certain services between the health professional and the Bangladeshi mother. According to M., mothers-in-law are not in favour of such classes. Certainly they must appear iu stark contrast to the preparation for childbirth that many of these older women would have experienced in Bangladesh. Similar findings were made in a wider study carried out into attitudes of Asian women to antenatal care (Jam, 1985). In her study, Jain found that only 2% of Asian women attended parentcraft or relaxation classes, and those who had were young mothers who had been educated in Britain. For those who did not take up the classes, Jain concludes that “the concept of mothercraft and parentcraft was a novelty.” It is possible that in families where mothers or mothers-in-law no longer form part of the household as a result of immigration to Britain, that in time parentcraft classes may be perceived as useful. J., who was the only one of the women interviewed to have attended parentcraft classes explained that her mother was dead. As J. was married to a White British man she would not be subject to the influence of her mother-in-law in the same way some Bangladeshi women would be. J. was also the only woman to have had her husband present at the birth of her child. DISCUSSION The difficulties of accessing Bangladeshi women were highlighted by this study, showing them to be a largely “hidden” group. Their position seemed to be compounded by a lack of English language skills, potentially rendering them “powerless” outside the private domain of their home. By accessing and interviewing a small group of women an opportunity for their voices to be heard was created, much of what they recounted being included in the main text of this article. Black women have been stereotyped as presenting special problems and not using maternity services in an “appropriate” way (Bowler, 1993; Phoenix, 1990). In this study all those women interviewed had attended antenatal clinics. When asked, they did not know of any Bangladeshi women who had avoided antenatal care in Britain. In Bangladesh, pregnancy
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and childbearing are located within the private sphere, under the control of women: Men are excluded. By taking up antenatal services in Britain a shift is discernible in the boundaries between the private and public spheres of the women’s lives. Because women often do not possess the language, or are perceived as needing to be chaperoned, men have increasingly become involved in clinic and hospital visits. Yet although women may have handed over some of their “control” over their pregnancy to health professionals in the clinic setting, it is suggested that men continue to be excluded from discussions within the private domain of the home. The comment by the GP who complained “that husbands and wives never seem to have discussed anything before they come to the clinic” reflects this. Although the women in this small study had attended antenatal clinics, it is necessary to question the quality of the care received. Because many Bangladeshi women do not speak English, and their husbands are not always keen for them to learn, husbands have increasingly come to play an intermediary role. At the antenatal clinic they interpret for their wives, translating what the health professional says. There is a danger in this practice that the womans emotional and other “needs” may remain unvoiced, yet exposure of these may further erode her control in this area. Information and advice given may be couched in unfamiliar terms. Cultural assumptions and stereotyping by health professionals may also affect the quality of the antenatal care given. The women interviewed in this study were all practising Muslims. It was apparent from what they said that, at times, religious beliefs and practices were in conflict with the predominately eurocentric model of antenatal care. Contradictory information given, on the one hand by the Imam and on the other hand by the health professional, leads to confusion and highlights competing models of what constitutes “good practice.” The issue of ramadan illustrated this. The changing pattern of the traditional extended Bangladeshi family, in part the result of migration to Britain, does appear to have led to some changes in the role adopted by husbands. Although cultures are dynamic, not all adaptation or change is welcomed. Whilst husbands may now be involved “publicly” with an area which has traditionally been both private and
female, these Bangladeshi women had rejected attempts to move other, traditionally private areas of their pregnancy and childbearing into a more public arena. Parentcraft classes were an example of this. The perception of the need for certain antenatal services was found to differ between the women and service providers. Parentcraft classes were attended by one of the women interviewed. Preparation for parenthood in this way was not perceived as necessary by the women, or according to one informant, by their mothers-in-law, because of the nature of their “different culture.” Language difficulties are a major consideration in any cross-cultural research, and the potential problems of using an interpreter were apparent in this study. As a woman and mother who had lived and worked in Bangladesh I was able to join the group and establish rapport with some of the women, while others continued to be suspicious of me. This necessarily dictated what could be talked about and with whom. By joining the group I was able to talk to some of the women on an individual basis about their experiences of maternity care in Britain and begin to explore how the boundaries between traditionally private and public areas may be changing. Larger studies have tended to assume cultural and religious homogeneity, grouping women according to skin colour or continent of origin, and some health professionals have been found to stereotype accordingly. The women interviewed were all British citizens, and in a multicultured society it is imperative that maternity services are sensitive to women’s individual “needs”, however and whatever they may interpret them to be. REFERENCES Bowler, Isabel. (1993). Stereotypes of women of Asian descent in midwifery: Some evidence. Midwifery, 9,7-16. Campbell, Rona, & Macfarlane, Alison. (1990). Recent dkbate on the place of birth. In Jo Garcia, Robert Kiloatrick. . . & Martin Richards (Eds.), The politics of matemily care (pp. 217-237). Oxford:~&re~don Press~ Charles, C. A. (1983). A midwife’s experience of the Asian community. In Midwife, Health Visitor and Community Nurse. 19,471-473. Clarke, M., & Clayton, D. G. (1983). Quality of obstetric
care provided for Asian immigrants in Leicestershire. British Medical Journal, 286,621-622. Edwards, Rosaiind. (1993, April). fnterprefing infer-views: Language and power: The we and abuse of interpreters
in the research process. Paper presented at the British Sociological Association Annual Conference, University of Essex.
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Firdous, R., & Bhopal, R. S. (1989). Reproductive health of Asian women: A comparative study with hospital and community perspectives. Public Health Journul, M(4),
307-315.
Garcia, Jo, Kilpatrick, Robert, & Richards, Martin (1990). The politics ofmutemity care. Oxford: Clarendon Press. Islam, Mahmuda (I 980). Folk medicine and rural women in Bangludesh. Dhaka: Women for Women Research Group. Jain, Chanchal. (1985). Attitudes ofpnqant Asian women to antenutal care. Birmingham: West Midlands Regional Health Authority. Lumb. K. M., Congdon, P. J., & Lealman, G. T. (1981). A comparative review of Asian and British born maternity patients in Bradford 1974-1978. Journnl of Epidemiology and Community Health, 35,106109.
Mayes, Mary. (1988). Mayes midwifery: A textbook for midwives (I I th ed.). London: Bailliem. and Trindall.
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McConville, Frances. (1988). The birth attendant in Bangladesh. In Sheila Kitzinger (Ed.), The midwife challenge (pp. 143-154). London: Pandora Press. Munro, June. (1988). ParentcraB classes with Bengali mothers. Health Ksitor. 61.48. The National Audit Office. (1990). Report on maternity services. London: HMSO. Oakley, Ann. (1979). From here to maternity: Becoming a mother. Oxford: Martin Robertson & Company. Phoenix, Ann. (1990). Black women and the maternity services. In Jo Garcia, Robert Kilpatrick, & Martin Richards (Eds.), The politics of maternity care (pp. 274-299). Oxford: Clarendon Press. Rhodes, Penny J. (1994). Race-of-interviewer effects: A brief comment. Sociology, 22.547558. Short Report (Second Report From the Social Services Committee). (I 980). Perimztul and Neonatal Mortulity. London: HMSO.
Women’s Studies InternationalForum.Vol. 18. No. 3, pp. 2%309. 19% CopyrightQ 1995 Elsevier Science Ltd Printedin the USA. All tights reserved 0277~5395/95$9.50 + .oO
SHIFTING BOUNDARIES Exploring the Influence of Cultural Traditions and Religious Beliefs of Bangladeshi Women on Antenatal Interactions TINA MILLER School of Social Sciences, Oxford Brookes University, Gipsy Lane Campus, Headington, Oxford OX3 OBP, UK
Synopsis - For the majority of women living in Bangladesh there is no formalised system of antenatal care. Bangladeshi women coming to live in the United Kingdom are confronted with a highly developed system of preventative antenatal care, alien in many respects to their previous experiences. In this study the religious beliefs and cultural practices of Bangladeshi women were explored to see how they may influence take up of antenatal services. In turn, the boundaries between traditionally “private” (domestic and female) and “‘public” (wider, professionally defined) spheres were considered, and the implications of this for “control” in pregnancy and childbearing were explored. The difftculty of locating and accessing a “hidden” group was a major methodological consideration. The data collected showed that the women interviewed had attended antenatal clinics, and that whilst some shifts in the boundaries between “private” and “public” spheres were accepted, others had been rejected, and “control” retained.
During the early 1980s I lived in Dhaka, the capital of Bangladesh, for 2 l/2 years. I worked at a children’s hospital and spent time in the “bustees” the urban slums, tracing former inpatients of the hospital in order to assess their nutritional status. I returned from Bangladesh midway through my stay for the birth of my frost child. The morning after my daughter was born I was aware of a commotion in the next bed. The new mother, a Bangladeshi, was in a state of bewilderment, and the two auxiliary nurses she was appealing to had failed with sign language and were looking slightly bemused. I was able to interpret for her; she was in pain and was thirsty. The sense of her bewilderment at being in alien surroundings with no means of communication remained with me. By the time my third daughter was born I was studying for an M.Sc. and able to pursue my interest in the delivery of maternity services to women from minority ethnic groups living in Britain. The following is an account of a pilot study which set out to explore how cultural and
religious beliefs might affect the use of maternity services by a small group of Bangladeshi women living in Britain, and how boundaries between traditionally “private” and “public” spheres may be changing. “Private” being the domestic and female domain and “public” the wider context of professional definitions and domination. The methodological implications involved in accessing a largely “hidden” group and undertaking a piece of cross-cultural research were also considered. Between the years 1975 and 1987 perinatal mortality rates in Britain, that is “all stillbirths and all deaths in the first week of life per one thousand registered total births” (Mayes, 1988) were halved. Despite this, a report on Maternity Services published in 1990 (National Audit Office, 1990) confirmed that certain minority ethnic groups showed an unacceptably high incidence of perinatal mortality, which could not be explained by socioeconomic factors alone. These findings are supported by other studies (Lumb, Congdon, & Lealman, 1981; Short Committee Report, 1980) which in recent years have focused on the “problems” of minority ethnic groups and access to health
With thanks to the women who allowed the author to join their group and who shared their experiences. 299
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services. Other research has suggested that higher perinatal mortality and congenital malformation rates occur in Asian mothers when compared with British born mothers (Clarke & Clayton, 1983; Lumb et al., 1981). Mothers of Asian origin have also been found to be more susceptible to dietary deficiencies during pregnancy, premature labour, and to be delivered of small-for-dates babies (Charles, 1983; Lumb et al., 1981). In recent years interest has grown in antenatal care provision and take up of services by women from minority ethnic groups; underutilisation of antenatal services has been associated with higher perinatal mortality rates (Firdous & Bhopal, 1989). Yet the extent to which lower perinatal mortality rates can be attributed to “better” maternity care is a matter of some debate. Campbell and Macfarlane (1990. p. 221) have confirmed that “. . . the results of a number of studies had been published which did tend to suggest that the relationship between the hospital delivery rate and the decline in perinatal mortality was spurious.” Oakley has also argued that despite a more healthy population in which women have fewer children, the “tendency is to attribute greater safety in childbirth wholly to better medical care” (Oakley, 1979. p. 15). In a society where the process of pregnancy and childbearing have become medicalised, and a “cultural dependence on professional health care” exists (Oakley, 1979), women from minority ethnic groups have been identified as presenting “special problems,” and not using the maternity services in an “appropriate” way. Research into the use of maternity services by women from minority ethnic groups has also tended to identify and label service users in terms of broadly defined racial groupings. Asian women have been studied as an homogeneous group which has led to different cultural norms and religious beliefs being masked. As Phoenix (1990, p. 288) has pointed out, “the propensity to see black women as being ‘all the same’ is not only inaccurate, but also racially discriminatory, in that it can mask individual needs.” By focusing on a small group of Bangladeshi women and their childbearing experiences, I hoped that individual voices would be heard. Bangladeshi women coming to live in Britain are confronted with a highly developed system of preventative antenatal care. In Bangladesh, pregnancy and childbirth have for centuries been shrouded in the mystery of “Purdah,” the
associated concept of “pollution” and in many areas the belief in evil spirits or “bhuts” who are believed to be particularly attracted to pregnant and breast feeding women (Islam, 1980; McConville, 1988). Any knowledge a woman may possess about childbearing will usually have been gained in the private domain, passed on by her mother-in-law or another female relative. But activities and diet during the preand postnatal periods may be strongly influenced by traditional practices and religious beliefs. The religious teachings of the Koran are followed fervently by the majority of Bangladeshis who are Muslim; their belief is that their destiny is God’s will. Only those women from wealthy families can afford to pay for medical “check ups” during pregnancy, and only l-2% of Bangladeshi women deliver their babies in clinics or hospitals (McConville, 1988). For the vast majority there is no system of “professionalised” antenatal care; delivery occurs at home either alone or with the assistance of female relatives or women experienced in delivering babies but having no formal training or qualification, known as “dais” or “dhorunis” (Islam, 1980). Pregnancy and childbearing in Bangladesh are part of a “natural,” nonmedicalised process from which men are largely excluded, and in which women have control. In contrast, in Britain the move away from domicilliary midwife care to hospital based, male-dominated care that has occurred over the last 40 years has served to reinforce the illness view of pregnancy and childbearing “the health care system usually operates from the . , . assumption that all pregnancies are pathological until their normality is demonstrated after the event” (Garcia, Kilpatrick, & Richards, 1990, p. 4). Whilst pregnancy and childbearing in Bangladesh have remained within the private domain, and largely under the control of women, boundaries have shifted in Britain. A difference in the perception of need for medicalised antenatal care may then exist. METHODOLOGICAL
CONSIDERATIONS
The aim of the study was to examine how cultural and religious beliefs may influence use of maternity services amongst Bangladeshi women living in Britain, and the impact of a highly developed system of antenatal care on the “private” and “public” spheres of the women’s
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lives. I proposed to interview Bangladeshi women to find out how they perceived antenatal services and their need for them. There were some obvious obstacles to be considered in the data collection process. These included: language difficulties, the difftculty of talking to Bangladeshi women on their own, the sensitive nature of potential data, and possible reactivity to a White researcher. As I had lived, worked, and travelled in Bangladesh and was sensitive to the religious beliefs and cultural traditions, some potential difficulties were avoided. As a woman and a mother I also hoped that a sense of shared sisterhood would exist/be achieved. But it was my research question being pursued, and I was aware of the power imbalance that might exist. As researcher and interviewer I would be an integral part of the research process, and although aware of the potential for reactivity, I was also aware that I could “never be a de-personal&d data collecting instrument purified of ‘bias”’ (Edwards, 1993, p. 16). It was after all because of who I was, my own experiences, that I had set out to explore this particular topic. I would also be in a position to interprete, include, or disregard the data collected as I chose, as Rhodes (1994, p. 555) has commented “. . . no matter how egalitarian the terms of the encounter and how much room the informants have to express themselves in their own terms, the interpretation usually remains that of the researcher.” By presenting as much of the transcribed data in the main text of the resulting research paper, I hoped to enable the women’s voices to be heard. Language difficulties have resulted in the common practice of women attending antenatal clinics accompanied by their husbands or a child who can translate for them. Attempts to collect data under such circumstances may result in inhibited responses; matters conceming pregnancy and childbirth have traditionally been located within the private sphere and the domain of women alone. Employing an interpreter to help overcome language difficulties could itself present problems (Edwards, 1993). The interpreter may interpret selectively, interpreting only that data she feels to be relevant or appropriate. Access to Bangladeshi women on their own is not only affected by the practice of using a husband or child as a translator. The behaviour of women in public and private is governed according to Islamic law by a strict code and by “purdah,” the physical exclusion
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from the outside world. For this reason women may be chaperoned by their husband or a male relative. Yet given the sensitive nature of the data sought it was considered preferable to interview women on their own, although this might prove difficult. The potential reaction to a White researcher was another factor to be considered. Although pregnancy and childbearing may be openly discussed amongst Bangladeshi women, I, as an ethnically different woman might have difficulty gaining their confidence. It was possible that I would be regarded with suspicion, perceived as an official figure, resulting in potential data being withheld. The anonymity that could be achieved through the use of a questionnaire was rejected, the advantages of an exploratory approach being favoured. Although the data collection process could be protracted, negotiating access and establishing rapport could take weeks or months; the potential richness of the women’s own accounts, collected in this way, far outweighed any time saving that might result from using quantitative methods of data collection. It was also decided to opt for a nonmedical setting. Interviewing respondents in a clinical stetting might give the study an official appearance and affect the data collected. The use of informal, in-depth interviewing would, it was hoped, enable data of a possibly sensitive nature to be collected, the setting and informality of the interview and the establishment of rapport enabling the respondent to feel relaxed and respond accordingly. As this was a pilot study, the data collection process would be constantly under review. NEGOTIATING INITIAL ACCESS Bangladeshi women living in Britain are a largely “hidden” group; their position is compounded by language difficulties and competing cultural traditions and religious beliefs. In order to talk to Bangladeshi women about their experiences of maternity services in Britain I had first to locate willing respondents. I had not anticipated just how difficult this would be, or appreciated the extent to which Bangladeshi women were a “hidden” group. The initial plan was that three interviews should be conducted with pregnant Bangladeshi women. The first would be carried out by myself and an interpreter, the second by the interpreter alone, and the third by myself and an interpreter interviewing a Bangladeshi
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woman who had been born in the United Kingdom and so might have been more exposed to “western” ideas of childbearing behaviour. Eventually these proposals were modified, but in any exploratory research the process of design is an ongoing part of the fieldwork. I hoped that initial access to potential respondents might be through a health visitor contact. Although I realised that this might result in a “biased” sample, that is, women who had attended antenatal clinics, I felt that by using snowball sampling to locate subsequent respondents the risk of “bias” would be reduced. A health visitor working in the locality was contacted, through a mutual friend, and the proposed area of research discussed. Although interested, she felt unable to act as a potential link to Bangladeshi women in her care. She thought that her involvement might make the women feel obliged to participate, her interest giving the research official sanction. She was able to suggest a Bangladeshi community worker who she felt might be able to help. Several attempts were made to contact the Bangladeshi community worker by telephone. Finally contact was made and I was able to explain my research interests. The community worker listened patiently and then explained that she was not in fact Bangladeshi but Indian. However, she was able to give me the name of a Bangladeshi lady who worked in the language organ&s office. Contact was eventually made with J. after telephone calls to her office and home. Once again I explained who I was and what I was doing. We arranged to meet to discuss my proposed area of research. At the meeting it transpired that J. had migrated from Bangladesh when a young child. She was married to a White British man, able to speak only limited Bengali but continued to observe the Muslim faith and dressed traditionally in a sari. She was interested in the research I was trying to carry out and shared some of her own experiences. It transpired that a Bangladeshi women’s group had been set up a few weeks previously. The group had been established through the language centre where J. worked, to encourage Bangladeshi women to venture outside their homes, to socialise with other Bangladeshi women, to sew and to learn English if they wished. The group met on a weekly basis in rooms above the language centre. I was invited to attend the next meeting when I would be able to discuss my research interests with the
women. The difficulty of accessing Bangladeshi women had been highlighted by my attempts to locate even a “gatekeeper.” NEGOTIATING A ROLE IN THE SElTlNG The process of gaining access had been initiated
with the invitation to the women’s group; however, the role I was to adopt there was not yet clear. I did not want to present myself as just a researcher, although that was primarily why I was joining the group, and determined to try to avoid such an overt role at the initial meeting. I felt that it would be counterproductive, casting me in an “offtcial” role and disturbing the “natural” setting of the group. In fact, at the first meeting J. introduced me to the women as a researcher, interested in antenatal care and Bangladeshi women, the very role I had hoped to avoid! The reaction of the women to this introduction was to look embarrassed, and murmur amongst themselves. I was aware that, in some ways, the information that I sought would involve the women sharing with me aspects of their lives traditionally bound within the private sphere. As Bangladeshi women they represented a collection of voices not often heard: “muted voices.” I hoped that through friendship and trust being established their voices might be heard, but I also recognised that the women might not be prepared to share their experiences with me, might remain suspicious of me, and that “self-muting” might occur. Over the course of the next three meetings I sought to minimise my appearance as a researcher and to negotiate a role of participant in the group, taking my children with me to join the others in the creche and taking my sewing along to the sewing group. The way in which I was perceived by the women would ultimately affect the data collected. During these meetings, which were usually attended by up to 10 women, I was quizzed about the time I had spent in Bangladesh and invited to speak Bengali. The women were keen to know whether I had visited Sylhet, the north eastern area of Bangladesh from which most of them came and what I had thought of it. It was this shared knowledge and appreciation of Bangladesh (“Bangla” - beautiful, “desh” - country), its religion, customs, and language, which united me with the other women in the group. Without this first-hand knowledge, I could not have presumed to undertake the research I was now embarking on.
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I avoided talking about pregnancy and childbirth and usually spoke to the women individually, despite attempts by J. to get me to talk to the women as a group. I had judged by their initial reaction to my introduction that to address the women as a group would not be conducive to collecting data of a potentially sensitive nature, which on an individual basis I hoped to be able to gather. Throughout the process of gaining access and negotiating roles the contact who had enabled me to join the group used her authority to act as a “gatekeeper.” She appeared at times to be concerned about the time the interview sessions might take and that I was not actually giving the whole group a lecture on antenatal care. Eventually a research bargain, in a very real sense, was struck when I agreed to help organise the group creche once the interviews had been completed. The Bangladeshi women’s group had been set up with the help of a grant from the City Council. The women were brought to the meetings and taken home by mini-bus. An indication of how aware I was of the possibility of my presence disturbing the group, which had not been long established, was apparent when I attended my second meeting. Only three women were in the classroom and J. was looking very cross. She asked me to sit down and then left the room. By the time she returned I had convinced myself that the reason for the poor attendance was because the women did not want a “bideshi,” a White woman, joining their group. I was ready to apologise and leave when J. explained that the bus driver had failed to collect all the women, J. was especially cross because the driver was a Pakistani and had completely disregarded her instructions seeming to think he knew better than any woman. THE INTERVIEWS Three interviews were carried out during the course of my attendance at the Bangladeshi group meetings. The fitst interview lasted for approximately 2 hours and produced some interesting data. M. quickly relaxed as the interview progressed, and it was M. who raised issues of a potentially sensitive nature, for example, the 40 day period after birth in which a Muslim woman must abstain from any physical relationships with her husband and is not allowed to pray. Rapport had been established
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before the interview when we had spoken informally, we had found we had similar aged children and were closer in age ourselves than most of the other women. This respondent was unusual because she had worked as a checkout assistant in a supermarket whilst her husband was in Bangladesh, although she confided that to do so was “actually completely against our religion.” M. had been educated in Britain and was able to speak English fluently. The second interview was carried out during the course of the weekly meetings. This interview was set up as a result of time having become a major consideration in the research process and the failure of an interpreter to appear. (M., whom I had interviewed first, had agreed to act as an interpreter in subsequent interviews, but was by now heavily pregnant and waiting for the birth of her child before resuming attendance at the group). In the second interview I spoke to J., the group organiser and the person with whom I had first had contact. Although J. had come to live in Britain when she was 6 years of age and was now married to a White British man, she had continued to be a practising Muslim. She had also had contact, through her language teaching, with many Bangladeshi women living in both London and Oxford. Our relationship had passed through several stages. I felt that some rapport had been established when, having attended the group for 3 months, J. telephoned me to let me know that the meeting had been cancelled. Previously I had always to telephone her, or turn up to find out. As J. had introduced me to the group and was well aware of my research interests I felt able to ask more direct questions. However, I felt unable to ask what may have been perceived as questions of a sensitive nature, possibly because J. was older than me. Although J. did not think she would be a useful respondent, the interview produced some unexpectedly useful data. The third interview was carried out in a group. Three women were present and a younger Bangladeshi woman acted as an interpreter. This was the least “successful” interview. The women were all originally from rural Bangladesh and did not speak English. They were all older than me and, although they were used to me sitting in the sewing room alongside them and had asked me questions about my time in Bangladesh, our age differences and the language difficulties that existed had
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made it difftcult to establish any degree of rapport. I was aware that they had continued to be slightly reserved in their behaviour and chatter when I was present. The problems of using interpreters in research were highlighted by this interview. The only available interpreter from within the group was not really acceptable to the group. She was much younger than they were, unmarried, and had no personal experience of pregnancy and childbirth. The interpreter felt embarrassed, and so did the women. This interview lasted only 30 minutes, and, although I used the same agenda as in the other interviews, I felt restricted in the questions I could ask. The interview was not only dominated by the oldest woman present, but termlnated when she decreed. Their short responses may have been a result of not wishing to appear to be complaining about services in a country to which they had immigrated. They may have continued to regard me in an offrcial light and have been worried that their responses would become public. The process of “self-muting” was apparent amongst the women; the eldest, and possibly the most “powerful” within the group dictating to the other women present how the interview should “progress.” The disadvantages of using an interpreter were all too apparent from this exercise. I had very little control over the proceedings, and the ascribed attributes of the interpreter clearly affected the sort of data that could be collected. Interviewing the women in a group would, I had hoped, enable them to feel more relaxed. Clearly in this instance this was not the case. The fact that I could speak some Bengali and understand a lot more enabled me to follow the limited “progress*’ of the interview. Once the data had been collected the two taped interviews were transcribed and notes from the group interview written up. Throughout my attendance at the weekly meetings I had also kept a diary. The data was then segmented into different areas and analysed for recurrent themes. FINDINGS Practice of the Muslim religion To the non-Muslim it is difficult to appreciate how all-embracing the Muslim faith is. To the practising Muslim it is a way of life; every act has religious significance, and people judge themselves and others accordingly. However,
living in a non-Muslim society it appears that some adaptation may have to be made, boundaries between private and public spheres shift. How far this occurs varies from family to family. During our interview, M. commented Actually when we are living in England we can’t keep everything like we would in Bangladesh . . . when you step out from your home everything is different. It depends on the family actually . . . my friends their parents were not so strict and they did a lot of things the western way . . . all sorts of things I couldn’t do. The extent to which Muslims coming from Bangladesh adapt their traditional practices to fit in with the predominant traditions of British society may depend on whether they migrated from the rural areas of Bangladesh or from Dhaka, the capital city. The first respondent drew a distinction between rural women and those like herself who had lived in Dhaka. Interestingly, it was only in the group interview that it was necessary to use an interpreter; although the women had lived in Britain for at least 10 years, they had not learnt to speak English. The women in the group interview were all originally from rural Bangladesh. J. also made a distinction between women from rural Bangladesh and the city dweller, who was more likely to be educated. When I had asked her whether she would fast during ran&an (a month of fasting during daylight hours) she had replied, Yes, but not during pregnancy as most of these women would. The women she was referring to were those in the group from rural Bangladesh. Attendance at antenatal clinics All the women interviewed had attended antenatal clinics during their pregnancies in Britain. Of the five women interviewed only three had also had children whilst in Bangladesh. These women were the respondents in the group interview. I was able to ascertain that in Bangladesh they had not had any formalised antenatal care when pregnant, but the limitations imposed by the use of the interpreter, and
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self-muting on the part of the women, meant that I was unable to gather any detailed information about this. The women in this group said that they had attended the antenatal clinic because they thought they had to. J. and M. had also regularly attended antenatal clinic sessions. This appeared to represent a partial acceptance of the dominant culture, an acceptance of one aspect of pregnancy and childbearing which had traditionally been located within the private domain shifting into the public domain. In turn, this had involved an erosion of the power that women had traditionally held in all matters relating to pregnancy and childbearing. The procedures followed during regular antenatal check-ups may involve practices that are contrary to the teachings of the Koran and Islamic law, for example, internal examinations by male doctors. On this matter M. had commented that this practice was . . . totally against our religion you see and that’s why we do prefer a lady doctor . . . I feel shame actually.
On the subject of recently arrived Bangladeshi women, M. went on to say, I’ve heard people talking, like you know they are embarrassed and feel shamed the way they check you out, especially with your first baby . . . it’s because they’re so different they’ve never seen these sort of things before. Four of the women interviewed had been able to register with female doctors and were happy with this arrangement. The other, who was registered with a male doctor was not so satisfied. Despite these reservations all the women had attended antenatal clinics. Language di#iculties and use of antenatal services Language difficulties, combined in some cases with the break up of extended family units, have led to changes in traditional practices amongst some Bangladeshis living in Britain. Because many women do not speak English they must take a relative with them to the antenatal clinic to translate for them. In Bangladesh all matters relating to pregnancy
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and childbirth are the domain of women alone; mothers, or more commonly mothers-in-law, would give any advice thought necessary. Migration to Britain has led to the break up of large extended family units. In many cases there is no mother or mother-in-law living in Britain and so increasingly husbands are becoming in-volved in this traditionally female area. In our discussion, M commented that The husband goes because they (the women) feel scared to death, they don’t speak the language and everything is so strange. For a woman from the village they feel really strange. J., the woman married to the White Briton, acknowledged that language problems had led to the practice of husbands acting as interpreters and that this was forcing them into a new role. It was also possible that the women’s needs were remaining unvoiced. J. went on to comment . . . the GP has complained to us (the language organisers) that husbands and wives never seem to have discussed anything before they come to the clinic. Once again the shifting of boundaries between private and public are apparent. Men may now chaperone their wives and become involved as interpreters, and appear to conform to a model of marital relationship expected by, in this instance, a GP. But within the private domain of the home it is apparent that matters relating to pregnancy and childbirth remain within the control of women and are not openly discussed with men. Although there may have been a shift in traditional practices in some families, not all are ready to accept change, as M. explained Some people they don’t understand and said “oh, it’s shame for boy to go.” The attitudes of other Bangladeshis living in the community also appeared important. When M. told me that she did not intend observing the fasting period of Ramadan as she was pregnant she added . . . but I know it will be awkward for me because people don’t think it’s a reasonable excuse.
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The influence of the Imam
Attitudes of other Bangladeshis may be more influential than those of the health professional. The attitudes of the Imam, the Muslim prayer leader, may be particularly influential. Decisions about whether to observe the period of ramadan when pregnant must be made by Bangladeshi women. Advice given by the Imam and the health professional may be contradictory. When interviewing M., she had said that although she had not observed ramadan when pregnant with her second child, she intended to in this her third pregnancy I did not fast (then) . . . but I wasn’t scared of religion so much then . . . But now to our religion it is quite a sin. She also expected her GP to advise her not to fast as ramadan would occur during the eighth month of her pregnancy, but she said she would disregard this advice. But not all Bangladeshi women would follow the advice of their religious teachers . . . some women you know they are not so religious, they actually prefer their doctor to tell them not to fast, so they enjoy not fasting.
The issue of ramadan highlights the potential conflict which can arise between the teachings of the Muslim religion and the practices of antenatal care. Interestingly, the teachings of the Muslim religion may also vary according to the Imam and his interpretation of the Koran, the Muslim holy book. M. explained . . . they just learn it (the Koran) by heart without having much idea of the meaning. They only get an idea of these meanings from the lrnam.. . that’s why a lot of people fast when theyarepmgnant... the Koran does say that you needn’t if it is going to make your baby ill . . . but they were sure they had to. The perception by health professionals of the significance of some Muslim practices to some Bangladeshi women may affect interactions in antenatal services. Health professionals may consider some religious practices such as the observance of ramadan as feckless behaviour during pregnancy. Yet the Bangladeshi mother may consider it feckless not to observe
ramadan, highlighting competing views of what is “feckless.” Cultural stereotyping and cultural change
Cultural perceptions and cultural stereotyping by health professionals may also influence use of antenatal services. J., who had lived in Britain since she was 6 years of age, spoke of her treatment at the antenatal clinic and her experiences of stereotyping by health workers Well, I think I give the image of being an Asian woman and people have their barriers . . . It’s difficult to be assertive even when you have the language, I feel I was bossed around and I feel quite resentful about that . . . and then the health visitor who came to see me before my child was born was making all sorts of wild assumptions too. She was alright once she got to know me, but she was being patronising at first. There is a danger of considering all Asian women to be the same. Yet clearly cultural differences and expectations exist, and these may independently affect an individual’s take up of antenatal services. There has been a tendency for health services and health workers to reflect a commonly held belief that all women from the Asian subcontinent are culturally homogeneous. Cultures are dynamic and, amongst the Bangladeshi women who attended the meetings, certain traditions appear to have changed, and boundaries shifted. The gradual involvement of men within what has previously been a woman’s domain has been described earlier. When interviewed and asked whether women would find it embarrassing to talk abouj. matters relating to pregnancy and childbirth m the presence of their husbands, M. commented No, nowadays it isn’t to be honest. It was (in) my Mums day when everything was so different, nowadays I think they don’t feel that shame . . . It’s nothing harmful or shameful to talk to one’s husband, it’s not, and this is what we are learning. Changes have occurred then over a generation.‘It is possible that these changes in behaviour and expectations may, in part, be as a
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result of migration to Britain. M. and J. had both been educated in the British school system and appeared more open to change even in the face of parental opposition. M. had even worked in a supermarket . . . the job I did is actually completely against our religion because Muslim women mustn’t show their hair, they mustn’t serve men . . . my Dad was very, very upset actually.
J. worked full time as a language teacher. The three women who had been interviewed in a group were all older and had migrated to Britain as married women. None of them had worked outside the home or learnt to speak English. Take up of parentcrafi classes
All the women interviewed had attended antenatal clinics when pregnant in Britain. An aspect of antenatal care which has been the focus of many initiatives by health authorities has been the promotion of Parentcraft classes (Munro, 1988). Only one of the five women interviewed had attended parentcraft classes. When the subject of parentcraft classes was raised in the group interview the interpreter did not at first understand what I meant. I explained what these classes were and went on to say that these classes were sometimes held in the evening, at which point she looked horrified and said “these women would not go out in the evening.” In the first interview it was M. who raised the subject of parentcraft classes. Toward the end of our interview I asked M. what she liked or did not like about antenatal care and was surprised to hear her warm to the subject of parentcraft classes. This was something she clearly had thought about and spoken to friends about. She went on to say That is what most mothers-in-law doesn’t like, they said “why so much bothering?’ . . . you have to go and practice . . . I think that’s not necessary, because our culture is so different, we do learn so much from our Mum. A lot of like English girls they’re away from their Mum, and I think for them it’s good. But for us it’s not because we do listen to our mum . . . our culture is totally different.
This suggests that some Bangladeshi women may be selective in the antenatal care they take up. It also highlights a difference in the perception of the need for certain services between the health professional and the Bangladeshi mother. According to M., mothers-in-law are not in favour of such classes. Certainly they must appear iu stark contrast to the preparation for childbirth that many of these older women would have experienced in Bangladesh. Similar findings were made in a wider study carried out into attitudes of Asian women to antenatal care (Jam, 1985). In her study, Jain found that only 2% of Asian women attended parentcraft or relaxation classes, and those who had were young mothers who had been educated in Britain. For those who did not take up the classes, Jain concludes that “the concept of mothercraft and parentcraft was a novelty.” It is possible that in families where mothers or mothers-in-law no longer form part of the household as a result of immigration to Britain, that in time parentcraft classes may be perceived as useful. J., who was the only one of the women interviewed to have attended parentcraft classes explained that her mother was dead. As J. was married to a White British man she would not be subject to the influence of her mother-in-law in the same way some Bangladeshi women would be. J. was also the only woman to have had her husband present at the birth of her child. DISCUSSION The difficulties of accessing Bangladeshi women were highlighted by this study, showing them to be a largely “hidden” group. Their position seemed to be compounded by a lack of English language skills, potentially rendering them “powerless” outside the private domain of their home. By accessing and interviewing a small group of women an opportunity for their voices to be heard was created, much of what they recounted being included in the main text of this article. Black women have been stereotyped as presenting special problems and not using maternity services in an “appropriate” way (Bowler, 1993; Phoenix, 1990). In this study all those women interviewed had attended antenatal clinics. When asked, they did not know of any Bangladeshi women who had avoided antenatal care in Britain. In Bangladesh, pregnancy
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and childbearing are located within the private sphere, under the control of women: Men are excluded. By taking up antenatal services in Britain a shift is discernible in the boundaries between the private and public spheres of the women’s lives. Because women often do not possess the language, or are perceived as needing to be chaperoned, men have increasingly become involved in clinic and hospital visits. Yet although women may have handed over some of their “control” over their pregnancy to health professionals in the clinic setting, it is suggested that men continue to be excluded from discussions within the private domain of the home. The comment by the GP who complained “that husbands and wives never seem to have discussed anything before they come to the clinic” reflects this. Although the women in this small study had attended antenatal clinics, it is necessary to question the quality of the care received. Because many Bangladeshi women do not speak English, and their husbands are not always keen for them to learn, husbands have increasingly come to play an intermediary role. At the antenatal clinic they interpret for their wives, translating what the health professional says. There is a danger in this practice that the womans emotional and other “needs” may remain unvoiced, yet exposure of these may further erode her control in this area. Information and advice given may be couched in unfamiliar terms. Cultural assumptions and stereotyping by health professionals may also affect the quality of the antenatal care given. The women interviewed in this study were all practising Muslims. It was apparent from what they said that, at times, religious beliefs and practices were in conflict with the predominately eurocentric model of antenatal care. Contradictory information given, on the one hand by the Imam and on the other hand by the health professional, leads to confusion and highlights competing models of what constitutes “good practice.” The issue of ramadan illustrated this. The changing pattern of the traditional extended Bangladeshi family, in part the result of migration to Britain, does appear to have led to some changes in the role adopted by husbands. Although cultures are dynamic, not all adaptation or change is welcomed. Whilst husbands may now be involved “publicly” with an area which has traditionally been both private and
female, these Bangladeshi women had rejected attempts to move other, traditionally private areas of their pregnancy and childbearing into a more public arena. Parentcraft classes were an example of this. The perception of the need for certain antenatal services was found to differ between the women and service providers. Parentcraft classes were attended by one of the women interviewed. Preparation for parenthood in this way was not perceived as necessary by the women, or according to one informant, by their mothers-in-law, because of the nature of their “different culture.” Language difficulties are a major consideration in any cross-cultural research, and the potential problems of using an interpreter were apparent in this study. As a woman and mother who had lived and worked in Bangladesh I was able to join the group and establish rapport with some of the women, while others continued to be suspicious of me. This necessarily dictated what could be talked about and with whom. By joining the group I was able to talk to some of the women on an individual basis about their experiences of maternity care in Britain and begin to explore how the boundaries between traditionally private and public areas may be changing. Larger studies have tended to assume cultural and religious homogeneity, grouping women according to skin colour or continent of origin, and some health professionals have been found to stereotype accordingly. The women interviewed were all British citizens, and in a multicultured society it is imperative that maternity services are sensitive to women’s individual “needs”, however and whatever they may interpret them to be. REFERENCES Bowler, Isabel. (1993). Stereotypes of women of Asian descent in midwifery: Some evidence. Midwifery, 9,7-16. Campbell, Rona, & Macfarlane, Alison. (1990). Recent dkbate on the place of birth. In Jo Garcia, Robert Kiloatrick. . . & Martin Richards (Eds.), The politics of matemily care (pp. 217-237). Oxford:~&re~don Press~ Charles, C. A. (1983). A midwife’s experience of the Asian community. In Midwife, Health Visitor and Community Nurse. 19,471-473. Clarke, M., & Clayton, D. G. (1983). Quality of obstetric
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Garcia, Jo, Kilpatrick, Robert, & Richards, Martin (1990). The politics ofmutemity care. Oxford: Clarendon Press. Islam, Mahmuda (I 980). Folk medicine and rural women in Bangludesh. Dhaka: Women for Women Research Group. Jain, Chanchal. (1985). Attitudes ofpnqant Asian women to antenutal care. Birmingham: West Midlands Regional Health Authority. Lumb. K. M., Congdon, P. J., & Lealman, G. T. (1981). A comparative review of Asian and British born maternity patients in Bradford 1974-1978. Journnl of Epidemiology and Community Health, 35,106109.
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McConville, Frances. (1988). The birth attendant in Bangladesh. In Sheila Kitzinger (Ed.), The midwife challenge (pp. 143-154). London: Pandora Press. Munro, June. (1988). ParentcraB classes with Bengali mothers. Health Ksitor. 61.48. The National Audit Office. (1990). Report on maternity services. London: HMSO. Oakley, Ann. (1979). From here to maternity: Becoming a mother. Oxford: Martin Robertson & Company. Phoenix, Ann. (1990). Black women and the maternity services. In Jo Garcia, Robert Kilpatrick, & Martin Richards (Eds.), The politics of maternity care (pp. 274-299). Oxford: Clarendon Press. Rhodes, Penny J. (1994). Race-of-interviewer effects: A brief comment. Sociology, 22.547558. Short Report (Second Report From the Social Services Committee). (I 980). Perimztul and Neonatal Mortulity. London: HMSO.