“A mixture of positive and negative feelings”: A qualitative study of primary care midwives’ experiences with non-western clients living in the Netherlands

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Abstract

Background

Non-western women living in the Netherlands are diverse in origin, which implies diversity in their needs and expectations for midwifery care. Furthermore, it has also been shown that non-western women make suboptimal use of prenatal care. Midwives may therefore face difficulties when caring for these clients.

Objective

The main objective of our study was to explore Dutch primary care midwives’ experiences with non-western clients.

Methods

A qualitative design was used. Thirteen midwives were interviewed individually and 8 participated in a focus group. All interviews were transcribed and analysed by two researchers who compared and discussed their results. Analytical codes were organised into subthemes and main themes.

Results

Midwives perceived ethnic diversity as both difficult and interesting. Caring for these women was perceived as demanding, but also rewarding. They experienced a variety of difficulties when caring for these women: communication problems, suboptimal health literacy, socioeconomic problems, lack of knowledge of the maternity care system, pressure from the family and a strong preference for physicians. In spite of these difficulties, midwives aim for optimal care by being alert and proactive, taking these women by the hand and making use of alternative resources.

Conclusion

Provision of care to non-western clients can be difficult and may require additional measures. These problems and measures should be included in midwifery education programmes as well as training programmes for midwives.

Introduction

Migration to the more developed regions of the world has shown a rising trend over the past years. The proportion of migrants worldwide living in more developed regions of the world increased from 53% in 1990 to 60% in 2010. Female migrants exceeded male migrants in number and comprised 51.5% of the migrant population in these regions (United Nations Population Division). Several studies conducted in developed countries have shown that the needs and expectations of migrants in terms of maternity care are not always met by the healthcare system (Hoang et al., 2009, Murray et al., 2010, Reitmanova and Gustafson, 2008). Healthcare systems tend to focus their care mainly on the majority population and are not responsive enough to the ethnic diversity within the client population (Cioffi, 2003, Hoang et al., 2009).

In the Netherlands, 11.4% of the population in 2011 was of non-western migrant origin, in the sense that at least one parent was born in Africa, Asia, Latin America or Turkey. Data from 2010 show that non-western women contributed 17.7% of all live births (Statistics Netherlands Statline). In the three major cities of the Netherlands – Amsterdam, Rotterdam and The Hague – they in fact contributed 47, 48 and 42% of the births respectively (de Graaf et al., 2008). It can be concluded from this data that Dutch midwives, especially those working in the major cities, are providing care to a client population of which a substantial part is non-western in origin. These non-western clients are very diverse in origin, with Turks, Moroccans, Surinamese and Antilleans/Arubans comprising the largest groups in the Netherlands. This diversity in country of origin implies a diversity in cultural backgrounds and hence a variety of needs and expectations regarding maternity care. The Royal Dutch Organization of Midwives (KNOV) attaches great importance to placing women at the centre of care. This implies that midwives have to take the cultural background and the specific needs and expectations of their clients into account.

Non-western clients have also been shown to make suboptimal use of prenatal care compared to the majority population of the Netherlands (Alderliesten et al., 2007, Choté et al., 2011). This less than optimal use is mainly characterised by late start of prenatal care, and may delay detection and treatment of pregnancy complications, concurrent illnesses and health problems. Two Dutch studies have reported that the late start of prenatal care explains at least part of the high perinatal mortality observed among certain non-western groups (Alderliesten et al., 2008, Ravelli et al., 2011). Furthermore, non-western clients have been shown to be at higher risk of maternal mortality and congenital disorders (Waelput and Achterberg, 2007). Thus, both the suboptimal use of prenatal care and the different needs and expectations may complicate the provision of optimal care to non-western clients who are at greater risk for poor pregnancy outcomes.

Only a few studies in developed countries have explored the experiences of midwives or other maternity care providers with women from ethnic minorities. In a survey conducted among midwives in Spain, 67% of the 102 respondents stated that language barriers were a key difficulty in providing health education to African women (Goberna-Tricas et al., 2005). Fifty-four per cent of the respondents used additional materials such as books, videos and leaflets to educate these women. In the UK, maternity care professionals were interviewed about their perceptions of the effect that ethnic background, social status and class have on service delivery for UK-born ethnic minority women (Puthussery et al., 2008). The maternity care professionals perceived UK-born ethnic minority women to be more assertive and to have better language proficiency and better comprehension of the healthcare system than ethnic minority women born elsewhere. In an ethnographic study carried out in a British hospital, midwives were found to have stereotypical ideas about South Asian women that were used to make decisions about the care these women want, need and deserve (Bowler, 1993). These stereotypes were centred on four themes: communication problems, lack of compliance with care and misuse of services, making a fuss about nothing, and a lack of maternal instinct. In a qualitative study conducted in Ireland, communication difficulties, cultural differences and suboptimal knowledge and use of services were some of the main issues raised by maternity service providers about ethnic minority women (Lyons et al., 2008). In another qualitative study conducted in Canada, health care providers reported several differences in expectations between them and immigrant clients: language, cultural competency, the type of care provided and the medicalisation of pregnancy (Ng and Newbold, 2011). A focus group study conducted in Norway revealed that midwives and public health nurses encountered health challenges and cultural challenges when caring for migrant women (Lyberg et al., 2012). The first three studies each focused specifically on a certain aspect of experiences with ethnic minority women: communication, the effect of the migrant's background, social status and class on service delivery or stereotypes. Only the remaining three studies considered various aspects of maternity care providers’ experiences with ethnic minority women. These studies were conducted in Ireland, Canada and Norway, countries with a different migration history and different migrant groups than the Netherlands. Furthermore, the maternity care system in the Netherlands is unique, with primary care midwives being the lead professionals providing care to women with uncomplicated pregnancies and births (Wiegers and Hukkelhoven, 2010). Dutch primary care midwives may have different experiences with non-western clients, so we decided to conduct a sub study within a national midwifery study to look at their experiences. The following questions are addressed in this article:

  • 1)

    What specific issues do primary care midwives in the Netherlands experience in their working relationship with non-western clients?

  • 2)

    Do these primary care midwives adjust their care for non-western clients and if so in what way?

Section snippets

Methods

A generic qualitative approach was used, implying that not one specific qualitative methodology was used as guidance, and that a declaration of the researcher's position, congruence between methodology and method, a clear articulation of the researcher's approach to rigour and an explanation of the analytic lens are provided (Caelli et al., 2003). Our interest in the subjective experiences and perceptions of midwives providing care to non-western clients meant that holding qualitative

Results

Several themes could be identified in the experiences of midwives providing maternity care to non-western clients. These aspects were categorised into three main themes: (1) Having a mixture of positive and negative feelings, describing the feelings midwives have about caring for non-western clients, (2) Facing challenges in the provision of care, describing the difficulties midwives experience when providing care to non-western clients, (3) Aiming for optimal care in the interests of both

Discussion

This study aimed to explore the experiences of primary care midwives with non-western clients in the Netherlands. Data were collected through individual interviews and a focus group. Three main themes emerged from the analysis: having a mixture of positive and negative feelings, facing difficulties in the provision of care and aiming for optimal care in the interests of mother and child.

The mixture of positive and negative feelings sheds new light on the experiences of care providers with

Conclusions

The study results indicate that midwives see providing care to non-western clients as difficult and demanding, but simultaneously as fascinating and rewarding. As midwives aim for optimal care in the interests of both mother and child, they take a variety of additional measures, some of which they have invented themselves. The quality of midwifery care might be improved by collecting these measures and including them in midwifery education programmes and training programmes for midwives.

Acknowledgements

We would like to thank the midwives who participated in this study. We would also like to acknowledge the contributions by Trudy Klomp, Fuusje de Graaff, Janneke Gitsels and Carien Baas to the recruitment process for this study.

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