Rethinking Prenatal Care Within a Social Model of Health: An Exploratory Study in Northern Ireland

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UHCW #900061, VOL 00, ISS 00

Rethinking Prenatal Care Within a Social Modelof Health: An Exploratory Study in Northern

Ireland

JENNY ANNE MCNEIL AND KERREEN M. REIGER

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TABLE OF CONTENTS LISTING

The table of contents for the journal will list your paper exactly as it appearsbelow:Rethinking Prenatal Care Within a Social Model of Health: AnExploratory Study in Northern IrelandJenny Anne Mcneil and Kerreen M. Reiger

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Health Care for Women International, 00:1–21, 2014Copyright © Taylor & Francis Group, LLCISSN: 0739-9332 print / 1096-4665 onlineDOI: 10.1080/07399332.2014.900061

Rethinking Prenatal Care Within a Social Model1

of Health: An Exploratory Study in Northern2

Ireland3

JENNY ANNE MCNEIL4School of Nursing & Midwifery, Queen’s University Belfast, Belfast, Northern Ireland, UK5

KERREEN M. REIGER6Department of Sociology, School of Social Sciences, La Trobe University, Bundoora,7

Victoria, Australia8

Implementation of maternity reform agendas remains limited by9

the dominance of a medical rather than a social model of health.10

This article considers group prenatal care as a complex health11

intervention and explores its potential in the socially divided,12

postconflict communities of Northern Ireland. Using qualitative13

inquiry strategies, we sought key informants’ views on existing14

prenatal care provision and on an innovative group care model15

(CenteringPregnancy R©) as a social health initiative. We argue that16

taking account of the locally specific context is critical to introduc-17

ing maternity care interventions to improve the health of women18

and their families and to contribute to community development.19

Contradictory policy directions currently limit the reform of maternity care on20

policy agendas in the United Kingdom (UK), Australia, and the United States21

(Carter, Corry, & Delbanco, 2010; Commonwealth of Australia, 2009; Depart-22

ment of Health [DH], 2007). On the one hand, the discourse of women’s23

autonomy and empowerment has made its way from the women’s health24

movement to mainstream discourse—professionals are now exhorted to pro-25

vide “women-centered care” and “consumers” should be “consulted.” Yet on26

the other hand, even though pregnancy and birth are a normal part of27

the lifecycle and most women having babies are well, the dominant mater-28

nity system remains focused on medical risk, pathology, and hospital-based29

Received 16 October 2012; accepted 17 February 2014.Address correspondence to Kerreen M. Reiger, Department of Sociology, School of

Social Sciences, La Trobe University, Bundoora, Victoria 3086, Australia. E-mail: [email protected]

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2 J. A. McNeil and K. M. Reiger

services. As the World Health Organization (WHO, 2007) points out, health30

systems are themselves a social determinant of health and well-being. Con-31

sumers or service-users, feminist activists, and some health professionals32

argue that women are often disempowered within medicalized systems of33

maternity care. Furthermore, the process of becoming a mother (or father)34

is greatly influenced by health inequalities and other social factors (Schrader35

McMillan, Barlow, & Redshaw, 2009). Many women need social support and36

care rather than specific clinical assistance or medical intervention (Declerq,37

Sakala, Corry, & Applebaum, 2006; Kitzinger, 2005; Reiger, 2001). As argued38

in other fields of health care (Marmot, Atkinson, & Bell, 2010), it is time to39

move away from an “illness-oriented” framework toward a social model of40

maternity care (Bryers & van Teijlingen, 2010).Q2 41

In this article we therefore explore the potential of an innovative model42

of prenatal care for contributing to social health and community develop-43

ment. We take as our focus the distinctive context of Northern Ireland, a44

society slowly recovering from many decades of conflict. This period, com-45

monly referred to as “the Troubles,” had major impact on women and their46

families (Hamilton, Byrne, & Jarman, 2003), and its legacy continues toaffect47

current health service delivery. We first introduce our conceptual approach,48

then we give an overview of the broader maternity policy environment shap-49

ing prenatal care provision in the UK and in Northern Ireland in particular.50

In the second half of the article, we use this framing to discuss the method-51

ology and findings of an exploratory study investigating the potential of52

group-based prenatal care, notably CenteringPregnancy R© (CP), as an inter-53

vention to improve social as well as clinical outcomes in Northern Ireland.54

In doing so, we also make a broader argument—that introducing and as-55

sessing interventions to improve women’s health and well-being requires56

attending to local social and community contexts and the specific challenges57

they present. The value of effective maternity interventions such as prenatal58

care goes beyond improving the health and well-being of women as individ-59

uals to supporting their families and communities. The maintenance of close60

ties between individuals and within groups and networks, the “bonding and61

bridging” involved in what is often termed “social capital,” is widely regarded62

as beneficial to health (Campbell, 2000; Franklin, 2005). Although women’s63

contribution to community-building can be inward-looking and exclusionary64

(Wilson, Abram, & Anderson, 2010), it can also develop networks that bring65

people from diverse identities together.66

RESEARCHING HEALTH CARE INTERVENTIONS67

Applying a social framework to maternity care interventions entails a rather68

different conceptual and methodological approach to that dominant in much69

health research. The emphasis on standardized, evidence-based scientific70

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Rethinking Prenatal Care Within a Social Model of Health 3

investigation can lead to neglect of humanistic forms of inquiry into the71

complex social relationships intrinsic to maternity care (Reiger & Morton,72

2012). Taking a social rather than medical model of health, researchers have73

increasingly argued that multiple forms of data gathering are needed to as-74

sess innovations in models of maternity care (Rycroft-Malone et al., 2004).75

In effect, these constitute what are termed “complex interventions” in health76

care, that is, those in which many factors have to be taken into account in77

assessing outcomes, including those in the social environment (May, Mair,78

Dowrick, & Finch, 2007). This means that as well as investigating the measur-79

able clinical outcomes of perinatal care, for example, we need to examine80

the specific social and institutional contexts in which innovations are imple-81

mented and their unanticipated as well as anticipated consequences. Within82

the National Health Service modernization project in the UK, “Realistic Eval-83

uation” (Pawson & Tilley, 1997) has gained traction as a useful theoretical84

approach. Rather than the context of a health intervention being seen merely85

as background, the local environment assumes a potentially causal role in86

shaping outcomes (Pawson & Tilley, 1997; Rycroft-Malone et al., 2004). On87

this basis, then, we turn to exploring the debates on the need for innovation88

in prenatal care and their relevance within the specific sociopolitical context89

of Northern Ireland.90

REFORMING PRENATAL CARE91

Although maternal and infant survival rates have improved during the twen-92

tieth century, the typically medicalized systems of maternity care in Western93

countries have been the focus of sustained critique (e.g., Kitzinger, 2005;94

Reiger, 2001; Wagner, 2008). In response to such critiques, UK maternity95

care since the early 1990s has encouraged service innovation and user or96

consumer participation, and has focused on mitigating persistent health in-97

equalities (DH, 1993, 2004, 2007). Supports for hospital-based midwifery-led98

care have increased, and community-midwifery and health visitor roles have99

been included in various social programs in the UK, notably the early child-100

hood intervention, Sure Start. Yet many mainstream services like prenatal101

care have been less affected, and implementation of innovative policies102

across diverse health services remains limited. Some important English ini-103

tiatives, for example, Maternity Matters (DH, 2004), have not been rolled104

out consistently across the UK (Cheyne, McNeill,Hunter, & Bick, 2011) and Q3105

health policy and practice varies considerably in the devolved regions of106

Wales, Scotland, and Northern Ireland. In the latter case, in spite of a period107

of “permissive managerialism,” which allowed limited opportunities for in-108

novation, effective health policy development has been “stalled” by politics109

(Greer, 2004). Q4110

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The development of modern prenatal services originally focused on re-111

ducing maternal and infant mortality rates and reflected eugenic responses to112

imperialist or nationalist population anxieties (Oakley, 1984; Reiger, 1985). In113

recent years, with new forms of anxiety reflecting the pressures of contempo-114

rary “risk society” (Beck, 1992), there has been increased recognition of the115

need to make prenatal care in many countries more “women-friendly” and116

health promoting rather than predominantly focusing on medical surveil-117

lance. International reports have pointed to problems with the common118

“cattle run” approach of public hospitals, with overcrowded clinics, long119

waiting times, short appointments, fragmentation of care, poor communi-120

cation, and lack of individualized attention (Phillippi, 2009). Accordingly,Q5 121

increased interest in prenatal care reform has ensued, particularly, in the122

innovative approach of providing group-based prenatal care using a model123

known as CenteringPregnancy R© (CP; Schindler-Rising, Powell Kennedy, &124

Klima, 2004).125

ASSESSING GROUP-BASED PRENATAL CARE126

CP has been implemented mainly in the United States, but also in other127

high-income countries including Canada, England, and Australia. CP was128

developed in the United States in the 1980–1990s by nurse-midwife Sharon129

Schindler Rising who emphasizes that the key difference between CP and130

usual prenatal care is that it is designed as a social intervention to em-131

power women and build their support networks (Schindler Rising et al., 2004;132

Sharon Schindler Rising, personal communication, July 2009 and November133

2010). CP includes the three usual components of prenatal care—effective134

clinical assessment, health education, and professional support—but is pro-135

vided within a group setting, and it is facilitated by professionals practicing136

in an egalitarian rather than a “knowledgeable expert” way (Manant & Dodg-137

son, 2011; Schindler Rising et al., 2004). Groups of 10–12 women, who attendQ6 138

approximately 10 times during pregnancy, are facilitated by midwives with139

specialized training. The aim is to encourage women to assume responsibility140

for most aspects of their care, to build relationships, and to establish ongoing141

support networks, thus improving social support. Group sessions generally142

take place in community settings rather than in a hospital environment.143

The majority of evaluative studies of such group prenatal care have144

focused on clinical outcomes although some have also pointed to social145

advantages. Several studies (mostly in the United States) have identified146

positive health outcomes from CP. Ickovics and colleagues (2003) reported147

from a cohort study that the birthweight of infants of women attending for148

group care was greater, and in a subsequent randomized controlled trial149

(Ickovics et al., 2007) reported a 33% risk reduction (CP group) of preterm150

births, findings supported by Picklesimer and colleagues (2012) based on a151

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retrospective cohort study. Ickovics and colleagues (2011) extended the CP152

model to include skill building in assertiveness and negotiation, (referred153

to as CP+), and reported that “high stress” women who were assigned to154

CP+ had significantly increased self-esteem anddecreased stress and social155

conflict in pregnancy. Depression scores and social conflict were lower at156

1 year postnatal compared with women who had routine care. Manant and157

Dodgson’s (2011) review of literature on the CP model concluded that there158

was some inconsistency in definitions of the intervention, measurements, and159

outcomes that subsequently limit evaluation of its effectiveness, particularly160

in relation to clinical outcomes.161

In countries with comprehensive national health systems, however, ev-162

idence of positive social outcomes are also important in seeking further163

improvement in women’s care. A UK pilot of CP, for example, concluded164

that the emphasis on an equal relationship with care providers rather than a165

hierarchical one facilitates confidence and health efficacy beyond pregnancy166

(Gaudion et al., 2011). The CP model was reported to have been adapted suc-167

cessfully to suit policy and professional regulation in the UK where midwives168

are the major maternity care providers (Gaudion et al., 2011). Although evi-169

dence on CP from settings similar to the UK is limited, Australian data (Teate,170

Leap, Schindler Rising, & Homer 2011) support the conclusion of a recent171

Canadian qualitative report: this summed up women’s experiences of CP in172

very positive terms, as “getting more than they realized they need” from this173

form of group-based, personally supportive care (McNeil et al., 2012). Q7174

For our purposes here, the most salient research goes beyond measures175

of women’s individual well-being. It suggests that CP can offer important176

benefits to local communities in terms of social connection and inclusion,177

including in multicultural settings (Picklesimer et al., 2012; Powell Kennedy178

et al., 2009; South Community Birth Program, 2006; Teate et al., 2011). Teate179

and colleagues (2011) concluded that group = based prenatal care assists180

women to share their experiences, learn from one another, and develop181

an invaluable network of social support for the new mothering period, a182

finding also supported by McNeil and colleagues (2012). Antecedents of the183

CP model can be found in the community-based work of the former Albany184

practice in London (Leap, Sandall, Buckland, & Huber, 2010), and in the185

group support role of community midwives in some Sure Start programs186

in the UK, including one in Belfast, Northern Ireland. While CP remains187

somewhat unique in seeking to empower women through the self-directed188

clinical component of prenatal care, it is consistent with a policy focus on en-189

hancing social outcomes as well as producing sound clinical results. Further190

research is needed, however, into the specific contexts in which group-based191

care such as CP has been implemented and into its broader social potential.192

Given the range of interacting factors, group-based prenatal care is clearly193

best seen as a “complex intervention” in health care. As the British Medical194

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Research Council guidelines (MRC, 2008) emphasize, understanding context195

is crucial in developing these types of interventions.196

THE CONTEXT OF MATERNITY SERVICES IN NORTHERN IRELAND197

In Northern Ireland, the transition to parenthood—a period known to have198

long-lasting impact on health and community well-being (Marmot & Wilkin-199

son, 2006; Nilsen & Brannen, 2005)—may be particularly difficult. Social200

and health problems continue to reflect the impact of past political con-201

flict on both physical and mental health (Dillenburger, Fargas, & Akhon-202

zada; O’Reilly & Stevenson, 2003). Northern Ireland includes several of the203

most socially disadvantaged areas of the UK, with high levels of deprivation204

and unemployment in some areas (Northern Ireland Statistics and Research205

Agency, 2010). Lewis (2011) reports that social inequities clearly affect preg-206

nancy and childbirth: in the UK vulnerable, socially disadvantaged women207

were less likely to seek prenatal care or to stay in contact with maternity ser-208

vices, and neonatal mortality and morbidity are associated with deprivation209

(Centre for Maternal and Child Enquiries, 2011). Analysis of 10 years of N.I.210

data highlighted geographical variation in infant mortality, stillbirth, and low211

birth weight and recommended greater attention to interventions focusing on212

health behaviors and social factors (Pattenden, Casson, Cook, & Dolk, 2010).213

In postconflict societies like NI, gender relations produce further social214

inequalities. Women are particularly disadvantaged as citizens for they do215

not shape political priorities, yet they are often victims of poverty and of216

a culture in which masculine violence is entrenched (McMurray, 2009; Nı217

Aolin & Rooney, 2007). Women have reported that they face ongoing chal-218

lenges as mothers, not only in keeping children safe from recurrent patterns219

of violence and intimidation, but also in preparing them for overcoming220

community conflicts (Ward, 2004). Even since the official peace settlement221

in 1998, historical patterns of social inclusion/exclusion continue to be re-222

produced, including through family ties (Porter, 1998; Ward, 2004). Intense223

sectarian loyalties to the Protestant and Catholic communities shape personal224

and collective identities and produce tight local networks. The ongoing so-225

cial tensions and the effect of past trauma mean that the potential for positive226

attention to and involvement in parenting, by both women and men, can227

be limited (Cummings, Goeke-Morey, Schermerhorn, Merrilees, & Cairns,228

2009; McMurray, 2009). In light of the challenges of the Northern Irish social229

context then, moving from models of care based around health profession-230

als and hospital services toward those that engage and empower women231

and their families and bring them into wider networks would seem to of-232

fer important opportunities to enhance “social capital”—understood here as233

community development that contributes to building bridges and strength-234

ening women’s participation in civil society (Franklin, 2005).235

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Until the recent Maternity Strategy (Department of Health, Social Services236

and Personal Safety Northern Ireland [DHSSPSNI], 2012), maternity care in237

Northern Ireland had received limited political attention. Some surveys sug-238

gested that women were largely satisfied with their antenatal care (Picker In-239

stitute, 2007; Price WaterHouse Coopers, 2006), but these findings are limited240

by their nature as retrospective audits. The difficulties of reliably measuring241

satisfaction in maternity care are also well known as the “what is must be242

best” notion prevails (Hodnett, 2002). Although maternity services in North-243

ern Ireland generally follow UK policy recommendations, such as supporting244

women’s choice, control, and continuity of care, the implementation of such245

socially oriented objectives remains uneven. More recently there has been246

an important move to increase maternity care options for women in light of247

national U.K. health policies and paying greater attention to social factors.248

The 2012 Maternity Strategy for Northern Ireland asserts that prena-249

tal care provision is of high quality, but as “times have changed,” at “the250

heart of this strategy is the need to place women in control of their own251

pregnancy and support women and their partners to make proactive and252

informed choices” (DHSSPSNI, 2012, p. 3). The strategy also acknowledges253

the impact of socioeconomic and cultural factors on maternal and infant254

pregnancy outcomes, the importance of providing the majority of prenatal255

care in the community, and the significance of early intervention (DHSSPSNI,256

2012). With regard to prenatal care, it acknowledges the need for innovative257

forms of care and recommends involvement of women in prenatal educa-258

tion. As a social rather than medically oriented health intervention, CP or259

similar group-based care would seem to offer significant benefit in the con-260

text of ongoing community divisions. The advantages of providing women261

with group prenatal care include learning from one another through shared262

experiences, and reducing individual isolation and building community ties.263

If specifically organized across existing community boundaries, there is the264

potential for attitudinal change through group interactions that could support265

inclusive interaction in postconflict societies. Given the reported vulnerabili-266

ties of many women in Northern Ireland and advantages of the group model267

as a complex social health intervention, ascertaining interest in developing268

such an innovative intervention in this distinctive context seemed a valuable269

step toward undertaking a fuller intervention study.270

EXPLORING THE POTENTIAL OF GROUP-BASED PRENATAL CARE271

IN NORTHERN IRELAND272

The aim of our exploratory study, therefore, was to investigate both perspec-273

tives on current prenatal provision in Northern Ireland, and likely interest in274

an innovative model of prenatal care, such as CP, with a view to a potential275

pilot program. Like much feminist health research (Reiger & Liamputtong,276

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2010), the strategies we used reflected the epistemological and methodolog-277

ical principles arising from an interpretive feminist research paradigm rather278

than the positivist or postpositivist approach more common in medically279

oriented health services research (Bourgeault, DeVries, & Dingwall, 2010;280

Ramanzanoglu & Holland, 2002). These are also consistent with the con-281

ceptual approach to considering complex health interventions and a social282

model of health already outlined.283

First, as Denzin and Lincoln’s (1998, p. 3) classic discussion points out,284

a qualitative researcher is often constructing a bricolage, one “pieced to-285

gether, [a] close-knit set of practices that provide solutions to a problem in a286

concrete situation.” Rather than a study that is tightly designed in advance,287

the researcher as a bricoleur is like a “professional do-it-yourself person”288

working at an emergent construction “that changes and takes new forms as289

different tools, methods and techniques are added to the puzzle.” The task290

in such research is to build understanding and become better informed both291

about a local situation and participants’ perceptions and feelings about it. The292

significant point about such critical field research is that as the researchers’293

understanding develops, “the sum becomes greater than the parts”: Patterns294

emerge in the material and become shaped into what is then called “data.”295

Research validity, rather than being based on use of specific research tech-296

niques, comes from communication between researchers and dialogue with297

participants and with scholars in the field—the critical “test” is the trans-298

parency of the reported processes, the plausibility of empirical evidence299

used, and the contextualized “sense-making” and reasoned argument in the300

final product (Maxwell, 2002; Ramanzanoglu & Holland, 2002).301

Second, feminist principles such as stressing emancipatory objectives302

and a dialogical and reflexive process of inquiry (Ramanzanoglu & Holland,303

2002) encourage diverse research strategies, sometimes shaped by partici-304

pants themselves. Along with formal and informal interviews, the “embod-305

ied knowing” gained from observational fieldwork can provide visual images306

and unexpected encounters that contribute further sources of critical analysis307

(Giacomini, 2010). Finally, the researchers also have to acknowledge their308

own biographically shaped “situatedness” and potential power. In this case,309

one (J.M.) was a local N.I. midwifery researcher embedded in the local cul-310

ture and social environment, and the other (K.R.) an interested “outsider,” a311

feminist sociologist who could take less for granted about the N.I. political312

and health care context. As both shared the social status of the key infor-313

mants and their evident commitment to improving maternity care, however,314

no major disparities of power were involved.315

Participants316

Following local university ethical approval (application mumber: 2/1/2009),317

recruitment commenced in June 2009. Flyers about the project were318

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distributed to several agencies involved in providing support to women319

during pregnancy and afterward. Follow-up to the flyer distribution was320

conducted through email or telephone contact or following-up referrals and321

using a snowball or nominated sampling technique. The voluntary sector322

agencies were the first point of contact to assist in identifying key “insid-323

ers” who know who is most appropriate or knowledgeable about the topic324

(Morse, 1991, p. 130). In addition, informal conversations, seminar presen-325

tations, and discussions with key informants all contributed to building and326

layering the bricolage. Using this approach, we established contact with ap-327

proximately 35 women who were working in this field as professionals or328

maternity consumers, including a National Childbirth Trust member and Ma-329

ternity Service Liaison Committee members ([MSLCs] in the UK, MSLCs are a330

forum for users, providers, and commissioners of maternity services). These331

midwifery leaders, community workers, and service users were valuable key332

informants (KIs), well placed to offer the “expert” or informed opinion valu-333

able for health policy research (Wrede, 2010, p. 98). As Gilchrist and Williams334

(1999, p. 73) point out, in fieldwork settings, KIs offer an “information-rich335

connection to a research topic” and informal communication, which adds336

greatly to the observation and interview data. Written consent was obtained337

from those participating in individual interviews, and following detailed ex-338

planation of the study and purpose, the active participation in professional339

group contexts of others indicated their informed consent.340

Undertaking the Study341

The project took place between June 2009, when meetings and interviews342

were held, followed by writing up and then further discussions in June 2010.343

The exigencies of fieldwork in a busy community sector meant that only344

formal interviews with the coordinators of two centrally located Sure Start345

programs were able to be recorded and transcribed, but these provided sub-346

stantial information on the operation of current programs, on local context347

and on perceptions of community need. Shorter discussions with two work-348

ers in another women’s community center, where a planned formal interview349

was interrupted, provided a valuable overview of that community’s issues.350

Due to the interest generated in one Sure Start center, further meetings were351

arranged. One included eight local community workers, following which the352

researchers were invited to attend a regional meeting of approximately 15353

Sure Start leaders from across Northern Ireland, including two community354

midwives. At this forum we presented information on CP and heard the355

views of many present concerning local needs and the present care system.356

Discussions by phone or in person included those with a consumer repre-357

sentative from the NCT and members of the Belfast and Women’s Voices Q8358

(Derry) MSLC Groups. Other KIs contacted about challenges facing women359

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during and since the Troubles in Northern Ireland included several col-360

leagues in history and social science programs and in women’s community361

organizations.362

Data Analysis Strategies363

Using the concept of the bricolage in qualitative inquiry requires recognition364

of the social processes entailed in developing and then analyzing what be-365

comes designated as “research data” and acknowledging the social context366

in which this occurs. In keeping with dialogical feminist methodologies in367

particular (Nelson, 2003), the approach taken to the emerging evidence re-368

flected the relationship both between the researchers and with participants369

who brought multiple perspectives on implementing CP in the sociopolitical370

context of Northern Ireland. In the varied encounters with KIs, new issues371

emerged in an iterative and reflexive process as the researchers became372

known and interest in the issues increased, generating a range of data that373

were then analyzed to identify and explore major themes (Pope & Mays,374

2006). Field notes recorded following informal interviews and group and375

phone discussions were later included with interview material to contribute376

to conclusions emerging and then shared with some leading KIs for further377

feedback.378

KEY THEMES EMERGING379

As participating individuals came from a range of positions within the health380

and social care sector in Northern Ireland, they provided diverse perspectives381

concerning the current context of prenatal care provision and the potential382

of CP. The key themes that emerged are described below, illustrated by383

quotations from the Sure Start coordinators’ interviews and by comments384

from informal interviews and observations as recorded in field notes.385

The Legacy of Community Division386

Informants stressed that public participation in decision-making, including387

access to childbirth care and education, is complicated in Northern Ireland by388

community divisions and by women’s lack of power, especially those suffer-389

ing social disadvantage. Overlapping class and sectarian boundaries meant390

that even existing formal provision is not always experienced as being con-391

genial. Recent community-based research shows that the lack of confidence392

and feeling of being socially disempowered expressed by many women in393

Northern Ireland’s disadvantaged communities impacts on their parenting394

capacity (McMurray, 2009). As one consumer representative said, the politi-395

cal context “inveigles its way into every aspect of life” even though women396

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“from all walks of life, of whatever background, all use maternity services”397

(NCT member, June 2010). In spite of a decade of formal peace arrange-398

ments and some lessening of the historical animosity between the Catholic399

nationalist and Protestant unionist communities, she, like local community400

workers, pointed out that many working-class people still mostly accessed401

services only within their own community of identity.402

Although health services are expected to span community divisions,403

some Sure Start programs have had to provide parallel programs and many404

only operate in what in effect are segregated areas. Distrust over hospitals405

seen as “belonging” in the past to one or other group still lingers, along406

with resentment about closures and service realignment in recent years. The407

regional maternity hospital, the Royal Jubilee Maternity Service, however,408

increasingly is used by both Protestant Unionists and Catholic Nationalists as409

well as by women of non-Irish or British ethnicity. Although women were410

reported to be less likely to avoid mixed-community health care gather-411

ings than their menfolk, many fathers would be likely to feel uncomfortable412

in such parenting programs, especially if they had been involved in polic-413

ing or military service. Some programs are reported as making significant414

achievements in meeting local needs, but this is primarily within community415

boundaries. For example, while the Troubles have been of less immediate416

significance in recent years, their legacy continues to affect families and417

conflict continues. In view of housing improvements, more people are now418

staying in the (mostly Protestant) Shankill area rather than moving to new419

estates, but “I mean if you ask anyone in the Shankill, there’d be some420

trauma in the past,” including from family violence, and also “there’d still be421

that legacy that prescription drugs would still be problems—[The] women’ve422

been doing it so long—surviving and sharing tablets around” (Sure Start423

coordinator 2).424

Several of our sources suggested that the stress and trauma in families425

affected by past conflicts continue to affect parenting now (e.g., Ward, 2004,426

and personal communication, 2010; Bell, Hansson, & McCaffery, 2010). De-427

pression in the older generation can, they said, mean increased anxiety in428

daughters about their parenting and a loss of childrearing skills. A commu-429

nity worker expressed concern about grandmothers “taking over” and further430

deskilling younger women. The importance of including men in parenting431

programs was widely acknowledged. As a women’s health leader showed432

one of us (K.R.) around her center in the process of closing up after a busy433

day, she commented that many of her Protestant community’s “young dad-434

dies” felt not only politically disenfranchised but unclear about fatherhood435

roles as they lacked good relationships with their own fathers. “As a com-436

munity, there’d be a lot of complex family dynamics going on,” said another437

Sure Start coordinator. She also pointed out that disclosure of quite common438

experiences of family violence required long-term relationships with health439

UHCW_A_900061 702xml March 27, 2014 16:38


professionals, a continuity that one of their existing prenatal programs made440

possible for some.441

In view of other research into the problems faced by women in general,442

and as mothers in particular, in the postconflict situation of Northern Ire-443

land (McLaughlin, 2009; Ward, 2004), the transition to motherhood is clearly444

an especially vulnerable time. A study initiated by Mothers’ Voices (an N.I.445

Maternity Service Liaison Committee), echoed many of the issues raised by446

our other key informants as well (Campbell & Doherty, 2007). The authors447

reported that women felt disempowered as a result of poor communication448

with health care workers, and that there was a lack of support and advice449

regarding birth options and a need for continued support in the postnatal450

period. The central goal of CP, empowering women, was warmly received451

both by the professionals and consumers with whom we spoke. Although452

several MSLCs represent women’s voices in policymaking in Northern Ire-453

land, participants pointed to the constraints on this system. One consumer454

MSLC representative commented that in her area, mothers had become more455

active in recent years, but it had been difficult to attend MSLC meetings as456

no creche was provided, and the agenda was set by the health professionals.Q9 457

Others too reported lack of effective training for MSLC members. As in other458

areas, hospital managers were too often concerned only with immediate de-459

tails of women’s “satisfaction” with services, like hospital food quality, rather460

engaging with informed consumers about the “bigger picture.”461

Another Sure Start leader, also an MSLC representative, was strongly462

committed to empowering women not only through the chance to have463

their voices heard in service delivery, but also in order to avoid further social464

disempowerment. She saw the very process of childbirth itself as potentially465

worsening existing disadvantage:466

You see . . . people talk about quality, you know they very much go on,467you know, “it was a healthy birth” you know . . . whereas, to me, it’s the468social aspects of childbirth, and how the person feels about the whole469thing and then the implications of feeling kind of disappointed, upset,470disempowered through the experience of childbirth, the effects that has471had, how that adds to other sociological factors in the women’s life to472make another painful life experience. . . and [for lots] of mothers in our473areas who’ve had some sort of sexual abuse in their lives. . . for many474of those women, childbirth is like another trauma, it opens up painful475memories those people have, that have been sort of pushed down, so476it’s just adding to that feelin’ of being worthless, and just when you’re477needin’ to feel strong with your baby. (Sure Start coordinator 1)478

As several respondents commented, motherhood can potentially draw479

women together, even across ongoing community divisions. Supporting480

UHCW_A_900061 702xml March 27, 2014 16:38


them in developing community networks can offer more than personal481

benefits.482

Current Provision of Care483

Maternity care in Northern Ireland was seen by several key informants, es-484

pecially MSLC consumers, as lagging behind developments in other parts of485

the UK—reform was “not really on the political agenda” until quite recently.486

This was partly attributed to the N.I. government’s imperative of financial487

stringency but also to the generally conservative and uncritical tenor of local488

society in which authority was less likely to be questioned, including that489

of GPs and private obstetricians. For the majority of women, the GP is the Q10490

first point of contact for prenatal care, and many doctors continue to play a491

stronger role than elsewhere in the UK through providing shared care with492

local hospitals. Both Sure Start professionals and consumers commented that493

shared care often meant limited care—GPs were time-poor, it was often hard494

to get appointments with them, and some at least seemed to lack adequate495

knowledge and skills in obstetrics. For example, at one Sure Start meeting,496

a community worker who was an experienced mother discussed her own497

recent appointment. She said that whilst she could feel how the baby was498

lying, when she asked about the positioning of her baby in late pregnancy,499

the GP was unable to provide further information and she was told that if500

she was concerned, she should ask for an ultrasound at the hospital. Oth-501

ers reported that as GPs were perceived as “not doing much,” women only502

attended the prenatal visits that were scheduled at the hospital, often for503

scans.504

Many socially disadvantaged women in particular were reported as miss-505

ing out on educational opportunities for preparing for motherhood, relying506

instead on the advice of family members. The overcrowded prenatal clinics507

at major hospitals were described as disempowering to women, especially508

those with low self-esteem in the first place:509

Women would be sitting on window ledges, and if they’ve got partners510with them, they stand. . .. It’s a like a cattle market or a conveyor belt.511And what does that say? Even if they don’t have an expectation other512than a healthy baby, um, I don’t care, when you put somebody with low513self-esteem in those circumstances, they feel, “that’s what I am worth.” It514reaffirms that, “I am not worth very much.” (Sure Start coordinator 1)515

In a casual discussion, a Sure Start worker herself recounted her frustration516

at prenatal waiting times. When she was 36 weeks pregnant, she sat on an517

uncomfortable hard chair for 2-and-a-half hours at a public hospital clinic,518

increasingly anxious about getting back to work. When she was finally seen519

by a midwife, there was no apology for delay or any sense that the woman’s520

UHCW_A_900061 702xml March 27, 2014 16:38


time was valuable. Reflecting what she described as a “typical” disempow-521

ering public sector mentality, she found many women were all booked to522

arrive at the same time and that the resulting delays were accepted as in-523

evitable. Another woman, a consumer representative on the local MSLC and524

active in the National Childbirth Trust, was also critical of the impersonal525

“herd” mentality in which women were not treated as individuals. This, she526

said, is why those who can afford it prefer private obstetricians: “They want527

to feel ‘special.”’ Nonetheless, she pointed out that some GPs’ clinics have528

midwifery clinics attached and that GPs do like to see pregnant women to529

provide continuity of family care.530

It is important to note, however, that innovations are also underway.531

One Sure Start coordinator interviewed reported that her center already offers532

a weekly daytime prenatal care program similar to the CenteringPregnancy533

model. Both community midwives and the local health visitor (a family care534

specialist) run the prenatal classes. These involve group meetings covering535

the usual pregnancy, birth, and parenting topics and visits to the hospitals,536

but also financial advice, communication, and the value of involvement of537

fathers in parenting. The uptake of the model varies, and women do not538

participate consistently in the full program in spite of support from many lo-539

cal employers. For many couples, however, the group-based model is highly540

valued, especially those who find the main hospital classes too “middle class”541

in orientation, and feel more comfortable in this local setting:542

Women love coming to the classes and tell their friends, and I suppose543in terms of the actual program, it’s targeted to their needs more than544hospital classes can be, [so] we do need more community-based ones.545(Sure Start coordinator 2)546

The group also has lunch together during which time women have individual547

time with the midwife and listen to their baby’s heartbeat. Unlike in the CP548

model, however, they do not do their own clinical checks, and many women549

also receive shared GP care.550

This community center developed this model on the basis of early child-551

hood intervention programs funded several years ago, along with other552

services including pregnancy counselling, testing, and advice and postna-553

tal support services for breastfeeding, child safety, and mental well-being.554

Asked about unmet needs, this coordinator noted that they are still limited555

in that they do not actually “have a midwife employed here,” and they really556

need midwives in the center who can also be available as contacts work-557

ing closely with the family until children are 2 years old. The value of this558

existing model in Northern Ireland lies in the strong community setting and559

range of health linkages upon which it is based, but it is both strengthened560

and limited by not seeking to operate across sectarian community borders.561

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Accessing Information About Choice562

A second issue discussed by KIs was related to access to information about563

the availability of birthing choices. Community-based women’s health work-564

ers in particular drew attention to the problems faced by childbearing565

women in the fairly traditional, paternalistic society of Northern Ireland,566

one in which women generally had low expectations and influence. Publicly567

funded midwifery-led care is available for women in Northern Ireland, but568

consumers and Sure Start coordinators reported that women frequently had569

little knowledge about care options such as birthing at home. Prenatal care570

was often inadequate in informing them about choices and developing their571

competence in making decisions.572

The educative role of most prenatal care was regarded as limited by573

present provision. Parentcraft classes held in a hospital setting were per-574

ceived as overcrowded and oriented to a middle-class audience, so many575

of the “Mums don’t go,” but rather they rely on families and friends for576

information. Even private obstetric practices were seen as not always of-577

fering women adequate information. Other KIs also noted the inadequacy578

of postnatal support, especially for breastfeeding. As the previous genera-579

tion lacked knowledge and skills in breastfeeding, it was hard to encourage580

mothers enough, or even to find enough local peer support, even though the581

health and child development benefits were officially promoted. A commu-582

nity worker noted that sometimes “Grannies take over,” further diminishing583

the parenting capacity of young mothers. A representative of the MSLC and a584

mothers’ support group outside Belfast commented that in rural areas, post-585

natal problems, including postnatal depression, reflected isolation and that586

the system “just wasn’t good enough.” A study that evolved from an MSLC587

group (Mothers’ Voices) echoed many of these issues, reporting that women588

felt disempowered as a result of poor communication with health care work-589

ers and that there was a lack of support and advice regarding homebirth and590

a need for continued support in the postnatal period (Campbell & Doherty,591

2007).592

Although a considerable amount of written information was made avail-593

able, a Sure Start coordinator commented, “the difficulty is that quite a sig-594

nificant proportion of our mothers would have literacy problems” and can595

only take in “so much. . .. So no, they don’t have ‘options or choices’ even if596

they officially are available.” Many had no idea of the possibility of shared597

care with a community-based midwife, and, even in areas where it was598

available, it was sometimes “word of mouth” and “who you knew” that de-599

termined access to this service. Another community worker stressed that as600

the working-class mothers in her area, including immigrants, mostly did not601

receive information about possible hospital or midwifery options, they “just602

do what their GP says and just get booked in” to the local hospital. Even603

one middle-class woman, a local consumer representative, reported feeling604

UHCW_A_900061 702xml March 27, 2014 16:38


quite intimidated when a new midwife sought to discourage her from her605

planned homebirth on spurious grounds, finding it difficult to contest her606

“professional authority” even though she was confident about her rights and607

the normality of the pregnancy.608

CHALLENGES AND LIMITATIONS609

The key informants with whom we spoke for this project could also foresee610

several challenges in implementing innovations like CP. Institutional chal-611

lenges focused on integrating a new model of care, the role that doctors612

might play, and how acceptable this would be to both women and to hos-613

pital and community-based midwives. Funding, political will, and explicit614

strategies to manage social divisions would also be needed. At the com-615

munity level, ensuring easy access to a mixed-community local center and616

building on existing networks are essential but present challenges in view of617

entrenched local loyalties. We recognize that this small qualitative study can-618

not fully represent the views or perspectives of all stakeholders, especially in619

view of time limits and lack of funding, which has precluded contact to date620

with GPs. There was considerable consensus from a range of voices that a621

program similar to CP would be a valuable option for women in Northern622

Ireland, however, one offering advantages as a social model of health.623

CONCLUSIONS: THE POTENTIAL OF INNOVATIVE PRENATAL624

CARE IN NORTHERN IRELAND625

In this article, we have argued for the importance of placing prenatal care626

within a social rather than medical model of health and explored the value627

of group prenatal care such as CenteringPregnancy R©. Given the issues faced628

by women in the context of societal and community divisions of Northern629

Ireland, innovative social health interventions can be particularly valuable630

for enhancing women’s social capital and contributions to community build-631

ing. Our conclusion accords with other research reporting the social benefits632

of CP as a group prenatal care model, but we go further. In this article we633

have also argued that implementation of such programs are best viewed and634

should be evaluated as “complex interventions” within a social model of635

health. As such, paying close attention to the specific local context is crit-636

ical to planning and implementation. In the distinctive social and political637

circumstances of Northern Ireland, the transition to motherhood is an espe-638

cially vulnerable time, one in which empowerment-oriented, group-based639

prenatal care could develop new social networks for women and support640

their capacity for social participation. Given the complexity of implementing641

a group-based prenatal care intervention, it is important that future research642

uses an appropriate conceptual framework and methodology to evaluate643

UHCW_A_900061 702xml March 27, 2014 16:38


outcomes. This article represents an introductory exploration of group-based644

prenatal care in Northern Ireland and has provided initial data concerning645

the potential of this intervention to achieve much beyond clinical outcomes.646

Suitably resourced and supported, models of care during pregnancy and647

motherhood have the potential to optimize health and well-being of women648

and their families, through both clinical and social outcomes, enhancing the649

likelihood of improved social cohesion in postconflict Northern Ireland.650

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Rethinking Prenatal Care Within a Social Model of Health: An Exploratory Study in Northern Ireland

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