UHCW_A_900061 702xml March 27, 2014 16:38
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
QUERY SHEET
This page lists questions we have about your paper. The numbers displayedat left can be found in the text of the paper for reference. In addition, pleasereview your paper as a whole for correctness.
Q1. Au: Please confirm that this is the complete mailing address.Q2. Au: Is “illness-oriented” a direct quote? If so, please provide source and
page number.Q3. Au: Verify spelling of author names in Cheyne et al. reference.Q4. Au: Provide source and page number for quotes in this paragraph (“per-
missive managerialism” and “stalled”).Q5. Au: Very spelling of Phillippi.Q6. Au: Provide page number for quoted material (“knowledgeable expert”).Q7. Au: Provide page number for quoted material from McNeil et al., 2012.Q8. Au: Spell out NCT at first occurrence.Q9. Au: Identify word—“creche”?.
Q10. Au: Spell out GP at first use.Q11. Au: Please cite Bruegel 2005 in text or delete item from list.Q12. Au: Confirm page range for Cheyne et al.Q13. Au: Provide city of publication for Commonwealth of Australia.Q14. Au: Placement of colon to separate subtitle? Au: Spell out HMSO at first
occurrence.Q15. Au: Provide location of publisher For DHSSPSNI 2012Q16. Au: Cite Downe 2010 in text or delete reference for list. If keeping,
please verify title.Q17. Au: Provide first initials of editors for Gilchrist & Williams.Q18. Au: Spell out journal name for Hodnett.Q19. Au: Spell out journal name. Reference cited as meant (article title)?Q20. Au: Spell out journal name for May et al., and confirm article is only 1
page long.
1
UHCW_A_900061 702xml March 27, 2014 16:38
Q21. Au: Spell out journal name for McNeil et al., and confirm article is only1 page long.
Q22. Au: Spell out journal name for Picklesimer et al., and verify page nos.Q23. Au: Provide country of publication for Reiger 2001.Q24. Au: Verify issue number for Teate et al.Q25. Au: Provide chapter page range for Ward 2004.Q26. Au: Verify issue number for Wilson et al.
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
0
UHCW_A_900061 702xml March 27, 2014 16:38
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]
1
UHCW_A_900061 702xml March 27, 2014 16:38
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
UHCW_A_900061 702xml March 27, 2014 16:38
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
UHCW_A_900061 702xml March 27, 2014 16:38
4 J. A. McNeil and K. M. Reiger
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
UHCW_A_900061 702xml March 27, 2014 16:38
Rethinking Prenatal Care Within a Social Model of Health 5
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
UHCW_A_900061 702xml March 27, 2014 16:38
6 J. A. McNeil and K. M. Reiger
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
UHCW_A_900061 702xml March 27, 2014 16:38
Rethinking Prenatal Care Within a Social Model of Health 7
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
UHCW_A_900061 702xml March 27, 2014 16:38
8 J. A. McNeil and K. M. Reiger
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
UHCW_A_900061 702xml March 27, 2014 16:38
Rethinking Prenatal Care Within a Social Model of Health 9
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
UHCW_A_900061 702xml March 27, 2014 16:38
10 J. A. McNeil and K. M. Reiger
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
UHCW_A_900061 702xml March 27, 2014 16:38
Rethinking Prenatal Care Within a Social Model of Health 11
“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
12 J. A. McNeil and K. M. Reiger
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
Rethinking Prenatal Care Within a Social Model of Health 13
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
14 J. A. McNeil and K. M. Reiger
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
UHCW_A_900061 702xml March 27, 2014 16:38
Rethinking Prenatal Care Within a Social Model of Health 15
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
16 J. A. McNeil and K. M. Reiger
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
Rethinking Prenatal Care Within a Social Model of Health 17
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
REFERENCES651
Beck, U. (1992). Risk society: Towards a new modernity, London, England: Sage.652Bell, J., Hansson, U., & McCaffery, N. (2010). The troubles aren’t history653
yet—Young people’s understanding of the past. The Institute for Conflict Re-654search and Achieve Enterprises for Community Relations Council NI. Re-655trieved from http://www.community-relations.org.uk/fs/doc/the-troubles-arent-656history-yet.pdf657
Bourgeault, I. L., DeVries, R., & Dingwall, R. (Eds.). (2010). The Sage handbook of658qualitative methods in health research. London, England: Sage.659
Bruegel, I. (2005). Diversity and trust in the UK. London, England: London South660Bank University, Families & Social Capital ESRC Research Group. Q11661
Bryers, H. M., & van Teijlingen, E. (2010). Risk, theory, social and medical models: A662critical analysis of the concept of risk in maternity care. Midwifery, 26, 488–496.663
Campbell, A., & Doherty, P. (2007). Birth matters better outcomes for mothers and664babies. Derry, NI: Mother’s Voices Maternity Services Liaison Group.665
Campbell, C. (2000). Social capital and health: Contextualising health promotion666within local community networks. In S. Baron, J. Field, & T. Schuller (Eds.).667Social capital: Critical perspectives (pp. 182–196). Oxford, England: Oxford Uni-668versity Press.669
Carter, M., Corry, M., & Delbanco, S. (2010). 2020 vision for a high quality high value670maternity care system Women’s Health Issues, 20, S7–S17.671
Centre for Maternal and Child Enquiries. (2011). Perinatal mortality 2009: United672Kingdom. London, England: Author.673
Cheyne, H., McNeill, J., Hunter, B., & Bick, D. (2011). United but divided? The674need to consider the potential consequences of devolved UK government on675midwifery education and practice. Midwifery, 27, 770–7744. Q12676
Commonwealth of Australia. (2009). Report of the Maternity Services Review. Australia:677Author. Q13678
Cummings, M., Goeke-Morey, M., Schermerhorn, A., Merrilees, C., & Cairns, E.679(2009). Children and political violence from a social ecological perspective:680Implications from research on children and families in Northern Ireland. Clini-681cal Child and Family Psychology Review, 12, 16–38.682
Declerq, E. R., Sakala, C., Corry, & M. P., Applebaum, S. (2006). Listening683to mothers: Report of the second national US Survey of women’s child-684bearing experiences. New York, NY: Childbirth Connection. Retrieved from685www.childbirthconnection.org686
UHCW_A_900061 702xml March 27, 2014 16:38
18 J. A. McNeil and K. M. Reiger
Denzin, N. K., & Lincoln, Y. S. (1998). Introduction: Entering the field of quali-687tative research. In N. Denzin & Y. Lincoln (Eds.), Collecting and interpreting688qualitative materials (pp. 1–34). London, England: Sage.689
Department of Health (DH). (1993). Changing childbirth: (The Cumberledge Report)690The Report of the Expert Maternity Group. London, England: HMSO.Q14 691
Department of Health (DH). (2004). Maternity matters. London, England: Author.692Department of Health (DH). (2007). Maternity standard, national services framework693
for children, young people and maternity services. London, England: Author.694Department of Health, Social Services and Public Safety Northern Ireland (DHSSP-695
SNI). (2012, July). A strategy for maternity care in Northern Ireland. Author.696Retrieved from http://www.dhsspsni.gov.uk/maternity-strategy.htm.Q15 697
Dillenburger, K., Fargas, M., & Akhonzada, R. (2008). Long-term effects of political698violence: Narrative inquiry across a 20-year period. Qualitative Health Research,69918, 1312–1322.700
Downe, S. (2010). Beyond evidence-based medicine: Complexity and stories mater-701nity care. Journal of Evaluation in Clinical Practice, 16(1), 232–237.Q16 702
Franklin, J. (Ed.). (2005). Women and social capital. London, England: London South703Bank University; Families & Social Capital ESRC Research Group.704
Gaudion, A., Menka, Y., Demilew, J., Walton, C., Yiannouzis, K., Robbins,705J., . . . Bick D. (2011). Findings from a UK feasibility study of the706CenteringPregnancy R©Model. British Journal of Midwifery, 19, 796–802.707
Giacomini, M. (2010). Theory matters in qualitative research. In I. L. Bourgeault, R.708DeVries, & Dingwall, R. (Eds.). The Sage handbook of qualitative methods in709health research (pp. 125–156). London, England: Sage.710
Gilchrist, V. J., & Williams, R. L. (1999). Key informant interviews. In Crabtree &711Miller (Eds.). Doing qualitative research (2nd ed., pp. 71–88). London, England:712Sage.Q17 713
Greer, S. L. (2004). Territorial politics and health policy: UK health policy in compar-714ative perspective. Manchester, England: Manchester University Press.715
Hamilton, J., Byrne, J., & Jarman, N. (2003). A review of health and social care needs716of victims and survivors of the Northern Ireland conflict. (NI) Eastern Health717and Social Services Board (unpublished manuscript).718
Hodnett, E. (2002). Pain and women’s satisfaction with the experience of childbirth:719A systematic review. AJOG, 185(5), S160–172.Q18 720
Ickovics, J. R., Kershaw, T., Westdahl, C., Schindler Rising, S., Klima, C., Reynolds, H.,721& Magriples, U. (2003). Group prenatal care and preterm birth weight: Results722from a matched cohort study at public clinics. Obstetrics and Gynecology, 102,7231051–1057.724
Ickovics, J. R., Kershaw, T., Westdahl, C., Magriples, M., Massey, Z., & Reynolds, H.725(2007). Group prenatal care and perinatal outcomes: A randomized controlled726trial Obstetrics and Gynecology, 110, 330–339.727
Ickovics, J. R., Reed, E., Magriples, U., Westdahl, C., Schindler-Rising, S., & Ker-728shaw, T. S. (2011). Effects of group prenatal care on psychosocial risk in preg-729nancy: Results from a randomised controlled trial. Psychology and Health, 26,730235–250.731
Kitzinger, S. (2005). The politics of birth. Edinburgh, Scotland: Elsevier.732
UHCW_A_900061 702xml March 27, 2014 16:38
Rethinking Prenatal Care Within a Social Model of Health 19
Leap, N., Sandall, J., Buckland, S., & Huber, U. (2010). Journey to confidence:733Women’s experiences of pain in labour and relational continuity of care. Journal734of Midwifery and Women’s Health, 55, 234–242.735
Lewis, G. (Ed.). (2011). Saving mothers’ lives: Reviewing maternal deaths to make736motherhood safer 2006-2008. BJOG: An International Journal of Obstetrics &737Gynaecology (The Eighth Report of the Confidential Enquiries into Maternal738Deaths in the United Kingdom), 118(S1), 1–203. Q19739
Manant, A., & Dodgson, J. (2011). CenteringPregnancy: An integrative literature740review. Journal of Midwifery and Women’s Health, 56, 94–102.741
Marmot, M., Atkinson, T., & Bell, T. (2010). Fair society, healthy lives. Retrieved from742www.ucl.ac.uk/marmotreview743
Marmot, M., & Wilkinson, R. G. (Eds.). (2006). Social determinants of health. Oxford,744England: Oxford University Press.745
Maxwell, J. A. (2002). Understanding and validity in qualitative research. In A. M.746Huberman & M. B. Miles (Eds.), The qualitative researcher’s companion (pp.74737–64). London, England: Sage.748
May, C. R., Mair, F. S., Dowrick, C. F., & Finch, T. L. (2007). Process evaluation for749complex interventions in primary care: Understanding trials using the normal-750ization process model. BMC Family Practice, 8, 42. Q20751
McLaughlin, H. (2009). Women living in disadvantaged communities: Barri-752ers to participation. Belfast, Ireland: Women’s Centres Regional Infrastruc-753ture Partnership (WCRP). Retrieved from http://www.wrda.net/Documents/754Barriers_to_ParticipationFinal_March_2009_version_2.pdf755
McMurray, A. (2009). Women’s experiences of violence: Mapping experiences756and responses. Belfast, Ireland: Women’s Centres Regional Infrastructure757Partnership (WCRP). Retrieved from http://www.wrda.net/Documents/WCRP_758Women_&_Violence_Report_Final.pdf759
McNeil, D., Vekved, M., Dolan, S. M., Siever, J., Horn, S., & Tough, S. C. (2012).760Getting more than they realised they needed: A qualitative study of women’s761experience of group prenatal care. BMC Pregnancy and Childbirth, 12, 17.762doi:10.1186/1471-2393-12-17 Q21763
Medical Research Council (MRC). (2008). Developing and evaluating complex764interventions: New guidance. Retrieved from www.mrc.ac.uk/complexinter765ventionsguidance766
Morse, J. (1991). Strategies for sampling. In J. Morse (Ed.), Qualitative nursing767research (pp. 127–145). London, England: Sage.768
Nelson, N. (2003). Feminism and method: Ethnography, discourse analysis and ac-769tivist research. New York, NY: Routledge.770
Nı Aolin, F., & Rooney, E. (2007). Underenforcement and intersectionality: Gendered771aspects of transition for women. The International Journal of Transitional Jus-772tice, 1, 338–354.773
Nilsen, A., & Brannen, J. (2005). Transitions research report #8: Negotiating parent-774hood: Consolidated interview study report. Report for the EU Framework 5 funded775study “Gender, parenthood and the changing European workplace”. Manchester,776UK: Manchester Metropolitan University, Research Institute for Health and Social777Change.778
UHCW_A_900061 702xml March 27, 2014 16:38
20 J. A. McNeil and K. M. Reiger
Northern Ireland Statistics and Research Agency. (2010). Northern Ireland Multiple779Deprivation Measure 2010. Belfast, Ireland: Author.780
O’Reilly, D., & Stevenson, M. (2003). Mental health in Northern Ireland: Have “the781troubles” made it worse? Journal of Epidemiology and Community Health, 57,782488–492.783
Oakley, A. (1984). The captured womb: A history of the medical care of pregnant784women. Oxford, England: Basil Blackwell.785
Pattenden, S., Casson, K., Cook, S., & Dolk, H. (2010). Geographical variation in786infant mortality, stillbirth and low birth weight in Northern Ireland, 1992-2002.787Journal of Epidemiological and Community Health, 65, 1159–1165.788
Pawson, R., & Tilley, N. (1997). Realistic evaluation. London, England: Sage.789Phillippi, J. C. (2009). Women’s perceptions of access to prenatal care in the United790
States: A literature review. Journal of Midwifery and Women’s Health, 54(3),791219–225.792
Picker Institute. (2007). Maternity Survey 2007. The Belfast Health and Social Care793Trust. Oxford, England: The Picker Institute Europe.794
Picklesimer, A., Billings, D., Hale, N., Blackhurst, D., & Covington-Kolb, S. (2012).795The effect of CenteringPregnancy group prenatal care on preterm birth in a796low-income population. AJOG, 206(5), 415.e1–7.Q22 797
Pope, C., & Mays, N. (2006). Qualitative research in health care. Oxford, England:798Blackwell.799
Porter, E. (1998). Identity, location, plurality: Women, nationalism and Northern800Ireland. In R. Wilford & R. Miller (Eds.), Women, ethnicity and nationalism:801The politics of transition (pp. 36–61). London, England: Routledge.802
Powell Kennedy, H., Farrell, T., Paden, R., Hill, S., Jolivet, R., Willetts, J., & Schindler803Rising, S. (2009). “I Wasn’t Alone”—A study of group prenatal care in the804military. Journal of Midwifery and Women’s Health, 54, 176–183.805
Price WaterHouse Coopers LLP. (2006). Audit of Acute Maternity Services-Department806of Health, Social Services and Public Safety. Belfast, Ireland: Author.807
Ramanzanoglu, C., with Holland, J. (2002). Feminist methodology: Challenges and808choices. London, England: Sage.809
Reiger, K. (1985). The disenchantment of the home: Modernizing the Australian810family, 1880-1940. Melbourne, Australia: Oxford University Press.811
Reiger, K. M. (2001). Our bodies, our babies: The forgotten women’s movement.812Carlton: Melbourne University Press.Q23 813
Reiger, K., & Liamputtong, P. (2010). Researching reproduction: Intersections of814personal and political. In I. L. Bourgeault, R. De Vries, & R. Dingwall (Eds.).815The Sage handbook of qualitative methods in health research (pp. 641–657).816London, England: Sage.817
Reiger, K., & Morton, C. (2012). Standardising or individualising?: A critical analysis818of the “discursive imaginaries” shaping maternity care reform. International819Journal of Childbirth, 2, 173–186.820
Rycroft-Malone, J., Seers, K., Titchen, A., Harvey, G., Kitson, A., & McCormack, B.821(2004). What is the evidence in evidence-based practice? Journal of Advanced822Nursing, 47(1), 81–90.823
Schindler Rising, S., Powell Kennedy, H., & Klima, C. (2004). Redesigning prenatal824care through CenteringPregnancy. Journal of Midwifery and Women’s Health,82549, 398–404.826
UHCW_A_900061 702xml March 27, 2014 16:38
Rethinking Prenatal Care Within a Social Model of Health 21
Schrader-McMillan, A., Barlow, J., & Redshaw, M. (2009). Birth and beyond: A re-827view of the evidence about prenatal education. Oxford, England: University of828Oxford, National Perinatal Epidemiology Unit.829
South Community Birth Program. (2006). Final report 2003–2006: A primary care830transition project. Vancouver, Canada: Author.831
Teate, A., Leap, N., Schindler Rising, S., & Homer, C. (2011). Women’s experiences832of group prenatal care in Australia—The CenteringPregnancy pilot study. Mid-833wifery, 27(20), 138–145. Q24834
Wagner, M. (2008). Born in the USA: How a broken maternity system must be fixed835to put women and children first. Berkeley, CA: University of California Press.836
Ward, M. (2004). Motherhood in Northern Ireland. In P. Kennedy (Ed.), Motherhood837in Ireland. Cork, Ireland: Mercier. Q25838
Wilson, R. J., Abram F. Y., & Anderson, J. L. (2010). Exploring a feminist based839model of community building. Qualitative Social Work, 9(40), 519–535. Q26840
World Health Organization (WHO). (2007). Challenging health inequity through841health systems. WHO Commission on the Social Determinants of Health Final842Report. Geneva, Switzerland: Author.843
Wrede, S. (2010). How country matters: Studying health policy in comparative per-844spective. In I. Bourgeault, R. Dingwall, & R. DeVries (Eds.). The Sage Handbook845of qualitative methods in health research (pp. 88–105). London, England: Sage.846
Top Related