Clinical Practice Guidelines Antenatal care - Module I

4.1 Women from culturally and linguistically diverse backgrounds

Page last updated: 02 April 2013

“Caring for individuals from diverse backgrounds is a daily reality for nurses and midwives, who are expected to provide care which is both clinically safe and culturally sensitive” (Williamson & Harrison 2010)

Around a quarter of women who give birth in Australia were born in another country (Laws et al 2010). These women experience slightly higher rates of fetal death than Australian-born women (7.9 versus 7.1 per 1,000 total births) (Laws et al 2010).

Women bring with them the knowledge and practices from their first home countries and expectations of early antenatal attendance vary between countries. For example, more than half (57%) of women giving birth in NSW in 2004 who were originally from a developing country attended antenatal care later than 12 weeks in the pregnancy (Trinh & Rubin 2006).

Factors affecting uptake of antenatal care
Women from culturally and linguistically diverse backgrounds are diverse, and different groups have differing issues and outcomes. As well as cultural background, women’s experiences differ with residential status, educational level and prior experience of pregnancy and birth. However, there are some common issues that can affect uptake of antenatal care by women from culturally and linguistically diverse backgrounds. These include (McCarthy & Barnett 1996):

  • language or lack of literacy;
  • inaccessibility or unacceptability of health services;
  • cultural issues regarding male health professionals;
  • lack of usual female family and community support systems;
  • conflict between traditional practices around antenatal care and mainstream health services;
  • lack of cultural competency among health professionals;
  • history of grief, loss and trauma, in addition to migration;
  • lack of entitlement to free health care; and
  • lack of suitable resources (eg female interpreters).
Women from culturally and linguistically diverse backgrounds who have no previous experience with the western health care system may lack understanding of reasons for antenatal visits, medical procedures and use of technology. They may not feel confident to ask questions or participate in discussions about their care plan or birth options. Different cultural beliefs may also influence aspects of antenatal care such as involvement of the father in pregnancy and childbirth, consent for interventions such as caesarean section, willingness to be cared for by a midwife rather than a doctor, understanding of dates and times of appointments, and knowledge about medical aspects of pregnancy.

Information needs to be explained carefully and clearly, with the assistance of an accredited interpreter, in addition to providing written information. Written material can serve as a prompt or can be shown to other health professionals who can then remind the woman or explain the information again. Video or audio resources may also be appropriate.

Issues affecting women from particular groups

Different groups of culturally and linguistically diverse women face specific issues that may affect their experience of pregnancy and birth. Increased awareness of such issues and variation between groups will promote better antenatal care of women from culturally and linguistically diverse backgrounds.
  • Women who are refugees or asylum seekers — Many refugee women experience issues such as poor prior health (including oral health, co-existing health issues, inadequate nutrition and Post Traumatic Stress Disorder). They may feel fear of authority figures, including health professionals, due to past experiences of trauma and/or torture, and may also have financial, employment and housing issues. Women with a history of torture or trauma are at increased risk of mental disorders, including anxiety and depression; screening for these disorders and referral to appropriate counselling services should always be offered. Women in this situation will require reassurance and explanation of the care offered to them, including tests, procedures and pregnancy risks. More time may be needed, and specific strategies used (often in collaboration with other services and migrant agencies) to build necessary confidence and trust.
  • Women affected by Female Genital Mutilation (FGM) — FGM is the collective term used to describe the cultural practice of cutting or removal of either a part, or the whole external female genitalia. Some of these procedures are minor, while others involve significant change and have an impact during the antenatal period. Some women may need to be deinfibulated to enable ongoing clinical assessment and avoid complications; this is usually performed in the second trimester but the first trimester is the optimum time to discuss the procedure. Women affected by FGM have specific care needs and should where possible be referred to an FGM team for ongoing support and management of their physical and psychological wellbeing.
  • Women in higher risk groups — some culturally and linguistically diverse groups have higher rates of risk factors such as gestational diabetes, smoking in pregnancy and vitamin D deficiency. Lifestyle advice may need to take cultural issues into account (eg giving culturally relevant nutritional advice on managing gestational diabetes and educating both women and men about passive smoking as in many households it may be men rather than women who smoke). Domestic violence is high among some communities, and may be hidden within the family structure and or the community.
Health professionals are encouraged to develop an understanding of the issues facing mothers and babies from the culturally and linguistically diverse groups that they regularly work with and to use this information to improve the appropriateness of their care.

Improving antenatal care for women from culturally and linguistically diverse backgrounds.

Experiences of antenatal care among women from culturally and linguistically diverse backgrounds, including refugee backgrounds, may be improved through (State Perinatal Reference Group 2008):
  • social support, for example through ethnic-specific cultural liaison officers and women’s groups, to maintain cultural connections with the traditions, birthing ceremonies and rituals of women’s countries of origin;
  • cultural competence among health professionals, including knowledge of cultural traditions and practices relevant to pregnancy and birth and associated expectations of women, especially of groups in the local community;
  • cultural brokerage, for example through maternity liaison officers/bilingual health workers who can help women to understand and navigate the health system, provide education and resources in relation to maternity care, act as a patient advocate and liaise between women and maternity staff, or through partnerships with multicultural resource centres and English language providers;
  • education, including linguistically appropriate information, parenting education workshops, education about accessing the health system, different models of care available, and education for fathers/partners on antenatal issues; and
  • culturally appropriate resources, including materials available in the woman’s own language, resources in spoken format for women who lack literacy in their own languages and access to interpreter services during appointments or important events.
The care needs of women from culturally and linguistically diverse backgrounds can be complex. The first point of contact (eg first antenatal visit) is important and should be undertaken with an accredited health interpreter.

This section includes provisional guidance on improving the experience of antenatal care for women from culturally and linguistically diverse backgrounds. A more comprehensive approach to care for these women will be included in Module II of these Guidelines.