Improving Postnatal Care in Hospital For BME Women by Exploring Healthcare Workers Capabilities

Improving Postnatal Care and Experience in Hospital for Black and
South Asian Women by Exploring Health Care Workers

Capabilities.

Marsha Jones
Clinical Lead-Maternity Inpatients
Mary Seacole Leadership Awardee 2011
Barts Health NHS Trust
Newham University Hospital

Improving Postnatal Care and Experience in Hospital for
Black and South Asian women; exploring the capabilities of health care workers.

Marsha Jones, Mary Seacole Leadership Award 2011-2012 2

ACKNOWLEDGEMENTS
The awards are funded by NHS Employers and the Department of Health, and are awarded in
association with Royal College of Midwives, Royal College of Nursing, Unison and
Unite/CPHVA.



I am indebted to the memory of Mary Seacole; to NHS Employers and the Department of Health for
providing me this opportunity to undertake a service development project.
The project aimed to improve the postnatal care experience for Black and South Asian women in
hospital, through the exploration of the capabilities of midwives and other health care workers.
Undertaking this project has helped me to develop my leadership skills as well as challenging my
writing and analytical skills. It has given me a sense of the possibilities for making things better for
the families I care for.
Being a fellow Jamaican, I am immensely proud to be a Mary Seacole Scholar. I have been given an
opportunity as a global citizen to make an effort, however small, to address inequalities under the
banner of Jamaicas motto: Out of Many, One People.
I am grateful to the women and staff who shared their experiences with me, without their openness
and honesty, this project would not have been possible.
I thank my employers for enabling me to undertake the project and I am grateful to my colleagues
and my manager Scott Johnston, for their support during the project. I would like also to thank the
many people who supported and cheered me on including, Amanda Clifton, Abiola Jinadu and
Sonia Jabke for providing leadership support to my team in my absence. My sincere thanks also to
the Research and Development team at Newham University Hospital for their guidance.
I would also like to thank Sanchia Alisia, Farida Malik and Desiree Campbell-Richardson for being
so generous with their time and support. A big thank you is sent to Gail Adams - Chair of the Mary
Seacole Steering Committee; my mentors Dr David Foster, Sue Jacob and to Janet Fyle and other
members of the Mary Seacole Steering Committee for their constant guidance and support
throughout the project. In addition, a big thank you to Lynette Phillips who coached me along the
journey.
I am truly blessed to have had such wonderful support from my friends and family; especially my
mother Mena Smith, my husband, Dr Emmanuel Ako and my daughter, Mya Ako.
Thank you all for your inspiration, support, patience and encouragement.
Most importantly and above all, I thank God for guiding me along this journey.


EXECUTIVE SUMMARY
Introduction
As a Mary Seacole Scholar, I undertook a service improvement project in an East London Maternity
unit between the 6
th
to the 28
th
August 2012.
Background
Postnatal care is sometimes said to be the poor cousin and referred to as the Cinderella of the
maternity services (Royal College of Midwives, 2000a). It is known that a positive birth experience
and good postnatal care has an impact on the physical, psychological and emotional outcomes for
women in general (Medforth, et. al., 2011).
The rationale for the project was as a result of the reported poor experiences of Black and South
Asian women on the postnatal ward, which were highlighted in complaints, on-going feedback to
the Trust and an independent report on the hospitals Maternity Services by the Care Quality
Commission (CQC) in 2010.
Black and Minority Ethnic (BME) women in the locality have self reported poorer experiences of
postnatal care. It is important for BME women to be given appropriate and relevant information and
support in their immediate post birth period, to enable and equip them to better able to care for
themselves and their infants in order to improve their health outcomes.
Aim
The project aimed to engage with and elicit the views of women, midwives and other healthcare
workers, to gain an insight into the barriers to equality of postnatal care design and delivery, to give
participants the opportunity to identify areas for improvement and to suggest solutions for
improving hospital-based postnatal care for BME women and the wider community.
Methods
A mixed method approach using semi-structured interviews, questionnaires and focus groups for
women, midwives and other health care workers were used to inform, design and analyse the
findings.


Data Analysis
Data from the interviews and focus groups were analysed using thematic content analysis.
Findings
The study revealed some poor staff attitudes, cases of inadequate support of women in the postnatal
period, inadequate information provision and poor cultural understanding in the provision and
delivery of the service provision. The study also revealed stress and frustration amongst staff as a
result of being unable to provide adequate quality care and services to all women. However, there
were areas of positive feedback such as the environment. These findings have implications for BME
women and the wider community. The outcomes from the project provide essential information and
pointers for the local organisation, to address the issues which have been identified as having some
of the highest impact on service delivery, in order to improve the experiences of both patients and
staff.
Conclusion
This was a small study in a local maternity unit serving a diverse ethnic population and it focused
on service improvement issues which could make a difference if addressed. The groups of women
and staff who participated in the study identified issues which were already partly known to service
providers. However, the conclusion of this study could incentivize the local organisation to
reinvestigate how services are planned and delivered to a multi-ethnic population; as these findings
resonate with local and national research.
If we are to improve services for BME women, we must also improve the attitudes and morale of
the staff that deliver care to these women, especially as the staff perceived organisational
constraints as a factor in their inability to deliver quality care. The potential impact from the issues
identified in this study should not be underestimated. The findings and recommendations, if
implemented, are crucial to improving the delivery of postnatal care services for BME women and
the wider community. It is hopeful that the report recommendations from this study will act as a
catalyst for action, in devising a strategy of positive change to improve the experiences of both
patients and staff.



CONTENTS
1.0 INTRODUCTION ...................................................................................................................... 7
1.1 Rationale for project ............................................................................................................... 9
2.0 BACKGROUND AND CONTEXT ......................................................................................... 10
2.1 Demographics ....................................................................................................................... 10
2.2 Local demographics .............................................................................................................. 10
2.3 Project aim ............................................................................................................................ 13
2.4 Objectives of the project ....................................................................................................... 13
3.0 LITERATURE REVIEW ......................................................................................................... 14
3.1 Literature search ................................................................................................................... 14
3.2 Health Inequalities ................................................................................................................ 14
3.3 BME women experiences of postnatal care.......................................................................... 16
3.4 Hospital postnatal care.......................................................................................................... 18
3.5 Staff views and perceptions on providing postnatal care ..................................................... 19
4.0 METHODOLOGY ................................................................................................................. 221
4.1 Ethical considerations ......................................................................................................... 221
4.2 Promotion of project ........................................................................................................... 221
4.3 Interviews ........................................................................................................................... 232
4.4 Questionnaires .................................................................................................................... 254
4.5 Focus groups ....................................................................................................................... 265
5.0 FINDINGS ............................................................................................................................. 298
5.1 Introduction ........................................................................................................................ 298
5.2 Women Participants ............................................................................................................ 298
5.3 Emergent themes ................................................................................................................ 298
5.3.1 The attitude of clinical and non-clinical staff ............................................................. 309
5.3.2 Lack of understanding of cultural needs ....................................................................... 32
5.3.3 Imperatives breastfeeding support ................................................................................ 33
5.3.4 Poor care and support at night ..................................................................................... 34
5.3.5 Expectations of care ..................................................................................................... 35
5.3.6 The positive impact of the environment ...................................................................... 38
5.4 Staff- Participants ................................................................................................................. 39
5.5 Emergent themes Not enough time to care ........................................................................ 39
5.6 Emergent themes - Adequate staffing................................................................................... 40


5.7 Areas for improvement ......................................................................................................... 42
5.7.1 Improving attitudes of clinical and non-clinical staff ................................................... 42
5.7.2 Meeting the cultural needs of women ........................................................................... 43
5.7.3 Breast feeding support .................................................................................................. 44
5.7.4 Adequate staff, resources and support .......................................................................... 44
6.0 DISCUSSION ........................................................................................................................... 46
6.1 Introduction .......................................................................................................................... 46
6.1.1 The impact of staff attitude ........................................................................................... 46
6.1.2 Poor care and support at night ...................................................................................... 47
6.1.3 The positive impact of the environment ....................................................................... 49
6.1.4 Enough time to care ...................................................................................................... 50
6.1.5 Discharge Process ........................................................................................................ 50
6.1.6 Mentoring and support for staff ...................................................................................51
7.0 RECOMMENDATIONS.......................................................................................................... 52
7.1 Limitations of the study ........................................................................................................ 53
7.2 Conclusion ............................................................................................................................ 54
8.0 REFERENCES ......................................................................................................................... 55
9.0 APPENDICES .......................................................................................................................... 62
Appendix 1 ....................................................................................................................................... 63
Appendix 2 ....................................................................................................................................... 64
Appendix 3 ....................................................................................................................................... 65
Appendix 4 ....................................................................................................................................... 66
Appendix 5 ....................................................................................................................................... 67
Appendix 6 ....................................................................................................................................... 69
Appendix 7 ....................................................................................................................................... 70
Appendix 8 ....................................................................................................................................... 71
Appendix 9 ....................................................................................................................................... 76
Appendix 10 ..................................................................................................................................... 77



1.0 INTRODUCTION
Midwives often advance the notion that pregnancy is a normal life and family event and should be
seen within a socio-cultural context. Nonetheless, this may not be the case for some women, - it
being a time of physical and psychological change. These changes impact on women as they adjust
to being pregnant and to the changes of their social roles within the family and society (RCM,
2000a; 2000b; 2009). Womens experiences of maternity services contribute to their overall
experience during pregnancy, child birth, post birth care and therefore to health outcomes.
The Audit Commission review of maternity services (1997), shed light on womens poor
experiences of hospital postnatal services which were thought to be worse than any other aspect of
maternity care. Over the last 14 years, we have seen a steady decline in postnatal care for women,
both in hospital and community despite the perceptions that community postnatal care fared
better. However, women have consistently rated hospital based postnatal care as being poor through
various surveys over the years. If the general perception is that postnatal care is poor, it could be
argued that for Black and Minority Ethnic (BME) women, the experience is worse. This concurs
with surveys on postnatal care conducted after 1997, which highlighted that BME womens
experiences of postnatal care are more likely to be less favourable in comparison to other areas of
maternity services (Redshaw, et. al., 2006; Health Care Commission, 2008; Bhavani and Newburn,
2010).
Policy initiatives in the UK have aimed to improve womens experiences in maternity care (DH,
1993; 2007) but despite these various policies hospital postnatal care remains a low priority.
Maternity services and clinicians place much emphasis on the antenatal and labour period (and
rightly so), but this perceived low priority for post birth care gave rise to the notion of postnatal care
being the Cinderella of maternity services (Schmeid and Everitt 1996 cited in Dykes 2005, RCM
2000a). The current structure of some maternity services in parts of the UK does not always
facilitate a more holistic care of women post birth. Consequently, opportunities for midwives to
provide women with adequate support and advice for parenting is missed, because the emphasis
tends to be on a series of tasks which midwives may feel they have to complete (RCM 2000b).
The health needs of some BME women are already complex without the added burden of a deficient
postnatal care service, although government policies have acknowledged that service delivery
should be sensitive to the care needs of BME communities and be focussed on the needs of


vulnerable women and patients that need care the most (DH, 2007; 2010). Recent reports continue
to cite issues such as language barrier, access to services and poor communication as contributing
factors for BME women who have had poor pregnancy and health outcomes and for those who died
in childbirth (Lewis, 2007; 2011). Involving women in their own care and listening to their views is
important in getting postnatal care right. (Redshaw and Heikklia 2010).
The new proposal for the health service in England and a priority in the public health agenda is to
reduce health inequalities (DH, 2010a). This is not new in itself, as successive health policies in this
area have held this objective. One of the strategies proposed to achieve this outcome, is to focus on
the immediate post birth care, by engaging with new mothers and providing high quality care. It is
the most practical time to empower women, by providing them with relevant information and
support in such a way and format that they can engage in making decisions about their own care and
that of their newborn. It is believed that this would enable them to have a better start as parents
(Medforth, et. al., 2011). Therefore improving elements of the content of postnatal care through its
organisation and delivery in hospital is one aspect of improving health outcomes for BME women
and the wider community.
The role of the midwife is essential in the public health agenda. As they are the key providers of
maternity care, they are perceived as advocates for women and a source of advice and support for
the new mother on issues such as infant care, nutrition, recognising abnormalities or ill health in the
infant and other health promoting activities (RCM, 2006, NMC, 2010a). Given the shortfall in
midwife numbers to meet the complex care needs of an ethnically diverse population (Kings Fund,
2008); it must be acknowledged that there are other professionals involved post birth in the care of
the mother and baby. The Healthy Child Programme means that the health visiting workforce is
being strengthened, including the redevelopment of the health visitor role with families (DH,
2010a). It could be assumed that a more collaborative approach to care by midwives, health visitors
and support staff would provide a new approach to the issue of poor standards of postnatal care.
It is debateable as to whether the deficiency in this aspect of maternity and midwifery care is simply
down to the fact that midwives have failed to effectively articulate the needs of mothers, or to the
lack of acknowledgement as to the importance of midwives role in public health. From my
experience, it could be that midwives make a case-specific judgment as to which aspect of care is
priority - both at clinical and managerial levels. It is also possible that midwives are in a state of


learnt helplessness, because midwives may feel powerless to change situations, or that they are of
the view that postnatal care can be handed to someone else, whilst they support women during
childbirth.
1.1 Rationale for project
There is a need to improve services for BME women, for whom poor experiences of maternity
services were a key feature in local complaints, patient surveys, comments cards and face to face
feedback. Experiences were shared by women on the postnatal ward and supported by research
evidence. Some of the issues identified in these complaints and other feed-back mechanisms
included:
the feeling that care was rushed
lack of consistency in advice
poor staff attitude
non-evidence based infant feeding advice and support
general support and advice to care for themselves and their babies
on-going physical illness and poor outcomes
feeling of neglect

Because of these areas of complaints, it was important to engage more closely with these women, to
understand their experiences of postnatal care and suggestions as how best to improve their care.
Alongside this, it is important to engage with the health professionals providing immediate post-
birth care, to understand their perceptions of this area and how best to improve postnatal care
locally while also meeting the needs of BME women.



2.0 BACKGROUND AND CONTEXT
2.1 Demographics
The United Kingdom (UK) is becoming more ethnically diverse. The 2001 Census revealed that 8%
of the UK population described themselves as non-white (Office of National Statistics (ONS),
2001) and that BME groups now account for 73% of the UKs total population growth
(Parliamentary Office of Science and Technology (POST), 2007). For example, in London, around
50% of people in inner London are from an ethnic group other than white British and a further 40%
of the population in outer London are not white British (Trust for London and New Policy Institute,
2011). With such changes come a rich cultural diversity, but this is not without its challenges.
Pakistani, Bangladeshi and Indian groups, referred to as South Asians, make up 4% of the UKs
population and are considered to be the largest ethnic minority group in the UK (ONS, 2001). They
are also considered to be among the poorest in the UK, highly represented in the lower socio-
economic groups and encounter difficulties in accessing healthcare (Smaje 1995, Dale, 2002 and
Jayaweera, et. al., 2005 cited in Urhoma, 2009). Black Africans and Black Caribbeans make up 2%
of the population and in inner London, Black Africans and Black Caribbeans are the largest non-
White groups; Indians are the largest non-white group in outer London (Trust for London and New
Policy Institute, 2011). Black and South Asian groups tend to have pre-disposing factors through
genetics and lifestyle choices that may contribute to higher incidence of hypertension, diabetes and
cardiovascular diseases (Smaje, 1995, The Information Centre, 2006). Given these factors, it was
important to look at how we provide maternity services and in particular, postnatal care and support
to our diverse population in Newham.
2.2 Local demographics
The project site, Newham University Hospital (NUH) is located in the borough of Newham, which
has one of the most diverse and deprived populations in the UK. 61% of the population is from
BME backgrounds and this was projected to reach 70% by 2010 (ONS 2001 cited in Newham
Council, 2009; Greater London Authority (GLA) cited in Newham Joint Strategic Needs
Assessment, (JSNA), 2010). The borough also has one of the highest unemployment rates in
London. The picture which emerges from these statistics would indicate that there should be a focus
and emphasis on providing quality care that improves health outcomes for mothers and their
families.


Newham has one of the highest birth rates in the country; 6,003 births in 2009 and 7,389 in 2011
(Newham Recorder, 2012), with the highest proportion of births to overseas women in London -
totalling 74.8% (Newham Voluntary Sector Consortium (NVSC), 2011). Of these births, 80% of the
babies are born at NUH Maternity Unit (London Health Program, 2011). Please see Appendix 1 for
a breakdown of births by ethnicity at NUH from 1
st
January-31
st
December 2012.
It has been estimated that more than a hundred languages are spoken locally in Newham (Newham
Council, 2009). The non-white service users are from an ethnic minority population with very
limited English speaking ability (ONS 2001). NUH provides a health advocacy service which
includes access to a language line, to ensure that there is a translation service available to meet the
communication needs of the population (NUH, 2011). Despite the availability of interpreting
services, the majority of information provided to women in the maternity services is in English.
However, the need for multilingual print must be balanced against costs (including accurate and
culturally appropriate translation) and the ability to read the written word regardless of the language
in which it is written. Improving information and communication for non-English speaking BME
women is a national requirement (Lewis, 2007, NHS Litigation Authority, 2008); as a lack of
understanding of how services are organised and delivered is a key indicator of inequalities in
access to health care.
Although NUH (2011) takes the concern of all service users seriously and actively does so by
listening to patient feedback and experiences. In the absence of a maternity services liaison
committee (MSLC), this creates a challenge for service users feedback in improving services and
many women feel that the only way to impact change is to write a formal complaint. The MSLC is a
local forum to contribute to improving maternity, service design and delivery by listening to the
needs of women and articulating their wishes to service providers. The need for public and patient
involvement (PPI) as outlined in the National Service Framework (NSF) for Children, Young
People and Maternity Services Section 11 (DH, 2004), is a legislative framework to report on how
user feedback has assisted in the commissioning of services. At the time of writing this report, a
MSLC had been set up so that various stakeholders can discuss pertinent issues (NUH, 2012).
The local BME groups identified to be of interest for the purposes of this project were:
Black - African and Caribbean women
South Asian - Bangladeshi, Indian and Pakistani women


Staff
Crucial to improving the delivery of postnatal care services for BME women is the attitude,
willingness and competence of the staff working in NUH Maternity Unit. NUH (2011) has a very
diverse workforce; Table 1 provides the ethnic breakdown at the time of writing, but this is in a
state of flux due to resignations and new appointments.
Ethnic Groups Percentage %
Black African 23
Black Caribbean 7
White 25
Asian 15
White other 5
Other 25
Table 1. Ethnic breakdown of NUH workforce
A diverse workforce is essential in providing culturally sensitive care, that in turn contributes to
better care (Prime Ministers Commission, 2010, Darzi Report (DH, 2009), Governments 2010
White Paper, (DH, 2010) cited in Johnson, 2011). However, in the maternity unit approximately
85% of the workforce is Black Africans, whilst South Asians (including Bangladeshis, Indians and
Pakistani women) are the largest ethnic client group. The dissatisfaction from women with their
postnatal care may be due to the lack of understanding of the importance of considering the part that
culture plays in health care and crucially, childbirth. Midwifery 2020 and Delivery Expectations
(2010), clearly highlights that midwives need to be able to deliver culturally competent care in an
ethnically diverse population (Midwifery 2020: 2010).
Staff engagement and understanding of the client group is essential in identifying the challenges and
barriers to quality care delivery. In delivering the Quality, Innovation, Productivity and Prevention
(QIPP) agenda, it is advised that listening to staff views and suggestions on how to improve


services should be explored, as this is crucial to improving efficiency and quality of care (DH,
2010b, NHS Employers, 2012). Therefore staff were approached to understand the challenges and
barriers in providing hospital postnatal care and to identify key areas for further development. This
approach was envisaged to produce findings that will positively impact on BME women
experiences and the wider community.
2.3 Project aim
The project aimed to engage with women, midwives and other health workers to gain insight into
the barriers to care delivery and service provisions and to identify solutions in improving hospital
based postnatal care for BME women and the wider community.
2.4 Objectives of the project
The objectives of this project were to:
engage in a meaningful way with Black and South Asian women in understanding their
perceptions of postnatal care
identify areas in the care pathways that could be improved
gain insight as to how they feel their care and experiences could be improved
understand health care professional views on postnatal care
identify barriers to care delivery
gain input of health care professionals into how postnatal care can be developed.



3.0 LITERATURE REVIEW
3.1 Literature search
The aim of the literature search was to identify research exploring postnatal care and experience in
hospitals with Black and South Asian mothers and staff and their experiences of providing postnatal
care. A literature search using various nursing, medical, midwifery and other health care journals
and databases was completed. Manual searches of websites including Department of Health, Office
of National Statistics were to locate policies, unpublished and grey literature.
The literature search resulted in an unexpectedly small number of studies. There is a dearth of
literature specifically looking at BME womens experiences of postnatal care in hospital so the
search was extended to include countries similar to the UK, such as Australia where they have a
diverse population. Often the literature identified individual groups e.g. Somali women but women
were also referred to non-specifically as migrant groups. For the purposes of this project, all Black
groups were grouped together whether from Africa, the Americas and the Caribbean. Pakistani,
Indian and Bangladeshi women were all grouped as South Asian. The term BME will be used
throughout although the project was specifically focused on Black and South Asian women.
3.2 Health Inequalities
Reducing health inequalities has been identified as one of the National Health Services top five
priorities that broadly impact on care and health outcomes of vulnerable groups and the wider
communities (Acheson 1998; Darzi, 2007; Marmot 2009). The Commonwealth Immigrants White
Paper (1965) acknowledged early on that ethnicity and health policy is an ongoing challenge for the
health service (Smaje 1995). However, Public Authorities also have a general equality duty as
outlined in the Equality Act (2010) (Feldman, 2012).
Maternity services
Changing Childbirth (DH, 1993) advocated equity in access, continuity of care and continuity of
carer for all women using maternity services. However, the Confidential Enquiry into Stillbirths and
Deaths in Infancy (CESDI) (1998) and CEMD (2001) have highlighted the need for maternity
service delivery to meet the care needs of BME women (Rosser 1998, Lewis 2001). This concurs
with Acheson Report (1998) which highlighted that services must meet the needs of BME women


(Parliamentary Office of science and Technology (POST), 2007). The health committee report on
Inequalities in Access to Maternity Services (2003) highlighted the availability of maternity care to
all women but identified the inequities in access to care. Such findings have the greatest impact on
BME women as these groups of women continue to have poorer health outcomes and encounter
challenges accessing care.
Guidance and examples of best practise has been shared in addressing the poor health outcomes of
BME women using maternity services (The Commission for Racial Equality (CRE), 1994 cited in
RCM, 2000c). The National Service Framework for Maternity (DH 2004) and Maternal and Child
Nutrition Guidance (NICE, 2006) support the aim of equal access to health services and care.
Maternity Matters (DH, 2007) also advocated for equity in care, with an emphasis on BME women
and vulnerable groups. Furthermore, the NHS Constitution for England (DH, 2010b) policy sets out
clear guidance for the NHS, identifying the core values that a patient can expect from the care and
service they receive. This sets the tone in providing guidance to ensure all women receive high
quality, woman-centred care, but this is not always the case in practice.
Tackling health inequalities remains a key challenge for the Government and led to the publication
of the Marmot Review (2009). The review by Urhoma (2009) of health inequalities policies
included a summary of the key points from Marmot review. These include:
Health outcomes across the social determinants of health gradient are variable; however
these were not explored.
Infant mortality, a good indicator of overall health of the nation. There was a decrease in the
national infant mortality rates (IMR) from 5.6 infant deaths per 1000 live births in 1995-
1997 compared to 4.7 in 2005-2007.
Rise in Infant Mortality Rate for BME women compared with previous years
Infant Mortality rates are significant findings in the general population; however the higher
statistics for BME groups can be attributed to genetic predispositions through ethnicity, poor health
and late access to health care and socio-economic factors (Acheson 1997, Lewis 2007, DH 2007).
BME women are often more likely to have poorer maternal and birth outcomes, such as low birth
weight babies, still births, premature labours and congenital abnormalities. This can be further
compounded with mental ill health either before or after birth (DH 2007 cited in Urhoma, 2009).
However, poverty also has a direct co-relation to poor birth outcomes and equity to access remains
the main factor affecting BME groups when compared to white-British Population (Acheson 1997,


Platt 2002 cited in POST 2007, Marmot, 2009). All these contributing factors create the
predicament of women not being able to provide the basic nourishment and balanced diet required
for the healthy growth and development of the child, before and after birth. These findings are all
relevant to the population of Newham, which has high still birth rates and more babies with low
birth weights (JNSA, 2010).
3.3 BME women experiences of postnatal care
Stereotypical behaviours and attitudes
Poor staff attitudes such as harsh communication can have a negative, physical and psychological
impact on women immediately post birth who may already feel vulnerable because it could prevent
them from asking for help and support. This concurs with similar findings of women experiences at
NUH not being treated with respect and dignity (CQC 2010). In addition, an ethnographic study
using a non-participant observation approach with in depth interviews on the stereotypes of Asian
women in Maternity care identified that midwives routinely stereotype women in providing care;
the perception was midwives did not have enough time to care so felt it was easier to provide care
based on their views rather than the individual needs of the women (Bowler, 1993). Despite staff
were being observed whilst providing care, the stereotypical behaviours of staff were apparent.
These findings are not representative of all midwives but highlight the need for midwives to provide
individualised care that is culturally sensitive. This approach would diminish the need to stereotype
and help to address some of the concerns that BME women may have.
Similar findings of stereotypical behaviours were highlighted in a qualitative study exploring
Pakistani women and white women experiences of breastfeeding in hospital and home. It reported
health professionals assumed these groups of women would bottle feed, without even discussing the
known benefits of breastfeeding (Bowes and Domokos, 1998). This study was exploring
breastfeeding but clearly highlights the stereotypical behaviours of staff caring for BME women.
Further evidence suggests that stereotypical behaviour of staff is an ongoing issue as highlighted in
a qualitative study in East London with Asian women. These women felt there were tensions with
staff as cultural influences encourage rest during this period and the midwives did not provide any
support in caring for their babies when asked or to support their cultural needs (Woolett and
Matwala, 1990). It has been reported that BME women experiences in the postnatal period are
guided by their cultural beliefs (Callister, Seminic and Foster, 2010). This requires health
professionals to be able to provide culturally competent care for these groups of women.


Language barrier
Adequate advice and emotional support is a real issue for BME women as it impacts on how they
care for themselves and their newborns. However, language barrier has been reported as one of the
main factors preventing women from accessing care. These findings were highlighted in a
qualitative study conducted in Tower Hamlets exploring Bangladeshi womens understandings and
experiences of postnatal distress (Parvin, Jones and Hull, 2004). Despite this study was not
specifically about postnatal care and the women were all born and raised in Bangladesh, the
findings resonate with the views of some BME women. Harper, Bulman and McCourt, (2001)
qualitative study of Somali womens experiences of maternity care also echoed similar findings of
inadequate support that is individualised to the needs of the women. It is clear the experiences of
BME women are further compounded by language barriers as is demonstrated through the findings
of a qualitative study exploring the views of BME born in the UK. The findings reported that this
group of women felt that because they did not have language barrier they were able to navigate
themselves through the services and felt the care received was similar to that of white women.
However, these women recommended that health professionals need to become more sensitive and
delicate in their interactions with BME women as well as providing consistent advice (Puthussery,
et. al., 2010). This study would suggest that language barrier is the main challenge for BME women
accessing services.
Continuity of care
It is important for maternity services to explore different options in providing care for BME women,
as this would improve access to services and facilitate a better relationship with midwives. This
appreciation of continuity of care was demonstrated through a qualitative study exploring if
continuity of care matter to BME groups comparing case load (women seen by a team of midwives
throughout the antenatal, intrapartum and the postnatal period) and hospital based services. The
findings highlighted that women valued the quality of the communication and support they received
through seeing the case loading midwives. However, women receiving conventional care were
disappointed and did not feel that the care was individualised to their needs. The women that were
caseloaded also showed greater trust and confidence in the staff (McCourt and Pearce, 2002). A
similar study exploring BME womens views on continuity of care and hospital care reported
similar findings that women that were caseloaded had a favourable experience compared to women
that used hospital based services (Hindley, 2005). These studies were not specific about postnatal


care but add to the evidence that BME women do not receive high quality care when accessing
hospital based care. These women would like to be involved in their care, have an opportunity to
build rapport with health professionals and to receive consistent advice and support. It can be
inferred that institutional organisational structures of care are likely to contribute to poor postnatal
experiences of BME women and the wider community.
3.4 Hospital postnatal care
A qualitative study of 20 women from an English maternity unit exploring the experiences and
expectations of women receiving inpatient postnatal care findings were difficulties with staff
attitude, the level of breast feeding support, unmet information needs and unsuitable ward
environment (Beake, et. al., 2010). This sample size was not representative of a diverse population,
but it adds to an existing body of evidence of the poor care received by women in hospital. Hospital
based postnatal care is not only a challenge in the UK, but there is also a growing body of evidence
in other developed countries. Similar findings were highlighted in Australia through a postal survey
sent to women 5-6 months post birth exploring the views on their experiences of hospital postnatal
care. Some women perceived their care to be rushed, not always sensitive and did not feel that they
got enough advice and support prior to leaving hospital (Brown, Davey and Bruinsma, 2004). These
views resonate with feedback through surveys in the UK.
Further research in Sweden highlighted similar findings through surveys sent to new parents six
months post birth reported; unfriendly and unhelpful staff, lack of breastfeeding support and a
general lack of support. The findings also acknowledged dissatisfaction with fathers not being
allowed to stay overnight (Hildingson, 2007). Anecdotal evidence suggests that care at nights is
poorer compared to day time. This may due to the additional support that is available from family
and friends during day time. Care in hospitals at night has been recognised by the Government and
initiatives have been implemented to improve patients experience (The Information Centre, 2012).
The dissatisfaction of womens experiences of hospital postnatal care is of the homogenous
population. These women are usually proficient in expressing their concerns, therefore BME
women that have linguistic challenges are arguable more likely to have poorer experiences.
A survey seeking to explore what matters to women about postnatal care reported women were
generally satisfied with their community based postnatal care (Wray, 2006). Despite, the response
rate being 42%, the findings resonate with BME women experiences of hospital postnatal care -
lack of support to care for babies, visiting arrangements, rest period, baby care advice and support


(Wray, 2006). Further evidence through a longitudinal population based survey of 2338 women in
Sweden carried out in early pregnancy, 2 months post birth and 1 year post birth reported only 32%
of the women were satisfied with their interpersonal care, time spent on physical checkups, time
spent on information and support, time spent on assistance with breastfeeding. However, specific
groups such as migrants were dissatisfied with areas of postnatal care such as interpersonal care and
time spent on information and support (Rudman, El Kouri and Waldenstom, 2008). These findings
clearly relate to BME women experiences of hospital based postnatal care in the locality.
3.5 Staff views and perceptions on providing postnatal care
Midwives and other health professionals expectation is to provide the best care. However, barriers
to care such as inadequate administrative support and adequate staffing are usually the concerns
highlighted by staff. These views were also shared by midwives through a qualitative study in North
West England engaging midwives providing postnatal care either in hospital or the community
(Cattrell, et. al., 2005). Further evidence highlights administrative tasks as a potential barrier in care
provision. This was acknowledged in a first of its kind study in the UK accessing midwives views
in the South of England on a quality improvement project through questionnaires. The study found
that staff acknowledged the benefits to the women, but commented on the requirement of more
paper work (Bick, et. al., 2011). These findings are not the views of all midwives, but are of
relevance as additional administrative tasks impacts on the quality of care women received.
Forster, et. al. (2006) explored the adequate provision of staff in the postnatal unit; the findings
highlighted staffing as a major factor impacting on the quality of hospital postnatal care. These
findings are of relevance in the UK but will require further exploration due to the shortage of
midwives and ageing of the workforce. It was anticipated if staffs views were explored on
improving postnatal care, adequate staffing levels may emerge. A similar study conducted in
Australia capturing the views and experiences of midwives on the postnatal ward highlighted that
midwives remained positive in the care they give, however felt the quality of the care they give
were compounded by midwife to women ratios, length of stay, busyness of the ward and the effect
of visitors on care delivery. It also highlighted that midwives saw their role to include educating and
supporting women with their physical needs, breastfeeding and parenting skills (Rayner, et. al.,
2008).
These experiences of midwives feeling unable to provide adequate care due to various factors such
as staffing levels do impact on staff morale. This contributes to midwives leaving the profession.


Ball, Curtis and Kirkham, (2002) reported midwives often leave the profession as they are unable to
provide a standard of care and build relationships with their clients in ensuring they get the best
care. The main barriers are staffing levels and other organisational factors as highlighted in previous
studies.
Having explored the literature and established that there is a limited amount of literature specifically
looking at postnatal care in hospital for Black and South Asian women, this Mary Seacole
Leadership Award project identified a gap in the knowledge in this area. Black and South Asian
women, midwives and other health workers were engaged with to explore how best to improve this
area of care.



4.0 METHODOLOGY
A mixed method approach was used to undertake the project to inform, develop and triangulate
various stages of the data collection. This approach used more than one data collection tools to
cross reference in ensuring validity and feasibility of the findings (Sandelowski, 2000). The data
collection tools used were semi-structured interviews, questionnaires and focus groups. The target
group were Black African, Caribbean and South Asian mothers. Caucasian women also formed part
of the study group to identify any differences in experiences of the two groups.
4.1 Ethical considerations
The local ethics committee-National Research Ethics Committee, London City and East was
consulted and the chairs action determined that full approval was not required as this study was
deemed to be service development rather than research (appendix 2). Following this, Newham
Research and Development Department provided guidance on the criteria to be met for the project
to go ahead (appendix 3).
Confidentiality was maintained throughout by preserving the anonymity of participants of those
who agreed to participate by allocating them a code and referring to them by that code only.
Participants were aware that they could withdraw from the study at any time. Participants were
assured should they reveal any issues that were of concern or compromised patient safety; these
issues would be discussed outside the interview and dealt with in accordance with the Trusts Policy
on escalation.
The transcriptions, questionnaires and focus groups notes were locked in a cupboard in the office of
the project leads office. All other parties that were provided access to the information maintained
confidentiality.
4.2 Promotion of project
Following the announcement of the award to undertake the project, the project lead attended the
womens forum-patient engagement in November 2011 and provided information about the project.
The communication department publicised the project in the staff news letter (July 2012) as well as
the local paper, The Newham Recorder (appendix 4). The information about the project was also
disseminated in staff meetings held in June and July 2012 prior to the start of the project. The data
collection tools used will be discussed in the subheadings to follow.


4.3 Interviews
Semi-structured interviews were used to gain insight into womens experiences of postnatal care in
hospital and the areas that needed to be improved. A similar format was used for staff to gain
insight into what postnatal care means to them, their experiences and barriers in providing care and
to elicit any areas for improvement.
Semi-structured interviews were used to engage both women and staff. Both women and staff were
encouraged to express their views clearly as this approach provided the opportunity to clarify any
points that were not clear (Hancock, Ockleford and Windridge, 2009). A prompt sheet (appendix 5)
was designed to guide the project lead to ensure all the key points were covered (Hancock,
Ockleford and Windridge, 2009).
Insider
The project lead was also the Matron of the area. Inquiring into an area that you have direct
involvement and connection with is challenging, it is not always easy to combine what the inquirer
knows compared to what is revealed (Robinson, 2002 cited in Rooney, 2012). However, being in
this situation has some advantages as the project lead aim is to improve practice and gain a better
understanding about the issues and events (Jarvis 1999, cited in Rooney, 2012). The potential for
coercion and to detach from the situation was overcome because the project lead did not interview
the staff members personally. Staff members would feel more comfortable discussing challenges
about their role and practice in providing care and did not have inhibitions or fear that information
shared will be later disclosed other than its intended use (Fraser, 1997 cited in Rooney, 2012).
Staff interviews
The equality and diversity lead for the Trust was commissioned to conduct the staff interviews due
to the nature of the role and awareness about the aims and objectives of the project. A pilot
interview was conducted with a research nurse outside of the department to ensure that the trigger
questions were clear and elicited information related to the study aims (Teijlingen and Hundley,
2001).
The project lead discussed in depth the prompt sheet and the requirements as outlined by Research
and Development.



Eligibility, Recruitment and Sample
All health professionals working on the postnatal ward, qualified and unqualified staff (including
obstetric and paediatric doctors) were invited to participate in the study by the equality and diversity
lead for the Trust over a one week period; 6-10
th
August 2012. The intention was to interview
fifteen members of staff (sample size similar to the women on the ward). However, fifteen staff
members were a fair representative sample of thirty staff members working on the postnatal ward.
A total of seventeen staff members were recruited, three of whom then declined to participate due to
leaving the postnatal ward. Fourteen staff members age ranges 30-50; midwives (10), nurse (1) and
support workers (3) were interviewed with verbal consent. All staff interviewed were either Asian
(2) or Black origin (12) (appendix 6).
All participants were given an estimated time as to when the interview would be conducted, this
enabled participants to be released from the ward environment if they were on duty. The interviews
were all recorded by a digital voice recorder and were conducted in an office or meeting room to
ensure privacy.
Women interviews
The interviews for the women were conducted by the project lead. Pilot interviews were conducted
with two women on the postnatal ward to ensure the questions were clear and elicited information
related to the study aims.
The midwife caring for the women initially approached the women between 6
th
-10
th
August 2012
and an information sheet was given. The project lead then met with the women to seek verbal
consent prior to the interview. The intention was to recruit and interview five Afro-Caribbean
women, five South Asian women and five Caucasian women over a five day period. A total of
twenty five women were recruited from a thirty seven bed postnatal ward, of which two women
declined to participate as they did not feel their views would make a difference to their care
experience. The sample size was increased, to capture women who also had language challenges, as
most of the women who had initially consented were fairly conversant in English. This was to
ensure data saturation and that the views of the women were representative of the ward population.
Women were given the choice of being interviewed either in a private room or at their bed sides.


All women opted to be interviewed at their bed sides. It appeared that this approach encouraged
other women to participate.
Women who had experienced bereavement such a stillbirth were excluded. The project lead found it
a challenge identifying Caucasian women on the ward to participate in the study because they were
under-represented. It was possible that these groups of women are accessing other maternity units
or in that particular week there were fewer Caucasian women.
Twenty three interviews were conducted and recorded via a digital recorder with verbal consent by
the project lead between 6
th
-10
th
August 2012 prior to the women leaving hospital. The age ranges
of the women 18-41. Most of the women were from Black (8) and South Asian (9) ethnic groups.
Two women were white British; one woman was Chinese, one woman was Columbian and two
women were Lithuanian. Four of the women from Black and South Asian ethnic groups were born
in the UK (appendix 7).
Data analysis and interpretation
The interviews for the women and staff were initially listened to several times to capture the
emergent themes. The interviews were transcribed verbatim by a professional transcription service
that is aware and demonstrated confidentiality. Each transcript was read capturing the main themes,
these themes were then grouped together (Aronson, 1994). The project lead analysed the data, and
another person with research competence was commissioned to analyse the data independently.
Following this, the project lead and the researcher discussed areas of agreement and discrepancy.
This approach was to ensure that there was no bias from the project lead-being an insider and the
validity of the findings (Aronson, 1994; Granheim and Lundman, 2004). The emergent themes will
be discussed in the findings.
4.4 Questionnaires
The inpatient survey (appendix 8) used monthly in the Trust to get service users views was adapted
to capture the emergent themes of the interviews. Both questionnaires for the staff and the women
were piloted to identify any areas that may require adjustments.



Women
The midwives and the health care support workers providing care during 13
th
-17
th
August 2012
approached all women prior to going home from the postnatal ward and offered them the option of
completing the questionnaires to provide feedback on the service. It was anticipated that normally
an average of forty women would be transferred to the community. Twenty nine women responded
to the questionnaire. South Asian (14/29) women were the highest proportion of women to respond.
White British (5/29), three (3) African women, two (2) Eastern European women, one (1) Chinese
woman and four women did not disclose their ethnicity. The completed forms were dropped in a
closed box on the postnatal ward.
Staff
The project lead sent an electronic copy of the adapted questionnaire via the maternity administrator
to thirty staff working on the postnatal ward on the 13
th
August 2012. Hard copies were also printed
and kept on the ward for easy access. All staff were advised to return the questionnaire to the
administrative office to ensure that the project lead was unable to identify the respondents. Eight
staff members responded to the questionnaires, five of the staff were of Black origin. Four of the
staff were midwives and two were support workers (appendix 9).
Data analysis
The completed questionnaires and data for both women and staff were entered into an Excel
Spreadsheet for analysis. The results will be discussed in the findings chapter.
4.5 Focus groups
Two focus groups each for women and staff were arranged to triangulate the emergent themes from
the interviews and findings from the questionnaires (Morgan, 1988 cited in Gibbs 1997). The aim
was to confirm the validity of the emergent themes identified and to identify any new evidence that
was not explored in earlier data collection tools. A focus group guide was designed as a prompt
sheet (appendix10) for both women and staff.



Women
All women (40) prior to going home from the postnatal ward 20
th
-26
th
August were invited to
participate in a focus group scheduled for the morning and afternoon of the 28
th
August 2012 at one
of the local children centre. Women going home from the Birth Centre, Delivery Suite or those who
were currently pregnant were excluded. The venue was intentionally chosen as women would have
easier access from their homes and the opportunity to access baby changing facilities and support
groups such as breastfeeding drop in sessions (Hancock, Ockleford & Windridge, 2009). Most
women were also reminded a day prior to the planned focus group via a courtesy phone call by the
team leader of the postnatal ward.
The focus group was facilitated by the project lead. A note taker experienced in conducting focus
groups was present to capture the discussion points. A total of nine (9) women participated of
whom three were pregnant. Three (3) women were South Asian, one (1) African woman, one (1)
Columbian, one (1) Philipino, two (2) White British and one (1) woman from Lithuania attended.

Staff
The focus groups were also advertised on the ward scheduled for the 20
th
and 24
th
August 2012.
Only staff working in that clinical area-postnatal ward were included to participate in the study. All
other staff members were excluded. Five members of staff attended the Focus Group; three (3) staff
members were of Black origin and the other two (2) staff members of South Asian origin. The job
roles of this group of staff will not be disclosed in order to maintain anonymity of the group.
However, the group was populated by midwives, nurses and support workers.
The project lead met with the equality and diversity lead beforehand to discuss the focus group
agenda and discuss agreements and any discrepancies. Having the same person conducting the
interviews and the focus groups meant continuity and familiarity with the content. The focus groups
were facilitated by the equality and diversity lead. A research nurse who has experience of focus
groups was tasked with note taking. Five (5) staff members participated.



Data analysis
The notes taken from the focus groups for the staff were discussed with the project lead, facilitator
and the note taker to clarify points. The notes were re-read by the project lead identifying the codes
which gradually became themes (Aronson, 1994)). This same approach was used for the focus
group attended by the women. The researcher previously commissioned to analyse the data from the
interviews also analysed the data from the focus groups (Graneheim and Lundman, 2004).
Following this, the project lead and the other researcher discussed areas of agreement and
discrepancy. This approach was to ensure that there was no bias from the project lead-being an
insider researcher and ensure the validity of the findings (Aronson, 1994). The emergent themes
will be discussed in the findings.



5.0 FINDINGS
5.1 Introduction
A large amount of data was generated from the interviews, questionnaires and focus groups with
postnatal women and with staff. The findings relating to the womens experiences of hospital
postnatal care from the interviews, questionnaires and surveys will be presented together in this
chapter and where relevant, staff findings will be incorporated and used as supportive evidence. The
findings also included Non-BME women experiences.
5.2 Women Participants
Interviews: Twenty three (23) women between the ages of 18-41 from a 37 bed postnatal ward
were interviewed. Most of the women were from Black (8) and South Asian (9) ethnic groups. Two
(2) women were white British; one woman was Chinese and one woman was Columbian. Two (2)
women were Lithuanian. Four (4) of the women from Black (3) and South Asian (1) ethnic groups
were born in the UK. Data on ethnicity, mode of birth, parity, age, marital status duration of time in
the UK are presented in (appendix 7).
Questionnaires: Twenty nine (29) women responded to the questionnaire with the highest response
rate, almost 50% from South Asian women (14/29), followed by white British women (5/29) and
three (3) African women. There were also two (2) Eastern European women one (1) Chinese
woman including (4) women who did not disclose their ethnicity.
Focus group: Nine (9) women attended the focus group. Three women were South Asian, one
African woman, one Columbian, one woman from the Philippines, two White British women and
one Lithuanian woman.
5.3 Emergent themes
The main themes that emerged from the interviews, questionnaires and focus groups centred on the
attitude of clinical and non-clinical staff, lack of understanding of cultural needs and imperatives
such as breastfeeding support, poor care and support at night and the expectations of the service.



5.3.1 The attitude of clinical and non-clinical staff
Positive experience
An analysis of the interviews and the focus groups showed how some women had positive
experiences interacting with most staff, from domestic staff to doctors.
Midwife really nice (Participant 3: 31yrs Nigerian woman, 1
st
baby).
Positive experience of staff attitude gives women pride in feeling there was a collaborative
approach in caring:
It was really good, the staff and the people, they were co-operative, nice, supportive, yeah..
(Participant 1: 27yrs Pakistani woman).

Chart 1 and 2 analysed from questionnaire data rating courtesy of staff

Chart 1. Rat i ng of st af f court esy by women Chart 2. Rat i ng of st af f court esy by st af f

Identification of staff
Although some women were fairly satisfied with their care, they would have liked staff to have
been courteous by way of self introduction so that they know who people are and what they do. It
appears that staff did not routinely introduce themselves, or explain their job role to the women in
their care as illustrated in the quote below:
17%
45% 28%
3%
7%
0%
How would you rate
the courtesy of the staff
who cared for you on
postnatal ward?
Excellent
Very Good
Good
Fair
Poor
Don't Know
12%
12%
63%
13%
0%
0%
How would you rate the
courtesy of your
colleagues who provide
care for women on the
postnatal ward?
Excellent
Very Good
Good
Fair
Poor


I think it was wonderful because theres so many people there to help you, even though you dont
recognise the faces or even know what is going on because of the drugs youre taking, but in the
end everyone really cares about you, you can tell (Participant 7: 27yr Chinese woman 1
st
baby).
Other women felt the ladies in blue were very attentive (Participant12, Participant3), but it was
confusing not knowing staff job roles. The lack of staff identification was also acknowledged by
one of the women at the focus group (Woman 4)
Poor staff attitude
Some women were unhappy with the way they felt staff spoke to them:
The way the nurse spoke to me was.... I dont think it was polite, I found it a bit rude.
(Participant 15-24yr Bangladeshi woman 1
st
baby).
Domestic and receptionist staff are often overlooked, but they also have an important role to play
and have an impact on womens experience as illustrated in the quote below:
I think people, like if youre a professional and youre a midwife, whatever you are, if youre
working on this ward, even if youre a cleaner, you should be polite because even though the
cleaner was a gentleman, he was giving attitude.(Participant 2-21yr Kenyan woman 1
st
baby).
Some women felt that the support workers were rude and appeared disinterested in supporting
women with their needs.
I think its the assistants who are a bit, hmm, sometimes not interested (Participant 3-31yr
Nigerian woman 1
st
baby).
However, this was not the case for all staff members.
..you get some staff that are friendly...you get ones that are really firm with a bit of attitude...then
some staff argue (Participant 2: 21yr Kenyan woman 1
st
baby).
The staff on the ward at Newham University Hospital generally are ethnically diverse as previously
stated in the local context of the report; with a dominant group from West Africa. Staff members
born and raised in these countries have a distinctive accent that can come across as very assertive. If
not understood, such staff members can be interpreted to be abrupt; however this is not the case for
all staff as illustrated below:
I just feel generally there seems to be a culture on the ward whereby some of the staff from a
particular background, you know, culturally, for example, from West Africa, their approach seems
more abrupt and thats not the case for all of them, but the majority... (P22: 41 yrs Caribbean
woman, 4
th
baby.)


Poor staff attitude was also of concern to most of the women who attended the focus group. The
women felt staff attitude to frequently be a hindrance in asking for additional support or raising any
concerns that they may have. Some women had a general feeling of fear and felt reluctant to
complain whilst in hospital and felt it was better to keep quiet. The attitudes of staff were also
perceived by women as if they were being told off (Woman 4). One woman who had learnt to
speak English felt language barriers made it more difficult:
Language barriers do make it more difficult; you cant explain exactly or say what you want to
say but nurses could talk nicer (Woman 8-Pakistani woman, 2
nd
pregnancy).
Hospitals develop a reputation from experiences of past services users. Therefore it is important that
all women have positive encounters with staff and it is apparent that staff attitude is a real concern
for women. But findings from the questionnaires showed that the majority of women (27/29) felt
they were treated with respect and dignity. One woman had shared what other women had told her
about the hospital. However, her experiences had been very different:
I think its got [theres been] a lot of improvement here because there was time people used to say
Newham was really bad and recently, people used to make comments, its much better; this is much
better (Participant 17-32 year old Indian woman 2
nd
baby).
A similar experience was shared from another woman who attended the focus group:
Generally, I was happy, I had heard bad feedback about the hospital before I went in [to
maternity services] and I was so shocked how good everything was(W2 Caucasian woman 1
st

baby).
Views of staff
Analysis of the interviews and focus group revealed a consensus amongst staff who think that
perceptions and experiences of poor or negative staff attitude are a result of: the womens
expectations of the service and managerial expectations-provision of high quality care versus staffs
ability to deliver the required standards of care in an often busy environment. The womens
expectations were based on their experiences of ante-natal and delivery care and they could not
understand why they did not receive one-to-one care. Staff did acknowledge staff attitude (Health
care worker 4, Health care worker 1) to be an issue within the workforce and felt it needed to be
addressed:
Many staff attitudes need to be changed when addressing patients, as this may help patients to be
more understanding (Health care worker 3).


5.3.2 Lack of understanding of cultural needs
Care provisions that meet the diverse needs of the population are important, as often culture
influences childbirth and womens behaviours in the postnatal period. It was apparent that some
women appreciated the efforts that some staff made in relation to meeting their needs, such as
providing food that was specific to their culture and religion, (Participant 10, Participant 11).
I am really happy.... they gave us our traditional food...they gave me Halal food (Participant 10-
29yr old Pakistani woman 2
nd
baby).
The findings from the questionnaire showed that most women (26/29) were satisfied with the meal
choices. The majority of these women (17/29) were from a Black and South Asian ethnic group.
On the postnatal wards, the staff are predominantly from a Black African ethnic group. One woman
interviewed felt the workforce should reflect the diversity of the community as this would help
remove language barriers that some women have (Participant 1), but most women (24/29) felt the
staff were able to meet their cultural needs.
Staff views
Staff members acknowledged the diversity among the client group and the fact that individual
women have different needs.
Given the cultural diversity of the clientele population...they do have different needs and
expectations (Staff 3).
We look at our population and gear it that way because a lot of the time its about language, so
even from our midwives, you have a lot of diversity...every culture speaks differently...sees things
differently, understands things differently...and if you are going to provide care for that culture you
need to know that culture (Staff 12).
Diversity brings richness and provides staff with a wealth of experience (Staff 3). However, this can
be challenging for some health care workers:
Its quite challenging in the sense that you are dealing with people of different backgrounds who
expect different things so maybe what someone from Asia will expect is different from what people
from Eastern Europe expect, especially in terms of breastfeeding (Staff 17)


The data from the questionnaire show most staff (7/8) felt they were able to meet the cultural needs
of women. Despite this, they expressed anxieties, about the potential for misunderstandings if such
expectations of the service are not met. These anxieties were confirmed in the focus group
discussions when a staff member acknowledged that there were no Caucasian midwives on the
postnatal ward (Health care worker1), she felt that the diversity of the workforce should reflect the
women in their care. This was further explained in the quote below.
For example, in a pressurised environment Asian clientele are usually confrontational with Afro-
Caribbean midwives. Eastern Europeans are most receptive to being cared for by another Eastern
European. I find Caucasian and Afro-Caribbean are receptive to anyone. However when the care
giver is from the same ethnic group, they are more receptive and complain less. The ethnic
diversity of staff is not representative of the clientele and this is an issue (Health care worker 1).
5.3.3 Imperatives breastfeeding support
Breastfeeding is known to be the best way to ensure a baby is appropriately nourished. However, it
is not a skill that comes naturally to some new mothers despite an infants instinctive reflex.
Through the interviews, it was apparent that some women value breastfeeding support, as supported
by the quote below:
There was a great lady that was on last night who actually took the time with me and kind of
helped with breastfeeding (Participant 12:29yr old Indian woman 1
st
baby).
Although some women were happy with the support provided for infant feeding, findings from the
questionnaires identified a small number of women (2/29) who were dissatisfied with infant feeding
support. The lack of support for infant feeding, be it breast or bottle, was discussed in the focus
group and it became apparent that the recalled experiences were upsetting for some mothers:
...No-one seemed to bother, no-one at any point came to help with feeding the baby...feeding the
baby was stressful [I had] no awareness about colostrum and I thought I had no breast milk
(Woman 4-Caucasian woman 1
st
baby)
It was a first baby, it was hungry and I didnt know what to do. I didnt know about breastfeeding
but the hospital wouldnt give me formula. In the end the nurse brought a tiny taste of formula
which settled the baby (Woman 3-Phillipino woman 1
st
baby).



Staff views
Educating and supporting women with their choice of infant feeding is important and all staff (8/8)
felt they were able to support the women with their chosen method of infant feeding.
Some of the mothers say Oh I dont know how to feed, but when you once youve asked it to
them they believe its not hard work... (Staff 10).
Showing them how to wash bottles if theyre not breastfeeding (Staff 11).
However, one staff member in the focus group acknowledged that breastfeeding is a public health
issue but the delivery of support to women is affected by managerial constraint whereby there is not
an infant feeding specialist in post (Health care worker 2).
5.3.4. Poor care and support at night
Women often value the support they get from family and friends during the day, but the absence of
this support is felt mostly at nights. More than half of the women (16/29) said that they noticed a
difference between the care received at night and during the day. In addition, the majority of women
in the focus group expressed genuine concern and disappointment about the care they received at
nights:
..at night there was no help though..the night staff are the worst, they didnt even come even
though my baby was crying and crying ...night staff they just sit in one place, they dont move or
check out the beds (Woman 3-Phillipino, 1
st
time mother).
The clinical needs of a woman and her child do not change, however, from some of the women
interviewed, there seems to be inconsistencies in the care they received:
..its not that bad...but during the night I felt a bit of roughness here and there... we feel a bit
scared to ask them...especially during the night because during the daytime we have our partners
and stuff, but during the night we are worried, are we going to get nice people...are they going to be
happy to help us? (Participant 17: 32 yrs old Indian woman 2
nd
baby).
Some womens perceptions of the poor quality of care received at night was owing to fewer
midwives on duty (Woman 4). However, this is not the case as the midwife to women and baby
ratio is same throughout the twenty four hour period.



Staff views
In the interviews, staff did not raise any concerns about care delivery at night (Staff 12). However
the questionnaire data showed that more than half (5/8) of the staff thought there was a difference in
the care they provide at night and during the day. The focus group discussions showed that some
staff acknowledged that this could be as a result of women not having their partners and family
around to help them (Health care worker 4). However, they accepted that regardless of night or day,
the clinical expectations remain the same (Health care worker 2).
5.3.5 Expectations of care
Some women were satisfied with the overall experience of the care received (Participant 6). This
view is illustrated by one of the women who attended the focus group:
The midwives were really good.. everything was good, the assessment, observation and
recovery...They made you aware and kept you informed of everything...communication was
good...getting attention was ok I just shouted for it (Woman 2 Caucasian woman, 1
st
baby).
From the interviews, it is clear that some women had a genuine concern about the lack of relevant
and timely information which caused them some anxiety one woman expressed she felt scared:
...I was scared at first cause obviously I didnt know what to expect, you know, cause obviously
being my first baby and in all it was ok...the midwife I had was really, really nice and she was
really straightforward, explained everything... (Participant 3: 31yrs old Nigerian woman 1
st
baby).
With regards to the Caesarean section and stuff, I didnt know what to expect and no-one has
actually spoken to me about that so I didnt know that I shouldnt be getting up and trying to pick
her up straight away and stuff, so I presumed it would be fine although I was struggling....
(Participant 12: 29yrs old Indian woman 1
st
baby).
These unfavourable experiences were also shared by some women in the focus group:
It was my first child so I didnt know what to expect...with a first baby you just dont know and its
hard to keep asking to many people...no-one came to ask me of the baby needed a bath or
anything.. (Woman 3-Phillipino woman SVD, 1
st
baby).
The questionnaire data also identified the positive experiences of two women (Caucasian) but also
the small number of women (2/29) who felt they were not given relevant information.


Overall, the majority of the women (28/29) were satisfied with the support provided by midwives.
The chart below shows womens views about staff knowledge base

Chart 3. Womens vi ews of staff knowl edge
Staff views
Analysis of staff interviews show that staff felt able to meet womens expectations:
When they first come to the ward we know they cannot do anything. In my role, we assist them
with breastfeeding, empty their urine bags, make their bed, make everything clean, encourage them
to get up and walk around (Staff 9).
I make sure they are well informed. I make sure they get the facts right...try to allay anxiety
because some of them they panic and they become tearful when support is not there (Staff 1)
I think its like a platform, especially for new mothers...so they get the foundation and experience
of what to do post-natally, it helps to alleviate some of the anxieties and step forward (Staff 17).
These findings were reiterated in the focus group; staff felt the focus should be on post birth care
and support to ensure that women can cope when they go home (Health care worker 5, Health care
worker 4). The questionnaire data revealed that staff felt they were able to provide women with
adequate information and most staff (7/8) felt they were able to give women adequate support
The Buzzer/summoning help
Ringing the buzzer is one way of getting the attention of the midwife should assistance be required.
When some women rang their buzzers someone came, but this was not the case for all women
(Participant 3).
27%
38%
28%
7% 0%
0%
Staff knowledge about your condition or
treatment
Excellent
Very Good
Good
Fair
Poor
Don't Know


I was pressing the buzzer and nobody was coming so I didnt like that (Participant 15:24 yrs old
Bangladeshi woman 1
st
baby).
A small number of women (4/29) felt the call bells were not answered promptly.
Staff view
This is in line with the reported views of the women above as some staff (3/8) felt the buzzers were
not always responded to promptly, but this was not acknowledged as issue in the interviews and
questionnaire.
Pain relief
Emotional and physical needs are important aspects of care immediately after birth. One woman
said that she had a particularly negative experience, whereby her perceptions of her physical and
emotional needs were not met:
Lack of communication, lack of care, being ignored when in pain...my physical and emotional
needs were not met... it was horrendous (Participant 22: 41 yrs old Caribbean woman 4
th
baby).
This view was also shared by a small number of women (2/29) who were dissatisfied with the pain
assessment and analgesic provided.
Staff views
Pain assessment was discussed in the focus group; one midwife illustrated her view as follows:
Women are in pain so its understandable...they are not happy but I dont think the postnatal care
is explained prior to admission (Health care worker 4.)
However, most staff (6/8) felt confident in assessing and supporting women with pain management.
It can be inferred from some midwives views that pain is invisible and a certain amount of pain
should be tolerated by women.
5.3.6 The positive impact of the environment
Women had positive views on the renovated postnatal wards (Participant 1, Woman 2).
Its like staying in a hotel (Participant 5: 29 year old Caucasian woman 1
st
baby).


However, there was minor concern about the shower room; one woman highlighted the need to
maintain the environment (Participant 5)
Privacy and dignity
One of the women that had used the service before expressed her views on having closer access to
toilets:
...last time toilet very far...I like the toilet being close to my room and the TV. Compared to last
time, with this time, this time is much better, so maybe in the future...more improvement
(Participant 10:29yrs old Pakistani woman 2
nd
baby).
Single rooms with en-suite bathrooms are available at a cost; this allowed some women to have
privacy should they wish to pay for this facility. However this provision is made available at no cost
for women who that have been re-admitted or require isolation for medical reasons.
Its been quite nice being into my own room so I kinda, you know, just bonded with my little one
(Participant 23:26 yrs old Caucasian woman 2
nd
baby).
One woman felt the single room facility should be advertised more, to enable choice.
5.4 Staff- Participants
Interviews: Fourteen (14) health care workers between the ages of 30-50 were recruited from the
postnatal ward; ten (10) were midwives and two (2) were health care assistants. All staff
interviewed were either Asian (2) or Black origin (12). Data on ethnicity, age range, trained in the
UK, years of experience and years working in Newham are presented in (appendix 6)
Questionnaire: Eight (8) staff members responded to the questionnaires, five (5) of the staff were
of Black origin. Four (4) of the staff were midwives and two (2) were health care assistants.
Focus group: Five (5) members of staff attended the Focus Group; three (3) staff were of Black
origin and the other two staff of South Asian origin. The job roles of this group of staff in the focus
group have not been disclosed in order to maintain anonymity of the group.
5.5 Emergent themes Not enough time to care
The emergent themes from the interviews, questionnaire and focus groups are not enough time to
care and adequate staffing.


Newham has high birth rates, which contributes to a high turnover of women on the postnatal ward.
Staff sometimes felt that there is not enough time to meet the individual care needs of the women:
So they tell you Can you feed my baby?. The thing is if you go about feeding this one, this one,
you wont have time to do your normal things that youre supposed to do (Staff 1).
It was apparent that staff were keen to give of their best as highlighted in the following quotes:
I like to give my best to the women, but sometimes there are circumstances that are preventing me,
like time frame...If I spend too much time with A, Ill not be able to give care to B or C or D and I
want to. Sometimes its not possible (Staff 6).
...you are rushing to do things...but if we had fewer women to look after, then we can give them
quality of care...(Staff 15).
These views were also highlighted by staff that attended the focus group. Most staff felt that they
did not have enough time to provide care (Health care worker 3, Health care worker 4) and the pace
at which they deliver care is very fast (Health care worker1) and this impacts on documentation as
one staff member pointed out:
Time for appropriate documentation is essential...in areas with reduced staff and high volume of
clients, documentation is poor...this is curtailed therefore when complaints are made, you are left
exposed... activities are done but not documented...as your documentation sells you (Health care
worker1).
Most staff (7/8) felt there were able to give adequate support and information to the women in their
care.
Womens views
Some women felt staff did not provide them with enough information; however, there was
acknowledgement that the hospital is very busy and as a result staff have to rush the people
quickly (Participant 16). Despite this, the majority of women (27/28) felt they were provided with
adequate information and support.
5.6 Emergent themes - Adequate staffing
Due to the high turnover of women; the interviews and focus groups revealed a perception that
more staff are required. The quality of the care at night was highlighted; some staff felt this was due


to the lack of senior support in the unit at nights (Staff 12, Health care worker 2). There was a
genuine concern highlighted through the interviews and focus groups; quality of care was
compromised through lack of adequate staffing:
The staffing level with the level of care you are required to give and the number of patients you
have doesnt really give you that opportunity to meet your expectations of delivering high quality
woman-centred postnatal care (Staff 17).
Because of the current staffing level, patients arent getting enough care (Health care worker 3).
Due to staffing levels...some people have lost the concept of quality... some just dont know how to
differentiate what is quality. Has quality got distorted over the years? Staffs main focus is to cover
their workload so quality is lost as they are just doing their work (Health care worker 2).
Some staff also felt that other factors such as language barrier and cultural practises which had a
direct impact on the quality of care provided (Health care worker 1) are not always considered.
Staff morale
In addition, staff felt this situation of hurried care was also affecting staff morale as they felt de-
motivated that they were unable to deliver quality care (Participant 9, Health care worker 4, Health
care worker 5). There was discussion in the focus group that poor staff morale was as a result of the
intensity of the workload and a contributing factor to negative staff attitude (Health care worker 1).
Chronic understaffing affects staffs attitude as they become burnt out. It is not acceptable to have
to be constantly conveying they are short staffed to partners. The variability and intensity of the
workload over the day affects the ability to build relationships with patients...the system is playing
against us...this leaves us exposed to clinical incidents due to the inability to care appropriately as
we constantly have to re-prioritise care given based on clinical needs and capacity (Health care
worker 1).
Staffing ratio
Through the interviews it was apparent that staff felt if they had fewer women to care for, the
quality of care would be improved as would the sense of job satisfaction:


What Ive realised is that if Im looking after 8 women a day, Im able to give out a care properly
and I go home and I feel content that Ive done my best today...But if I move to 12 to 14 plus
caesarean sections...it makes it a bit difficult. That is when Im struggling to do my best... (Staff 14).
This finding was also supported in the focus group; most staff felt one midwife to eight women and
babies to be a good ratio (Health care worker 1, Health care worker 2). All staff (8/8) who
responded to the questionnaire did not feel there was enough staff to care for women.
Women views
Through the interviews some women felt there was not enough staff on duty, which contributes to
the poor quality of information they received (Participant 3). Due to the busy nature of the postnatal
ward, some women perceived care to be rushed (Participant 17). Some women in the focus group
also felt there were not enough staff on duty (Woman 4). However, this was not the case in the
findings from the questionnaire as a majority of women (25/29) felt there was adequate staff on
duty to care for them.
5.7 Areas for improvement
Throughout the interviews, focus groups and interviews staff identify a few areas that require
improvement and further development, the result of which would further enable them to provide
high quality care and improve postnatal care for Black and South Asian women and the wider
community. The emergent themes in areas for improvement were improving attitudes of clinical
and non-clinical staff; meeting the cultural needs of women; breastfeeding support and adequate
resources to provide care.
5.7.1 Improving attitudes of clinical and non-clinical staff
Customer care
Staff attitude appears to be an area that the women felt required improvement. This was highlighted
through the interviews, questionnaires and focus group, with emphasis on improving
communications and customer care. Five (5) women interviewed, mostly from Black (3) and South
Asian (1) ethnic group felt this was an area that needs improvement (Participant 2, Participant 7,
Participant 8, Participant 15, and Participant 22). This was also identified in the questionnaires
responses as an area that requires improvement However in the focus group, one Caucasian woman
(Woman 3) emphasised that customer care is needed to improve staff attitude.


Some staff also acknowledged better communication through customer care is needed to improve
staff attitude in providing care in an empathetic manner (Staff 16, Staff 13). This was also shared by
staff in the focus groups (Health care worker 4, Health care worker 5).
5.7.2 Meeting the cultural needs of women
Cultural competency training
In addressing the needs of an ethnically diverse community, cultural competency training was
acknowledged to be essential in improving the quality of care staff provides. Four staff (Staff 3,
Staff 11, Staff 14, and Staff 15) felt this would enable staff to understand best the needs of the
women in their care and reduce the potential for conflict. It was also felt that conflict resolution
training would be useful in addressing any potential issues (Staff 4). In addition, stress management
techniques were suggested, as a way of improving staff morale and enabling them to deal with
culturally sensitive issues in a demanding environment (Health care worker 1).
Diversity of workforce
One woman (Participant 1) of South Asian origin felt staff from other ethnic groups should be in the
workforce. This view was also supported by staff through the questionnaires and focus groups
(Health care worker 1) - the diversity of the workforce needs to reflect the diversity of the women.
Visitors
The interviews revealed how some women felt that if the visiting times were more flexible
(Participant 2) and a family member or friend was allowed to stay with them overnight in hospital
(Participant 11), this would improve their experience. This was also a view shared by women at the
focus group (Woman 3, Woman 6) and the comments provided on the questionnaire.
Information giving
The consistency of advice and information provided is important to women, especially for those
women who do not have English as a first language. The interviews and focus groups showed that
staff felt women were not always accessing antenatal classes (Staff 2, Health care worker 3). This
view was also shared by a women interviewed (Participant 3). In addressing this, staff felt more
support and choice should be provided for women to attend antenatal classes whereby this is


facilitated in different languages, more time provided which means a longer length of stay in
hospital to accommodate this or fewer women to care for (Staff 2, Health care worker 3).
5.7.3 Breast feeding support
Although only two women reported feeling dissatisfied with the breastfeeding support they received
and that they felt most staff felt generally competent and confident in providing infant feeding
support to women, both staff (Staff 1, Staff 2, Staff 9, Staff 16, Staff 17) and women (Participant
16, Woman 3, Woman 4) felt there is a need for a breastfeeding specialist on the ward to provide
on-going support to both women and staff.
5.7.4 Adequate staff, resources and support
Staffing levels
Staff felt the care and experiences of the women could be improved if there were more staff to care
for women. This was a recurrent view among the staff interviewed (Staff 3, Staff 6, Staff 12, Staff
15, Staff 16, Staff 17) and staff that attended the focus group (Health care worker 1, Health care
worker 2, Health care worker 3). Some women interviewed (Participant 3, Participant 12,
Participant 16) also felt more staff were required. This was also the view (Woman 3) at the focus
group among some women.
Support for staff
Midwives new to the organisation and newly qualified midwives also require additional support to
their roles as they go through the preceptorship program to feel confident as clinicians (Staff 2).
Support workers are keen to support the midwives but would value more guidance on providing
care for the women (Staff 13).
Equipment
The use of equipment such as blood pressure machines is essential to providing safe care. However,
from time to time, this equipment is not easily accessible; staff found it challenging to locate
equipments when taken to or on loan to other departments which highlight the need for an inventory
book (Staff 2). This gives rise to the perception more equipment is needed such as blood pressure
machines (Health care worker 1, Health care worker 2, Health care worker 3, and Health care
worker 4).


Discharge process
Administrative support was identified as a key issue to free the staff to meet the care needs of the
women. This meant midwives and other health care workers could focus on providing care for the
women, babies and their families (Staff 4). However, the delay in the discharge process appears to
have an impact on the experiences for the women as it made it less of a positive experience
(Participant 10, Participant 17). This view was further supported by comments on the questionnaire
as well as the focus group for women (Woman 2).



6.0 DISCUSSION
6.1 Introduction
The findings from this study suggest that some Black and South Asian women who attend for
childbirth care at NUH appear to have poor experiences of postnatal care in hospital. This was
mainly attributed to poor staff attitudes, lack of consistent information about care such as
breastfeeding support, catering on issues of organisational structure and constraints. Although the
information was elicited from a small group of participants, these findings are important in an
ethnically diverse population in ensuring that services are culturally competent and tailored to meet
the individual health needs of BME women, their babies and their families (DH, 2007, Midwifery
2020). The findings also have implications for staff that provide care in terms of education, training
and development and the way care is organised and delivered in line with national policies and
guidance.
6.1.1. The impact of staff attitude
Positive interaction between staff and women has an important and lasting impression on womens
experiences of their postnatal hospital stay. In reviewing many complaints from women about
midwifery care, often, the woman may have had good clinical care. However, when the issues are
examined more closely, it is usually staff attitude and indifference that comes to the forefront as
some of the women may base their complaints under the general context of poor care.
Poor staff attitude is one of the main areas that women were often dissatisfied with as evidenced
through local feedback mechanisms such as complaints and CQC (2010) report on Maternity
services at NUH. This issue was one of the drivers for undertaking this study. Information from this
small study would suggest women tend to feel positive about their care experiences and were
encouraged to engage with staff for further support. However, a majority of the Caucasian women
in the study reported positive staff attitude towards them which could be due to their fluency in
English and their ability to escalate their concerns should their needs not be met. Interestingly, the
behaviours reported by some of the women were consistent with what some staff members
acknowledged they had observed in their colleagues.


Some of the women highlighted in this study felt that staff behaviour prevented them from
accessing support. This is an added anxiety for Black and South Asian women as this group of
women often access care late; and are more likely to have poorer health outcomes. Through a small
local study, the findings pointed to the fact that staff attitude does play an essential role in building
relationships with women so they can feel confident to trust their carers. These findings concur
with previous surveys and studies that reported the negative effect of staff attitudes and the lack of
support on womens experiences of postnatal care (Parvin, et. al., 2004; Redshaw, et. al., 2006;
Health Care Commission, 2008).
Although there were mixed responses from the questionnaire data in comparison to the findings of
the interviews and the focus groups, both the women and the staff felt fairly satisfied with the
courtesy of staff, as most of the women felt they were treated with respect and dignity by the staff.
Despite this, the issue of poor staff attitude was consistently raised in the interviews and the focus
groups by most women, but some of the women acknowledged that not all staff demonstrated poor
attitudes towards them. One reason could have been because the staff were aware of women sharing
their views on the quality of care and the service received. Therefore, this may have impacted on
how staff portrayed themselves during this period.
The findings also highlighted staff awareness of poor staff attitude and felt it needed to be
addressed. It was apparent, that staff witnessing this behaviour did not feel confident to challenge it.
It can be argued that such behaviour is culpable as midwives are advocates for women and have a
duty of care to ensure women are treated with respect and dignity. However, in the focus group, it
was the support workers who did acknowledge staff attitude to be an issue. On the other hand, it
was this group of staff most women complained about. As support workers are not registrants; the
sanction of removal from the register for behaviour is not valid. However, it appears as if the role of
the support worker is substituting for midwives rather than supporting the role of the midwives.
6.1.2. Poor care and support at night
Given the ethnic and cultural diversity of the client group who give birth and experience of staff
who work at NUH; it is appropriate to assert that culture influences some behaviour during and post
childbirth, which involves the support of extended family. The women who participated in this
study emphasised this fact. The women reported a notable difference in the care that they received
during the day compared to night time. It was thought that staff were reluctant to help, and


expressed the view that the difference could be as a result of their family not being around. The care
at night should not be different as the same numbers of staff are allocated both at night and during
the day. However, this is the perception of the women. It could well be that the additional support
during the day is provided by family members who are not usually around at night. The absence of
family and friends were also acknowledged by staff in the focus group as being a contributory
factor of womens perception of poor care at night.
The midwives and other health care workers on the postnatal ward are from an ethnically diverse
group; so it could be argued that these staff members are cognisant of the impact of culture during
childbirth. This behaviour could be contributed to their lack of compassion to care for these women
rather than lack of awareness of the womens cultural needs. Having said this, it should not be
assumed that because an individual is from a BME group, that this makes them culturally
competent.
Despite the same midwife to mother and babies ratio throughout the twenty four hour period, staff
highlighted in the focus group that some difference at nights such as the inability to discharge
women at night and the limited access to senior support. This was not identified as an issue in the
interviews; more than 60% of the staff who responded to the questionnaires felt there was a
difference in the care they gave during the day compared with night time. This could be as a result
of reduced management presence and visibility that contributes to such poor display of behaviours.
It can be argued that staff are reliant on the support women receive from their family and friends
and are unable to offer the same level of support during the night. However, it is the responsibility
of the staff to meet the needs of the women as they are employed to do. It appeared to be an
expectation from staff when family support is not available, that women should get on with it.
This could be one reason for women perceiving staff to be unsympathetic and unprofessional in
their behaviours at nights. This finding was first identified in a qualitative study where Bangladeshi
women who asked staff for help were told to do it yourself (Parvin, et. al., 2004). However, from
the evidence provided, this behaviour is probably as a result of poor supervision at nights and
failure to act as advocates for women at this, their most vulnerable time. Some women felt, if family
and friends were allowed to stay at nights, their experiences would be better.
Women and their families rely on timely and relevant information to guide them in their post birth
recovery to minimise risks to themselves and their babies. The findings highlighted that women


valued this on occasions when information was provided, although this was not always the case for
most women who took part in this small study and feedback to NUH, This lack of information left
some women feeling vulnerable and some women reported not knowing what to expect, contributed
partly to their poor experiences which was also acknowledged by staff.
Over 40% of the women who participated in the study were first time mothers and some women
reported feeling scared due to the lack of information provided. Staff often attributed this to the
fact that some women do not attend antenatal classes, to discuss their options for care and access
information about the services on offer. This was true of the population with exceptions mainly
among Caucasian women.
However, the staff who participated felt that more provisions should be made for women to access
antenatal classes, especially women with language difficulties. It remains the responsibility of
midwives and other health professionals to provide women with appropriate and accurate
information, relevant to their care needs and in a format that they can understand. About 6% of
women who responded to the questionnaire felt they were not given relevant information.
Interestingly, most staff members felt they were able to meet the expectations of women by
providing them with information. The findings have highlighted, some women felt they were not
given relevant information at the time when it was most needed. It was recommended by some
women that more information is provided as they do not access antenatal classes.
6.1.3 The positive impact of the environment
The environment plays a part in womens experience of postnatal care and to an extent, helps post
birth recovery. The postnatal wards have been fully renovated since July 2010 and it was apparent
that the women interviewed and those in the focus group commented positively about the
environment. However, the environment is not only physical as have been demonstrated in this
study; interactions, such as kindness and positive attitudes do have an impact.
The new wards have more single occupancy rooms and easy access to toilets, which has addressed
issues of womens privacy and dignity, which is of particular importance to BME women. Some
women in the survey expressed satisfaction with the extra amenities of having their own televisions
and were keen to see the environment maintained.


6.1.4 Enough time to care
Midwives and other health professionals views would suggest that they are competent to provide
care. However, one of the barriers that exist is having enough time and capacity to provide quality
care for the women which meet all their needs. The staff also highlighted that this has impacted on
the quality of their documentation which comes under scrutiny when women complain or have
unfavourable outcomes. Clear and accurate documentation provide evidence that care has been
given in line with National and Local Policies. Accurate documentation is also an obligation of the
midwife (NMC, 2009). In this study, staffing levels appeared to have an impact on the care the
women receive and the morale of the staff who feel unable to provide care and support for the
women to a higher standard. The study revealed that staffing levels and the high turnover of women
are having a negative impact on staff morale. The midwives expressed a sense of no job satisfaction
as they were constantly stretched and some suffer burn out. These issues have been well
documented in the work of Ball, Curtis and Kirkham, (2002). If we are to recruit and retain
midwives and other health professionals to provide quality, sensitive and respectful care for women,
the structures must be such that staffing levels are appropriate and support and training in place for
midwives. As these situations do not only harm the care women receive, but also harm the
midwives and their livelihood.
6.1.5 Discharge Process
Providing the necessary information for safe transfer of care in the community also impacts on staff
ability to care. The discharge process was seen to have an impact of womens perception of care.
Women cited having to wait for a long time before being transferred home as a problem. It is
known from feedbacks and surveys that the discharge process which involves a lot of paperwork
can cause bottle neck in the system, as most staff do not see this as a priority over more urgent
needs of other women. The process itself impacts on other areas with a knock on effect on bed
management. The majority of women cited the discharge process as an area for improvement and
correspondingly, the staff also felt that improvements are needed, especially in the area of
administrative support, as this would free them up to provide the care for women. Further evidence
through a qualitative study in the North of England highlights that midwives acknowledged that
administrative tasks impact on the quality of care delivered (Catterel, et. al., 2005).


The findings highlighted that most women felt they had confidence in staff knowledge base, but felt
their care needs were not met due to their perceptions of reduced staffing levels. However, the staff
expressed the view that if there were adequate resources they would be able to meet the needs of the
women. The findings of this small study are similar to two studies conducted in Australia which
highlighted that resource such as staffing levels impact on the quality of care women received
(Forster, et. al., 2006; Rayner, et. al., 2008).
From this small study, it is apparent that when staffing levels are low, the priority may not always
be to address issues of culture or religious beliefs rather the focus is likely to be on safe clinical
care. However, the challenges of language barriers and the cultural needs of BME women are
requisites of maternity care.
6.1.6 Mentoring and support for staff
Support workers play a key role in supporting midwives on the postnatal wards. The assumption is
the development of this role would reduce the workload of the midwife. However, support workers
are not registrants and require constant guidance and support from the midwives. Support workers
do value their role, and this study highlighted the fact that they needed more guidance from the
midwives. In an area where the expertise of the midwife is required to provide midwifery care or
supervise others, such as support workers and newly qualified midwives, it highlights issues of
quality of care offered and how the midwives themselves perceive their role in postnatal care and
their understanding of the role of support workers. The argument can be advanced that the
environment does not lend itself to appropriate mentoring and support of junior registrant and
unregistered staff. This is partly due to experienced midwives expressing concerns of the workload
with inadequate time to provide quality care.



7.0 RECOMMENDATIONS
The findings of this study have identified issues which are important and impact on the experiences
of a key group of women in the local population. In order to respond to the issues identified in this
project and study which are broadly in line with issues from the literature and other national
studies and reports. The following recommendations are given as a way of addressing the issues
identified and suggested by the women and staff who participated in the project
Education and Training - It is of utmost importance to address poor staff attitudes - clinical and
non clinical staff - through designated customer care training, awareness raising and training in
cultural competency.
Staff Attitudes - Managing poor standards of behaviour by emphasising the accountability and
responsibility framework within the context of the role of the midwife and Nursing and Midwifery
Council Codes of conduct performance and ethics (NMC, 2010) and the 6 Cs - compassion,
courage, competency, commitment, care and communication (NHS Employers, 2012). In addition,
local policies should be utilised in managing poor attitude and conduct.
Mentoring and Support - Review the quality of mentoring and support available to student
midwives, newly qualified midwives and support workers on the postnatal ward.
Increased visibility and availability of more senior staff at nights to provide support to staff
on the postnatal ward
Further investigation into the difference between care delivery during day time and night
time.
Resources Review of skill mix, i.e. midwife to women and babies ratio on the postnatal ward and
allocation of adequate resources to postnatal care with an emphasis on quality of care provision.
This should include identifying support for co-ordinating the administrative element of the
discharge process and specialist infant feeding adviser role.
Information Provision the availability of appropriate information and resource on options for
care through language specific antenatal classes and postnatal information in different formats.
Overnight stays for carers/partners - Explore the possibility of allowing a family member or
friend to stay overnight. In other units, partners often stay, given the cultural diversity, flexibility
would be key.


Staff defusing and counselling Explore opportunities for staff to defuse issues and offer if
appropriate provision for independent counselling for those who need it.
Periodic surveys of womens views In addition to the NHS surveys, it would be appropriate to
review local interventions in relation to the outcome of this project by way of a survey in the next
year or two.
7.1 Limitations of the study
Hancock, et. al. (2009) highlighted the use of semi-structured interviews allows flexibility. During
the interviews for the women, the project lead acknowledged that all the participants were not asked
the questions in the same format. This could have impacted on the quality of the responses, this was
apparent on listening to the recorded interviews.
The questionnaire findings appeared isolated in comparison to the focus groups and the interviews.
This could be as result of the midwives and support workers request for women to participate. It
would have been appropriate if the patient experience team who were neutral to the women had
disseminated the questionnaires. However, Research and Development guidance stipulates, only
staff caring for the women could approach them to participate. The staff respondents for the
questionnaire were small; this appeared to have been affected by internal rotation of shifts, tight
deadlines and the restricted opening times of the administrative office.
There was also a poor uptake of the focus group for the women. Most of the women that attended
the focus group did not bring their babies. Perhaps this was related to cultural beliefs about taking
the child out of the home post birth but some Caucasian participants did not bring their babies. In
addition, the focus group for the women became more like a forum as women dropped in and out. It
may be useful in any future study to consider conducting focus groups on the dates that postnatal
clinics are held or six to eight weeks post birth as some mothers may feel more inclined to attend.
This was a small study and cannot be generalised, but is relevant to the care needs of BME women
in the locality. The findings of this study are valid and reliable through the rigour that was
employed in data collection and analysis. These findings can be used to inform Policy, Education
curriculum for student midwives and a base for service improvement and development for all
women and in particular BME women.


If the study is to be replicated, it should use a much larger sample in more than one maternity unit
to have a better representative sample and views from both BME and Caucasian women in order to
make comparisons and target policy response appropriately.
7.2 Conclusion
This was a small study in a local maternity unit which serves a diverse ethnic population and
focussed on service improvement issues which could make a difference if addressed. The groups of
women and staff who participated in the study identified issues which were partly known to service
providers. However, the findings from this survey will give an impetus to NUH to look at the way
services are delivered to a multi-ethnic population as these findings chime with local and national
feedback from women.
If we are to improve services for BME women, we must also improve the attitude and morale of the
staff who deliver care to the women. The staff perceived organisational constraints as a factor in
their ability to deliver quality care, nonetheless, the impact of a combination of these factors on care
should not under estimate the experiences of BME women, the wider community and staff morale.
The findings and recommendations if implemented are crucial to the delivery of postnatal care
services for BME women and the wider community at NUH. It is hopeful that the recommendations
from this report will act as a catalyst for action in devising a strategy of positive change to improve
the experiences of both women and staff and contribute to further Policy Development in postnatal
care and inform the curriculum for the training and development of midwives.



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9.0 APPENDICES


Appendix 1

Table 2: showing ethnic
breakdown for births from 1
st

J an-31
st
Dec 2011 at NUH

Ethnicity Totals
% of
deliveries
Asian or Asian British Bangladeshi 869 15.91%
Asian or Asian British Indian 732 13.40%
Asian or Asian British Other 358 6.56%
Asian or Asian British Pakistani 695 12.73%
Black or Black British African 929 17.01%
Black or Black British Caribbean 128 2.34%
Black or Black British Other 62 1.14%
Mixed Other 138 2.53%
Mixed White & Asian 16 0.29%
Mixed White & Black African 12 0.22%
Mixed White & Black Caribbean 21 0.38%
Not Stated 18 0.33%
NULL 1 0.02%
Other Ethnic Groups Chinese 37 0.68%
Other Ethnic Groups Other 87 1.59%
White British 427 7.82%
White Irish 6 0.11%
Grand Total 5461



Appendix 2
From: ubh-tr.CityandEastREC@nhs.net
To: Marsha.Jones@bartshealth.nhs.uk
CC: Jones-Ako2010@hotmail.co.uk
Date: Mon, 2 Apr 2012 12:38:42 +0100
Subject: Advice on Project Proposal
Dear Marsha,
I have had a chance to discuss your query with the chair of the Committee.
In his opinion, based on the information provided your project seems to be service development and
therefore may not require a full ethical review.
Regards,
Raj

Rajat Khullar| Committee Co-ordinator
Health Research Authority
NRES Committee London City & East
Tel 01173 421386
www.nres.npsa.nhs.ukand www.hra.nhs.uk



Appendix 3

From: Joanne Morris
Sent: 21 May 2012 14:32
To: Marsha Jones
Cc: Neeta Patel Solle
Subject: RE: Advice on Project Proposal
Importance: High
Hi Marsha,
Sorry for not getting back to you sooner I had raised one more question with Raj which he has only just
responded to in the e-mail below.
I am happy that the proposal you presented to the ethics committee is service development rather than
research and that this doesnt need to go for ethical review. I am copying in Neeta to confirm this (Neeta is
the R&D manager).
However, you should ensure that you follow the following principals;
All data collected, or copied, is fully anonymised
You must seek approval from senior management within your area of work and any other areas impacted by
your project (all individuals impacted by your project must be aware of this)
If you use questionnaires or interviews or focus groups they must be;
Fully anonymised; it should not be possible to identify any participant from the collected data
Administered by individuals who are subject to the NHS Code of Practice for Confidentiality

Patients should only be approached and asked if they would be happy to participate by one of their existing
care team
Consent should be sought (verbal / written) and include information on (where relevant):
why they have been approached, the purpose in the project, who is funding / sponsoring the project, who is
conducting the project, what will be involved, how long will they be involved, what data about them will be
used, how the data will be stored, who will have access to their data and contact details for further
information or concerns. The information should also make it clear that their participation is voluntary and
that they could withdraw at any time and non-participation will not impact their treatment in any way.
Should not involve clinically vulnerable groups (children, elderly, pregnant women, subjects with mental
illness or learning disabilities, the terminally ill or those recently bereaved)
Questions should not be unduly detailed or contain potentially intrusive enquiries related to cultural, sexual,
self- medication or other personal data
You must comply with the provisions of the Data Protection Act or satisfy NHS governance requirements
related to data protection, patient confidentiality and information security as enshrined in the Caldecott
principles
If you have any problems with the above, please let me know.
Best wishes,
Jo
R&D lead
R&D office, Education Centre, Newham University Hospital NHS Trust London E13 8SL



Appendix 4
When PM David Cameron met Newham midwife
Marsha
by Colin Grainger , Editor Sunday, July 8, 2012
5.00 PM
An award-winning midwife was honoured this week as she got a visit to meet the Prime Minister.
Matron Marsha Jones kick started her Mary Seacole award winning project with the trip to Number
10 Downing Street.
The Prime Minister, who was keen to hear about new ways of improving health outcomes, invited
Marsha, a matron within the Newham Maternity Department, along with the other five Mary
Seacole Award 2011 winners from around the UK to meet with him to discuss their proposals.
Marsha was able to tell the PM first hand of her plans to improve the health outcomes for women
from black and minority ethnic communities at the Newham Maternity Unit.
Marsha scooped the award for her project, which aims to improve the experience of postnatal care
for black and Asian women coming to the hospital.
With the project about to start its research phase, Marsha is keen to involve women across Newham
by getting feedback on the experience of the postnatal care they have received.
Marsha said: Current NHS policies such as the NHS constitution set out the aim of improving the
patient experience by putting patients at the centre of their care and ensuring they are treated with
dignity and respect. Patient feedback is of vital importance in order to make real and meaningful
improvements to services.
The project started on Monday and will look at whether we meet our users expectations of their
postnatal care. Women who are admitted to the maternity department will be asked if they wish to
take part in the project.
The research findings will provide vital data to help us understand the views of our service users
and improve the experience for women coming to Newham.
Public Health Minister Anne Milton said: These awards have a long standing history of recognising
and encouraging future leaders in the NHS. Thats what we want to see putting patients first and
showing by example what can be achieved.
2012 Archant Community Media Ltd.



Appendix 5
Interview prompt sheet (for women)
1. WELCOME AND INTRODUCTION
Introduce self
Chat about and overall purpose of project
Go through the information sheet and answer any questions, reassurance of confidentiality,
take verbal consent
Start tape

2. BACKGROUND
(Place/duration of residence, country of origin, ethnicity, age, parity, date & place of
recent/anticipated birth, relationship with babys father)
How long have you lived in Newham?
Where were you born? / Where did you grow up? (How long have you been in the UK?)
How old are you?
Is/was this your first pregnancy? (If no, how many children do you have?)
[Note: be sensitive to women who may have lost a child]
When was your (youngest) baby born?
Where was s/he born?
Are you with the babys father? (married, cohabiting, single)
General chat about pregnancy/baby (boy/girl, name etc)

3. PARTICIPANTS STORY THEIR PERSONAL EXPERIENCE OF CARE RECEIVED ON THE POSTNATAL
WARD:

Id like you to now tell me about your experience of the care you received on the postnatal
ward starting from when you were first admitted to the ward?

What were your experiences and if they had met your expectations?

What do you think could be done better to improve your care and experience on the
postnatal ward?

If training was provided for staff, what information/topics do you think should be shared
with them?

4. CLOSING COMMENTS AND THANKS

Is there anything else youd like to tell me?
Do you have any questions for me? (Signposting)

EXPRESS THANKS AND ASK IF THEY WOULD LIKE TO RECEIVE A SUMMARY OF THE RESULTS, WHEN
AVAILABLE (IF SO, HOW? EMAIL/POST)



Interview prompt sheet (for staff)
1. WELCOME AND INTRODUCTION
Introduce self
Chat about and overall purpose of project
Go through the information sheet and answer any questions, reassurance of confidentiality,
take consent
Start tape

3. BACKGROUND
(Place/duration of residence, country of origin, ethnicity, age, parity, date & place of
recent/anticipated birth,)
How long have you worked in Newham?/Postnatal ward
Where were you born? / Where did you grow up? (How long have you been in the UK?)
How old are you?
Where did you do your training? Level of training
Do you have children? Are you a parent/carer?
If yes, Where did you experience childbirth UK or abroad? Any difference in care?
General chat about their experience of receiving care

3. PARTICIPANTS STORY THEIR PERSONAL EXPERIENCE OF PROVIDING CARE ON THE POSTNATAL
WARD:

Id like you to now tell me about your experience of providing care on the postnatal ward.

What does postnatal care means to you?

What are your experiences and if you feel you are meeting your expectations of delivering
high quality woman centre postnatal care.

What do you think is required to support you in providing better postnatal care?

In providing training for staff, what topics do you think should be included?

4. CLOSING COMMENTS AND THANKS

Is there anything else youd like to tell me?
Do you have any questions for me? (Signposting)

EXPRESS THANKS AND ASK IF THEY WOULD LIKE TO RECEIVE A SUMMARY OF THE RESULTS, WHEN
AVAILABLE (IF SO, HOW? EMAIL/POST)



Appendix 6

Code Role Training Place of birth/Ethnicity Yrs worked in NUH
S1 RM UK UK/Nigerian 2yrs
S2 RM Ghana/UK Ghana 15yrs
S3 RM UK Trinidad/Black Caribbean 2yrs 7mths
S4 RM UK UK/Nigerian 8mths
S6 RM UK UK/Nigerian 9yrs
S9 HCA UK Nigerian 17yrs
S10 HCA India India 24yrs
S11 HCA UK UK/Caribbean 11mths
S12 RM UK Ghana 22yrs
S13 RN India India 2 yrs 3mths
S14 RM Ghana/UK Ghana 6yrs 6mths
S15 RM Nigeria/UK Nigeria 4yrs 3mths
S16 RM UK Nigeria 6yrs 6mths
S17 RM Nigeria/UK Nigeria 9yrs
Table showing participants in interviews (staff)



Appendix 7
Code Ethnicity Parity Birth Age/Status In UK In Newham

P1 India 0 SVD 29/M 4yrs 4yrs
P2 Kenya 0 SVD 21/M UK born 6yrs
P3 Nigerian 0 SVD 31/S UK born
P4 Somalia 0 SVD 19/S 2yrs 2yrs
P5 White-
British
0 SVD 27/S UK born 27 yrs
P6 Lithuania 0 SVD 18/S 14 mths 14 mths
P7 Chinese 0 SVD 27/M UK born 2yrs
P8 Nigerian 2 SVD 36/M 5yrs 5yrs
P9 Bangladesh 1 SVD 25/M 23yrs 23yrs
P10 Pakistani 1 SVD 29/M 3yrs 3yrs
P11 Pakistani 0 SVD 27/M 9mths 9mths
P12 Indian 0 EMCS 29/M UK born
P13 Senegal 1 SVD 28/M 18 mths 18 mths
P14 Bangladesh 1 SVD 22/M 2yrs
P15 Bangladesh 0 SVD 24/M 5 yrs 2-3wks
P16 Columbia 0 SVD 39/S 14 yrs 14
P17 India 1 SVD 32/S 9 yrs
P21 Nigerian 0 SVD 34/S 5 yrs
P22 Caribbean 3 SVD 41/S UK Born
P23 White
British
1 ELCS 26/S UK Born Since birth
P24 Lithuania 1 EMCS 29/divorced 4 yrs 3 yrs

Table showing participants of interviews (women)



Appendix 8











Appendix 9

Band
7 1
6 3
2 1
Unknown 3

Years Experience
20 or more 1
Unknown 3
1 or less 1
10 2
2 1

Qualification
Midwife 4
Unknown 2
HCA 1

Table showing interview participants (staff)



Appendix 10

Improving Postnatal Care in Hospital
FOCUS GROUP
Women

Approx. times
5mins Welcome and Introductions

5mins Background to MJs work and having a focus group

10mins Quick brainstorm: one positive, one negative about (post-natal)
experience at NUH

30mins 2 main issues want to find out more about and discuss with group today
(based on findings so far):

Quality of Care [prompts to include staffing issues/night care/ nursing
responses (e.g. getting help to move baby) availability of information & care;
environmental aspects: visiting/ food/bells etc.]

Attitudes [prompts to include diversity issues (e.g. disparity between staff
and service user ethnicities/cultural awareness); professionalism;
communication issues (including non-verbal) etc.]

10mins Conclude with: service user suggestions for improvements and/or future
changes in Newham maternity services

EXPRESS THANKS FOR TIME AND PARTICIPATION


Improving Postnatal Care in Hospital
FOCUS GROUP
Staff

Approx. times
5mins Welcome and Introductions

5mins Background to MJs work and having a focus group

10mins Quick brainstorm: one positive, one negative about (post-natal)
experience at NUH

30mins 2 main issues want to find out more about and discuss with group today
(based on findings so far):

Quality of Care [prompts to include staffing issues/night care/ nursing
responses (e.g. getting help to move baby) availability of information & care;
adequate resources, environmental aspects: visiting/ food/bells etc.]

Attitudes [prompts to include diversity issues (e.g. disparity between staff
and service user ethnicities/cultural awareness); professionalism;
communication issues (including non-verbal) etc.]

10mins Conclude with: staff suggestions for improvements and/or future
changes in Newham maternity services

EXPRESS THANKS FOR TIME AND PARTICIPATION



This Mary Seacole Leadership Award project was funded by NHS Employers. Image; Royal
College of Midwives.
NHS Employers 2012

Improving Postnatal Care in Hospital For BME Women by Exploring Healthcare Workers Capabilities

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