Chapter 1:
Literature Review

Ethnic Minority & the Health care
Importance of Parent Education

Asian Women & Parent Education
Research Question

Chapter 2:
Research Proposal

Summary of the Literature Review

Data Collection
Data Analysis
Access to Research Site
Ethics Approval
Dissemination of Findings



Research Plan
Checklist of Resources for Funding

Home page

Asian Women & Parent Education

Very limited research mostly opinion articles suggest that Asian women are not interested in parent education (Walker & Pollard, 1995), furthermore, research indicates negativity towards culture and religion, thus reflecting lack of understanding and poor knowledge base on the professional part (Rooke 1991 & Hill 1999).

Schott & Henley (1996) & Henley & Scott (1999) argue that in some Asian cultures, the idea of turning to outsiders for help and advise about pregnancy and childbirth is extraordinary, therefore, the women’s network still exists within these communities. Women expect to learn all they need to know from elder, experienced members of the family informally as and when they need it. Some women may not understand the function and importance of parent education classes and others may be discouraged from coming by conservative family members, and in turn these women are stereotyped as "not interested" or have "total lack of knowledge" (Bowler, 1995 & Rooke 1991)

However, there was a formal study conducted by two dedicated Bradford midwives Walker & Pollard in 1995. There study consisted of 20 randomly chosen women from the Pakistani and Bangladeshi background, this immediately reflects that the generalisabilty was poor. The sample group can not represent the rest of the Asian population. These women were interviewed and asked what their information needs were and whether they felt their needs were being met, but it does not mention whether these women had been attending parent education classes in the first place nor does the article go into depth about the interviews. Walker & Pollard (1995) only acknowledge the negative points highlighted by the women, concentrating on why the women do not attend classes; their responses were as follows:

1) Domestic issues like housework and childcare took priority

2) They felt anxious about attending classes

One argues the fact that, are the above reasons enough to justify that these women are not interested or whether they lack knowledge? but further research in the area is needed to justify what Walker & Pollard (1995) found. Although, the Bradford study tried to achieve the needs of the Asian women through a video approach to present information to Asian women more extensive research need to be carried out to find out why Pakistani or Bangladeshi women are poor uptakers of parent education and what can be done to encourage them to attend classes and how can health professionals move away from stereotypical assumptions and judgements would be the ideal step forward? The video approach was a good approach but again women are silenced for the time being, no choice has been given to them as to what their preferences were in the first place and whether the content of the video met their needs. Although, the midwives did acknowledge the evaluation of the videos, there was a lot of topics covered in each video and with housework and children taking priority would the women have time to watch such lengthy videos and absorb the content?

Whilst on community placement in an area of Birmingham where the majority of the population were Muslim, non-English speaking discussions with members of the local Asian communities which suggested that to gain real understanding of the views of Asian women, it would be ideal to conduct individual interviews in their own homes, rather than expecting women to attend group discussions or respond to written questions. Another point, which was acknowledged, was that some people from the community did not think that parent education was an important issue in their daily lives but this evidence remains anecdotal until further research is done. When looking into research, which evaluates parent education, it always has focused on the middle-class English speaking population not the Asian women and again it has been evaluated poorly with regards to teaching styles and choice (Hallgren et al, 1995). But Summers et al (1997) further argues that upon asking for views and opinions from the black and ethnic minority groups on what they thought of maternity services they saw four priorities for change; dealing with communications: improving and expanding the use of link-workers; meeting the demand for women doctors; and eliminating cultural hostility but still, some of the key issues raised in Changing Childbirth were seen as secondary.

Bowes and Dokomos (1996) argue that research carried out exploring ethnic minority issues have always been quantitative, and there is evidence that such a method of approach, involving standardised, often self-completed postal questionnaires, can fail adequately to collect the views of minority ethnic groups and the muted voices of Pakistani women continues. Their work suggests that the view of many health professionals is that there is nothing wrong with the services they provide. It is ‘those people’ with ‘special diets’, ‘strange religious practices’ or ‘funny maternity habits’ who have the problem (Parsons et al, 1993, P71)

An example of this can be seen in Bowlers study (1995) which showed very significant stereotyping of South Asian women by hospital midwives. Her work highlights the role of the services in silencing South Asian women particularly clearly: when they cried out in childbirth, their pain was dismissed by midwives as "fuss about nothing" (P166). Issues such as these reflect in research that needs of Asian women are not met whether it be parent education or pain relief in labour. These women do not have vast needs but individual needs and this needs to be acknowledged by health professionals. Bowlers (1995) study portrayed very ill-formed views by the midwives about women of the Asian descent in relation to pain relief. The aim of this study was to investigate the inequality in health experienced by black and ethnic minority Britons. It was a small-scale ethnographic research which was conducted using variety of qualitative methods, but ethnographic studies on its own have huge ethical dilemmas about informed consent because the researcher wants the participant to know very little about the study. The two main methods that were used were observation and interviews with midwives. The concept of ‘theoretic sampling’ was used to guide data collection and both formal and natural interviews were taken. Stereotyping of women of the Asian descent contained four main themes; communication problems; failure to comply with care and service abuse; making fuss about nothing and a lack of maternal instinct. Midwives did not always acknowledge that individual women did not fit the stereotype. It is therefore suggested that the application of these stereotypes to all Asian women is inappropriate and may lead to poorer delivery service. Bowlers (1993) work describes Asian women as ‘over-users’ or even ‘abusers’ of the service then is it any suprise when these women do not take interest in parent education when negative attitudes are held by health professionals they rather stay at home and learn from each other. The student concluded from some responses by the local Asian communities that women do learn better from each other but again, this remains anecdotal evidence.

A staff midwife in the postnatal ward remarked: "She’s having her ninth baby. It is a disgrace. Talk about abuse of the service", if this is the way to treat women when they are in hospital, one questions the fact that are the same midwives in the best position to take on parent education classes for these women?

Although the Bradford midwives Walker and Pollard (1995) attempted to recognise the needs of the non-English speaking women, this study can not voice the needs of the rest of the population, but likewise its a step forward. It is essential that our services are sensitive and relevant to each individuals cultural needs. Research has continued to voice the opinions, attitudes and stereotypical judgements of midwives but has not yet explored the feelings of the Asian women in depth especially about parent education. As mentioned before, the Pakistani families are very close knit, in which extended ties still exist. Members of the family tend to rely very much on each other and rarely do they approach an outsider for advice. Along with many additional problems to those normally encountered in primary health care, a lack of cultural awareness and language barriers are the most obvious and this is a two way process, it involves both women and the health professionals. Two research papers based on anecdotal evidence have commented on such problems and approached the subject in a judgmental way. Hill (1999) explains how to address the health issues of a Muslim practice population and Rooke (1991) wrote an article based on pure anecdotal evidence on a existing parent education classes in Reading which consisted of non-English speaking population.

It is very interesting to read articles such as these but one should not make assumptions that their work teaches a health professional the values and cultures about the Muslim population or any other. Rookes (1991) work is based on anecdotal evidence throughout; she does not mention any other source of reference to support her arguments, which reflected she has not really taken any time to explore in depth. Both articles suggest that Asian people have "a total lack of knowledge" about pregnancy and childbirth, but yet they do not acknowledge the problems with the service provided, therefore, with attitude such as this, is there again any wonder why women turn for others for help instead of attending classes run by such professionals? There are over thousands of references which guide a non-Muslim through a Muslims world, we don not need research in this area its about time that health professionals asked women about their experiences and their needs and give choice and control back to them.

Rooke (1991) and Hill (1999) describe some of the cultural/religious duties which are practised by the Muslims i.e. why women fast during the month Ramadan, why do Muslims shave their baby’s head when it is born and why some women do not want to breast feed are some examples? Before we can actually attempt to run parent education classes for the ethnic minority especially the non-English speaking Pakistani women, health professionals must have a sensitivity towards their cultures and values, health professionals need to educate themselves, culturally be aware and be non-judgmental before teaching women about pregnancy and childbirth. When analysing the work by Rooke (1995) and Hill (1999), we do not see lack of knowledge on the women’s part but ignorance and lack of knowledge from the health professionals. We need to begin by asking the non-English speaking women what their preferences are with regards to parent education, this is the way forward to implement the recommendation and guidelines by the Changing Childbirth and reports such as Making a Difference (DOH, 1999). Health professionals should avoid taking the paternalistic attitude that we are the professionals and we know best, thus taking choice, continuity and control away from these vulnerable women and work in partnership to give best possible care during pregnancy and beyond.

Parent education not only has been weak with regards to Asian non-English speaking women but the paternalistic attitude is reflected in the existing parent education classes for the Caucasian population (Hallgren, 1995). We are teaching adults not children, so therefore the classes need not to be didactic but more discussion based. This allows the author to take a step forward and introduce another piece of work by Ramsay (1999), a National Childbirth Teacher (NCT), who describes the highs and lows of teaching English to Asian women while they are pregnant. She shares in her work the optimism that was achieved in 11 two-hour sessions. As a ante-natal teacher, she was used to running discussion based courses in which people pooled their knowledge and analysed advantages and disadvantages, but she realised that ‘informed choice’ seemed a distant dream when you did not know how to make an appointment. Her approach in teaching Asian women about pregnancy was unique and articulate, she moved away from classroom teaching, paternalistic attitude and ignorance towards their culture and achieved remarkable results simply by respecting women and acknowledging their needs. Despite, the fact that her work reflects great enthusiasm and initiative along with determination it does not again reflect the feelings and attitudes of women; a qualitative form of design would show this. Even though her classes were not overwhelmingly large but she felt that she had taught the women valuable means of coping in England when having their babies, she addressed simple tasks such as how to cancel and make appointments through role-plays. Her commitment also allowed her to organise lifts to and from classes and one of the plans for the future was to obtain grant funding for a mini bus, which was very positive.

This course allowed the women to become more independent and be more familiar with the terminology used in hospitals, instead of trying to digest information they never had heard of. Along with teaching basic topics about pregnancy and childbirth, her aim was to have a discussion based class and this was achieved with the help of Asian helpers and link-workers. Although she felt that it was like an unfinished story because she did not know how their births went, she relished the chance to support women who would not normally be reached by NCT classes. She does not seem convinced that 11 weeks were enough to teach them ‘all the English you need to know when you are having a baby in England’ but she is confident that many skills they learned would be useful to them in the long run. One weakness if any, would be that the course could have been longer that 11 weeks so that more Pakistani women could benefited from such luxury, but the strength over rules its weakness in that this course was very special and unique it targeted only the non-English speaking Pakistani women showing great sensitivity towards their needs.

Again it can be said that this small proportion of women can not represent the rest of the population and the student still feels that the needs of the ethnic minority are ignored and it was about time that researchers and health professionals researched into what the women want from the maternity services especially in the area of parent education. The user’s voice is an important and irreplaceable source of expertise because they are the recipients of health care services, they in turn can identify ways in which racism and lack of cultural awareness impinges upon service delivery (Cortis, 1998, P131).

After analysing the topic area, it can be said without doubt that it is time to explore the feelings and attitudes of the Asian, non-English speaking Pakistani women. As health professionals, we need to know their preferences and whether they feel, parent education is important to them and if taught would it benefit them. It is acknowledged that language barriers and cultural awareness are two major obstacles when delivering this service but these can be resolved by the help and expertise of trained interpreters and link-workers. This in turn allows the student to introduce the research question:

What are the parent education needs of the non-English speaking Pakistani women?