Introduction

The term ‘social context’ refers to a range of factors that shape and influence our lives, including concepts such as social class, ethnicity, gender, family and faith. Midwives need to understand this wider social context of women’s lives in order to appreciate their needs and provide appropriate care, support and guidance. Additionally, in understanding their own social context, including their professional knowledge and power, midwives can develop greater self-awareness and recognize the influence this has on relationships with women and their families. While pregnancy and childbirth are biological processes and universal events, they are also related to specific social settings which are socially created and given meaning. The different meanings and language of pregnancy, childbirth, motherhood and fatherhood have varied over periods of time, across cultures, among women and men and between professional groups (Davis-Floyd 2003, Kent 2000, Squire 2003, Symonds & Hunt 1994).

A society’s views encompass a range of differing standpoints and opinions depending upon individual experience. Women’s own writing of their experiences of health, children and motherhood are examples from bodies of knowledge through which women understand and explain their lives (Cusk 2008, Douglas 2005, Wolf 2001). Yet this body of knowledge is given scant regard and considered unscientific by the predominantly masculine medical profession. As Kitzinger comments, ‘Obstetric language is mechanistic; women’s is experiential’ (Kitzinger 2005a:60).

In studying western societies, sociologists divide individuals into categories such as race, social class and gender, which tends to imply homogeneity within groups. Such an oversimplification ignores the complexities of these individual lives and often does not account for multiple identities, differences in life events, and an individual’s quality of life. As Bilton et al (2002) comment:

However, these artificial divisions between individuals is a practical way of examining aspects of society that are of interest and help us understand social organization and social interaction (Bilton et al 2002, Giddens 2006). Social differentiation is important to midwives as it reflects an unequal access to healthcare for certain groups within society. Recognition of this unequal access and the underlying reasons helps midwives to provide appropriate care for the women and their families.

Social class and social disadvantage

Whilst some may argue that differentiation by social class is no longer relevant within society, it continues to be used by statisticians in data gathering. For example, breastfeeding statistics and perinatal mortality rates are both produced using the British Register General classification. Criticized because of its focus on the occupation of the man of the house, consequently excluding the unemployed, retired, lone parents and students, it continues to provide evidence of health inequality gradients; that is, the lower the social class, the greater the incidence of poorer health and social outcomes.

Evidence for this first appeared 30 years ago in the seminal Black Report (DHSS 1980), although at the time the report was suppressed by the Conservative Government. It was brought to a wider audience and discussed further by Peter Townsend et al in their 1988 book The Black Report and the health divide. Within it, Townsend et al (1988) focus on those disadvantages that are social or cultural rather than biological differences, such as age or sex. The acknowledgement that health inequalities exist and that it need not be inevitable stems from the Black Report and was followed in 1998 by an independent enqiry into health inequalities led by Sir Donald Acheson (DH 1998). This report recommended that high priority be given to policies that improve health and reduce inequalities for women of childbearing age, expectant mothers and young children.

Health inequalities are clearly linked to income inequality, but income inequality also affects self-esteem and social standing. Access to healthcare is influenced by both economic factors and the motivation to improve one’s situation. This may be known as self-efficacy. This concept is linked to the idea of the ‘inverse care law’ (described in 1971 by Julian Tudor Hart), namely, those in most need of healthcare are least likely to get it. Several factors affect this; local services tend to be of poorer quality – fewer staff caring for sicker people; access tends to be more difficult – restricted appointment times or geographically more difficult to get to; and people are also more likely to suffer multiple external disadvantages – poorer environment, housing and nutrition (Appleby & Deeming 2001). In recent years this multiple disadvantage has come to be known as social exclusion, which refers not only to poverty and low income but also to its wider causes and consequences. The Government describes it as:

The Acheson report, alongside more recent health policy documents such as the National Service Framework for Children, Young People and Maternity Services (DH 2004), The NHS Plan (DH 2000) and Sure Start local programmes, have all helped to increase the public health profile of midwives. This has been endorsed by the Royal College of Midwives in their position paper The Midwife’s Role in Public Health (RCM 2001) and highlighted by both the 2004 and 2007 Confidential Enquiries into Maternal and Child Health (CEMACH 2004, Lewis 2007). While public health has always been part of a midwife’s role, more formalized public health midwifery posts are increasingly being developed, at consultant midwife, community-based and management levels.

Addressing health inequalities and poor pregnancy outcomes through service improvements for disadvantaged women is a challenge for midwives (Chapter 23). The National Service Framework, Standard 11 Maternity services (DH 2004) highlighted the need to provide inclusive services, particularly for the most vulnerable who do not acccess maternity services; travellers, homeless women, young pregnant women, young men, those misusing drugs and alcohol, refugees and asylum seekers, women experiencing domestic abuse and women who are HIV positive. Many of these women also experience socio-economic hardship and they have poorer pregnancy outcomes than do women in households with higher incomes. One example of this is poor nutrition among economically disadvantaged women, usually associated with women who are underweight or, increasingly, obese (Guelinckx et al 2008). Inadequate nutrition is linked with low-birthweight babies, who are at increased risk of physical and intellectual disabilites as well as being at greater risk of developing coronary heart disease and diabetes in later life. As Ihunnaya et al (2008:558) commented: ‘Birth weight, a leading determinant of infant survival, has implications for public health policy making and practice.’ Mcleish (2007) discussed this challenge and identified that while poorer women are aware of the meaning of a healthy diet there are a number of barriers to healthy eating, such as lack of cooking skills, access to affordable quality food, safe storage and putting others first (especially other children). Mcleish (2007) identified that midwives have a key role in providing nutritional advice to pregnant women alongside informing them about the government-funded scheme ‘Healthy Start’ which gives food vouchers for milk, fresh fruit, fresh vegetables and infant formula milk to women on low incomes and to their young children (DH 2009).

Midwives have a unique opportunity to be welcomed into the homes of such families at a time when the prospect of a new baby provides a motivation to improve their health and lifestyles. Whilst having no financial aid to offer (apart from ensuring that they are claiming their entitled benefits), midwives can, by their recognition of the complexities of some people’s lives and by providing the care and respect entitled to these women and their families, help to empower them. Midwives working in these areas of socio-economic deprivation have an important role in building constructive relationships with women and their families as well as with other health professionals and community-based agencies. These may include housing associations, benefit advisors, Connexions (a government-funded support and advice service relating to health, education, work and relationships for 13–19-year-olds), sexual health services, advocacy workers and local voluntary support groups as well as doctors, health visitors and other health professionals; awareness of local services is crucial. Davies (2008) emphasizes how enhanced midwifery care can contribute to improving the lives of women in areas of socio-economic deprivation, particularly in relation to their health, confidence and personal aspirations.

Ethnicity

When considering social disadvantage, it needs to be recognized that amongst those most disadvantaged, certain groups are overrepresented, including black and minority ethnic groups. Britain is increasingly multicultural, particularly in larger cities. Midwives should be aware of different cultural groups and related community support within their localities, but essentially they need to demonstrate a willingness to learn about others and develop relationships that are open and honest.

Differing terminology around race and ethnicity can be confusing. Race is the term often used for the genetic, physical characteristics of individuals, factors that midwives need to be aware of when considering, for example, haemoglobinopathy screening or the significance of pelvic shape for women in labour. However, the biological basis of race does not link it to disadvantage; it is the social construct of ethnicity and its differing perceptions that is important. Phillips & Rathwell (1986) suggest that ‘race’ is a social construct that has more to do with social structures and power relationships than with biology.

Ethnicity is a difficult concept to define but is generally recognized as ‘shared origins’ (Sookhoo 2003). This embraces a sense of belonging to a particular community; common geography, beliefs, language and history, but does not imply homogeneity within a group any more than shared views could be expected within the ‘white’ ethnic group. Within any society, the most dominant ethnic group is likely to be relatively invisible, whilst ‘difference’ is identified in all other groups. Consequently, it can be hard for those members of the dominant group to recognize racism within their organization and to make the transition to seeing the service as others may see it. Cross-Sudworth (2007) argues that although legislation and policy directives address discrimination and racism, midwives need to actively tackle racism in the workforce as well as in the organization and provision of services. Ethnicity may also be complicated as these ‘shared origins’ change over generations, between first- and second-generation immigrants and in the meeting and pairing of different cultures and ethnicities. Individuals may describe having a dual heritage, as they recognize the differing cultures and ethnicities of each parent.

For midwives to be able to determine the needs of women, it is clear that generalizations are no more appropriate for women from minority ethnic groups than they are for women from more dominant groups. Effective communication and understanding of the expectations of women from a range of diverse backgrounds is key to what is termed ‘cultural competence’ (Sookhoo 2003). This does not necessarily require indviduals to be highly competent about all cultures but it is about openness and respect, a willingness to learn and self-awareness.

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