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This community profile is based on an area in the outskirts of Glasgow and the objective is to identify the current provisions of maternity care and other health care services, which cater for the needs of the local population in the physical, emotional, intellectual and social needs for groups in the community, additionally, commenting on any deficits in care. Health promotions have been identified as resources that will enhance the health of this specific community's health and are included in the profile. Also, the role and contribution of the midwifery services is explored, along with other primary healthcare providers and how they use teamwork to deliver healthcare to the community. Professional and ethical issues have been discussed throughout the profile and as all aspects of health are unrelated and interdependent, (Ewles & Simnett, 1992: Ch1 p7), a holistic and professional view has been taken to evaluate the needs, and health services of this community.
The RCM believes that truly woman-centered care must encompass midwifery-led care of normal pregnancy, birth and the postnatal period and services that are planned and delivered close to women and the communities in which they live or work, (NHS Evidence, 2008). This statement shows the importance of a community midwife, as their role is to not only provide the clinical skills, but also be accessible for support and advice at the time of much adjustment for a woman. If the midwife can become a part of the woman's community, getting to know the woman and her family more personally, learning to understand their lives and the nature of the life around them, she will be able to be more responsive and understanding to them as individuals, and move away from the depersonalization of the institution. Individual societies each have their own specific needs and characteristics, and it is vital for a midwife to know her area well in order to respond appropriately, along with poverty levels and racial mixes (Fraser and Cooper 2009, p. 43). Community-based care can be in the home or in community hospitals and centers, but is a process that emphasizes consultation, collaboration, and referral to the professionals who are most appropriately prepared to meet the women¹s needs (Walsh, 2001). It is also vital that women are educated and "women should be given appropriate, accurate and unbiased information based on research that would allow and encourage them to make informed choices in relation to their care" (Baston & Green, 2002). Women from different backgrounds, and areas can often have very contrasting education levels and as a midwife, it is essential to know your neighborhood well in order to take these into consideration when communicating with a woman.
The area chosen for this community profile is in the south west of Glasgow, which will now be referred to as area X, with a population of 10,024 (RDC - Registrar General's Census, 2001).
Table 1: Age Distribution - Area X
Population aged 0-15
Population ages 16-64
Population aged 65+
The majority of the population is in the age range 16-64 years and the relevant health care services in the community for this group are the antenatal clinics, family planning and screening clinics.
Graph 1: Hospital admissions for heart disease - Area X
With respect to the social and economical characteristics of the area, this graph shows the volume of people admitted to hospital for heart disease in Area X. Heart disease is more accurately described now as a disease "of social and economical disadvantage and poverty" (Blackburn, 1991:Ch2 p36) and the major risk factors contributing to heart disease are smoking and diet. These lifestyle factors also may echo a life associated with lower social class (Bond &Bond, 1994: Ch 4 p 70).
Nearly half of the houses in Area X are owner occupied, and that amount can be split into two; ex-council houses and private housing estates. The other half are tenanted homes, renting either from the council or private renting. Almost a quarter of all homes in the area suffer from overcrowding. These statistics indicate there are many occupants of tenement flats and these tend to be low-income families who have little or no choice about the type or standard of accommodation they live in (Blackburn, 1991). Higher income groups tend to live in the private housing sector, and have choices in the location and type of heating which are important influences affecting the health of families (Lowry, 1991).
Table 2: Housing - Area X
(RDC - Registrar General's Census, 2001).
Glasgow is home to the most workless households in the UK, according to the Office for National Statistics, (ONS). Figures measured in 2007 indicate 29% of households in the Glasgow City council area had members of working age who were unemployed (BBC, 2009). Area X also has a high percentage of people unemployed according to Scotland's Census from 2001, with both those who are unemployed and claiming and those who are economically inactive. Long-term unemployment can be a self-perpetuating cycle that leads to low morale and poor health (NHS: Greater Glasgow, 2005). Other effects of unemployment are the increased rates of depression, particularly in the young-who form most of the group who have never worked (BMJ, 2009). It is obvious from this that unemployment can alter both our mental and physical state, and in Area X almost 40% of the population of children live in a workless household, which would also have an influence on these children's quality of life.
Table 3: Unemployment - Area X
Children in workless households
(RDC - Registrar General's Census, 2001).
The role and contribution of midwifery services in Area X are vital in supporting childbearing women and their families, through a holistic approach. It is very important that midwives had a good understanding of social, cultural and context differences so that they can respond to the women's needs in a variety of care settings This is attained by an integrated midwifery service being part of an expert multidisciplinary team, allowing midwives to draw on other organizations to meet the holistic needs of individual women and providing a complete range of services. (Fraser & Cooper 2009, p. 7).
Midwives in Area X use the local hospital, and local health centers for antenatal and postnatal clinics, as well as parentcraft classes, working along side hospital doctors and GPs. The GP usually confirms the pregnancy and thereafter, an appointment is given to the woman to be introduced to the community midwife for a 'Booking visit', as these midwives often better understand social situations through working in the area. The women are generally referred, by the GP, to either the local hospital or a nearby health clinic to meet one of the midwives who work in Area X. These midwives work in teams of around 5, covering 2 or 3 certain postcodes in Glasgow each, and each team named after a colour to make it simple for women and their families to understand which group of community midwives they will be receiving care from, e.g. The Blue Team. This system also works well as it allows a certain degree of continuity as each woman will only be seen by the community midwives in her allocated team. Continuity of carer and care has been a key policy principle since the early 1990s. Research evidence demonstrates that women value continuity of carer in the antenatal and postnatal period (Waldenstrom & Turnbull 1998, Homer et al 2000, Page 2009). Working in Area X requires a high level of continuity in care as it has a lower social class and experiences problems related to pregnancy such as 49.9% of the population of Area X are smokers. Other statistics for Area X include 38.6% of women smoking during pregnancy, a total of 160 women over a 3 year total.
It is well known by midwives and obstetricians that smoking in pregnancy is associated with well recognized health problems and as midwives usually have the most professional contact with pregnant women, they have an important role in providing this advice and support (Buckley, 2000). Glasgow has a very well-organised network of smoke-free pharmacy services who provide NRT for smoking cessation services. They monitor carbon monoxide levels on a weekly basis and only dispense NRT if the breath test is negative (Mcgowan et al, 2008). Smoking cessation services are provided for Area X by specialist midwives, allowing continuity during pregnancy. These midwives speak to the woman and let them know what is available, without pushing them into quitting, and find out what their thoughts and feelings are, focusing on how good it is when women want to stop smoking. The chief executive of ASH Scotland, Sheila Duffy, stated in 2010 "life expectancy, health problems, smoking rates, and deaths from smoking are all markedly different between Scotland's richest and poorest communities. Research in Scotland has found that smoking is a greater source of health inequality than social class." This shows clearly that deprived areas such as Area X are at the greatest risk of being affected by smoking issues. 43% of adults who live in deprived areas smoke, compared with 9% in the least deprived areas and this is shown in the prevalence of tobacco related diseases and deaths. 32% of deaths in Scotland's most deprived areas are due to smoking compared to 15% in the most affluent (Duffy, 2010). This is also reflected in the rates of newborn deaths as the death rate for newborn babies is more than twice as high in deprived towns compared with affluent areas and the high rate of deaths in poor areas was linked to premature delivery or birth defects (BBC, 2010). This leads on to why so many pregnant women smoke in deprived areas, such as Area X. Smokers typically report that cigarettes calm them down when they are stressed and help them to concentrate and work more effectively (Jarvis, 2004), and this prospect could be highly desirable to those suffering from stress and anxiety due to financial problems and other socio-economic factors such as low employment, high crime rates, poor housing and poor health care.
Graph 2: Nicotine intake and social deprivation. Data from health survey for England (1993, 1994, 1996)
As reported in the recent Midwifery Practice Audit 1996-1997 (END, 1997), midwives are the lead professionals in providing care for childbearing women. However, midwives need to acknowledge that other health-care professionals also contribute to each woman's experience. Midwives work together with other professionals within the primary health-care team, providing integrated approaches to care delivery. Midwives have to use their own skills and expertise with the knowledge of how to access the expertise of other practitioners when required, allowing the women to receive holistic care (Houston S M, 1998). In the recent programme of work Midwifery 2020, a statement was made that women should be cared for in a multi-agency and multi-professional environment and NHS providers should have a collaborative working relationship with all other agencies based on mutual trust and respect to ensure that women and families receive optimum support. They should also ensure clear understanding of roles and facilitate effective communication between professionals and other agencies (Midwifery 2020, 2010). The first booking visit for antenatal care is important and a successful visit "lays the foundation for building that special relationship between mother and the midwifery services on which so much depends" (Cronk & Flint, 1989:ch2 p9). The visit enables the midwife to establish any physical, psychological or social needs that will form the basis of the woman's plan of care. In area X, the booking visit also allows midwives to inform the woman about the Healthy Start programme. Healthy Start is the Department of Health Welfare Food Scheme that helps pregnant women and eligible families, with children under 5, buy milk, fresh fruit and vegetables, infant feeding formula milk, and receive free vitamin supplements (NHSGCC, 2010). This is a clear example of how health services have integrated to allow women all the benefits they are entitled to, helping them achieve the best possible experience throughout their pregnancy.
As the pregnancy progresses, parentcraft education classes are offered to prepare women for the birth experience (Jamieson, 1993) and raise awareness to the advantages of breastfeeding, giving support to mothers who choose to breastfeed. Area X presents midwives with many teenage pregnancies and antenatal services should be flexible enough to meet the needs of all women, bearing in mind the needs of those from the most disadvantaged, vulnerable and less articulate groups in society are of equal if not more importance (Lewis, 2001). As Area X is a deprived area, this contributes greatly to the teenage pregnancy statistics and throughout the developed world, teenage pregnancy is more common among young people who have been disadvantaged in childhood and have poor expectations of education or the job market. Teenagers seem to be more likely to have sexual intercourse if they come from the lower social classes or unhappy home backgrounds. Another explanation may be that many young people lack accurate knowledge about contraception, STIs, what to expect in relationships and what it will mean to be a parent (Allen, 2002). There are also serious psychological concerns related to teenage pregnancy, which the midwives in Area X must address while working with these girls. The teenage years are a time of much change and difficulty without the added stress and anxiety of a pregnancy, birth and finally motherhood. It is a midwife's duty to give the necessary advice and proper holistic care, hopefully improving the service provision and having a good obstetric outcome. Comprehensive holistic antenatal care programmes specifically for pregnant teenagers have been found to be effective in reducing poor maternal outcomes (Fullerton, 1997). For teenage pregnancies in Area X, there is a specific midwife who will be contacted at the booking visit and will be a support network for girls 18 and under, available at all times for advice, encouraging continuity and individualized, specific care for young mums.
To conclude, through writing this community profile on Area X, I have discovered how difficult it is to work as a midwife in the community, especially in a deprived area such as Area X. From reading a large variety of articles on the psychological and social effects of poverty on pregnancy, there is much evidence that poverty has a significant effect on midwifery practice, and these women need the best care plan possible to ensure a positive experience. By having an awareness of the restrictions poverty can inflict on pregnancy and childbirth, the midwife can adapt her skills and provide care accordingly, keeping in mind aspects such as smoking during pregnancy and teenage pregnancies (Salmon et al, 1998). There is a reoccurring trend throughout this community profile confirming the link between lower socio-economic status and adverse pregnancy outcomes, such as prematurity, and the midwife is ideally placed to help identify and manage stresses, as it has been a very important consequence for the health and wellbeing of both mother and infant (Alderdice & Lynn, 2009). Working in Area X on clinical placement has given me an insight into the importance of individualized care, as every woman is in a different situation and therefore has different needs, socially and psychologically. Some women may need more specialized care and support than others, however they are all of equal importance. Investigating the role of the midwifery service in Glasgow has opened my eyes to how both the midwives and the primary health care team deals with problems, and how without integrating health services, it would not be possible to give women the best possible care. Only by working as an integrated team with users will health inequalities be reduced, social exclusion be limited and public health become relevant and cost-effective (Henderson, 2002). The importance of involving women in decisions about their care has long been part of the everyday practice of midwives (Proctor, 1998), and the importance of communication has been highlighted to me clearly throughout this community study, and through my placement, forcing me to realize how important it is for a midwife to fulfill her role.
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