Regulating migrant maternity: Nursing and midwifery’s emancipatory aims and assimilatory practices

I’ve just had the first paper from my PhD published: DeSouza, R. (2013), Regulating migrant maternity: Nursing and midwifery’s emancipatory aims and assimilatory practices. Nursing Inquiry. doi: 10.1111/nin.12020

In contemporary Western societies, birthing is framed as transformative for mothers; however, it is also a site for the regulation of women and the exercise of power relations by health professionals. Nursing scholarship often frames migrant mothers as a problem, yet nurses are imbricated within systems of scrutiny and regulation that are unevenly imposed on ‘other’ mothers. Discourses deployed by New Zealand Plunket nurses (who provide a universal ‘well child’ health service) to frame their understandings of migrant mothers were analysed using discourse analysis and concepts of power drawn from the work of French philosopher Michel Foucault, read through a postcolonial feminist perspective. This research shows how Plunket nurses draw on liberal feminist discourses, which have emancipatory aims but reflect assimilatory practices, paradoxically disempowering women who do not subscribe to ideals of individual autonomy. Consequently, the migrant mother, her family and new baby are brought into a neoliberal project of maternal improvement through surveillance. This project – enacted differentially but consistently among nurses – attempts to alter maternal and familial relationships by ‘improving’ mothering. Feminist critiques of patriarchy in maternity must be supplemented by a critique of the implicitly western subject of maternity to make empowerment a possibility for all mothers.

 

 

How can we better support new mothers to sing?

I am a member of the Perinatal Mental Health New Zealand Trust (PMHNZ) whose vision is to : “improve outcomes for families and whanau affected by mental illness related to pregnancy, childbirth and early parenthood”. They produce a quarterly newsletter that includes information about research, training, workshops and courses, innovative projects and services, topics for discussion and stories. It was a privilege to share my research with other members in the February newsletter (pdf) and on this Women’s day it seems apt to share it with a broader audience.

One of my favourite stories that I would tell when we ran workshops in the nineties about postnatal depression was by Jack Kornfield. I would share this story and half the room would be in tears.

“There is a tribe in East Africa in which the art of true intimacy is fostered even before birth. In this tribe, the birth date of a child is not counted from the day of its physical birth nor even the day of conception as in other village cultures. For this tribe the birth date comes the first time the child is a thought in its mother’s mind. Aware of her intention to conceive a child with a particular father, the mother then goes off to sit alone under a tree. There she sits and listens until she can hear the song of the child that she hopes to conceive. Once she has heard it, she returns to her village and teaches it to the father so that they can sing it together as they make love, inviting the child to join them. After the child is conceived, she sings it to the baby in her womb. Then she teaches it to the old women and midwives of the village, so that throughout the labor and at the miraculous moment of birth itself, the child is greeted with its song. After the birth all the villagers learn the song of their new member and sing it to the child when it falls or hurts itself. It is sung in times of triumph, or in rituals and initiations. This song becomes a part of the marriage ceremony when the child is grown, and at the end of life, his or her loved ones will gather around the deathbed and sing this song for the last time.” A Path with Heart (1993, p. 334).

For me the message in this story reflects the importance of love, being loved by a community and the importance of acknowledgement. Painfully, however, it highlights the ways in which women’s experiences of maternity can be just the opposite. That is, they can feel isolated, disrespected and invisible. As a clinician, I’ve learned that there are ways in which we, and the system that we work in can make this most magnificent, sacred and profound time in a woman and her family’s life also one that is painful, one that leaves long lasting scars. Health professionals can cause harm even especially when we think we are doing good. As an academic for 13 years prior to which I worked as a clinician for 10 years, I am deeply interested in the issue of power and how professional frameworks of care can undermine women’s personal experiences.

This song has been the background soundtrack to my recently completed PhD. I used data from a study funded by the Families Commission and assisted by Plunket, where I talked to 40 migrant women about their experiences of becoming mothers in New Zealand. I also talked to Plunket nurses about their experiences of caring for women from ethnic migrant backgrounds.

My motivation for doing research was prompted by my clinical experiences. Several years ago I decided to make a move from working in mental health to working in maternity. As someone who had worked as a community mental health nurse I took a lot of concepts about my work in mental health into this new setting, for example, I believed that care should be client centred and driven, that services should fit around consumers of services and that taking time to be with people was important. What I found in the institutionalised setting of hospital maternity care and later community care was that some of the routine procedures that are administered in hospitals and in the community with good intentions had negative impacts and were oppressive especially for women who did not tidily fit into the mould for the factory style model that was in place then. The conveyor belt metaphor is apt given that women who were the wrong fit were viewed as a problem, as only a single way of becoming a mother was acceptable. I saw that staff were frustrated at the extra demands or complexity of working with ‘diverse’ women, they lacked resources like time and knowledge. In turn, I could see that women who valued particular kinds of social support, acknowledgement and rituals were not getting their needs met. It seemed like a situation where no one was a winner.

What I found out in my research was that there was a big gap in satisfaction among women who were familiar with the structure of maternity services in the west and women whose lives had been shaped by growing up in other cultural contexts. Fundamentally there was a schism in the ways in which birth was understood. To be simplistic, western modes of being a mother valued independence, autonomy, taking up expert knowledge and using it and being an active consumer. By that I mean the individualising of responsibility for maternity on the mother, to take up scientific knowledge through reading self help books and for the role of the partner to be a birth coach and the goal of birth to be “natural”.

This dominant Pakeha middle class model of being a mother clashed with other understandings of motherhood, where responsibility was more collectivised, so that embodied knowledge from cultural authority figures (mother and mothers in law) protected mothers and where a range of rituals and supports were available for the mother (including some which were also not necessarily helpful). Women who became mothers in New Zealand had to negotiate these two different models of maternity and come to terms with what they negotiated. However, in the context of an assimilatory maternal health system it was very difficult for women to maintain traditions that were important to them. For example many women were not supported if they wanted to bring in traditional foods with them or have support from grandmothers. Many of these encounters left migrant mothers feeling disempowered. Another important clash was the different philosophies and roles of professionals and mother in the context of midwifery models and medical models. Some women viewed birth as a risky process and wanted the reassurance of visualising technologies. The view of birth as a risky process clashed with midwifery models of birth as a natural process that women are physically prepared for but need encouragement and support with.

Conclusion How can we support all kinds of women with different values, beliefs and rituals around birth, to feel loved, nurtured, safe and supported? How can we give women who might be separated from their loved ones, support to access those values, beliefs and that will allow them to manage the transition into motherhood? Returning to the metaphor of singing, and the power of connection it engenders, how can we connect and support people who are singing different kinds of songs? Can we adjust our tone so that we can harmonise? Can new songs and rhythms infuse the songs we already know with new energy and possibility?

Having a baby in New Zealand without your support base http://www.mentalhealth.org.nz/kaixinxingdong/page/486- resources+dragon-babies+parents-stories 

Postnatal depression in the Year of the Dragon

Women are more likely to develop emotional problems after childbirth than at any other time in their lives and the life time prevalence of major depression in women is almost twice that of men (Kohen, 2001). According to Lumley et al. (2004), one out of every six women experiences a depressive illness in the first year after giving birth. Thirty per cent of those women will still be depressed when their child is two years old. Of those women, 94% report experiencing a related health problem. Women who experience problems in the early stages of motherhood also report problems with their relationships, their own physical health and well-being. Women report that a lack of support, isolation, and exhaustion are common experiences.

Several years ago I was approached to develop a new brochure about Women’s perinatal mental health (given my expertise as as a clinician and educator in maternal mental health) for the New Zealand Mental Health Foundation who were partnering with EGG maternity a New Zealand company specialising in maternity wear. In developing the brochure, my partner and I consulted widely with consumer groups, mothers, fathers, health professionals in order to ascertain what would be the most important and clear information we could put inside the brochure. This was the end result:

The PND brochure has become widely available, it is included in information packs given to new mothers by Plunket, available from the resource centre at the Mental Health Foundation, the Foundation website and EGG maternity boutiques in New Zealand.  It has been one of the most requested brochures ever with 33,800 sent out in 2011 alone.

Women who have a baby in a new country and are separated from their support networks and special perinatal customs (including special foods, nurturing, rest and household help) through migration can experience isolation and postnatal depression.

For the Year of the Dragon this brochure has been translated into Chinese by Kai Xin Xing Dong -a public education programme aimed at reducing the stigma and discrimination faced by Chinese people who experience mental illness. Funded by the Ministry of Health, the project aims to raise mental health awareness in the Chinese community and to counter stigma and discrimination.

See here for other PND resources

When activists become oppressors: Nurses and migrant mothers.

This Sunday I’ll be doing a Picnic lecture where I’ll be sharing stories from nurses and migrant mothers from my PhD to discuss how well intentioned activism can become a form of oppression. The lecture will be held in the Albert Park rotunda in Auckland on Sunday 1st April at 3pm and is linked with Te Tuhi’s What do you mean, we? exhibition which brings together an international selection of artists to examine prejudice.

The kinds of questions that my work has been concerned with are:

  • What subjectivities and beliefs and values are being reproduced when a woman has a baby in neoliberal Aotearoa New Zealand?
  • How does a maternal health care system provide services for birthing women whose subjectivities have been partially or significantly formed outside a white settler nation context and specifically outside the colonial dyad of settler and indigenous?
  • Do the policy rhetoric of biculturalism in response to Treaty of Waitangi obligations and the requirement for culturally competent practice actually improve the care migrant mothers receive?
  • Do the liberal feminist aspirations for birth as an empowering experience extend to women outside the world of white middle-class feminism?

New mothers in a new land: Indian migrant mothers talk

Originally published in: DeSouza, R. (2010). New mothers in a new land: Indian migrant mothers talk. In S. Bandyopadhyay (Ed.), India in New Zealand: Local identities, global relations (pp. 207-217). Dunedin: Otago University Press.

Ethnic identity and acculturation become important issues in the transition to parenthood. The birth of a child presents parents with the opportunity to consider what values are important to them and whether they will look to the future or the past (or both) to determine what will sustain them in their role as parents and nurture their newborn to adulthood. This sifting process involves parents interpreting and accepting or rejecting the values, beliefs, and practices from both their heritage culture and their current community.

Migrant Indian mothers play a pivotal role in such negotiations. This chapter presents research findings from a study on the maternity experiences of Indian migrant women living in Auckland, New Zealand in late 20062. It begins with a brief discussion of the literature around the process of acculturation and its influence on Indian health and maternal health in particular. It then looks at the inherited beliefs and practices that shape the maternity experiences of Indian mothers, especially the centrality of motherhood to identity, and the idealisation and rewards of self-denial and good behaviour. Finally, the chapter discusses the study’s findings. These exemplify how motherhood is idealised and viewed as a socially powerful role among immigrant Indian mothers, and that these mothers have also taken on the messages of New Zealand models of motherhood (and parenting in general) where self-monitoring is required in order to be ‘a good mother’.

People of colour decolonisation hui

The Decolonise Your Minds! Hui on February 5th in Tamaki Makaurau, Aotearoa provided a great opportunity to present my PhD work to awesome folks with similar theoretical and political commitments. Outside a professional or academic context and supported by fabulous vegan food and great korero and creativity, the radical space provided a great opportunity to not have to explain everything!

In my presentation, I talked about the ways in which the people who are supposed to care in institutions can engage in subtle coercions and “do” violence. This violence works through the reproduction of taken for granted norms and values, such that pressure is exerted on those whose personhood sits outside the accepted norms and values and reshapes their personhood. Reflecting an assimilatory process similar to the colonial process of moral improvement. Hardly a surprise considering that institutions like health and education are colonial, having been transplanted from the metropole to the colony and super-imposed over indigenous ways of learning and maintaining health.

Using the example of maternity I talked about the ways in which heath professionals draw on culturally and socially available repertoires of care that can be less than helpful when imposed on women of colour. This is because so often these repertoires are drawn on the basis of an implicit ideal user who tends to be cis-woman, heterosexual, white, middle class and one who takes up the ‘imperative of health’. That is the ideal neoliberal consumer who makes herself an expert through her consumption of self-help books and its acceptable accoutrements, who takes responsibility by attending ante-natal classes and who labours naturally with her loving and supportive partner present. She obeys the edicts of the health professional and makes reasonable requests that align with the dominant discourse of maternity as an empowering experience (if you are “informed” and “take responsibility”).

You can listen to the audio which is hosted by the Pride New Zealand website. I take the audience through the idea of discourses and how they shape subjectivity and practice.

Please note I have a tendency to swear when I am speaking passionately about something!

New spaces and possibilities: The adjustment to parenthood for new migrant mothers

DeSouza, R. (2006). New spaces and possibilities: The adjustment to parenthood for new migrant mothers. Wellington, New Zealand.

I recently completed a report for the Families Commission about migrant maternity, based on interviews with new mothers in Auckland and with the help of Plunket and many colleagues (see the acknowledgements in the report).

Parenthood and migration are both major life events which, while stressful, can be mediated effectively with appropriate support. International research indicates that parenting in a new country without support, networks or access to information creates additional stressors.

There is a paucity of research about the transition to parenthood in New Zealand for migrant families and this research project explores the maternity experiences of women from five different migrant backgrounds. It is a starting point for further research about migrant families and the development of a migrant family life-cycle research agenda.

Forty migrant women were interviewed about their experiences of the adjustment to parenthood in a new country in order to ascertain their support needs. Early motherhood was chosen as a focus because migration policy selects healthy women and therefore the maternity experience is often when many migrant women are first initiated into the New Zealand health system. In consultation with Plunket, five groups were chosen for the study; three were from the largest Asian communities, Chinese, Indian and Korean (Chinese make up 44 percent of all Asians, Indians 26 percent and Koreans 8 percent). Two other new migrant groups were also selected for inclusion for different reasons. European migrant women were chosen because they are the largest migrant group yet little is known about their needs. These are assumed to be similar to those of other Pa-keha- because of their familiarity with language and systems. Arab Muslim women were chosen because their faith and cultural needs are not well understood. One focus group was undertaken for each group. AUT University’s Centre for Asian and Migrant Health Research and the Royal New Zealand Plunket Society conducted the research together in March 2006.

KEY FINDINGS

It is hoped that the research findings will inform policy, the development of appropriate resources and other research in this area, and will assist both health professionals and migrant communities in New Zealand. The key findings of the research were that:

  • migrant women lose access to information resources, such as family and friends, in the process of migrating and come to depend on their husbands, health professionals and other authoritative sources. Importantly, the expectations from their country of origin come to inform their experiences of pregnancy, labour and delivery in a new country
  • migration has an impact on women’s and their partners’ roles in relation to childbirth and parenting. The loss of supportive networks incurred in migration results in husbands and partners taking more active roles in the perinatal period
  • coming to a new country can result in the loss of knowledge resources, peer and family support and protective rituals. These losses can lead to isolation for many women.

RECOMMENDATIONS

The findings of the research suggest that:

  • support services for women who have a baby in a new country need to be developed and services also need to be ‘father-friendly’
  • the information needs of migrant women from all backgrounds need to be considered in planning service delivery (including European migrant women)
  • services need to develop linguistic competence to better support migrant mothers, for example by providing written information in their own language
  • those developing antenatal resources must consider the needs of migrant mothers; for example, by having antenatal classes available in a number of common languages, eg Korean
  • workforce development occurs among health professionals to expand existing cultural safety training to incorporate cultural competence
  • health and social services staff must become better informed as to the resources that are available if they are to provide effective support for migrant mothers.

FUTURE RESEARCH

Further research is required to:

  • explore the experiences of New Zealand-born women to identify whether the issues raised in this report are peculiar to migrant women or to women in general
  • explore the information needs of migrant parents through the family life-cycle
  • identify the factors that support breastfeeding in the absence of social support
  • understand the experiences of migrant father
  • understand the needs of additional migrant groups, including African, Middle-Eastern and Latin American communities
  • review the effectiveness of cultural safety for migrant women by focusing on outcomes.

Shifting Out the Sweetness: Migrant Motherhood in New Zealand

DeSouza, R. (2007). Sifting out the sweetness: Migrant motherhood in New Zealand. In P. Liamputtong (Ed.), Reproduction, Childbearing and Motherhood: A Cross-Cultural Perspective (pp. 239-251). New York: Nova Science Publishers.

Abstract

Migration leads to transformation, willingly or unwillingly, for both the migrant and the receiving society. The changes that result can be superficial or visible; for example, cuisine or more subtle and private, such as identities. In considering motherhood in a new country, women are challenged with an opportunity to reshape their identity, from viewing their culture as static with fixed boundaries and members to fluid, pliable, negotiated and renegotiated through interactions with others. The pluralising of identities that accompanies migrant motherhood is brought to the fore with migrant women having to sift and reclaim aspects of culture that may have been lost, preserve memories of cultural practices, transmit, maintain or discard traditional perinatal practices and  choose new practices. In addition, there may be old and new authority figures in the shape of midwives or mothers to appease. This chapter provides an overview of how women originating from Goa, India who had babies in New Zealand actively considered their past, present and future in terms of cultural maintenance and reclamation during the perinatal period. The history of Goan colonisation as a catalyst for dispersal had already led to the modification of cultural practices. The development of plural identities and the strategic utilization of cultural resources new and old are examined, as is the potential to apply notions of cultural safety to migrant health. The chapter concludes with a discussion of the implications of plural identities for health services and workforce development in New Zealand.

Introduction

At no other time in their lives do women get bombarded and overwhelmed with more information and advice, which is frequently unsolicited, as when they are pregnant and have babies. As a nurse working on a post-natal ward many years ago, I remember meeting a vibrant and loving couple, who said their strategy for managing the mountain of advice, was to “sift out the sweetness.” This sifting process is doubly significant for migrant women who have a baby in a new country. They must sift between their own cultural practices and those of the receiving communities. For many, it involves reclaiming long forgotten practices especially if they are separated from their traditional knowledge sources. In turn, there is an opportunity for receiving societies and their systems to sift through their practices and consider ones brought by immigrants to see if there are opportunities for improvement and innovation.

This chapter focuses on a study of women from the Goan/Indian community in Auckland, New Zealand and discusses how women manage the dual transition of motherhood and migration while separated from networks and supports. A brief history of New Zealand demographics, migration and policy is given, followed by an overview of Goan migration. A description of the study that took place follows including the theoretical standpoint and social and cultural context. The findings of the study are then discussed, focusing on how women negotiated their cultural identities. The chapter concludes with an overview of implications for social care and health professionals.

Becoming informed health care consumers: Asian migrant mothers in NZ

Presented at the Prevention, protection and promotion. Second International Asian Health and Wellbeing Conference, November 11,2006.

Cite as: DeSouza, R. (2006). Becoming informed health care consumers: Asian migrant mothers in New Zealand. In S. Tse, M.E. Hoque, K. Rasanathan, M. Chatterji, R. Wee, S. Garg, & Y. Ratnasabapathy (Eds.), Prevention, protection and promotion. Proceedings of the Second International Asian Health and Wellbeing Conference, November 11, 13-14, (pp. 196-207). Auckland, New Zealand: University of Auckland.

Abstract
A central tenet of New Zealand’s midwifery and maternity services is the emphasis on a partnership between two equals namely the midwife and the woman. However, such a partnership rests on the notion of an informed consumer who is independent. When the consumer is a migrant who has experienced social upheaval, lost their knowledge resources and is experiencing isolation and language barriers, they may take up a more dependent role rather than the autonomous and self-determining consumer that midwives are prepared for. This imbalance can mean that health professionals are challenged to take up less facilitative and more authoritative positions and in turn migrant mothers and their partners are challenged to develop more proactive roles. This paper presents partial and preliminary findings from a qualitative study of Asian mothers in New Zealand with regard to their information needs.

Introduction
The notion of a partnership between the midwife and the woman underpins New Zealand midwifery models, where both parties are equal and make equally valuable contributions (Pairman, 2001). Midwives bring their knowledge, skills and experience and the woman brings her knowledge of herself and her family and her needs and wishes for her pregnancy and birth. However, for women become equal partners, they need to make informed decisions about their health and this in turn depends on having access to relevant and timely information. For mothers, biological knowledge about the pregnancy, birth and labour is only one form of knowledge. In addition, social knowledge and institutional knowledge are important (Lazarus, 1994). While biological knowledge can be obtained from authoritative sources like experts and electronic resources, social and institutional knowledge are more difficult to access for migrant women. AS access to these forms of knowledge is dependent on context and social networks which migrant mothers often lose in the social upheaval of migration. For many women who migrate, the separation from family and peers leads to ‘breaks in knowledge’ (Fitzgerald et al., 1998) and the loss of these knowledge resources which help prepare the mother for the processes of pregnancy, childbirth and parenting, creates what Liem (1999, p.157) calls a “vacuum of knowledge”. The vacuum of knowledge needs to be filled and most often this role falls heavily on health professionals (DeSouza, 2005).

This paper begins with a description of the dramatic population changes in New Zealand with a particular focus on Asian women. A discussion about receiving accurate and timely information follows suggesting that the quality of communication between women and their carers is critical for feeling safe and satisfied with care. An outline of research conducted in Auckland New Zealand follows and the findings are presented through the transition to parenthood. Strategies for managing the transition to parenthood and becoming an informed consumer are discussed with the paper concluding with practice, policy and research recommendations.

Literature Review
The following section contextualises the study by reviewing the changing demographics in New Zealand society with a focus on Asian women. This is followed by a discussion about the link between information and communication and satisfaction with care for migrants.

An increasingly diverse New Zealand
Service providers need to develop skills and competence for working effectively with diverse members of New Zealand society. International trends show that people of diverse racial, ethno-cultural and language backgrounds are underserved by health and social services, experience unequal burdens of disease, experience cultural and language barriers to accessing appropriate health care, and receive a lower quality of care when they do access health care services in comparison with members of the population (Johnstone & Kanitsaki, 2005). The 2001 Census revealed growing numbers of M␣ori (14.5%), Pacific Island people (5.6%), Chinese (2.2%) and Indian (1.2%), in addition to European/Pakeha who make up 79.6% of the population. There has been a 20% increase in the number of multilingual people and an increase in people whose religion was non-Christian. People who practice Hinduism increased by 56%, there was a 48% increase in Buddhists and a 74% of people practising Islam.

Asians are the fastest growing ethnic group; increasing by around 140% over the last ten years and predicted to increase by 122% by 2021 due to net migration gains rather than high fertility rates (Statistics New Zealand, 2005). The Asian community has the highest proportion of women (54%), (Scragg & Maitra, 2005) who are most highly concentrated in the working age group of 15-64 years compared to other ethnic groups, a reflection of a skills focused migration policy. 23% of New Zealand women were born overseas, predominantly in the UK and Ireland, Asia and the Pacific Islands. Some of the most dramatic demographic changes are evident in the Asian community, for example in the period between 1991 and 2001, the number of women originating from the Republic of Korea increased 23 times from 408 to 9,354, numbers of women from China quadrupled from 4,620 to 20,457 and women from South Asia doubled in the same time period (Statistics New Zealand, 2005). Such diversity has been unprecedented and present both unique challenges and opportunities to health and social service providers and policy makers.

Communication, caring and safety
Migration often results in the loss of reference points in the form of family networks, peer support and familiarity with health services. Such a loss amplifies the necessity for receiving accurate and timely information. Davies and Bath (2001) suggest that information provision during pregnancy and childbirth is critical for both supporting choices that are made but also in preparing women to manage uncertain outcomes. Citing a study by Kirkham (1989), Davies and Bath argue that women’s satisfaction with maternity services in secondary care is primarily dependent on the quality of communication between the women and their carers. Little is known about the health care experiences of migrant women, however, they are thought to report more acute concerns about communication and sensitivity of care than the population in general (Davies & Bath, 2001). Furthermore, language barriers can exacerbate isolation and promote dependency on health workers rather than enhancing self- determination, a dominant midwifery discourse. Small, Rice, Yelland, & Lumley (1999) found that Vietnamese, Turkish and Filipino women in Melbourne who were not fluent English speakers experienced problems in communicating with their caregivers and this made experiences of care less positive. Of more importance than knowledge about cultural practices, was care experienced as unkind, rushed, and unsupportive. Another Australian study found that migrant patients (and their families) did not feel safe when in hospital. Safety was undermined when effective communication with caregivers was compromised through being unable to access qualified health interpreters or being unable to have family members around to advocate and participate in decision-making (Johnstone & Kanitsaki, 2005).

The study
Migrants tend to maintain better health than the local population initially so often have little to do with hospitals (McDonald & Kennedy, 2004), but motherhood is a common aspect of migration requiring contact with the health system. The study took place in Auckland, New Zealand among White migrants (from South Africa, United Kingdom and the United States of America), Muslim Arab migrants (from Iraq and Palestine) and Asian women from three ethnic communities (Korean, Chinese and Indian) as part of a larger Families Commission funded study. Ethics approval was obtained from the Auckland University of Technology Ethics Committee and the Plunket Ethics Committee. Participants for the migrant mothers’ focus group were recruited though Plunket nurses who invited women to participate, selection criteria limited participation to migrant women who had become mothers within the last 12 months in New Zealand. Informed consent was obtained from all participants and consent forms were translated into Arabic, Korean and Chinese. Data collection involved focus groups using semi-structured interviews conducted in English, Chinese and Korean. The groups were facilitated by interviewers proficient in English and the language spoken by the women. These interviews were recorded and transcribed, translated into English if necessary and verified by an independent translator. The interview transcripts were then coded and analysed. The codes were clustered according to similarity and reduced. Similar phenomena were grouped into categories and named. The process was one of constant comparison, iteratively classifying and grouping the material to identify preliminary categories and sub- categories. This paper reports on a sub-theme about information needs and the findings focus on Asian women.

Findings
Midwives caring for migrant Asian parents are challenged to reconfigure their model of partnership and in turn migrant Asian parents experience a shift from birth being a social event to more of an individual responsibility. This shift requires a more proactive and self- sufficient role for women and their husbands, who become more involved than they might have been in their country of origin. In addition, language and communication drive experiences of care. This separation from knowledge resources places greater responsibility onto midwives to assume a more central role in information provision and support. In particular migrant mothers require detailed, individualised, stage specific information in order to take up the role of informed consumer.

Antenatal period
Not only are migrant mothers confronted with changing bodies and roles when they become pregnant, they also have to deal with an unfamiliar health system in the absence of a support network and knowledge resources they might have had in their countries of origin. In this study, Asian migrant women had to make decisions that required access to information in order to ascertain the choice of maternity carer and access to ante-natal classes. At this time women who were not fluent or confident English speakers had to contend with linguistic and cultural barriers to accessing services.

The loss of traditional sources of knowledge meant that pregnancy in a new country moved from being a social event and responsibility to being an individual one (DeSouza, 2005). This required the participants to become more involved and proactive in seeking out detailed, timely and specific information about the stages of their pregnancy. This allowed them to become more involved in the pregnancy than if they had been in their country of origin where this responsibility would have been shared. Husbands also became more involved in the processes of pregnancy, than they might have been in their countries of origin. Knowing where to begin the process was difficult:

I had no idea at all about the system here. It was through the pregnancy test kit that I found out I was pregnant, but did not know what the next step was. I wondered whether I had to show my test result to my GP. I had no knowledge of how to get the necessary information [Korean participant].

Obtaining language specific and precise information was important for many Korean women. Being given broad encouragement was not a substitute for specific information and was perceived as a laissez-fare attitude to their wellbeing.

I was given some information, but I didn’t read it, as it was not in Korean. I always felt that I was one step behind. It was not only the midwife who did not give enough information or necessary support. Everyone kept saying, “It is okay, you are doing well” but gave few information or specific support [Korean participant].

Pregnancy in a new country raised the need to develop active decision making strategies and to choose a health care provider. Many of the women were proactive about finding out about the New Zealand health system and turned to authoritative sources for information:

Luckily, I was attending school and the assignment from school was to complete a project. I chose ‘New Zealand’s maternity system’ and that was how I got some ideas about my situation [Korean participant].

For some women the absence of family members and the access to information meant that they could monitor themselves through the stages of pregnancy and this led to developing increased knowledge and greater self-sufficiency:

I have to take care of my own self. I found this good thing in New Zealand that you should take care of the baby and you should be aware of foods and what is going on each and every month, each and every week, what really is important [Indian participant].

One Indian woman found that she was more engaged in her pregnancy because her previous pregnancy was a joint responsibility with other family members while this time round she had to take more personal responsibility:

Why didn’t I get the feelings the first time? Time passed with families, mother in law, sisters, brothers and time passed like anything but here we are alone,  thinking about the baby early and so every moment for me was a first time moment, even though I’m a second time mother [Indian participant].

Many husbands become more involved during the pregnancy and were more in tune with what was happening to their partner’s bodies:

We used to wake up and the first thing we used to do was take a book and read ‘Okay, so now our baby’s doing that’ and he will pat me on my tummy saying ‘Oh my little one’ you know? So I doubt whether the same feeling would have come if my pregnancy was in India [Indian participant].

Language dictated the choice of LMC for many Chinese women and they, more than any other cohort, relied on their networks to find a care provider with Chinese newspapers also being a useful knowledge resource.

She speaks English and can speak Chinese. After I met her, I had a good impression of her. So I decided to have her as my midwife. My midwife has a partner who is also a Chinese (Malaysian Chinese). When I gave birth to my child, her partner delivered my child. The whole process was quite smooth [Chinese participant].

Antenatal classes
Antenatal classes were a pivotal mechanism for acquiring knowledge:

When you know something it’s better than just going without knowledge and you’re worried. , Yeah and as a first time mother I didn’t really know what was going to happen or what to expect and then yeah, I learnt a lot from that [Indian participant].

And for gaining confidence about what was to come by having some broad knowledge about what was to come:

I felt it was not so relevant to my delivery. But I felt more at ease and more confident during delivery. There are Chinese people in the class. The midwife was also careful when teaching us. We could understand her. My husband’s English is very good. He escorted me to the class. It was about some basic ideas. I didn’t find it useful for my delivery. During delivery, you follow the instructions of your midwife and have no time to reflect on what was taught in the class. But you feel relieved and less anxious. You roughly know what is going to happen and what is what [Chinese participant].

But language barriers made classes inaccessible for some:

I felt frustrated because I could not understand everything [Korean participant].

Both my husband and I have poor English so only attended once [Korean participant].

This section highlighted the importance of receiving detailed and specific information in one’s own language and how this influences the choice of LMC or attendance at ante-natal classes. Knowing where to start can be difficult. For women and their husbands who want to take up an informed consumer role there are resources available which lead women and their husbands to be more self-sufficient, proactive and engaged in the process.

Labour and delivery
Labour and delivery was also a time when information, support and cultural needs were highlighted. Women wanted information that was specific to their stage of labour and that was individualised (some felt they had too much and others too little information to feel that they could make the best choice for themselves). The value of specific stage by stage information was supported by a Korean participant rather than broad encouragement:

In Korea mums are given lots of warning and feedback of what is happening during labour, and told by Dr’s what to do regularly. This was missing in NZ. It would be good to be given feedback of our progress of labour and how many cm we are at each stage after the vaginal examinations. I was not told this. Not enough explanation and only told that “You are doing well” [Korean participant].

The need for not only specific information but also to be told the best option or given enough information to make the best choice was also voiced. The facilitative role of health providers was called into question with some participants wanting a more authoritative role. The partnership between the midwife and the woman underpins the midwifery model in New Zealand maternity services and is based on equity and the acknowledgement that both parties make equally valuable contributions (Pairman, 2001). Midwives bring their knowledge, skills and experience and the woman brings her knowledge of herself and her family and her needs and wishes for her pregnancy and birth. Midwives have moved from authoritative sources of knowledge to models of partnership and collaboration in a bid to empower women and distinguish themselves from the more hierarchical professional models of medical, nursing and obstetric practise (Tully, Daellenbach, & Guilliland, 1998). However, this is predicated on the notion of the informed consumer:

In NZ different delivery options are given to mums and we are asked to choose by ourselves but unable to choose the best options for ourselves due to lack of sufficient knowledge. Want more advice and guidance and even want to be told which better option for us is. So in the end we have limited options due to not enough knowledge of all the pros and cons of delivery methods [Korean participant].

Information does need to be individualised, one participant who felt that she was given too much information:

During the labour the ladies said that I need an epidural because I can’t go through the pain anymore, the anaesthetist comes in the room and says out of 150 million there are 10% of cases with risk all that information beforehand [Indian Participant].

This section has highlighted the importance of detailed and specific information and the need for information to be individualised. The midwifery model of care which emphasises facilitative rather than authoritative relationships was challenged.

Post-partum
The postnatal period is a critical time for women but it is also a time when their needs are often not met (Baker, Choi, Henshaw, & Tree, 2005). In the postpartum, information needs were an issue, women needed to know how to handle an unpredictable and unknown baby, there were issues around feeding from a cultural point of view and what to feed and when, the amount and type of information became important too:

We need more information. Iron deficiency for example. We don’t know what to feed our babies for this. And solid feeding too. We don’t know how to begin solid feeding with Korean food. The information is only on Kiwi way of feeding [Korean participant].
I didn’t even know how to care for her after delivering baby. No knowledge. Had to cook and clean and do everything after delivering baby , had no one to help. Breastfeeding was hard, received no help. Got sore bones and joints. No Korean appropriate services available, so often missed out altogether on information and the right kind of help [Korean participant].

However, not everyone wanted to be an informed consumer:

Yeah, you just want to get out of that place and these people are giving you like the advantages and disadvantages of various things, you don’t want to hear all these things [Indian participant].

The post-partum period highlights the need for the expansion of the information agenda from New Zealand models of infant feeding to incorporating other cultural models and the need for language specific information about breastfeeding. Some women contested the pressure to be informed consumers. The following section provides some discussion and recommendations.

Discussion

This section focuses on five key areas where further exploration and consideration by both migrant mothers and health professionals would be beneficial, namely:

  • Providing detailed and individualised information;
  • Language support;
  • Preparing women for new discourses of maternity;
  • Developing fluency; and
    Developing health literacy.

Providing detailed and individualised information

Health-care providers have a responsibility to make available, accessible and up-to-date information. However this is not as easy as it sounds, when facilitating informed choice. Midwives and other health professionals are caught in a difficult position and have to strike other balances, such as between giving enough information for the woman to make a choice but not giving too much information and frightening her (Levy, 2006). They also have to delicately meet the needs of women and to appear neutral in their advice, when they might have strong feelings regarding certain issues. In this study, migrant mothers looked to health professionals to fill the vacuum of knowledge by being authoritative rather than facilitative. Increasingly research shows that information is more effective when it is tailored to the individual and their needs (Rapport et al., 2006) and relevant to the women’s current stage of pregnancy (Benn, Budge, & White, 1999). In addition detailed information rather than ‘big picture’ was valued. Therefore highlighting the need for individualised and detailed information when planning for the provision of maternity information (Soltani & Dickinson, 2005). Information that is available in ones own language or written information is important. While translated information is available about childbirth in New Zealand from the Maternity Services Consumer Council of New Zealand it is not clear how well this information is distributed or whether LMCs are aware of its existence.

Language support
Communication as a part of information support can be improved through implementing a two pronged strategy. First, health professionals and systems can become more skilful at information provision through linguistic competence and secondly through identifying and assisting in the extension of sources of information. Health providers can assist new migrants to identify information sources and encourage women to develop information seeking skills. Developing linguistic and cultural competence can be achieved by:

  • Providing bilingual /bicultural staff;
  • Providing foreign language interpreting services; Having link workers/advocates; and     Having materials developed and tested for specific cultural, ethnic, and linguistic
    groups;
  • Having translation services including those of:Legally binding documents (for example, consent forms); Hospital signage; Health education materials; and Public awareness materials and campaigns, including ethnic media in languages other than English. Examples include television, radio, internet, newspapers and periodicals (Szczepura, 2005).

In the USA, health care organisations are required to both offer and provide language services such as bilingual staff and interpreter servicesat no extra cost to clients who require it. It is recommended that information about services is provided both in writing and in a timely manner with credentialed interpreters and bilingual workers available (U.S. Dept. of Health and Human Services, 2003).

Lastly, research is needed to assess the level of unmet information needs among new migrant women in greater depth. To borrow from a recommendation from a recent study:
Research is needed on cross-cultural and intercultural communication in particular on the nature and impact on Culturally and Linguistically Diverse (CALD) people not being able to communicate with service providers; not being able to get information and explanations about ‘what is going on’; not being able to get information in a timely manner; not being given information in a culturally appropriate manner; not being given any information at all; being given too much information; being given unwanted information (Johnstone & Kanitsaki, 2005, p.15).

Preparing women for new discourses of maternity
The study findings highlight the need for health providers to assist women socialise into new discourses in particular the discourse of partnership and the informed consumer. A useful mechanism for socialising women into an informed consumer discourse is to provide multi- lingual antenatal classes. Many women in this study felt the need for specific and detailed information in order to make the best choice but some women also wanted to be told the best option. The facilitative role of health providers was called into question with some participants wanting their LMC to have a more authoritative style. The partnership model underpinning midwifery in New Zealand maternity services assumes that midwives bring their knowledge, skills and experience and women brings their knowledge of themselves and their families to the relationship. This is intended to be a collaborative and empowering relationship but it requires that the woman wants the responsibility of being an informed consumer. It appears that the notion of partnership cannot contain women who don’t want the equal responsibility that is required. In addition, one needs to be information literate in order to take this role on (Henwood, Wyatt, Hart, & Smith, 2003).

Developing fluency
Lack of English language proficiency impacts on access to health care, employment prospects, income levels and other factors which determine health status (Asian Public Health Project Team, 2003).The link between language and accessing health care is further strengthened by the findings of a New Zealand study where self-rated fair or poor health was found to be associated with Chinese-only reading knowledge, residency of more than five years and regretting having come to New Zealand (Abbott, Wong, Williams, Au, & Young, 2000). While a study of Chinese American women which found that lack of English language ability was a major barrier to access (Liang, Yuan, Mandelblatt, & Pasick, 2004). Ensuring that migrants are aware of Language line and encouraging them to take up their English for Migrants language courses, as proficiency is a key settlement enhancer. The migrant levy that migrants pay when coming to New Zealand entitles migrants to take up English language classes (English for Migrants). The Tertiary Education Commission pays for English language tuition on behalf of migrants to New Zealand who have pre-paid for their training, recent news reports indicate that few migrants take up these classes.

Developing health literacy
The development of health literacy among health care recipients is gaining prominence as a health promotion strategy. Health literacy is defined by the World Health Organisation as “ the cognitive and social skills which determine the motivation and ability of individuals to gain access to, understand, and use information in ways that promote and maintain good health” (World Health Organization, 1998, p.10). Health literacy is a stronger predictor of health status than socio-economic status, age, or ethnic background (Speros, 2005). Speros claims that the lack of health literacy can act as a barrier to navigating the system and functioning successfully as a consumer, presumably then the combination of socio-economic status, ethnic background and low health literacy compound the issues of access. Speros cites a large study by Williams et al. (1995) which found that one-third of English -speaking patients at two public hospitals in the USA could not read and understand basic health-related materials. Sixty per cent could not understand a routine consent form, 26% could not understand information written on an appointment slip, and 42% failed to comprehend directions for taking medications. While little is known about health literacy is known in New Zealand, overseas research suggests that being culturally and linguistically different magnifies the problem.

Conclusion
This study highlights the importance of information provision for health care consumers, in particular migrant mothers. The study shows that migrant women frequently experience a vacuum of knowledge that needs to be filled. Factors such as poor English language proficiency, limited networks and unresponsive health providers can all increase the likelihood of migrant mothers experiencing a problematic birth experience and poor outcomes. This research suggests that improving the quality and range of information for migrant mothers and the inter-cultural resources for health providers could improve outcomes.

Further research is needed into how maternity information is provided and it is suggested that more attention is paid to the information needs of migrant mothers and migrants in general. Language proficiency is vital not only with regard to access to services but also for being empowered and prepared for the dual transition of parenthood in a new country. The study highlights the need for further exploration of changing demographics on dominant health care discourses in New Zealand such as partnership and whether there is space for new discourses. There are several aspects that contribute to a satisfying experience of health care for migrant mothers and these appear to be the ability to access a service, being able to obtain relevant information and having a supportive relationship between themselves and providers. These appear to be mutually dependent factors.

Acknowledgements

Funding for this research was provided by grants from The Families Commission and the Plunket Society volunteers in Central Auckland. The following people are gratefully acknowledged for their contributions: The mothers, Elaine Macfarlane, Sheryl Orton, Michele Hucker, Dr Wanzhen Gao, Rose Joudi, Paula Foreman, Rezwana Nazir, Lorna Wong, Jane Vernon, Zahra Maleki, Nagiba Mohamed, Hyeeun Kim, Catherine Hong and Stephanie Shennan.

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Mutual sustenance: Goan women and the Catholic church in New Zealand

First published in Goanet Reader Sun, 30 Apr 2006 and also published in the Indian Catholic May 21,2006

On December 3 2005, Catholic Goans in Auckland, New Zealand celebrated the Feast of St Francis Xavier with a mass in Konkani, the first time such an event had been held in New Zealand. For those who don’t know, Francis Xavier was actually born in the Spanish kingdom of Navarre. He arrived in Goa in May 1542 and went on from there to Cape Comorin in the south of India, spending three years working among the pearl-fishers, or Paravas, of the Fishery Coast. His journey took him to the East Indies, to Malacca and the Moluccas, and, finally, in 1549 to Japan. He died on December 3rd, 1552, as he attempted to enter China and was buried. Within a few weeks his body was recovered and found to be perfectly preserved. It was brought to Goa and received there with devotion and enthusiasm leading to his beatification by Pope Paul V in 1619 and later his canonization by Pope Gregory XV, on March 12th, 1622. He is now the patron Saint of Goa. This event led me to wonder about the significance of religion and faith among Goans and how this sustained them during their migration and settlement in other countries.

In terms of  the New Zealand population, there is growing cultural, linguistic and religious diversity. Three trends are apparent: first, that religious participation by White or Pakeha New Zealanders is declining while changes in immigration policy have resulted in the introduction and growth of both diasporic religious traditions (such as Islam, Hinduism, Buddhism and so on) and an invigoration of Christian denominations. The 2001 Census noted that more than half the New Zealand population identified with a Christian religion (Anglican, Catholic and Presbyterian dominating) and the largest non-Christian religions were Buddhism, Hinduism, Islam and Spiritualism and New Age religions.

In my research among Goan women in New Zealand, what became apparent to me is that while Goan women have become detached from their homeland (all participants were born outside of Goa) they continue to have a link with the homeland while surviving in, and engaging, a foreign culture. Also religion and cultural identity are tightly inter-connected. There is academic debate about whether religion is a core attribute of culture or whether it functions within it, is more prominent than culture or in the background. I found many women in describing their identity, forgot that there are Hindu and Muslim Goans.

My description would be Goan Roman Catholic. Primarily being Goan is being Catholic because all the Catholics normally came from Goa, which was one of the Catholic states of India (Lorna).

As I grew up you grow out of church and praying and you go the other way kind of thing, but that was very strong, I think the Catholic faith, which stayed throughout. I mean even now you just link up being Goan and Catholic together (Rowena).

Crossing borders as migrants do involves not only physical borders but also emotional and behavioural boundaries. Becoming a member of a new society stretches the boundaries of what is possible because one’s life and roles change, and with them, identities change as well. This involves trauma and then incorporating new identities and roles becomes necessary for survival.

For many Goans in Auckland, the Catholic religion and church provided a mechanism for coming to grips with a new environment and assisted the transition to living in New Zealand. They could mix with other ethnic communities while at the same time maintain their culture and faith, that is it provided a bridge connects Goans to other Catholics while who shared similar religious beliefs and values even if they were culturally different.

Thus Churches provide a vehicle for helping Goans participate in New Zealand life rather than isolating them. In the case of the Catholic Church Goan migrants were already familiar with the rituals and structure and the church provided a supportive and welcoming space for them as immigrants. As someone who grew up in New Zealand, our youth group provided a wonderful source of friendship and fellowship for me and my two sisters.

Churches provide not only institutional spiritual comfort but also practical support. For example when we first came to New Zealand, our family was able to buy what is now called ‘retro’ or ‘vintage’ through the recycling process of the mini-market where you could buy other parishioners unwanted clothes.

Churches have also responded to new migrants by attending to and incorporating religious practices that are culturally significant for immigrants; for Goans this includes celebration of the Feast of St Francis Xavier, the patron Saint of Goa. Thus immigrants have infused change and a rich range of experiences in the churches they have joined within their receiving communities. I also remember with delight the Samoan choir who would sing in Samoan and English elevating our services to celestial heights once a month.

Integration into New Zealand is made so much easier by belonging to a ‘mainstream’ faith, providing entry into New Zealand society and enhancing integration and acceptance for participants into the dominant society in a way that people from minority faiths don’t have access to. Because Catholicism can be accessed within mainstream society, it can mean that not as much energy is required to maintain the faith. I remember at a Muslim women’s Hui I attended last year the major efforts Muslims went through to obtain halal food, such as going to farms and butchering their own animals.

Furthermore, faith, prayer and networks from the church also provide the support to aspire and do well in New Zealand. Flora felt strongly that her transition and survival in New Zealand was due to her faith and the help of the church.

You know the help came from God, you know through the Church (Flora).

There is a risk of complacency in extending ourselves beyond our own faith and ethnic communities once we grow in size as a community. As ethnic communities increase in size they move from being multi-ethnic religious communities and later establish themselves into ethnically-specific religious institutions. Rowena developed a new network of support through her church, which went beyond Goans and was a lifeline:

I started going to a mothers group there and I met a lot of other Malaysian and Indonesian and Filipino women and we would go and have coffee together and that kind of thing and my social life. I got quite involved with the Parish and doing work for the Church because I mean I really didn’t know many other people. I did meet a lot of elderly parishioners they were wonderful they would come and give me flowers, chocolates and really spoil me because they knew I was on my own and they were wonderful (Rowena).

For many early Goan migrants the lack of a community meant that her faith took on great importance and in particular prayer:

Like prayer did help me it honestly did, because you are alone, you are alone a lot of the time. Even though there are lots of people, you can still be alone you know (Sheila).

Therefore it can be seen that religious institutions provide spiritual resources that offer sustenance through the tasks of adjusting to living in a new country. The recognition of faith is well recognised in the United Kingdom where it is recognised that “faith groups are part of the ‘glue’ that binds strong communities and we value the experience, skills and diversity they bring to wider society.”

In considering the New Zealand Immigration Settlement Strategy for migrants, refugees and their families it can be seen that Churches often provide many of the settlement resources and are linked with the strategy’s six goals for migrants and refugees. They are for migrants and refugees to:

  • Obtain employment appropriate to their qualifications and skills;
  • Are confident using English in a New Zealand setting, or can access appropriate language support to bridge the gap;
  • Are able to access appropriate information and responsive services that are available to the wider community (for example housing, education, and services for children);
  • Form supportive social networks and establish a sustainable community identity; Feel safe expressing their ethnic identity and are accepted by, and are part of, the wider host community.

This brief piece paper provides some new information about the place of religion among Goans in the diaspora by focussing on Goans who have settled in Auckland, New Zealand.

The Catholic Church has been a mechanism of integration, offering a two way exchange of support and energy through social support, spiritual and secular activities. The Church provides a mechanism for facilitating cultural continuity while simultaneously easing immigrants’ transitions into New Zealand. The Church has supported Goan migrants and in turn the presence of Goans has I am sure enriched the church itself (certainly in numbers, if not energy and dynamism. This paper demonstrates the enduring nature of religion as a social institution which plays a part in sustaining Goans through the settlement process, providing both spiritual resources (such as prayer, connections with other migrants and receiving community members) and practical help for managing both the psychological effects of migration and enduring the hardship of migration and settlement in a new country.