Provision of Antenatal Care during Ramadan by Alison Pearce: Article Analysis Using Purnell's Model

Using Purnell’s model for cultural competence, critically review and evaluate the article, ‘Provision of antenatal care during Ramadan,’ written by Alison Pearce, Pauline Mayho. British Journal of Midwifery (BJM). (Dec, 2004)

INTRODUCTION

The United Kingdom (UK) has become a multiracial society and with this the Midwife must meet the challenge of respect and understanding of the many different culture’s and religious beliefs. However stereotyping individuals into groups because of the way they dress, speak or their religion can have a detrimental effect on the way women interact with members of the health care team. It is essential that services are sensitive and relevant to each individual culture and religious needs. It is important for midwives to know whether a particular practice is effective and based on sound evidence although evidence is not a substitute for decision making. Using Purnell’s model for cultural competence, this assignment will critically review and evaluate an article published by the British Journal of Midwifery (BJM).

JOURNAL The BJM is the UK’s largest paid for midwifery journal, with an average monthly circulation of 6,059 and readership estimated at over 21,000. The BJM is primarily subscription based with a high cover price which results in dedicated and comprehensive readership. All articles submitted for publication are reviewed by at least two external reviewers, which can add reliability to the article, although in this case it is not known who reviewed the article. The review of the article by peers

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would have the appropriate knowledge to assess the quality of the paper prior to publication. Publication in a well respected journal does not therefore necessarily mean it is a good article (Bluff and Cluett 2000).

AUTHORS The authors Alison Pearce and Pauline Mayho are community midwives at Bradford NHS Trust. It is not known how long within this post that they have been employed. Many years experience compared with a couple would have added weight to their knowledge and understanding of the client group in question. Reynolds and Shams (2005) found that midwives with a large proportion of women from Asian backgrounds in their caseloads felt more comfortable in discussing sensitive issues with Asian women. It could therefore be argued that midwives from Bradford which has a large proportion of Asian women in their caseload could have a better understanding of issue affecting women from Asian communities.

RATIONAL FOR SUBJECT The aims and objectives of the study are clearly defined “to address the nonattendance at clinic during this period” “to provide an alternative clinic time to Muslim clients during an important holy period”. The rational for the study is also clearly defined, with the knowledge that no formal studies prior to the study having been undertaken. It is therefore conjectured that the authors presumed the reasons for non attendance. As to their understanding of the Muslim religious beliefs, this is

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gained by only one reference which is 8 years old. It may have been beneficial for the authors to have consulted with the women prior to the study to ascertain the views and beliefs of each woman on an individual basis.

TITLE “Provision of antenatal care during Ramadan” is a clear concise title for the study, with key words pertinent to the reader so they themselves can research other studies with the same theme. The abstract should be short, concise and not exceed 250 words and should provide the reader with a description of the entire report (Polgar and Thomas 1991). Although the abstract does provide the reader with a description of the report it claims that the focus of the report are the opinions of the participants, which is clearly not the case as only one quote is found in the text of a woman’s opinion.

DESCRIBING RACE 2.5 million Muslims live in the United Kingdom, making Islam the second largest religion after Christianity (Office for National Statistics 2001) The authors do not describe the Muslim religion or the population of Muslims within the Bradford area. This would have given the reader an understanding of the Muslim religious belief’s and the reasons why Muslim’s fast at Ramadan. Zaidi (2003) The author presumes that the reader is aware that Bradford has a high population of Muslim women, by including statistical data on the number of pregnant Muslims within its area would have benefited the article. The authors go on to explain that “all healthy Muslims aged 12 and over are required to fast from sunrise to sunset” Zaidi (2003) states that Muslims from the age of puberty are required to fast, this age is different for

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everybody, for boys it is from the age of nocturnal emissions and for girls it is from the age they start menstruating.

MATERIALS PRESENTED The authors have made no reference to any model of cultural competence. Purnell (1998) provides a comprehensive framework for learning about culture. If the authors had applied this model to their article then the reader could have been assured in the knowledge that the authors had an understanding of the factors affecting the women in their care.

Spirituality is one domain of Purnell’s model that was not covered, the authors mentioned that by fasting, women would benefit spiritually, but they do not explain how or why. Muslim’s obey Allah’s will and they follow five main duties or pillars of Islam, faith, giving alms, fasting during Ramadan and making a pilgrimage to the sacred city of Mecca. Muslim’s prey five set times each day, they follow rules which cover every aspect of personal, family and community life. Muslim’s also are expected to follow the code of behaviour laid down in the Quran. Faith is a vital source of support comfort and strength, most Muslim’s believe that Allah will reward them in life and after death and difficulties encountered in life, is Allah’s plan.

Nutrition is an important aspect, they believe that food does not just affect people physically but it effects their emotional and spiritually health. Hot foods are thought

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to raise the body temperature and cold foods are believed to cool the body. An excess of either hot or cold foods can unbalance the body and mind. One of the five pillars of

Islam is fasting at Ramadan, fasting is described as abstaining from food and drink between dawn and sunset throughout the month. Each year the dates of observance differ and the month contains 28 to 30 days. During this month all healthy Muslims are expected to fast. The purpose of Ramadan is for Muslim’s to learn self restraint, self discipline and obedience to Allah. By fasting it allow Muslim’s to appreciate hardship and hunger and to have empathy with the poor (Zaidi 2003).

Muslim Families are usually extended with all members living under the same roof, although in Britain house sizes has made this impractical. Family members commonly live in close knit communities. Authority within the household is that of the eldest male member and young pregnant women may well be under the authority of her mother in law. Men within the Muslim household are responsible for financial support of the family and for all matters outside of the home, all major decisions are the responsibility of the men. The woman’s role is one of running the home and the day to day matters within the home environment. It is not uncommon for women to stay within the safety of the home and only go out into the outside world a few times each year (Schott and Henley 2001). Women during Ramadan rise early to prepare food for the family before dawn, and after sunset friends and family gather to break the fast with an evening meal. There is no restriction on the amount of food that can be eaten after sunset (Pinar 2002). Over eating and dehydration can effect metabolic changes in the body from polyuria and ketoacidosis (Pinar 2002). Although clinical harm has not been proven (Zaidi 2003). Women usually spend daylight hours resting which

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Pearce and Mayho have acknowledged and this could be a factor in the poor attendance rates seen in antenatal clinic. Davidson (1979) found that during Ramadan clinic attendance for diabetic patients declined.

Many Muslim’s seek traditional medicine before seeking western medicine, this can be in the form of a change of diet or by contacting a traditional practitioner. If a woman needs western medication then she may well be reluctant to disclose that she is taking traditional medication. Many Muslim women will not discuss matters of pregnancy or childbirth in front of a male member of the family. This can cause problems if the woman does not speak English, communication failure is the biggest cause of complaints in the healthcare services. The lack of appropriate trained interpreters put healthcare professionals in very difficult positions in delivering effective care and makes it impossible for non English speaking people to obtain relevant information (Cortis 1998). Pearce and Mayho did provide an interpreter for their alternative clinic although they did not state if this person could speak the many different languages that many Muslim’s speak.

It is never possible to predict what is important to each individual person, the only way to find out is by listening to each woman on a individual basis. “To provide an alternative clinic time to Muslim clients during an important holy period” this is not listening to women on an individual basis, this is presuming that all Muslim women abide by the Quaran and fast at Ramadan. Not all Christians give up something for Lent but applying the authors thinking then this would indeed be the case. Muslim’s are not a homogeneous group of people they come from a wide range of cultural, political and racial backgrounds and they come from differing educational and

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socioeconomic levels. Bowler (1993) found that midwives commonly use stereotypes of women in order to help them to provide care. These stereotypes are particularly likely to be used in situations where the midwife has difficulty in getting to know the woman. The stereotypes of women from Asian descent contained four main themes; communication problems; failure to comply with care and service abuse; making a fuss about nothing and a lack of normal maternal instincts

EVALUATION The authors do not draw upon other sources to aid their article. By critiquing or evaluating other sources the authors could have used prior knowledge to inform decision making within their alternative clinic. In the British Journal of Nursing, Pinar (2002) discussed the implications of people with diabetes during Ramadan. This article could have added weight to the argument that there is a drop in attendance at clinic appointments during Ramadan. Zaidi (2003) informs the reader of the cross cultural issues with regards to fasting with the aims, rules and regulations discussed. This gives the reader an understanding of the Muslim faith. Zaidi also informs the reader of other faith’s that fast during certain religious festivals, this informs the reader that that not just Muslim’s abstain from food during certain periods. Zaidi refers to studies conducted which looks at whether fasting has any clinical effects on the pregnant woman.

CONCLUSION RECOMMENDATONS The authors acknowledge that the idea of the alternative clinic came close to the start of Ramadan and groundwork could have been carried out before the start of the clinic to compare the number of women not attending during Ramadan. This could have

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given accurate data for the purpose of an audit. The authors also acknowledge that advertising did not start early enough. Many women may not have been aware of the extra service during Ramadan. Advertising did occur through the local press and local radio station, this is presuming that Muslim women could understand English. Posters where placed in local clinics and surgeries they do not mention if these posters where in different languages. The posters may have had a wider audience if they had been placed in local places of worship and in a variety of languages.

Many women stated that the alternative clinic time was good but that they would still attend the daytime appointment due to the women wanting to be with their families during the evening. The authors with more time could have conducted a questionnaire prior the start of the clinic to ascertain the views of the women and what their preference would be with regards to daytime appointments versus alternative times. There was no mention in the article of the possibility of conducting home visits and again the views of the women could have been sought. The authors acknowledge that staff did not appreciate the aims and objective of the clinic and this area would need to be addressed before commencing again. The cost of this would need to be investigated to prioritise resources effectively.

The alternative clinic time appears to be an effective way of addressing non attendance during daytime hours. Over the weeks that the clinic ran uptake of the service improved, this could have been a combination of factors from word of mouth to midwives knowledge and understanding of the purpose of the clinic. This service could benefit all women and not just the Muslim community. Women from all different cultural backgrounds may find the alternative clinic times beneficial as some

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women may feel obligated to work commitments and also this would enable partners to attend without having time of work. Also childcare commitments can affect women’s choice on clinic times and many may well prefer evening appointments as siblings could attend or family members can take care of the children.

Cultural competence is an important aspect of the midwife’s role, individuals have the right to be respected for his or her beliefs.” You are personally accountable for ensuring that you promote and protect the interests and dignity of patients and clients, irrespective of gender, age, race, ability, sexuality, economic status, lifestyle, culture and religious or political beliefs” (NMC 2004). By applying Purnell’s model midwives can have a better understanding of the different cultural and religious belief’s that they may encounter during their career. WORDS 2297

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REFERENCES

BLUFF, R., CLUETT, E. (2000) Critiquing the Literature in CLUETT, E., BLUFF, R. (2000) Principles and Practice of Research in Midwifery (eds) Balliere Tindall. London. BOWLER, I, M. (1993) Stereotypes of Women of Asian Descent in Midwifery: Some Evidence. Midwifery, 9(1) pp. 7-16. CORTIS, J, D. (1998) The Experiences of Nursing Care Received by Pakistani (Urdu Speaking) Patients in Later Life in Dewsbury, United Kingdom (UK). Clinical Effectiveness in Nursing, 2 pp. 131-138. DAVIDSON, J, C. (1979) Muslims, Ramadan, and Diabetes Mellitus. British Medical Journal, 2 pp. 1511-1512. NURSING AND MIDWIFERY COUNCIL (2004) The NMC Code of Professional Conduct: Standards for Conduct, Performance and Ethics. NMC. London. OFFICE FOR NATIONAL STATISTICS (2001) The 2001 Census of Population. The Stationery Office. London. PEARCE, A., MAYHO, P. (2004) Provision of Antenatal Care during Ramadan. British Journal of Midwifery, 12(12) pp.750-752. PINAR, R. (2002) Management of People with Diabetes during Ramadan. British Journal of Nursing 11(20) pp. 1300-1303. POLGAR, S., THOMAS, S, A. (1991) Introduction to research in the Health Sciences. 2nd(ed). London: Churchill Livingstone. REYNOLDS, F., SHAMS, M. (2005) Views on Cultural Barriers to caring for South Asian Women. British Journal of Midwifery, 13(4) pp. 236-242. ZAIDI, F. (2003) Fasting in Islam-Implications for Midwifery Practice. British Journal of Midwifery, 11(5) pp. 289-292.

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References: BLUFF, R., CLUETT, E. (2000) Critiquing the Literature in CLUETT, E., BLUFF, R. (2000) Principles and Practice of Research in Midwifery (eds) Balliere Tindall. London. BOWLER, I, M. (1993) Stereotypes of Women of Asian Descent in Midwifery: Some Evidence. Midwifery, 9(1) pp. 7-16. CORTIS, J, D. (1998) The Experiences of Nursing Care Received by Pakistani (Urdu Speaking) Patients in Later Life in Dewsbury, United Kingdom (UK). Clinical Effectiveness in Nursing, 2 pp. 131-138. DAVIDSON, J, C. (1979) Muslims, Ramadan, and Diabetes Mellitus. British Medical Journal, 2 pp. 1511-1512. NURSING AND MIDWIFERY COUNCIL (2004) The NMC Code of Professional Conduct: Standards for Conduct, Performance and Ethics. NMC. London. OFFICE FOR NATIONAL STATISTICS (2001) The 2001 Census of Population. The Stationery Office. London. PEARCE, A., MAYHO, P. (2004) Provision of Antenatal Care during Ramadan. British Journal of Midwifery, 12(12) pp.750-752. PINAR, R. (2002) Management of People with Diabetes during Ramadan. British Journal of Nursing 11(20) pp. 1300-1303. POLGAR, S., THOMAS, S, A. (1991) Introduction to research in the Health Sciences. 2nd(ed). London: Churchill Livingstone. REYNOLDS, F., SHAMS, M. (2005) Views on Cultural Barriers to caring for South Asian Women. British Journal of Midwifery, 13(4) pp. 236-242. ZAIDI, F. (2003) Fasting in Islam-Implications for Midwifery Practice. British Journal of Midwifery, 11(5) pp. 289-292. Page 10 of 10