Factors Influencing South Asian Women's Access to Maternity Related Health Services: A Mixed Methods Study in an Ethnically Diverse Urban Setting in the UK

Background: Women of South Asian heritage are more likely to experience adverse pregnancy outcomes than White British women. Poor access and engagement with maternity services may be one reason for this. A key measure of access in relation to maternity care is the initiation of antenatal care within the first trimester of pregnancy and late initiation has been linked to adverse pregnancy outcomes. The importance of positive experiences of care is also recognised for improving outcomes.
The sociological concept of candidacy was used to understand how women of South Asian heritage access and experience maternity services. Access through a candidacy lens is defined as a dynamic and contingent process, constantly being defined and redefined through interactions between individuals, professionals and the service provision.

Aims: This thesis aimed to investigate factors that influence access to and engagement with maternity services for South Asian women living in a deprived, ethnically diverse urban setting.

Setting: The setting for this study is an inner-city borough in the UK, one of the poorest boroughs in London.

Design and methods: Mixed methods were used in this thesis. There were two components: (i) a quantitative analysis of anonymized maternity data of 11,768 women to examine the predictors of early initiation of antenatal care and (ii) a qualitative study of 30 semi-structured face to face interviews with South Asian women to examine their experiences with maternity services. Data were analysed by means of thematic synthesis of women’s journeys into and through antenatal care, labour, delivery and post-natal care.

Findings: Findings from the quantitative analysis of the predictors of late initiation of antenatal care found that late initiation amongst women of South Asian heritage was linked to not being able to speak English (p=0.000 ; 95% I:0.56-0.82), higher parity (p=0.002; 95% CI: 1.31-3.47), younger maternal age (p=0.005; 95% CI:0.42-0.86), housing status (living in rented accommodation) (p=0.000; 95% CI: 1.51-2.74), being a current smoker (p= 0.010; 95% CI: 1.10- 2.31), experiencing domestic violence (p=0.021; 95% CI: 0.45-0.57), and using alcohol (p=0.047; 95% CI: 0.01-0.97).

Findings from the qualitative study identified four key themes these were women’s ethnic and /or migrant identities, permeability of services (the unhelpful features of a service), adjudication (cultural biases of health providers), and the local operating conditions of the services (lack of continuity of care, shortage of resources). Explanatory subthemes related to the cultural distinctness of women where issues with access came to the fore in light of women’s diasporic and compounded identities. For women born and raised in the UK achieving access meant continuous negotiation and renegotiation of their identities in a contextual and contingent way. For recent migrants’ language was an additional barrier. Difficulties in navigating the services were linked to inability to speak English fluently, subjecting them to provider judgements. Women wanted to be taken seriously. They emphasised the importance of continuous care to enable them to develop a relationship with service providers and make informed choices.

Conclusion:
The candidacy frame provides a balanced platform to detect vulnerabilities associated with access to maternity services for women of South Asian heritage. Findings suggest that women’s needs were not static but are ever changing at each stage of their journey, both groups of women were faced with similar challenges when engaging with the services. This study reiterates the need to embrace the notion of super diversity and promote cultural health capital in health service settings.