Community Profile
Introduction
This assignment aims to compare the
epidemiological and demographic factors, which can affect the health and social
wellbeing of childbearing women within a locality. Epidemiological factors are indicators of morbidity and
mortality, that is the types of disability or disease experienced and the
causes of death (Ewles and Simnett 2003, Naidoo and Wills 2000). Demography is
the study of the structure and trends of the population, incorporating births
and deaths, employment and health (Tiran 2003). The study of determinants and measurements of ill health is
necessary to identify problem areas, which enables the planning of services
within these target areas. This allows for the allocation of resources into the
area of need, which should in turn help achieve the desired outcome of good
health.
The aim of public health is to promote
the health of communities and the individuals within them (Ewles and Simnett
2003). The World Health Organisation (WHO 1986) advocate the creation of health
policy, provision and access of services, promotion of community involvement,
as well as personal empowerment of individuals to achieve this. The Royal
College of Midwives (RCM 2001) points out that midwives have always played an
important role in promoting the public health of childbearing women and their
families and that this should be further developed in the future. Protecting and supporting the health of
individuals and that of the wider community are key principles of the Nursing
and Midwifery Council’s (NMC) code of professional conduct that all midwives
must adhere to (NMC 2004a), signifying that public health is an integral part
of the midwives role.
The Black Report (1980) conceptualised
the image of low socio-economic status being the major determinant of ill
health and mortality. Inequalities, however, between those who have and those
who have not, the rich and the poor, are inextricably tied into material
possessions such as housing quality and car ownership in providing the
principal disadvantage for the health and wellbeing of the community (Mathewson
et al. 1997; Byrom and Edwards 2005).
The Scottish Census was last carried out
in 2001 and the results are easily accessed via the Scottish Census results
online (SCROL) website (appendix i and ii), which will be the main source of
demographic information for this report. This locality study compares
Sighthill, a relatively deprived area in the west side of Edinburgh with the
City of Edinburgh council area as a whole.
This comparison drew attention to
several factors however those relating to household and education would be
expanded up on in the assignment (SCROL 2001a and 2001b).
Some of the main themes that were
highlighted (figure 1) were, 1) lone parent households with dependant children,
2) households with no car and 3) persons with no qualifications, and these will
be looked at in detail in the report.
(SCROL 2001a and 2001b) (Figure 1)
Discussion
The first area highlighted from this
community profile (figure 1) was the high number of lone parent households with
dependant children in Sighthill at 26.92% compared with Edinburgh, which has a
rate of only 5.44% (SCROL 2001a), indicating almost 5 times greater rate of
single parent families in this locality than the Edinburgh average. Lone
parents are principally female and are more likely to live in poverty and
experience exclusion (Scottish Executive 2003a), however some lone parents may
also be men and although they will be included in the SCROL (2001a) statistics,
the exact number of households of each sex is not made clear. Additionally these figures do not indicate,
at what stage one parent has solely maintained the family i.e. whether the
individual has always been single or became a single parent for example after a
relationship breakdown.
(GROS 2005) (Figure 2)
The General Register Office for Scotland
(GROS 2005) statistics indicate that there is a growing trend in Scotland of
births to unmarried parents (figure 2) however there is an increasing number of
births being registered jointly by unmarried parents from the same address.
This signifies a small proportion of lone parents, which in Sighthill is not
only higher than the Edinburgh average but also the Scottish average (GROS
2005; SCROL 2001a).
The Confidential Enquiry into Maternal
and Child Health (CEMACH) report 2000-2002 testifies that single mothers are
three times more likely to die than mothers in relationships (CEMACH
2004). Therefore extra support may well
be necessary from midwives and their supervisors in ensuring woman-centred care
(NMC 2004b) for women with impending single parenthood ahead, lack of a birth
partner or poor family support in the postnatal period. Initiatives such as Sure Start, which could
benefit a number of women and their children, are poorly advertised in the
Sighthill area. This is a problem which
the National Evaluation of Sure Start
(NESS 2005) Team themselves are aware of as the initiatives have been
found not to be targeting those in need.
In some cases this has been due to staffing problems, which has meant
that mainstream services are barely manageable and specialist services for vulnerable
women have been reduced dramatically (NESS 2005). When operating efficiently these schemes can offer vulnerable
women support in a variety of ways, such as offering child care to allow
mothers to access services, where the lone parent population in Sighthill is
inflated this would be a valuable asset.
By doing a search of the information available on sure start it appears
that Scotland is lagging behind its counterpart south of the border as there
appears to be little information on the programmes available. Literature and information that is available
appears to be primarily aimed at the education of preschoolers rather than in
tackling social exclusion through maternity services, in Sighthill and even
Edinburgh, the Scottish Executive (2000) briefly mentions that breastfeeding
and antenatal care are areas that could be ‘considered’.
The Black Report in 1980 made
recommendations specific to childbearing women, particularly the need to offer
more flexible and innovative antenatal care, yet over 20 years later antenatal
care continues to be identified as an area In need of improvement (CEMACH
2004). Lewis (2004) also found that provision of antenatal care appeared not to
be accommodating enough and she went on to promote less rigid support systems,
advocating measures such as establishing home appointments particularly for
marginalised women. The National Institute for Clinical Excellence (NICE 2003)
antenatal care guidelines, the Scottish Executive (2001 and 2003b) framework
and implementing a framework for maternity services and the Department of
Health (DH 2004) national service framework for maternity services all advocate
the importance of adaptable antenatal care provision. However Sighthill’s
efforts to provide creative and flexible care have been praised by the National
Childbirth Trust in written evidence to the House of Commons Select Committee
on Health (2003). The maternity care
they provide includes local ultrasound and antenatal appointments, home booking
appointments for vulnerable women, breast feeding support, one to one parent
craft education for ethnic minority families and can invariably adapt to meet
the needs of their clientele. It is essential for midwives and services not
only to be accessible and flexible but also approachable as advocated by CEMACH
(2004). In addition support from the
supervisor of midwives is essential when the scope of care is beyond the
limitations of the individual midwife or the case is complex and she requires
statutory support (NMC 2004b).
Babb et al. (2004) indicate that
of all households compositions in the UK, lone parents are less likely to be
working, estimating as much as 43% of single parents are workless. They
continue that more single mums are not working than mums from couples (Babb et
al. 2004). Although the trend from 1994 to 2003 is that more single parents
are working at least part-time (Babb et al. 2004). Both the Black Report (Black et al.1980)
and the subsequent Acheson Report (Acheson et al.1998) highlight the
need to reduce poverty in families and Acheson goes on to support the need for
maternity benefits. However as the
midwife must know of local services to be able to offer them to women (CEMACH
2004), midwives perhaps should also be able to offer benefit advice for a truly
comprehensive service, although utilising correct referral routes if they have
insufficient knowledge themselves would suffice.
Nevertheless even for working women
problems persist with women only earning 80% of men’s earnings in the same job
and if working part-time this figure dropped further to 60-70% (Scottish
Executive 2003a). In their longitudinal study on the effects of employment on
lone parents Baker and North (1999) discovered that for lone parents who do not
work not only are they financially worse off they are also significantly more
likely to suffer from depression or have a major depressive disorder. Thomson
(2004) supports this theory affirming that those with major stressors such as
unemployment, poverty, limited support and poor housing or lack of
qualifications all contribute to the risk of becoming depressed antenatally as
well as postnatally. Furthermore, poor
general health, previous depression, poor nutrition, alcohol and smoking can
not only lead to depression but also directly to worsening health of her self
and her baby (Thomson 2004). She highlighted partner abuse as a major stressor,
with reported occurrences in 5 to 23% of cases, very often escalating during
pregnancy. She also noted that women experiencing these problems were more
likely to book later and attend fewer appointments. D’Souza and Garcia (2004) concur maintaining
that poor social standing results in poor uptake of services. CEMACH (2004) reported that women who booked late or missed at least
4 antenatal appointments accounted for 20% of maternal deaths. They recommend
women who are poor attenders be followed up regularly and antenatal
appointments and classes need to become more flexible to account for this.
Thomson (2004) also clarifies the importance of good antenatal risk assessment,
including asking about stressors and abuse, sometimes this is the only time the
abusive partner is not around she furthermore advocated that all women should
be seen alone for at least one appointment, where possible to determine the
risk of domestic violence. CEMACH (2004) justifies the importance of
discussing issues like substance abuse, violence and psychiatric history or
depression to gain input from other sources such as community drugs liaison or
psychiatric follow up and not to struggle providing care in isolation or failing
their duty of care (NMC 2004a).
(Scottish Health Statistics
2005) (Figure 3)
Although the mean age of first birth in
affluent areas is 29 years, in areas of high deprivation women are more likely
to have their first births at 18 or 19 years (Scottish Executive 2003a). However Health Scotland (2004) indicate that
the average age in Sighthill for first birth is 23.6 years, admittedly still
older than that of some deprived areas as indicated by the Scottish Executive
(2003a), but also much younger than the average of more affluent areas. Areas suffering more deprivation have a
higher number of pregnancies in the under sixteen’s (Scottish Executive 2003a)
with the current Scottish rate currently sitting at just over 7 per 1000 women
(Scottish Health Statistics 2005) (Figure 3).
Bharj and Cooper (2003) recognise that teenage mothers have an increased
risk of complications of pregnancy particularly hypertensive disorders. Lewis
(2004) concurs and expands that the lower the age of first birth the greater
the risk of maternal deaths, which could be one reason why the maternal
mortality rate is highest among those women living in poverty. Scotland has one
of the highest rates of teen pregnancy in Europe (Scottish Executive 2003c), and
incredibly the Sighthill area has 196% more than that of Scotland as a whole in
13 to 19 year olds for the period 2000-2002 (Health Scotland 2004). This
indicates a need for high quality, yet sensitive midwifery care and the
importance of follow-ups for missed appointments, involvement of family members
and friends and inventive ways to improve concordance and with the backing of
the supervisor of midwives where needed (NMC 2004b). Bharj and Cooper (2003)
also point out that young mums are inclined to attend late for antenatal care,
which could put themselves or baby at risk, they additionally are more likely
to be living in poverty, and are liable to have other issues such as smoking.
Teenage pregnancy is approximately three
times more likely in girls from areas of deprivation than those of affluence
(Scottish Executive 2003c). In the 13 to 15 age group the difference widened
from 2.94% in the years 1991-1993 to 3% in the years 2000-2002 between those
from affluent and those from deprived areas, whereas in the 13 to 19 age group
the overall rate actually dropped during the same period (Scottish Executive
2003c). Again this raises the issue
that very young mums are more likely to die than those around the average childbearing
age (Lewis 2004).
CEMACH (2004) specifies that a 45%
higher death rate occurs in women from deprived areas compared to women from
affluent areas. It can therefore be assumed that as Sighthill is one such
deprived area, women who live here are more at risk.
Different classifications have been used
over time in determining deprivation such as social class, but using social
class as a classification has weaknesses as it only looks at the occupation of
head of household, with the head of household usually being male (Office for
National Statistics (ONS) 2005). Its
limitations include the fact that not all households are the same in that other
individuals in the household maybe of a higher or lower social class than the
head of household, thus skewing the data (ONS 2005).
National
Statistics Socio-economic Classification (NS-SEC)
|
|
1
|
Higher
managerial and professional occupations and large employers
|
|
2
|
Lower
managerial and professional occupations
|
|
3
|
Intermediate
occupations
|
|
4
|
Smaller
employers and own account workers
|
|
5
|
Lower
supervisory and technical occupations
|
|
6
|
Semi
routine occupations
|
|
7
|
Routine
occupations
|
|
8a
|
|
|
8b
|
Students
|
|
8c
|
Not
classified for other reasons
|
(ONS 2005) (Figure 4)
(CEMACH 2004) (Figure 5)
However since 2001 the National
Statistics Socio-economic Classification (NS-SEC) (figure 4) has been used for
the census, and it uses a household reference person who can be either male or
female but usually the highest earner (ONS 2005). The new NS-SEC classification
was the categorisation used in the 2000- 2002 CEMACH (2004) report (figure 5).
In Sighthill 50% of households have no
car compared with a rate of under 40% in the City of Edinburgh (SCROL
2001a). Car ownership is strongly
related to an individual’s income (figure 4)
(Scottish Household Survey 2004) and socio-economic status (Babb et
al. 2004). This can affect the
individual’s ability to obtain services, for child bearing women this could
mean inability to attend appointments at hospital. Providing local services such as ultrasound scanning in the
locality attends to these women’s needs.
|
Number of cars available by net annual
income in Edinburgh 2003
% within Banded net annual income
|
|
|
|
|
Banded
net annual income
|
Total
|
|
|
0-10,000
|
10,000
- 15,000
|
15,000
- 20,000
|
20,000+
|
|
|
Number
of cars household has access to
|
None
|
57.7%
|
27.1%
|
11.3%
|
2.1%
|
23.3%
|
|
|
One
|
34.5%
|
65.1%
|
72.2%
|
43.6%
|
49.9%
|
|
|
Two
|
4.2%
|
7.0%
|
13.4%
|
44.4%
|
21.4%
|
|
|
Three
or more
|
3.6%
|
0.8%
|
3.1%
|
10.0%
|
5.4%
|
|
|
Total
|
100.0%
|
100.0%
|
100.0%
|
100.0%
|
|
|
(Scottish Household Survey
2004) (Figure 6)
Being without accessible transport can
mean that women are unable to get to supermarkets to buy cheaper food or
healthy alternatives on offer at local stores (Babb et al. 2004). Local food co-operatives and token schemes
can help. Midwives can provide advice on healthy choices to help promote good
nutrition during pregnancy. In Sighthill many of the amenities are locally
available but the option to have support perhaps in the form of childcare could
make it easier for childbearing women to take up services available. Transport issues allied to lack of finances
can cause difficulties getting to and leaving hospital, this can mean women
feel they have to stay in hospital longer to await transport home, or can lead
to them feeling pushed out when they are not ready. Beake et al. (2005)
found that postnatal care was not good enough in hospital.
|
Qualifications (Scotland)
|
|
All people aged 16 - 74
|
|
Geographical level: Census Output Area
|
|
|
|
|
ALL PEOPLE
|
No qualifications or qualifications
outwith these groups
|
Group 1
|
Group 2
|
Group 3
|
Group 4
|
|
60QP001877
|
95
|
44
|
30
|
13
|
3
|
5
|
|
Footnote:
|
|
1 Highest level of Qualification is
defined as:
|
|
Group 1: 'O' Grade, Standard Grade,
Intermediate 1, Intermediate 2, City and Guilds Craft, SVQ level 1 or 2, or
equivalent.
|
|
Group 2: Higher Grade, CSYS, ONC, OND,
City and Guilds Advanced Craft, RSA Advanced Diploma, SVQ level 3 or
equivalent.
|
|
Group 3: HND, HNC, RSA Higher Diploma,
SVQ level 4 or 5, or equivalent.
|
|
Group 4: First degree, Higher degree,
Professional Qualification.
|
|
(SCROL 2001c) (Figure 7)
In Sighthill 46.32% of the population
have no qualifications at all in contrast to the City of Edinburgh population
as a whole where only 22.89% have no qualifications (SCROL 2001b). Not only is
there a link between lower qualifications and lower earnings (figure 7), but
also a lack of knowledge or understanding could jeopardise an individual’s
wellbeing through poor literacy or lack of comprehension of the English
language (Babb et al. 2004). In
some cases this could result from young women who have an interrupted education
due to pregnancy, or due to learning difficulties or cultural differences.
According to Bharj and Cooper (2003) disadvantaged women also feel less able to
make choices and therefore it would mean they are unable to make informed
choices. Midwives need to ensure that women are receiving the information need
to make informed choices (NMC 2004a)
The department of Health’s Changing
Childbirth Report stated in 1993 that women from socially disadvantaged
environments have limited information on options for pregnancy and childbirth.
CEMACH (2004) advise that the best health promotion opportunities are given at
booking, when patients and partners are most interested.
Midwives issue an abundance of leaflets
and advice, often to be read at later time. This could be through mistakenly
taking for granted that everybody can read, it is therefore important to assess
each woman’s ability and provide verbal information to back up the written. Ensuring women have the contact details of
the midwife and other essential services and the ability to seek help is vital.
Procter (1998) found in her research that women were disappointed just to be
given leaflets that they required a discussion as well.
Conclusion
A good understanding of the needs of
women in the community and the ability to apply her knowledge and skills to her
area is a fundamental role of the midwife.
The midwife must strive to gain the
confidence of women in her care to ensure the essential care provision is
delivered (Dunkley 2000). Empowering
childbearing women to request and expect the appropriate assistance and to
receive a quality service. Care must be taken not to alienate any women that
require her help and particularly those who are vulnerable. There must be a
relationship of trust between the midwife and the woman to achieve a positive
outcome.
Appreciating that inequality exists and
applying the theory of risk assessment to women, as individuals will help
develop a holistic package of care aided by care pathways to ensure excellence
and reduce unfairness and injustice of service provision. Bharj and Cooper
(2003) insist on the need to increase knowledge of both women and midwives;
midwives to ensure they don’t make generalisation, not all women in same
situation have same problems or same needs and women to ensure they are able to
make informed choices.
Flexibility is
required by midwives to offer more reliable and accessible resources in new and
creative ways with a paradigm shift from medical to woman centred care.
Midwives can
address the needs of childbearing women and their families by implementing and
adhering to policy, combined with research and audit to improve quality of care
along with establishing services that meet the needs specific to her community
and not discriminating against minority groups.
Without good
information women cannot utilise services well or make informed choices
resulting in poor uptake of some services (Bharj and Cooper 2003), addressing this
through open discussing and offering of information with respect shared
understanding from midwives can make a real difference not only to the quality
of the care but also to the long term health and social outcomes.
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