Health Care for Women International, 36:5–25, 2015 Copyright © Taylor & Francis Group, LLC ISSN: 0739-9332 print / 1096-4665 online DOI: 10.1080/07399332.2014.900061

Rethinking Prenatal Care Within a Social Model of Health: An Exploratory Study in Northern Ireland JENNY A. MCNEILL School of Nursing & Midwifery, Queen’s University Belfast, Belfast, Northern Ireland, UK

KERREEN M. REIGER Department of Sociology, School of Social Sciences, La Trobe University, Bundoora, Victoria, Australia

Implementation of maternity reform agendas remains limited by the dominance of a medical rather than social model of health. This article considers group prenatal care as a complex health intervention and explores its potential in the socially divided, postconflict communities of Northern Ireland. Using qualitative inquiry strategies, we sought key informants’ views on existing prenatal care provision and on an innovative group care model R ) as a social health initiative. We argue that (CenteringPregnancy taking account of the locally specific context is critical to introducing maternity care interventions to improve the health of women and their families and to contribute to community development. Contradictory policy directions currently limit the reform of maternity care on policy agendas in the UK, Australia, and the United States (Carter, Corry, & Delbanco, 2010; Commonwealth of Australia, 2009; Department of Health [DH], 2007). On the one hand, the discourse of women’s autonomy and empowerment has made its way from the women’s health movement to mainstream discourse—professionals are now exhorted to provide “women-centered care” and “consumers” should be “consulted.” Yet on the other hand, even though pregnancy and birth are a normal part of the lifecycle and most women having babies are well, the dominant maternity system remains focused on medical risk, pathology, and hospital-based Received 16 October 2012; accepted 17 February 2014. Address correspondence to Jenny A. McNeill, School of Nursing & Midwifery, Queen’s University Belfast, Medical Biology Centre, 97 Lisburn Road, Belfast, Northern Ireland BT9 7BL, UK. E-mail: [email protected] 5

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services. As the World Health Organization (WHO, 2007) points out, health systems are themselves a social determinant of health and well-being. Consumers or service-users, feminist activists, and some health professionals argue that women are often disempowered within medicalized systems of maternity care. Furthermore, the process of becoming a mother (or father) is greatly influenced by health inequalities and other social factors (Schrader McMillan, Barlow, & Redshaw, 2009). Many women need social support and care rather than specific clinical assistance or medical intervention (Declercq, Sakala, Corry, & Applebaum, 2006; Kitzinger, 2005; Reiger, 2001). As argued in other fields of health care (Marmot, Atkinson, & Bell, 2010), it is time to move away from an illness-oriented framework toward a social model of maternity care (Bryers & van Teijlingen, 2010). In this article we therefore explore the potential of an innovative model of prenatal care for contributing to social health and community development. We take as our focus the distinctive context of Northern Ireland, a society slowly recovering from many decades of conflict. This period, commonly referred to as “the Troubles,” had major impact on women and their families (Hamilton, Byrne, & Jarman, 2003), and its legacy continues to affect current health service delivery. We first introduce our conceptual approach, then we give an overview of the broader maternity policy environment shaping prenatal care provision in the UK and in Northern Ireland in particular. In the second half of the article, we use this framing to discuss the methodology and findings of an exploratory study investigating the potential of R (CP), as an intergroup-based prenatal care, notably CenteringPregnancy vention to improve social as well as clinical outcomes in Northern Ireland. In doing so, we also make a broader argument—that introducing and assessing interventions to improve women’s health and well-being requires attending to local social and community contexts and the specific challenges they present. The value of effective maternity interventions such as prenatal care goes beyond improving the health and well-being of women as individuals to supporting their families and communities. The maintenance of close ties between individuals and within groups and networks, the “bonding and bridging” involved in what is often termed “social capital,” is widely regarded as beneficial to health (Campbell, 2000; Franklin, 2005). Although women’s contribution to community-building can be inward-looking and exclusionary (Wilson, Abram, & Anderson, 2010), it can also develop networks that bring people from diverse identities together (Bruegel, 2005).

RESEARCHING HEALTH CARE INTERVENTIONS Applying a social framework to maternity care interventions entails a rather different conceptual and methodological approach to that dominant in much health research. The emphasis on standardized, evidence-based scientific

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investigation can lead to neglect of humanistic forms of inquiry into the complex social relationships intrinsic to maternity care (Reiger & Morton, 2012). Taking a social rather than medical model of health, researchers have increasingly argued that multiple forms of data gathering are needed to assess innovations in models of maternity care (Rycroft-Malone et al., 2004). In effect, these constitute what are termed “complex interventions” in health care, that is, those in which many factors have to be taken into account in assessing outcomes, including those in the social environment (May, Mair, Dowrick, & Finch, 2007). This means that as well as investigating the measurable clinical outcomes of perinatal care, for example, we need to examine the specific social and institutional contexts in which innovations are implemented and their unanticipated as well as anticipated consequences. Within the National Health Service modernization project in the UK, “Realistic Evaluation” (Pawson & Tilley, 1997) has gained traction as a useful theoretical approach. Rather than the context of a health intervention being seen merely as background, the local environment assumes a potentially causal role in shaping outcomes (Pawson & Tilley, 1997; Rycroft-Malone et al., 2004). On this basis, then, we turn to exploring the debates on the need for innovation in prenatal care and their relevance within the specific sociopolitical context of Northern Ireland.

REFORMING PRENATAL CARE Although maternal and infant survival rates have improved during the twentieth century, the typically medicalized systems of maternity care in Western countries have been the focus of sustained critique (e.g., Kitzinger, 2005; Reiger, 2001; Wagner, 2008). In response to such critiques, UK maternity care since the early 1990s has encouraged service innovation and user or consumer participation, and has focused on mitigating persistent health inequalities (DH, 1993, 2004, 2007). Supports for hospital-based midwifery-led care have increased, and community-midwifery and health visitor roles have been included in various social programs in the UK, notably the early childhood intervention, Sure Start. Yet many mainstream services like prenatal care have been less affected, and implementation of innovative policies across diverse health services remains limited. Some important English initiatives, for example, Maternity Matters (DH, 2004), have not been rolled out consistently across the UK (Cheyne, McNeill, Hunter, & Bick, 2011) and health policy and practice varies considerably in the devolved regions of Wales, Scotland, and Northern Ireland. In the latter case, in spite of a period of “permissive managerialism,” which allowed limited opportunities for innovation, effective health policy development has been stalled by politics (Greer, 2004, p. 159).

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The development of modern prenatal services originally focused on reducing maternal and infant mortality rates and reflected eugenic responses to imperialist or nationalist population anxieties (Oakley, 1984; Reiger, 1985). In recent years, with new forms of anxiety reflecting the pressures of contemporary “risk society” (Beck, 1992), there has been increased recognition of the need to make prenatal care in many countries more “women-friendly” and health promoting rather than predominantly focusing on medical surveillance. International reports have pointed to problems with the common “cattle run” approach of public hospitals, with overcrowded clinics, long waiting times, short appointments, fragmentation of care, poor communication, and lack of individualized attention (Phillippi, 2009). Accordingly, increased interest in prenatal care reform has ensued, particularly, in the innovative approach of providing group-based prenatal care using a model R (CP; Schindler-Rising, Powell Kennedy, & known as CenteringPregnancy Klima, 2004).

ASSESSING GROUP-BASED PRENATAL CARE CP has been implemented mainly in the United States, but also in other high-income countries including Canada, England, and Australia. CP was developed in the United States in the 1980–1990s by nurse-midwife Sharon Schindler Rising who emphasizes that the key difference between CP and usual prenatal care is that it is designed as a social intervention to empower women and build their support networks (Schindler Rising et al., 2004; Sharon Schindler Rising, personal communication, July 2009 and November 2010). CP includes the three usual components of prenatal care—effective clinical assessment, health education, and professional support—but is provided within a group setting, and it is facilitated by professionals practicing in an egalitarian rather than a knowledgeable expert way (Manant & Dodgson, 2011; Schindler Rising et al., 2004). Groups of 10–12 women, who attend approximately 10 times during pregnancy, are facilitated by midwives with specialized training. The aim is to encourage women to assume responsibility for most aspects of their care, to build relationships, and to establish ongoing support networks, thus improving social support. Group sessions generally take place in community settings rather than in a hospital environment. The majority of evaluative studies of such group prenatal care have focused on clinical outcomes although some have also pointed to social advantages. Several studies (mostly in the United States) have identified positive health outcomes from CP. Ickovics and colleagues (2003) reported from a cohort study that the birthweight of infants of women attending for group care was greater, and in a subsequent randomized controlled trial (Ickovics et al., 2007) reported a 33% risk reduction (CP group) of preterm births, findings supported by Picklesimer and colleagues (2012) based on a

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retrospective cohort study. Ickovics and colleagues (2011) extended the CP model to include skill building in assertiveness and negotiation, (referred to as CP+), and reported that “high stress” women who were assigned to CP+ had significantly increased self-esteem anddecreased stress and social conflict in pregnancy. Depression scores and social conflict were lower at 1 year postnatal compared with women who had routine care. Manant and Dodgson’s (2011) review of literature on the CP model concluded that there was some inconsistency in definitions of the intervention, measurements, and outcomes that subsequently limit evaluation of its effectiveness, particularly in relation to clinical outcomes. In countries with comprehensive national health systems, however, evidence of positive social outcomes are also important in seeking further improvement in women’s care. A UK pilot of CP, for example, concluded that the emphasis on an equal relationship with care providers rather than a hierarchical one facilitates confidence and health efficacy beyond pregnancy (Gaudion et al., 2011). The CP model was reported to have been adapted successfully to suit policy and professional regulation in the UK where midwives are the major maternity care providers (Gaudion et al., 2011). Although evidence on CP from settings similar to the UK is limited, Australian data (Teate, Leap, Schindler Rising, & Homer 2011) support the conclusion of a recent Canadian qualitative report: this summed up women’s experiences of CP in very positive terms, as “getting more than they realized they need” from this form of group-based, personally supportive care (McNeil et al., 2012). For our purposes here, the most salient research goes beyond measures of women’s individual well-being. It suggests that CP can offer important benefits to local communities in terms of social connection and inclusion, including in multicultural settings (Picklesimer et al., 2012; Powell Kennedy et al., 2009; South Community Birth Program, 2006; Teate et al., 2011). Teate and colleagues (2011) concluded that group-based prenatal care assists women to share their experiences, learn from one another, and develop an invaluable network of social support for the new mothering period, a finding also supported by McNeil and colleagues (2012). Antecedents of the CP model can be found in the community-based work of the former Albany practice in London (Leap, Sandall, Buckland, & Huber, 2010), and in the group support role of community midwives in some Sure Start programs in the UK, including one in Belfast, Northern Ireland. While CP remains somewhat unique in seeking to empower women through the self-directed clinical component of prenatal care, it is consistent with a policy focus on enhancing social outcomes as well as producing sound clinical results. Further research is needed, however, into the specific contexts in which group-based care such as CP has been implemented and into its broader social potential. Given the range of interacting factors, group-based prenatal care is clearly best seen as a “complex intervention” in health care. As the British Medical Research

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Council guidelines (MRC, 2008) emphasize, understanding context is crucial in developing these types of interventions.

THE CONTEXT OF MATERNITY SERVICES IN NORTHERN IRELAND In Northern Ireland, the transition to parenthood—a period known to have long-lasting impact on health and community well-being (Marmot & Wilkinson, 2006; Nilsen & Brannen, 2005)—may be particularly difficult. Social and health problems continue to reflect the impact of past political conflict on both physical and mental health (Dillenburger, Fargas, & Akhonzada; O’Reilly & Stevenson, 2003). Northern Ireland includes several of the most socially disadvantaged areas of the UK, with high levels of deprivation and unemployment in some areas (Northern Ireland Statistics and Research Agency, 2010). Lewis (2011) reports that social inequities clearly affect pregnancy and childbirth: in the UK vulnerable, socially disadvantaged women were less likely to seek prenatal care or to stay in contact with maternity services, and neonatal mortality and morbidity are associated with deprivation (Centre for Maternal and Child Enquiries, 2011). Analysis of 10 years of Northern Ireland data highlighted geographical variation in infant mortality, stillbirth, and low birth weight and recommended greater attention to interventions focusing on health behaviors and social factors (Pattenden, Casson, Cook, & Dolk, 2010). In postconflict societies like Northern Ireland, gender relations produce further social inequalities. Women are particularly disadvantaged as citizens for they do not shape political priorities, yet they are often victims of poverty and of a culture in which masculine violence is entrenched (McMurray, 2009; N`ı Aolin & Rooney, 2007). Women have reported that they face ongoing challenges as mothers, not only in keeping children safe from recurrent patterns of violence and intimidation, but also in preparing them for overcoming community conflicts (Ward, 2004). Even since the official peace settlement in 1998, historical patterns of social inclusion/exclusion continue to be reproduced, including through family ties (Porter, 1998; Ward, 2004). Intense sectarian loyalties to the Protestant and Catholic communities shape personal and collective identities and produce tight local networks. The ongoing social tensions and the effect of past trauma mean that the potential for positive attention to and involvement in parenting, by both women and men, can be limited (Cummings, Goeke-Morey, Schermerhorn, Merrilees, & Cairns, 2009; McMurray, 2009). In light of the challenges of the Northern Irish social context then, moving from models of care based around health professionals and hospital services toward those that engage and empower women and their families and bring them into wider networks would seem to offer important opportunities to enhance “social capital”—understood here as community development that contributes to building bridges and strengthening women’s participation in civil society (Franklin, 2005).

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Until the recent Maternity Strategy (Department of Health, Social Services and Personal Safety Northern Ireland [DHSSPSNI], 2012), maternity care in Northern Ireland had received limited political attention. Some surveys suggested that women were largely satisfied with their antenatal care (Picker Institute, 2007; Price WaterHouse Coopers, 2006), but these findings are limited by their nature as retrospective audits. The difficulties of reliably measuring satisfaction in maternity care are also well known as the “what is must be best” notion prevails (Hodnett, 2002). Although maternity services in Northern Ireland generally follow UK policy recommendations, such as supporting women’s choice, control, and continuity of care, the implementation of such socially oriented objectives remains uneven. More recently there has been an important move to increase maternity care options for women in light of national UK health policies and paying greater attention to social factors. The 2012 Maternity Strategy for Northern Ireland asserts that prenatal care provision is of high quality, but as “times have changed,” at “the heart of this strategy is the need to place women in control of their own pregnancy and support women and their partners to make proactive and informed choices” (DHSSPSNI, 2012, p. 3). The strategy also acknowledges the impact of socioeconomic and cultural factors on maternal and infant pregnancy outcomes, the importance of providing the majority of prenatal care in the community, and the significance of early intervention (DHSSPSNI, 2012). With regard to prenatal care, it acknowledges the need for innovative forms of care and recommends involvement of women in prenatal education. As a social rather than medically oriented health intervention, CP or similar group-based care would seem to offer significant benefit in the context of ongoing community divisions. The advantages of providing women with group prenatal care include learning from one another through shared experiences, and reducing individual isolation and building community ties. If specifically organized across existing community boundaries, there is the potential for attitudinal change through group interactions that could support inclusive interaction in postconflict societies. Given the reported vulnerabilities of many women in Northern Ireland and advantages of the group model as a complex social health intervention, ascertaining interest in developing such an innovative intervention in this distinctive context seemed a valuable step toward undertaking a fuller intervention study.

EXPLORING THE POTENTIAL OF GROUP-BASED PRENATAL CARE IN NORTHERN IRELAND The aim of our exploratory study, therefore, was to investigate both perspectives on current prenatal provision in Northern Ireland, and likely interest in an innovative model of prenatal care, such as CP, with a view to a potential pilot program. Like much feminist health research (Reiger & Liamputtong,

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2010), the strategies we used reflected the epistemological and methodological principles arising from an interpretive feminist research paradigm rather than the positivist or postpositivist approach more common in medically oriented health services research (Bourgeault, DeVries, & Dingwall, 2010; Ramanzanoglu & Holland, 2002). These are also consistent with the conceptual approach to considering complex health interventions and a social model of health already outlined. First, as Denzin and Lincoln’s (1998, p. 3) classic discussion points out, a qualitative researcher is often constructing a bricolage, one “pieced together, [a] close-knit set of practices that provide solutions to a problem in a concrete situation.” Rather than a study that is tightly designed in advance, the researcher as a bricoleur is like a “professional do-it-yourself person” working at an emergent construction “that changes and takes new forms as different tools, methods and techniques are added to the puzzle.” The task in such research is to build understanding and become better informed both about a local situation and participants’ perceptions and feelings about it. The significant point about such critical field research is that as the researchers’ understanding develops, “the sum becomes greater than the parts”: Patterns emerge in the material and become shaped into what is then called “data.” Research validity, rather than being based on use of specific research techniques, comes from communication between researchers and dialogue with participants and with scholars in the field—the critical “test” is the transparency of the reported processes, the plausibility of empirical evidence used, and the contextualized “sense-making” and reasoned argument in the final product (Maxwell, 2002; Ramanzanoglu & Holland, 2002). Second, feminist principles such as stressing emancipatory objectives and a dialogical and reflexive process of inquiry (Ramanzanoglu & Holland, 2002) encourage diverse research strategies, sometimes shaped by participants themselves. Along with formal and informal interviews, the “embodied knowing” gained from observational fieldwork can provide visual images and unexpected encounters that contribute further sources of critical analysis (Giacomini, 2010). Finally, the researchers also have to acknowledge their own biographically shaped “situatedness” and potential power. In this case, one (J.A.M.) was a local Northern Ireland midwifery researcher embedded in the local culture and social environment, and the other (K.M.R.) an interested “outsider,” a feminist sociologist who could take less for granted about the Northern Ireland political and health care context. As both shared the social status of the key informants and their evident commitment to improving maternity care, however, no major disparities of power were involved.

Participants Following local university ethical approval (application mumber: 2/1/2009), recruitment commenced in June 2009. Flyers about the project were

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distributed to several agencies involved in providing support to women during pregnancy and afterward. Follow-up to the flyer distribution was conducted through email or telephone contact or following-up referrals and using a snowball or nominated sampling technique. The voluntary sector agencies were the first point of contact to assist in identifying key “insiders” who know who is most appropriate or knowledgeable about the topic (Morse, 1991, p. 130). In addition, informal conversations, seminar presentations, and discussions with key informants all contributed to building and layering the bricolage. Using this approach, we established contact with approximately 35 women who were working in this field as professionals or maternity consumers, including a National Childbirth Trust member and Maternity Service Liaison Committee members ([MSLCs] in the UK, MSLCs are a forum for users, providers, and commissioners of maternity services). These midwifery leaders, community workers, and service users were valuable key informants (KIs), well placed to offer the “expert” or informed opinion valuable for health policy research (Wrede, 2010, p. 98). As Gilchrist and Williams (1999, p. 73) point out, in fieldwork settings, KIs offer an “information-rich connection to a research topic” and informal communication, which adds greatly to the observation and interview data. Written consent was obtained from those participating in individual interviews, and following detailed explanation of the study and purpose, the active participation in professional group contexts of others indicated their informed consent.

Undertaking the Study The project took place between June 2009, when meetings and interviews were held, followed by writing up and then further discussions in June 2010. The exigencies of fieldwork in a busy community sector meant that only formal interviews with the coordinators of two centrally located Sure Start programs were able to be recorded and transcribed, but these provided substantial information on the operation of current programs, on local context and on perceptions of community need. Shorter discussions with two workers in another women’s community center, where a planned formal interview was interrupted, provided a valuable overview of that community’s issues. Due to the interest generated in one Sure Start center, further meetings were arranged. One included eight local community workers, following which the researchers were invited to attend a regional meeting of approximately 15 Sure Start leaders from across Northern Ireland, including two community midwives. At this forum we presented information on CP and heard the views of many present concerning local needs and the present care system. Discussions by phone or in person included those with a consumer representative from the NCT (the UK’s largest charity for parents) and members of the Belfast and Women’s Voices (Derry) MSLC Groups. Other KIs contacted about challenges facing women during and since the Troubles in Northern

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Ireland included several colleagues in history and social science programs and in women’s community organizations.

Data Analysis Strategies Using the concept of the bricolage in qualitative inquiry requires recognition of the social processes entailed in developing and then analyzing what becomes designated as “research data” and acknowledging the social context in which this occurs. In keeping with dialogical feminist methodologies in particular (Nelson, 2003), the approach taken to the emerging evidence reflected the relationship both between the researchers and with participants who brought multiple perspectives on implementing CP in the sociopolitical context of Northern Ireland. In the varied encounters with KIs, new issues emerged in an iterative and reflexive process as the researchers became known and interest in the issues increased, generating a range of data that were then analyzed to identify and explore major themes (Pope & Mays, 2006). Field notes recorded following informal interviews and group and phone discussions were later included with interview material to contribute to conclusions emerging and then shared with some leading KIs for further feedback.

KEY THEMES EMERGING As participating individuals came from a range of positions within the health and social care sector in Northern Ireland, they provided diverse perspectives concerning the current context of prenatal care provision and the potential of CP. The key themes that emerged are described below, illustrated by quotations from the Sure Start coordinators’ interviews and by comments from informal interviews and observations as recorded in field notes.

The Legacy of Community Division Informants stressed that public participation in decision-making, including access to childbirth care and education, is complicated in Northern Ireland by community divisions and by women’s lack of power, especially those suffering social disadvantage. Overlapping class and sectarian boundaries meant that even existing formal provision is not always experienced as being congenial. Recent community-based research shows that the lack of confidence and feeling of being socially disempowered expressed by many women in Northern Ireland’s disadvantaged communities impacts on their parenting capacity (McMurray, 2009). As one consumer representative said, the political context “inveigles its way into every aspect of life” even though women “from all walks of life, of whatever background, all use maternity services”

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(NCT member, June 2010). In spite of a decade of formal peace arrangements and some lessening of the historical animosity between the Catholic nationalist and Protestant unionist communities, she, like local community workers, pointed out that many working-class people still mostly accessed services only within their own community of identity. Although health services are expected to span community divisions, some Sure Start programs have had to provide parallel programs and many only operate in what in effect are segregated areas. Distrust over hospitals seen as “belonging” in the past to one or other group still lingers, along with resentment about closures and service realignment in recent years. The regional maternity hospital, the Royal Jubilee Maternity Service, however, increasingly is used by both Protestant Unionists and Catholic Nationalists as well as by women of non-Irish or British ethnicity. Although women were reported to be less likely to avoid mixed-community health care gatherings than their menfolk, many fathers would be likely to feel uncomfortable in such parenting programs, especially if they had been involved in policing or military service. Some programs are reported as making significant achievements in meeting local needs, but this is primarily within community boundaries. For example, while the Troubles have been of less immediate significance in recent years, their legacy continues to affect families and conflict continues. In view of housing improvements, more people are now staying in the (mostly Protestant) Shankill area rather than moving to new estates, but “I mean if you ask anyone in the Shankill, there’d be some trauma in the past,” including from family violence, and also “there’d still be that legacy that prescription drugs would still be problems—[The] women’ve been doing it so long—surviving and sharing tablets around” (Sure Start coordinator 2). Several of our sources suggested that the stress and trauma in families affected by past conflicts continue to affect parenting now (e.g., Bell, Hansson, & McCaffery, 2010; Ward, 2004, and personal communication, 2010). Depression in the older generation can, they said, mean increased anxiety in daughters about their parenting and a loss of childrearing skills. A community worker expressed concern about grandmothers “taking over” and further deskilling younger women. The importance of including men in parenting programs was widely acknowledged. As a women’s health leader showed one of us (K.M.R.) around her center in the process of closing up after a busy day, she commented that many of her Protestant community’s “young daddies” felt not only politically disenfranchised but unclear about fatherhood roles as they lacked good relationships with their own fathers. “As a community, there’d be a lot of complex family dynamics going on,” said another Sure Start coordinator. She also pointed out that disclosure of quite common experiences of family violence required long-term relationships with health professionals, a continuity that one of their existing prenatal programs made possible for some.

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In view of other research into the problems faced by women in general, and as mothers in particular, in the postconflict situation of Northern Ireland (McLaughlin, 2009; Ward, 2004), the transition to motherhood is clearly an especially vulnerable time. A study initiated by Mothers’ Voices (a Northern Ireland Maternity Service Liaison Committee), echoed many of the issues raised by our other key informants as well (Campbell & Doherty, 2007). The authors reported that women felt disempowered as a result of poor communication with health care workers, and that there was a lack of support and advice regarding birth options and a need for continued support in the postnatal period. The central goal of CP, empowering women, was warmly received both by the professionals and consumers with whom we spoke. Although several MSLCs represent women’s voices in policymaking in Northern Ireland, participants pointed to the constraints on this system. One consumer MSLC representative commented that in her area, mothers had become more active in recent years, but it had been difficult to attend MSLC meetings as no cr`eche was provided, and the agenda was set by the health professionals. Others too reported lack of effective training for MSLC members. As in other areas, hospital managers were too often concerned only with immediate details of women’s “satisfaction” with services, like hospital food quality, rather engaging with informed consumers about the “bigger picture.” Another Sure Start leader, also an MSLC representative, was strongly committed to empowering women not only through the chance to have their voices heard in service delivery, but also in order to avoid further social disempowerment. She saw the very process of childbirth itself as potentially worsening existing disadvantage:

You see . . . people talk about quality, you know they very much go on, you know, “it was a healthy birth” you know . . . whereas, to me, it’s the social aspects of childbirth, and how the person feels about the whole thing and then the implications of feeling kind of disappointed, upset, disempowered through the experience of childbirth, the effects that has had, how that adds to other sociological factors in the women’s life to make another painful life experience. . . and [for lots] of mothers in our areas who’ve had some sort of sexual abuse in their lives. . . for many of those women, childbirth is like another trauma, it opens up painful memories those people have, that have been sort of pushed down, so it’s just adding to that feelin’ of being worthless, and just when you’re needin’ to feel strong with your baby. (Sure Start coordinator 1)

As several respondents commented, motherhood can potentially draw women together, even across ongoing community divisions. Supporting them in developing community networks can offer more than personal benefits.

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Current Provision of Care Maternity care in Northern Ireland was seen by several key informants, especially MSLC consumers, as lagging behind developments in other parts of the UK—reform was “not really on the political agenda” until quite recently. This was partly attributed to the Northern Ireland government’s imperative of financial stringency but also to the generally conservative and uncritical tenor of local society in which authority was less likely to be questioned, including that of general practitioners (GPs) and private obstetricians. For the majority of women, the GP is the first point of contact for prenatal care, and many doctors continue to play a stronger role than elsewhere in the UK through providing shared care with local hospitals. Both Sure Start professionals and consumers commented that shared care often meant limited care—GPs were time-poor, it was often hard to get appointments with them, and some at least seemed to lack adequate knowledge and skills in obstetrics. For example, at one Sure Start meeting, a community worker who was an experienced mother discussed her own recent appointment. She said that whilst she could feel how the baby was lying, when she asked about the positioning of her baby in late pregnancy, the GP was unable to provide further information and she was told that if she was concerned, she should ask for an ultrasound at the hospital. Others reported that as GPs were perceived as “not doing much,” women only attended the prenatal visits that were scheduled at the hospital, often for scans. Many socially disadvantaged women in particular were reported as missing out on educational opportunities for preparing for motherhood, relying instead on the advice of family members. The overcrowded prenatal clinics at major hospitals were described as disempowering to women, especially those with low self-esteem in the first place: Women would be sitting on window ledges, and if they’ve got partners with them, they stand. . .. It’s a like a cattle market or a conveyor belt. And what does that say? Even if they don’t have an expectation other than a healthy baby, um, I don’t care, when you put somebody with low self-esteem in those circumstances, they feel, “that’s what I am worth.” It reaffirms that, “I am not worth very much.” (Sure Start coordinator 1)

In a casual discussion, a Sure Start worker herself recounted her frustration at prenatal waiting times. When she was 36 weeks pregnant, she sat on an uncomfortable hard chair for 2-and-a-half hours at a public hospital clinic, increasingly anxious about getting back to work. When she was finally seen by a midwife, there was no apology for delay or any sense that the woman’s time was valuable. Reflecting what she described as a “typical” disempowering public sector mentality, she found many women were all booked to arrive at the same time and that the resulting delays were accepted as inevitable. Another woman, a consumer representative on the local MSLC and

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active in the National Childbirth Trust, was also critical of the impersonal “herd” mentality in which women were not treated as individuals. This, she said, is why those who can afford it prefer private obstetricians: “They want to feel ‘special.”’ Nonetheless, she pointed out that some GPs’ clinics have midwifery clinics attached and that GPs do like to see pregnant women to provide continuity of family care. It is important to note, however, that innovations are also underway. One Sure Start coordinator interviewed reported that her center already offers a weekly daytime prenatal care program similar to the CenteringPregnancy model. Both community midwives and the local health visitor (a family care specialist) run the prenatal classes. These involve group meetings covering the usual pregnancy, birth, and parenting topics and visits to the hospitals, but also financial advice, communication, and the value of involvement of fathers in parenting. The uptake of the model varies, and women do not participate consistently in the full program in spite of support from many local employers. For many couples, however, the group-based model is highly valued, especially those who find the main hospital classes too “middle class” in orientation, and feel more comfortable in this local setting: Women love coming to the classes and tell their friends, and I suppose in terms of the actual program, it’s targeted to their needs more than hospital classes can be, [so] we do need more community-based ones. (Sure Start coordinator 2)

The group also has lunch together during which time women have individual time with the midwife and listen to their baby’s heartbeat. Unlike in the CP model, however, they do not do their own clinical checks, and many women also receive shared GP care. This community center developed this model on the basis of early childhood intervention programs funded several years ago, along with other services including pregnancy counselling, testing, and advice and postnatal support services for breastfeeding, child safety, and mental well-being. Asked about unmet needs, this coordinator noted that they are still limited in that they do not actually “have a midwife employed here,” and they really need midwives in the center who can also be available as contacts working closely with the family until children are 2 years old. The value of this existing model in Northern Ireland lies in the strong community setting and range of health linkages upon which it is based, but it is both strengthened and limited by not seeking to operate across sectarian community borders.

Accessing Information About Choice A second issue discussed by KIs was related to access to information about the availability of birthing choices. Community-based women’s health

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workers in particular drew attention to the problems faced by childbearing women in the fairly traditional, paternalistic society of Northern Ireland, one in which women generally had low expectations and influence. Publicly funded midwifery-led care is available for women in Northern Ireland, but consumers and Sure Start coordinators reported that women frequently had little knowledge about care options such as birthing at home. Prenatal care was often inadequate in informing them about choices and developing their competence in making decisions. The educative role of most prenatal care was regarded as limited by present provision. Parentcraft classes held in a hospital setting were perceived as overcrowded and oriented to a middle-class audience, so many of the “Mums don’t go,” but rather they rely on families and friends for information. Even private obstetric practices were seen as not always offering women adequate information. Other KIs also noted the inadequacy of postnatal support, especially for breastfeeding. As the previous generation lacked knowledge and skills in breastfeeding, it was hard to encourage mothers enough, or even to find enough local peer support, even though the health and child development benefits were officially promoted. A community worker noted that sometimes “Grannies take over,” further diminishing the parenting capacity of young mothers. A representative of the MSLC and a mothers’ support group outside Belfast commented that in rural areas, postnatal problems, including postnatal depression, reflected isolation and that the system “just wasn’t good enough.” A study that evolved from an MSLC group (Mothers’ Voices) echoed many of these issues, reporting that women felt disempowered as a result of poor communication with health care workers and that there was a lack of support and advice regarding homebirth and a need for continued support in the postnatal period (Campbell & Doherty, 2007). Although a considerable amount of written information was made available, a Sure Start coordinator commented, “the difficulty is that quite a significant proportion of our mothers would have literacy problems” and can only take in “so much. . . . So no, they don’t have ‘options or choices’ even if they officially are available.” Many had no idea of the possibility of shared care with a community-based midwife, and, even in areas where it was available, it was sometimes “word of mouth” and “who you knew” that determined access to this service. Another community worker stressed that as the working-class mothers in her area, including immigrants, mostly did not receive information about possible hospital or midwifery options, they “just do what their GP says and just get booked in” to the local hospital. Even one middle-class woman, a local consumer representative, reported feeling quite intimidated when a new midwife sought to discourage her from her planned homebirth on spurious grounds, finding it difficult to contest her “professional authority” even though she was confident about her rights and the normality of the pregnancy.

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CHALLENGES AND LIMITATIONS The key informants with whom we spoke for this project could also foresee several challenges in implementing innovations like CP. Institutional challenges focused on integrating a new model of care, the role that doctors might play, and how acceptable this would be to both women and to hospital and community-based midwives. Funding, political will, and explicit strategies to manage social divisions would also be needed. At the community level, ensuring easy access to a mixed-community local center and building on existing networks are essential but present challenges in view of entrenched local loyalties. We recognize that this small qualitative study cannot fully represent the views or perspectives of all stakeholders, especially in view of time limits and lack of funding, which has precluded contact to date with GPs. There was considerable consensus from a range of voices that a program similar to CP would be a valuable option for women in Northern Ireland, however, one offering advantages as a social model of health.

CONCLUSIONS: THE POTENTIAL OF INNOVATIVE PRENATAL CARE IN NORTHERN IRELAND In this article, we have argued for the importance of placing prenatal care within a social rather than medical model of health and explored the value R . Given the issues faced of group prenatal care such as CenteringPregnancy by women in the context of societal and community divisions of Northern Ireland, innovative social health interventions can be particularly valuable for enhancing women’s social capital and contributions to community building. Our conclusion accords with other research reporting the social benefits of CP as a group prenatal care model, but we go further. In this article we have also argued that implementation of such programs are best viewed and should be evaluated as “complex interventions” within a social model of health. As such, paying close attention to the specific local context is critical to planning and implementation. In the distinctive social and political circumstances of Northern Ireland, the transition to motherhood is an especially vulnerable time, one in which empowerment-oriented, group-based prenatal care could develop new social networks for women and support their capacity for social participation. Given the complexity of implementing a group-based prenatal care intervention, it is important that future research uses an appropriate conceptual framework and methodology to evaluate outcomes. This article represents an introductory exploration of group-based prenatal care in Northern Ireland and has provided initial data concerning the potential of this intervention to achieve much beyond clinical outcomes. Suitably resourced and supported, models of care during pregnancy and motherhood have the potential to optimize health and well-being of women

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and their families, through both clinical and social outcomes, enhancing the likelihood of improved social cohesion in postconflict Northern Ireland.

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