Essay 307 - complex social factors

Language barriers especially in the immigrant population such as Eastern Europe, Indian Subcontinent. It can cause the patient not to be able to voice out their concerns for fear of the doctor not understanding them. There might be inadequate social, medical and surgical history taken during consultation. Patient might be afraid to come for appointment as they are afraid no one can understand them. Social and Cultural differences might also lead to important medical information being missed. Steps to take would be to have on site intepreters at each hospital or to refer them to units with the appriopiate interepreter. Other measures would include having an interpreter over the phone so that the consultation can proceed. Diagrams, illustrations can also be used to communicate with the patient.

In patients with young maternal age, they are at risk of defaulting their appointments. They are also at risk of Sexually transmitted diseases as well as drug abuse and domestic violence. They are also at risk of Intra uterine growth restriction as well as pre term labour. History of smoking and cocaine abuse should also be screened. To improve outcomes, patient should be booked early in a consultant led unit with specialist midwives. Detailed history should be taken with regards to smoking and drug usage. Their GP and local social services should be notified and kept updated of their antenatal progress. At each consultation, Doctor should look out for signs of domestic abuse such as bruises, cigarette burn marks, unexplained wounds and notify the social services. The doctor should also lookout for signs of intravenous drug abuse such as needle marks, poor nutrition etc. They should also be screened for sexually transmitted diseases such as chlymdia and gonorrhea and GUM physician notified if positive and partner screened for contact tracing.They should also have serial growth scans from 24 weeks onwards every 4 weekly as they are at risk of intrauterine growth restriction. They are also at risk of defaulting appointments and the local social services should be notified for follow up if it occurs. They are at risk of pre term labour and miscarraige and they should be given information on what signs and symptoms to expect and a 24 hour helpline as well as written patient information leaflets on where and when to seek help .

For patients suffering from domestic violence, they are at risk of defaulting their antenatal follow up, they are at risk of pre term labour, miscarraige. They are also at risk of depression and suicide. They also are at risk of sexually transmitted diseases as well as drug abuse. There is also a risk of intra uterine fetal death. Steps to be taken are to screen early for such patients. Patients with domestic abuse tend to default appointments. They are always accompanied by a family member and usually the family member speaks on their behalf. We need to refer them to social services or make a police report. They should be booked in a consultant led unit. They should have a consulation in private without the family member around and should be referred to the psychiatrist. They should also be screened for sexually transmitted diseases and smoking cessation or drug abuse cessation. If they are at further risk of domestic violence, they should be admitted into a maternity unit as it can lead to pre term labour, abruption, intra uterine death. THey should also have serial growth scans from 24 weeks onwards as they are at risk of intra uterine growth restriction.

The pregnant women whose English is not first language mostly belongs to ethnic minority group. Mostly they are recent immigrant, asylum seeker, refugee .Language barrier makes them high risk due to failure to communicate, to get information, to seek advice from health professional regarding intimate problems during pregnancy, such as domestic violence and less likely to follow the advice given. Using family member as interpreter may serve the purpose of free two way communication between health professional and pregnant lady.  They will be at risk of poor antenatal follow up, late booking at antenatal care, substance misuse, and poor housing condition and social problems as smoking and alcoholism. They are at risk of as may not be attended or taken care of when they come with serious condition when they might need urgent help or referral such as ectopic pregnancy.  Late and poor antenatal care is indicator of increase maternal perinatal mortality.

Young age pregnancies are mostly unwanted.  They at risk of poor nutrition, vitamin deficiencies, social problems as smoking, alcohol abuse, use of recreational drugs and poor attender at antenatal clinic. Sexually transmitted infections are more commonly seen in them. The young nulliparous women is at risk of obstetric complication such as preeclampsia, preterm delivery and small for gestational fetus, risk of vertical transmission of infection to the developing fetus. In post-partum period there is more chance of failure of lactation and sudden infant  death.

One in six women requesting abortion suffers from domestic violence. Pregnancies in these women are at high risk of intrauterine growth restriction, preterm delivery, intrauterine death and stillbirth.  Physical abuse put the women at risk of accidental hemorrhage. They are poor attender at antenatal care .increase stress , anxiety further deteriorate psychological condition and increase suicidal tendency, depression.

Strategy to improve;

The uptake of antenatal care follow up and early booking prior to 12 week of pregnancy should be improved by setting a target by health care system. It may involve the multidisciplinary team approach, developing protocol and guidelines and adhering to it. Appropriate referrals and providing self-help material which can be taken home by patient is important.

   Comprehensive history taking and risk assessment at booking is essential. Importance of regular visit should be emphasized and testing for infectious disease offered. Her financial , social condition inquired

Use of professional interpreter is helpful in overcoming the language problem.

The nonjudgmental, sensitive behavior by health professional helps to build trust worthy relationship with patient. Confidentiality is of paramount importance while dealing with young women, while delivering important information. Primary aim to decrease the number of pregnancies in adolescent age girl which is achieved through health education and information of safe sex practices, and use of contraception.

Referral to the quite smoking agencies and follow up of the progress is important to get the benefit Information of domestic violence should be asked to pregnant women as matter of fact by open ended question. If women do not divulge the information and health professional should always keep the door open to get more information at latter visit. Record of her confession should not be made in hand held notes and should be kept in hospital record.

Women should be informed that she is not he alone suffering and there help if she ask for.

She is provided with necessary addresses, contact number, web addresses.  Verbal information is provided with written information.

Women should be supported though out the journey of pregnancy and in postpartum period. Community midwife, health visitor has major role to play in postpartum period by supporting the women to establish lactation and to help the new mother in newborn care.