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Prenatal courses as health promotion intervention for migrant/ethnic minority women: high efforts and good results, but low attendance

Ursula Karl-Trummer PhD MA1*, Karl Krajic PhD2, Sonja Novak-Zezula PhD MA3 and Ju¨ rgen MPelikan PhD4

Sociologist, Senior Scientist, The Ludwig Boltzmann Institute for the Sociology of Health and Medicine, Vienna, Austria

Sociologist, Senior Scientist, The Ludwig Boltzmann Institute for the Sociology of Health and Medicine, Vienna, Austria

Sociologist, Senior Scientist, The Ludwig Boltzmann Institute for the Sociology of Health and Medicine, Vienna, Austria

Professor and Sociologist, Institute for Sociology, University of Vienna, Austria; Director, Ludwig Boltzmann Institute for the Sociology of Health and Medicine, Vienna, Austria

*Corresponding Author:
Ursula Karl-Trummer, Rooseveltplatz 2/4, 1090 Vienna, Austria.Tel:+43–1–4277 48296, fax: +43–1–4277 48290; email: [email protected]

Received: 30 November 2005 Accepted: 30 March 2006

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The World Health Organization initiative ‘Making Pregnancy Safer’ (2000) names working with individuals, families and communities in a health promotion and empowerment approach as key strategy for maternal and newborn health. As migrant women were found to have a higher risk than the average population of under-using prenatal care and of receiving inadequate care in the pre- and postnatal phase, the group is highlighted as of particular concern for health policies and programmes. Within the framework of a European hospital initiative (MFH) with 12 collaborating hospitals, two hospitals (in Austria and Italy) worked on the development and implementation of training courses for pregnant migrant/ethnic minority women. The courses, designed on the basis of a needs assessment with migrant women, focused on four quality dimensions: access, information, sensitivity to literacy levels and support of facilitators. Evaluation was based on post-course interviews with clients and staff, including ratings of the four quality dimensions and the effects on maternal literacy of participants. Main results in both countries showed that (1) women gave positive ratings on all quality dimensions and reported that their knowledge improved a lot; (2) staff members’ ratings concerning knowledge gain were less positive; (3) despite all efforts to make access to courses easy (no fees, transportation facilities, child care), participation was disappointingly low. Discussion and analysis of these results within the European project group indicate that (1) courses are a successful measure for women who attend; (2) the knowledge needs of clients are different from the perspectives of staff, something that should be investigated more fully; (3) closer co-operation with migrant communities and a better understanding of the role of men (husbands and relatives) and their integration into service planning are needed to increase the access rates of migrant/ethnic minority women to maternity care services.

Key words

access, empowerment, ethnic minorities, health literacy, health promotion, maternity care, migrants, prenatal course

Mother and child health of migrants/ethnic minorities

Mother and child health for migrantsand ethnic minoritieshas been highlighted as an area of particular concern for health policiesan d programmesfor several reasons. Migrant/ethnic minority status is associated with low birth weight (Jeffers, 1993) and increased infant mortality (Bollini, 2000) and hasturne d out to be one of the main predictorsof severe maternal morbidity (Waterstone et al, 2001). Studies also show that immigrant status is a highly significant predictor for postnatal depression (Glasser et al, 1998), and migrant women were found to have a higher risk of under-using prenatal care (Gissler et al, 1998) and of receiving inadequate care in both the pre- and postnatal phase (Nahas et al, 1999; Bollini, 2000).

Health promotion and empowerment in maternity care as modern concepts to improve maternal and newborn health

Within the ‘Making Pregnancy Safer’ initiative, launched by the World Health Organization (WHO) in 2000, working with individuals, families and communities in a health promotion and empowerment approach is considered to be a key strategy for maternal and newborn health (WHO, 2003). Thisappr oach highlightsthe importance of capacity building for individuals and communities/settings.

Prenatal training courses as an intervention for capacity building

Prenatal training courses are an important and commonly used measure for capacity building through education and training (WHO, 2003). For a migrant/ ethnic minority population, courses have to take into account cross-cultural issues (Chachkes and Christ, 1996; Gany and Thiel de Bocanegra, 1996). Within the European ‘Migrant-friendly hospitals’ project (see Box 1), six hospitals co-operated in a subproject that, based on a needs assessment conducted with migrant women, aimed at developing ethno-culturally sensitive information material and training courses to promote maternity health. In European workshops, it was discussed how to design services for migrant/ethnic minority pregnant women and their families. All six hospitals developed specifically tailored information material, and two of them invested in prenatal training courses focused on four quality dimensions: access, information, sensitivity to literacy levels, and support of facilitators. To support these local activities, a fact sheet and a European pathway were developed (Trummer et al, 2003a,b). Thisreport focuseson the two hospitals that developed courses, as these turned out the most comparable measures within the European project group.


Box 1 :The European project ‘Migrantfriendly hospitals’ (MFH)

The courses in Austria and Italy

The Kaiser-Franz-Josef-Spital in Vienna, Austria, designed courses for the Turkish community, which forms 35–40% of their obstetric clients. The courses were free of charge and conducted in co-operation with a Turkish midwife who worked as interpreter.

The Guastalla Hospital, Reggio Emilia, Italy, developed courses for women from Indian and Pakistani ethnic groups. To provide easy access, a taxi service for women and a baby-sitting service were offered. Intercultural-linguistic mediators for Arabic and Punjabi languagesfaci litated communication.


Evaluation wasbas ed on interviews with clients( n = 29 Austria, n = 12 Italy) conducted by a cultural mediator in the clients’ language, and self-administered questionnairesfor staff members (n = 27 Austria, n = 5 Italy).

Main results

In both countriesw omen gave positive ratingsin all quality dimensions and reported that they had learned a lot in the courses. Staff members gave less positive ratings, especially concerning knowledge gain. The most disappointing result for the local organisers was low attendance. Despite all efforts to make access to courses easy in Austria, 29 women attended the courses, and in Italy only 12.


Results indicate that courses are an effective measure for women who attend. They feel well informed and treated with sensitivity regarding their personal needs and cultural background. Interestingly, staff ratings concerning lessons learned at the course were consistently lower than the ratingsof women. This might be due to different conceptsconcerning the kind and amount of knowledge needed.

In discussing the low attendance rate, it turned out that men – husbands and male relatives – are important key persons who strongly influence the decisions of women concerning their participation in courses. Another reason for the low attendance rate might be that the courses were not well advertised and were not yet established within the community.

Conclusion and recommendation

To increase the participation of migrant/ethnic minority women in maternity care services it is important to develop closer links with the migrant communities and a better understanding and integration of husbandsand male relatives aswell as peers within the community.

Further studies are needed to investigate the different viewson knowledge needs and gainsof women and staff.


Thanks to the participating partner organisations: Kaiser-Franz-Josef-Spital, Austria; Hospital Punta de Europa, Spain; Turku University Hospital, Finland; Presidio Ospedaliero della Provincia di Reggio Emilia, Italy; Academic Medical Center, The Netherlands; Bradford Hospitals NHS Trust, UK.

Many thanksto the team in Subproject B: Alex Horsfall, Andrea Gigliobianco, Anneli Skovbjerg, Giorgio Benaglia, Julie Walker, LuisTor recilla Rojas, Pia Ahonen, Sergio Alberto Rivera, Sjaak Molenaar, Susanne Heller, who not only co-operated with high quality and respect for the diversity within the project team itself, but also became friends. Special thanks to Susanne Heller, Austria, and Andrea Gigliobianco, Italy, who provided information and gave advice to the authorsduring the processof writing.

Thanks to Susan Auger, Auger Communications, Aprendo Press, US, who provided expert support in the starting phase of the project, and to the team of the FEM-Su¨d, who supported the Austrian project team in conducting the client and staff surveys.


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