In Australia, the management of childbirth among Culturally and Linguistically Diverse (CALD) women is a complex issue due to the different expectations, language barriers and practices women bring from their original homeland.

An assessment on the needs of CALD women attending maternity services at Westmead Hospital showed a correlation between poor English proficiency and increased obstetric intervention. 

To address this, the project "Having your baby in Australia? We speak your language" was initiated.  A language specific audio CD was produced detailing the practices and procedures of childbirth in Australian hospitals.  CALD women and their support people would listen to this CD prior to giving birth.

Project evaluation shows that it has been a significant obstetric improvement among CALD women.  Vaginal birth increased by 11.45% and emergency caesarean decreased by 15.1% in comparison to the control group and against the corresponding NSW averages. Furthermore, improvement to the women's knowledge level about birth was also achieved.

To reduce by 10% the number of unnecessary Emergency caesareans among CALD women.

The management of childbirth in CALD women is complicated by language barriers and cultural disparities.  Poor English proficiency and a poor engagement of interpreters place CALD women at a childbirth disadvantage.

Support people are often used to communicate between staff and the woman. While a support person may have greater English proficiency, they do not necessarily have greater understanding of the childbirth process. 

It is well documented that a lack of awareness and knowledge contribute to fear and a failure to progress in normal labour. In essence, effective communication with CALD women and their support people in giving birth is pivotal when reducing a preventable obstetric intervention.

A retrospective audit from the hospital obstetric database during the period of 25/08 to 30/09/2006 showed the following:

• There was a total of 469 births in this period
• CALD women comprised 58.71% (n=273) of these births
• Vaginal birth in CALD women was 57.5% (n= 157) compared to English speaking women 65.6% (n= 273)
• Emergency caesarean section in CALD women was 22.7% (n=62) compared to English speaking women 14.6% (n=28)

During this period, a needs assessment survey of 238 CALD women was conducted.  It showed the following:

• Mothers surveyed represented 50 different countries and spoke 47 different languages other than English at home.
• 64.7% of the group surveyed were first time mothers.
• Self assessed English proficiency was rated:
  • 63% as good or above,
  • 13.4% (n=32) as average
  • 23.5% (n=56) as poor or lower (including 3.8% n=9 were no English at all).
• All mothers stated they did not request interpreters at birth preferring their support people to interpret for them.
• A retrospective audit confirmed a decline in the use of interpreter services in the maternity unit at Westmead.
• This data correlates with the NSW Mothers and Babies Report 2004.

At local level, the project addresses Sydney West's strategic focus as outlined in the Sydney West Area Health Care Services Plan 2005 -2010 by:

• Expanding midwifery-led services and accommodating the increasing number of caesarean sections.
• Maximising use of information and communication technology to enhance patient care.

At state level, the project specifically addresses the Strategic Directions of the NSW Heath plan Towards 2010 by:

• Improving access to maternity health care information for CALD women.
• Improving health outcomes for CALD women having their first baby in Australia.
• Increasing customer satisfaction with health care provided.
• Producing an accessible and cost effective resource for all health professional working with CALD women.

Following the needs assessment, a seeding grant of $9,414 was sought from the Multicultural Health Network at Sydney West to support the implementation of the project.

A multidisciplinary committee comprising a range of staff from Multicultural Health and Women's and Children's Health was formed.  In consultation with health professionals working with CALD women, the production of a language specific audio CD detailing the information about the routine practice and care at birth was initiated.

A script for the 15 minute audio-CD was drafted by the committee and distributed to staff in seven birth units in NSW for comment.  This ensured that natural variations of the birthing process were included to enable wide use of the resource.

The script of the CD details the routine information about the childbirth practise in Australian hospitals, including routine care practice, process of labour, important signs to report, self-help techniques and pain relief, role of support people and the care immediately after birth. The CD is designed to assist health professionals to deliver the information to CALD pregnant women and their support people upon the women admission to the birth unit and before an interpreter is requested or available.  

Following finalisation of the script, consideration was given to the language production of the CD.  Demographic data of the area, the severity of disadvantage of the group and the quality assurance of the project were considered before producing the CD in eight languages (English, Cantonese, Mandarin, Tamil, Korean, Arabic, Persian, and Hindi). 

The CD was piloted in two different groups in order to assess the appropriateness of the information being provided.  This assessment was used to finalise the CD.

The evaluation involved 257 CALD women and the following was achieved:

• 11.45% increase in the number of normal vaginal birth (from 156 out of 238 to 199 out of 257).
• 15.1% decrease in the number of emergency c/s (from 62 out of 238 to 28 out of 257) in comparison against the control group (data of the needs assessment).

When evaluating English proficiency and obstetric outcome the results were as follows:

• A decrease in Emergency Caesarean rate of  women with poor English from 37.5% (21 out of 56) to 4.17% (2 out of 48).
• A decrease among women with average English proficiency from 31.25% (10 out of 48) to 2.33% (1 out 43). This finding suggests a strong correlation between the language proficiency and birth outcomes among CALD women.

The evaluation also demonstrated a significant improvement in the women’s level of knowledge on birthing practices in Australia.

A questionnaire was developed to assess improvement in the woman’s level of knowledge of childbirth processes and practices after listening to CD. 

Of the women with poor or lower English proficiency, the mean improvement in the number of good or better knowledge level was 94.8% and the mean decline rate in the number of women ranked to be in poor or lower knowledge level was 82.14%.

Long-term sustainability of the project has been achieved through the following processes:

• Promotion of the resource and education of health professionals to ensure continued use of the resource.
• The translation of more languages consistent with community need and the identification of emerging CALD communities and communities with high rates of illiteracy.
• Development of additional CD's detailing other aspects of childbirth and parenting such as antenatal care, postnatal care, community care and breastfeeding.
• Development of hospital/health service policy to ensure its continued use.

The project is a low cost, easily accessible and transportable resource that contributes significantly to meeting the needs of the CALD women having babies in Australia.  The project has demonstrated its capacity to increase knowledge levels and achieve better birthing outcomes for CALD women, particularly, the most disadvantaged women in the maternity health care system

The project enhances the care and education needs of our greater CALD community who access Australian maternity services and has achieved the objectives stated in The Strategic Directions of the NSW Heath plan Towards 2010.

Associate Director - Clinical Governance, Clinical Governance Unit
Sydney West Area Health Service
Phone: 02 9881 7524