Same Story, Different Country – The Experiences of Muslim Women in Irish Maternity Hospitals

In 2020, just as the pandemic hit, Amal Women’s Association (Amal) and Maynooth University began working together on an investigation into the experiences of Muslim women in Irish maternity hospitals, the findings of which were published in ‘A Mother is Born Too’: Experiences of Muslim Women in Irish Maternity Settings. The drive behind this research was the direct experiences of some women in Amal who had given birth in Irish hospitals. They were struck by a sense that Hijab wearing women, especially those who are also migrants, do not get the same level of care as their non-Muslim counterparts especially when these are white women. International research confirms these experiences, and it is well-established that migrants engage less with maternity services and experience problems when they do. There is a growing body of research that has found that ethnic minority and racialised people endure general negative attitudes, harmful stereotyping, erroneous assumptions about pain tolerance, and individual acts of racism and bigotry. According to Firdous et al, Muslim women often do not vocalise their concerns because this can bring even more negativity towards them, which contributes to them shying away from antenatal and postnatal services.

Sometimes worsened outcomes for mothers and babies are connected to the conditions of a person’s life such as the quality of their housing or their overall health, and Amal was particularly concerned about poorer women who live with multiple, oppressive intersections of inequality. However, research has also found that negative attitudes in and of themselves do worsen maternity outcomes. For example, Lauderdale found poorer birth outcomes amongst ‘Arab-named’ women in the six months following the September 11th, 2001, terrorist attacks.

It is also well-established that, as is the case internationally, more racialised than non-racialised women die because of maternity related complications. Ireland’s most recent Confidential Maternity Death Enquiry notes:

‘a five-fold difference in maternal mortality rates amongst women from Black Ethnic backgrounds and an almost two-fold difference amongst women from Asian Ethnic backgrounds compared with white women’.

African women living in Ireland have a higher perinatal mortality rate and double the number of stillbirths than their Irish-born counterparts. These figures could be higher as maternity deaths can sometimes go unreported or can be misclassified.

Consequently, with funding from the Irish Human Rights and Equality Commission, a research team of Camilla Fitzsimons (Principal Investigator), Lilian Nwanze and Philomena Obasi (Researchers), and Basma Hassan (Community Connector), contacted over 100 self-selecting Muslim women from across Ireland, most of whom were migrants. We used the project as a platform for them to tell us about their time in hospital, stories that are typically drowned out by the more prevalent ‘truths’ of the dominant white narrative. As soon as the project started, one of the team from Amal realised she was pregnant and became our first participant. She shared her entire experience which was more difficult due to COVID restrictions. She expressed feeling sorry for women who did not speak English because during this time visitors or accompaniers were not allowed in the follow-ups or in the delivery suit. Migrant women with no English were very isolated and no support.

Unsurprisingly, given high levels of Islamophobia that exists in Ireland, we found much the same patterns as elsewhere. Many women did not use the services to the same extent as their counterparts in fact 4% presented for care when they were in labour, and only 21% attended antenatal classes. Sometimes this was because of other care responsibilities, best summarised by the comment:

‘we don’t have family; we don’t have support. There is no place to put our children and if it’s an emergency we don’t have a mother who will be available 24 hours, we don’t have someone who can accept our children straight away.’

Others could not go to antenatal classes because of work, or because they struggled to navigate a system that over relies on the English language. Some felt the antenatal classes on offer were not culturally appropriate and some did not understand their purpose as this was never explained to them.

For those who did attend services, most were broadly happy with their overall care especially the work of Public Health Nurses, who were often singled out for praise. However, there was also a strong thread throughout our interviews, focus-group, and online survey that although women determined that they were treated well, this was often interpreted as the absence of being treated badly rather than experiencing an excellent or even equal services as their non-Muslim counterparts. In fact, 85% could identify shortfalls across the same themes as are reported internationally. For instance, difficulties sourcing a halal diet (72%), no understanding of their need for modesty (39%), inadequate interpretation services (10%), not being able to access female healthcare workers (8%), and a lack of appreciation for cultural differences (10%). Overall, a pattern emerged where, although some staff tried to accommodate the needs of these Muslim women, there was an overriding sense of what one woman describes as ‘a tick-box approach’.

Time and again, simple solutions to respect for modesty were not considered. It is easy to prevent unexpected entrances to women’s bedsides or, as this woman puts it, ‘respect for the Hijab and giving time to dress properly before doctors enter’ if there is the will to do this. Instead, women endured a constant flow unannounced visitors, doctors, nurses, and cleaners created high levels of stress for Hijab-wearing women. Here is just one example of the impact:

‘whilst trying to breastfeed my child (not wearing a Hijab) a male student doctor opened my curtain and proceeded to ask me questions and check my chart. I had to cut him off and explain that I'm a Muslim and would like a minute to wear the Hijab and then he can come back and proceed to ask me questions. Which he did. But it had since happened again twice more. So, I just remained in my Hijab throughout my stay.’

Some women were particularly upset about the unannounced arrival of additional staff when they were giving birth, and some were still scarred by the experience. People talked about being ‘very upset’, of not being asked how they felt about male attendees, and of being completely dismissed when they objected. There were other problems, in fact, one in five of all the women we spoke to did not feel in control of decisions made about their bodies. Their birth preferences were never discussed, or, to quote one survey participant ‘whatever the midwife and doctor suggested, I just agreed to it.’

Communication problems in maternity hospitals are not unique to Muslim women or migrants, but this does not take away from the challenge of not being able to fully express yourself to a caregiver during such a significant life event. The impact of this comes to the fore in our focus group discussion:

‘lots of women cannot explain about themself, their feelings, there pain in another language and in a critical condition like pregnancy and labour pain. And I have seen myself lots of Arabic and Muslim women starting to cry in the hospital just because they cannot understand what the doctor says about her baby or her foetus, they are a lot and they really need help’.

Hospitals do provide interpreters, but the service was not always effective and there can be a shortage of phones. It can also be difficult to explain personal concerns to often male interpreters who have no specific healthcare training.

As well as these micro-aggressions, one in five women experienced overt racism. This included negative questioning, being blatantly ignored or dismissed, being spoken to roughly and of being accused of lying. There are reports of people’s requests being dismissed or minimised, of women being shouted at, and reports that women’s babies were treated differently. One woman shared, ‘my baby was not attended to while she was crying. The nurse on duty was a racist.’ From another interviewee:

‘I feel like my baby’s situation was overlooked. She showed signs of slow growth and no movement from early in the pregnancy, yet nothing was looked into. We later found out she contracted a virus whilst I was 13 weeks pregnant.’

One woman, who was denied gas and air and an epidural, was told to be quiet when experiencing contractions because she was ‘scaring other patients’. She told us ‘I was treated with a very negative attitude … I was quite shocked and so was my husband.’ Others were asked to remove their Hijab.

A final theme to emerge was reports of negative attitudes towards male partners as captured in the following comment: ‘I was pressed on more than one occasion to say that my husband was abusive. I felt this was based solely on the colour of our skin.’ Another shared ‘I don’t mind the need to be vigilant in terms of gender-equality but our partners are under more suspicion than “white-Irish” partners.’

We also spoke to 38 healthcare workers, some of whom corroborated our findings, as evidenced in the following comment:

‘I’ve witnessed staff not wanting to care for Muslim women, asking other staff to care for the “mussies”. I've seen pain relief denied and after giving birth Muslim women being described as “precious” if they seem a little lost (which is normal for every new mother) after their baby is born. Lack of willingness to support needs in relation to breastfeeding etc.’

This final excerpt captures how it can be difficult to articulate exactly what structural racism looks like given the extent to which it is normalised in maternity hospitals. A midwife shared:

‘I don't have any recollection of any staff to patient verbal racism however, I noted on numerous occasions that staff were generally less interactive with Muslim patients. Less chatty and appeared to spend less time caring for them in comparison to other women.’

Although this research was a great opportunity to highlight what migrant women really face in maternity services, it was hard to convince those women to participate in the research and speak up. It was also a challenge to get those in positions of power to take the matter seriously. Representatives from Amal met with a Government Joint Committee to share the research results, but nothing substantive came from the meeting. It is hard not to conclude that this is not an area of priority for the current government.

Niera Belacy, Amal Women’s Association

Dr Camilla Fitzsimons, Associate Professor at Maynooth University