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NIHR Signal Enhanced communication and staff training could improve the experience of maternity services for asylum-seeking women

Published on 24 September 2019

doi: 10.3310/signal-000822

Pregnant asylum seekers experience significant barriers to accessing maternity services in the UK. A review found that these barriers often relate to language differences and practical challenges associated with their status. Provision of interpreter services and training for health care professionals could improve maternity support for these women.

Pregnant women seeking asylum have often experienced significant trauma. Many arrive in the country having received no maternity care and experience further difficulties in accessing appropriate services once on UK soil.

Separation from family and relocation during pregnancy means that women often face challenges in developing therapeutic relationships and social support networks, and in maintaining continuity of care. Language barriers together with the physical and emotional challenges of pregnancy in unfamiliar surroundings add further complications to negotiating maternity care in the UK for this group.

This review of qualitative studies offers important advice on how the experience of maternity services could be improved for pregnant asylum-seeking women.

  •   Fertility and childbirth, Public and patient involvement, Primary care, Acute and general medicine, Midwifery
Enhanced communication and staff training could improve the experience of maternity services for asylum-seeking women

Why was this study needed?

Forced migration has reached unprecedented levels in recent years, with the United Nations High Commission for Refugees recording 68.5 million displaced people in 2017. In the UK there were 31,589 asylum applications in the year up until March 2019. 

Physical and psychological trauma among asylum seekers is common; for pregnant women the added physical and emotional demands can add further complications. These women have often experienced sexual trauma, in addition to infectious diseases and underlying health conditions which predispose them to increased maternal morbidity and mortality. Maternity care is therefore crucial to their health and wellbeing.

The experiences of asylum-seeking women who need to access maternity care in the UK are currently poorly documented in the literature. This review aimed to consider the views of this population group on the barriers and facilitators to good maternity care experiences.

What did this study do?

This systematic review included six peer-reviewed qualitative studies that focused on the experiences of UK maternity care amongst pregnant asylum-seeking women. The views of 89 women were captured by semi-structured interviews in these studies. The reviewers carried out a thematic synthesis to draw out commonly reported themes.

Participants were pregnant women who had lodged an application for asylum in the UK but had not yet gained refugee status. The review focused exclusively on service user perspectives rather than those of health professionals.

The overall quality of the studies was rated as low due to inadequate discussion of researcher-participant relationships, ethical considerations and data analysis techniques. The review, however, provides a useful basis upon which further research and guidance can be planned. Restriction of research to that carried out in the UK means that the context and relevance to staff and service here is high.

What did it find?

  • Problems with written and verbal communication relating largely to language barriers were common challenges identified in all studies reviewed. Lack of interpreters led to negative healthcare experiences and difficulties in accessing health services.
  • Feelings of isolation were commonly reported, due to being far away from family and friends. Financial restrictions imposed by the asylum application process were reported as stigmatising and problematic, affecting the ability to travel to important healthcare appointments. Mental health problems were also common.
  • Asylum seekers are initially housed in Initial Accommodation centres and those who qualify for support can then be moved to any part of the UK where affordable housing is available (called mandatory dispersal). The review reported that dispersal within the UK during pregnancy disrupted access to and continuity of healthcare and important social networks. Poor housing and culturally inappropriate conditions unsuitable for antenatal and postnatal periods were reported in both Initial Accommodation centres and dispersal housing.
  • The women’s experiences of attitudes of healthcare professionals towards pregnant asylum seekers were mixed. Some had experienced stereotyping, racial abuse, assumptions being made about their desired choices during pregnancy and a lack of awareness about the common difficulties experienced by asylum seekers in the UK.
  • Relationships with midwives and experiences of midwifery care were overwhelmingly positive. This was reported to help reduce feelings of isolation and stigmatisation and make the women feel more comfortable.

What does current guidance say on this issue?

Expectant mothers who are seeking asylum in the UK are entitled to NHS maternity care alongside free prescriptions and additional maternity payments during pregnancy. Specialist maternity services exist in areas in which asylum seekers are commonly dispersed, but are not provided consistently across the UK.

Current UK policy is that dispersal should only occur once in pregnancy wherever possible. In the late stages of pregnancy, dispersal should only be undertaken at the request of the woman or her treating medical practitioners.

The NICE guideline on service provision for pregnant women with complex social factors (2010) includes recommendations for asylum-seeking women and similar groups. Suggestions include using a variety of communication methods, telling women what antenatal services exist and how to use them, and using interpreters during consultations. Training for healthcare professionals on the specific needs of pregnant asylum seekers is also recommended.

What are the implications?

Effective communication is essential to good maternity care and the wellbeing of expectant mothers seeking asylum. Inclusion of interpreters within maternity care is an important part of this, including during labour.

Training for cultural competency and anti-discriminatory practice for all practitioners working with this group is also important in ensuring care is appropriate, respectful and delivered in partnership with pregnant women. Midwives are likely to provide a crucial link in bridging the gaps in current practice. Specialist service development should also be a consideration.

The review findings will be particularly useful for midwives, obstetricians, commissioners and others working with pregnant asylum seekers.

Citation and Funding

McKnight P, Goodwin L, Kenyon S. A systematic review of asylum-seeking women’s views and experiences of UK maternity care. Midwifery. 2019;77:16-23

This research did not receive specific grants from any funding agencies in the public, commercial or not-for-profit sectors. Two of the researchers are fully or part-funded by the NIHR through the Collaborations for Leadership in Applied Health Research and Care for West Midlands (CLAHRC-WM) programme, and the third by the West Midlands Internship programme delivered by Birmingham Health Partners.

Bibliography

Asif S, Baugh A, Wyn Jones N. The obstetric care of asylum seekers and refugee women in the UK. Obstet Gynaecol. 2015;17:223-31

Home Office. National statistics: how many people do we grant asylum or protection to? London: Home Office; 2019.

NICE. Pregnancy and complex social factors: a model for service provision for pregnant women with complex social factors. CG110. London: National Institute for Health and Care Excellence; 2010.

UK Visas and Immigration. Healthcare needs and pregnancy dispersal policy. London: Home Office; 2016.

Expert commentary

Pregnant asylum seekers have significant additional needs and face additional challenges when accessing maternity care.

Focus is upon communication and interpreters. Clinically this can be challenging due to the unexpected presentations and the out-of-hours nature of maternity care, but this study emphasises they have significant value.

A key factor in the provision of interpreters is the importance staff place upon them. If staff are more proactive this improves provision. Pregnant asylum seekers also have challenges with finance and being isolated.

Professor Derek Tuffnell, Consultant Obstetrician and Gynaecologist, Bradford Teaching Hospitals NHS Foundation Trust

The commentator has collaborated with one of the study authors on the MBRRACE-UK programme