Asylum seekers are people who have fled their home country due to a fear of being persecuted, and are awaiting a decision as to whether their asylum claim is accepted by the government of the country they have fled to. Refugees have had their claim accepted and are allowed to remain in the country, either temporarily or permanently (UN High Commissioner for Refugees (UNHCR), 2015). Asylum seekers and refugees (AS&R) living in the UK often have complex health and social care needs (Burnett and Fassil, 2004). On arrival in the UK, they may have poor underlying physical and mental health, which can deteriorate further due to living in poverty and experiencing social isolation (Aspinall and Watters, 2010). This can be exacerbated in pregnant women, who may experience pregnancy complications in addition to their existing poor health. Although there is a dearth of data specifically on AS&R women, migrant women are at a disproportionately increased risk of a negative pregnancy outcomes including low birth weight, preterm birth, and perinatal and maternal mortality (Lewis, 2007; Bollini et al, 2009; National Institute for Health and Care Excellence (NICE), 2010; Centre for Maternal and Child Enquiries (CMACE), 2011). Black women in the UK, including AS&R women, are four times more likely to die in childbirth than White women (CMACE, 2011; Lewis, 2007).
To improve AS&R women's chances of a positive pregnancy outcome, it is essential that they receive good-quality maternity care to ensure their specific health and social care needs are met. However, evidence suggests that migrant women, including AS&R, do not always access timely maternity care, booking late in their pregnancy (Phillimore, 2014; Shortall et al, 2015). Attendance for care can be sporadic, owing to social factors such as poverty as well as domestic abuse (NICE, 2010), and poor administration between different health and social care services (Shortall et al, 2015). Migrant women may also experience language barriers, with a lack of suitable interpreters (NICE, 2010). In addition, a fear of being charged for services may deter women from accessing care (Phillimore, 2014; Shortall et al, 2015).
When AS&R women do access maternity services, evidence suggests they may have poor experiences, with midwives and other maternity workers not understanding their specific health and social care needs (Haith-Cooper and Bradshaw, 2013a) or their entitlement to care (Phillimore, 2014; Psarros, 2014), and also not considering cultural issues that may influence their needs, such as female genital mutilation (Phillimore, 2014; Psarros, 2014) (see Case study). Migrant women report being stereotyped, which can lead to problematic and unsympathetic care (Phillimore, 2014). AS&R women also report experiences where staff display poor attitudes, prejudice and discrimination (Waugh, 2010; Briscoe and Lavender, 2009; Gaudion and Allotey, 2008; McLeish, 2005; Psarros, 2014).
In the UK, there is a dominant negative discourse around asylum seeking, with the public questioning AS&R genuineness and potential for criminality (Aspinall and Watters, 2010; Haith-Cooper and Bradshaw, 2013b). There is also a general confusion about the difference between AS&R and economic migrants, who choose to come to the UK to work rather than being forced to leave their home country (Greenslade, 2005). When considering the negative experiences some pregnant AS&R women have described when accessing maternity care, it can be argued that midwives' understanding of asylum seeking may be influenced by this dominant discourse. However, engaging the general public with AS&R people, listening and learning about their diverse backgrounds and needs, has been found to be helpful in constructing a more positive discourse around asylum seeking (Pearce and Stockdale, 2008) and this principle underpins the work of the Maternity Stream of the City of Sanctuary. Storytelling is a powerful learning tool in health professional education (Haigh and Hardy, 2011) and we argue that encouraging midwives and other maternity workers to listen to AS&R women telling their story around asylum will result in a better understanding of pregnant AS&R women's health and social care needs and how they can be met.
The Maternity Stream of the City of Sanctuary
The City of Sanctuary is a UK-wide movement aiming to build a culture of hospitality and welcome within towns and cities for asylum seekers and refugees (City of Sanctuary, 2015). Within the movement, streams of sanctuary have been developed which link people and organisations within or across cities around a particular theme. Maternity is one theme, and the Maternity Stream is now a well-established network of AS&R women, health professionals (including midwives), academics, commissioners and voluntary sector services who work together to achieve specific aims (Table 1).
| To ensure childbearing AS&R women's voices are heard and considered when discussing the development of maternity-related services and support groups |
| To develop maternity services and support groups that are welcoming and inclusive for pregnant AS&R women and are designed to meet their specific health and social care needs |
| To help AS&R women overcome the barriers they experience when accessing maternity services, understanding their choices and attending for care in a timely manner |
| To develop a supportive community for AS&R women, including a forum for sharing relevant resources |
This article will discuss how these aims are being addressed in the work that is being undertaken within the Maternity Stream.
Volunteers
Central to the Maternity Stream are AS&R mothers who act as volunteers for the charity and contribute to the activities undertaken in different forums. A refugee woman is the chair of the Maternity Stream and activities are very much led by the women who were trained as health befrienders in a previous Refugee Council project that has now lapsed due to a lack of funds (McCarthy and Haith-Cooper, 2013). Women had received training opportunities in public speaking and assertiveness, which has led to women speaking in a number of different contexts about their experiences of seeking asylum and birthing in the UK (Table 2).
| National and international nursing and midwifery conferences |
| Chairing conferences |
| As service users within a university, sitting on interview panels, teaching and assessing health-care students |
| Talking in parliament as part of the Dignity in Pregnancy campaign (Feldman, 2013) and the Sanctuary in Parliament event |
| Sitting on different forums including Health Watch and Maternity Services Liaison Committee |
| Co-applicant on research grants |
| Awareness-raising sessions for student midwives, social workers, medics and lecturers |
As identified earlier, AS&R women living in the UK are often socially isolated (Aspinall and Watters, 2010) and may experience poor mental health (Burnett and Fassil, 2004). Engaging women in the Maternity Stream as volunteers appears to be an important activity to reduce this isolation. Women meet on a monthly basis, making friends and providing a mutually supportive environment. Regular outings to the countryside are arranged, providing an opportunity for women and their children to have fun and temporarily suspend the anxieties and concerns associated with everyday life. This sense of community could be helpful in improving poor mental health in AS&R women.
Case study
Grace fled her home country due to political persecution. When she arrived in the UK alone, she spoke no English and was not aware that she could claim asylum. She did not register with a GP until she became ill, as back home that was the norm. She visited a GP, with a friend to interpret, and found out that she was 4 months pregnant. During her pregnancy, she only saw her GP twice and was never referred to a midwife. In her home country, midwives did not exist—doctors provided antenatal care—so Grace never questioned her situation.
When labour began, her friend took her to hospital and left her there to go to work. She was planning to return the next morning to take Grace and the baby home. However, Grace experienced painful contractions for 3 days; she could not communicate her needs, was never offered an interpreter and was left alone in a room for long periods of time, attached to a monitor.
When Grace's friend returned expecting to take her home, she translated for Grace, who was then provided with nitrous oxide and oxygen. However, the friend could not stay due to work commitments. The following night, Grace was put into a pool but left there all night as the water got colder. On day 3, when her friend returned, she asked for an epidural, which was finally sited 2 hours before the birth.
At full dilatation, Grace says that the delivery room suddenly got very busy and, through sign language, she understood her baby was lying transverse. The doctors gave her a piece of paper and pointed to a box to sign for what she thinks was a caesarean section. At the same time, a midwife entered the room and suddenly pressed down very hard on Grace's abdomen, causing the fetus to move to a cephalic presentation and shortly after, Grace birthed a healthy daughter.
Grace and her daughter were in hospital for 4 days. She was never offered an interpreter. She says that people came and poked something in her daughter's ears and kept examining her. She was very fearful that there was something wrong but could not ask. At home, she was only visited once, by a health visitor with a red book. Grace had no idea how to breastfeed or care for a newborn baby. Not surprisingly, Grace is terrified of having another baby.
This took place 5 years ago, but evidence suggests that some asylum-seeking women still experience poor maternity care (Haith-Cooper and Bradshaw, 2013a).
Developing services
To encourage maternity services (and other organisations and support groups) to work towards the aims of the Maternity Stream, the Maternity Service of Sanctuary (SOS) award has been developed. Services can work towards achieving this award by collecting evidence that demonstrates the achievement of three principles (Table 3). An appraisal team, including an AS&R Maternity Stream volunteer, assess the evidence provided by the service before presenting the award. There are currently a number of voluntary and statutory sector services applying for the award in Yorkshire and the Humber. The first—the Haamla service, a specialist NHS midwifery community service—has achieved this (The Leeds Teaching Hospitals NHS, 2015).
| Learn about pregnant AS&R women, their experiences of asylum, the challenges of living in the UK and their subsequent health and social care needs. Ensure women are aware of the service or support group and how and why to access it |
| Embed positive action. This could be through the development of guidelines or care pathways to inform clinical practice. Monitor and evaluate best practice in providing care that is inclusive and appropriate for AS&R women |
| Share best practice with maternity services and other related local organisations, including those in the voluntary sector |
Resources
Services are encouraged to utilise the resources offered on the Maternity Stream website to assist them to achieve these principles, in particular to learn about AS&R women's specific health and social care needs. The main resource is the women and their stories of seeking asylum and birthing in the UK, and services are encouraged to invite women to share their stories, from which maternity workers can learn about the women's health and social care needs. In addition, the Maternity Stream website contains the ‘Pregnant Woman within the Global Context’ model, an evidence-based model designed to consider how factors within the AS&R woman's UK and home context will have an impact on her health and social care needs (Haith-Cooper and Bradshaw, 2013a). From this, a film—Childbirth in the UK, stories from refugees—has been developed, exploring issues contained within the model in more depth. This features AS&R women recalling their experiences in the context of the UK and their home country (Maternity Stream of Sanctuary, 2015b). A second film, Childbirth in the UK: A Guide for Refugees, is also available on the website (Maternity Stream of Sanctuary, 2015b). This features women telling their stories in order to emphasise what services AS&R women can access and how and why they should access them. It is designed to address some of the barriers women may face, including a lack of understanding about preventive health care (Crawley, 2010) and what services are available (Norredam et al, 2005). Using peers to communicate public health messages has been found effective in other contexts (Haith-Cooper, 2014), and AS&R women explaining about health services to other AS&R women may increase their uptake of important health services.
‘Asylum-seeking and refugee women have specific health and social care needs that are not always met within current maternity care provision. The Maternity Stream of the City of Sanctuary has the potential to help develop services that are inclusive and welcoming, and meet those needs’
In order to aid learning, maternity-related services and organisations in one city requested that the Maternity Stream run a conference—‘Striving for excellence in maternity care’. The aim was for delegates from different statutory and voluntary maternity-related organisations to learn about the needs and maternity experiences of AS&R women. Another aim was to overcome the issue identified earlier around poor administration between different health and social care services (Shortall et al, 2015) by sharing examples of good practice through networking opportunities. The conference was based around the Childbirth in the UK, stories from refugees film and the ‘Global Context’ model, using films clips and relevant speakers to explore aspects of the model in more depth. This conference format is easily transferable and has been adopted by two other cities to date (Maternity Stream of Sanctuary, 2015c).
The Maternity Stream is now in the process of creating a maternity resource pack, which will provide useful information for services and also support applicants for the Maternity SOS award. Midwifery students have been involved in interviewing AS&R women to gather their stories in a written format to include in this pack.
Conclusions
AS&R women have specific health and social care needs that are not always met within current maternity care provision. The Maternity Stream of the City of Sanctuary has the potential to help services, organisations and support groups to develop services that are inclusive and welcoming for AS&R women and that meet their needs. The Maternity Stream activities also provide the potential for AS&R women who work as volunteers to benefit. This can involve developing assertiveness, self-esteem and also improving their mental health by making friends and working in a mutually supportive environment.
However, it is important that the activities of the Maternity Stream are evaluated. Work needs to be done evaluating the impact of the Maternity SOS award in terms of women's ability to access services, their experiences of services and also the impact on pregnancy outcomes; reducing both maternal and perinatal morbidity and mortality.
There is some evidence that volunteering has a positive effect on AS&R women, with women accessing further and higher education courses in health and social care and also securing paid employment (Stacey, 2014). These positive outcomes will be monitored further over time.
It is also important that the Maternity Stream constantly reviews and updates the resources provided on the website, ensuring they are evidence-based, contemporary and effective in helping organisations to achieve the Maternity SOS award. Ultimately, this could improve maternity services for AS&R women, a particularly vulnerable group in UK society.