The following reflection uses a flexible application of the John's model (2013) to explore a student midwife's experiences of working with a specialist migrant midwife, who works exclusively with women seeking asylum. The aims of this elective placement were to identify the psychosocial needs of this demographic, and better understand the challenges that migrant women experience in the UK, particularly when pregnant. It also seeks to critically evaluate how the specialist service met those needs, and explore the societal preconceptions and beliefs that surround those seeking asylum more generally.
Student midwives are often encouraged to use reflective tools to develop and improve both their practice, and strategies for resilience and self-care (Hunter and Warren, 2013). A less commonly discussed use for reflection can also be to develop levels of self-awareness regarding our cultural attitudes and positioning. Midwives are subject to the Nursing and Midwifery Council (NMC) Code, and therefore legally bound to provide care that challenges discriminatory attitudes (NMC, 2015); however, they are inevitably influenced by, and reflect, the wider society in which they live (Francis, 2010). Originally discussed in work that explored the cultural competence of practitioners in relation to the Traveller community, Van Cleemput (2012) advocates the application of a ‘culturally safe’ approach to health care. This theory recognises that a lack of respect for individual culture and institutionalised racism has a negative effect on health outcomes. Van Cleemput (2012) argues that culturally safe health care requires more than awareness of cultural beliefs; in fact, it can be insensitive to claim such knowledge, as claiming knowledge of a group one is not part of can lead to incorrect assumptions and stereotypes that do not represent the nuanced and complex nature of identity. As such, cultural safety focuses on the practitioner having good levels of self-awareness and reflexivity regarding their position, and aims to avoid stereotypical assumptions by seeking to understand and respect each person as an individual. In light of this theory, reflection becomes a fundamental process for investigating one's own preconceptions and providing care that promotes equality.
‘Women face gender-specific issues that make them particularly vulnerable when seeking asylum—especially if they are pregnant’
Background
The term, ‘asylum seeker’ is given to anyone who has applied for the right to live in another country on the grounds of a well-founded fear of persecution in their country of origin; this could be for reasons of race, religion, nationality, membership of a particular social group [inclusive of gender-related violence], or political opinion (United Nations Refugee Agency, 2010). In the UK, asylum seekers are entitled to free maternity and NHS care, although do not have the right to work nor an entitlement to state benefits (Maternity Action, 2017).
Home Office statistics show that the number of asylum applications in the UK has risen from 17 916 in 2010 to 32 414 in 2015 (Home Office, 2016). Statistics also show that asylum seekers in the UK tend to be young single males (Home Office, 2016). According to the Refugee Council (2016), in 2015, only 21% of asylum applications were made by women. Aspinall and Watters (2010) argue that the asylum system does not consider the specific health and social needs of women, a point that is echoed in research conducted by Reynolds and White (2010), who state that women face gender-specific issues that make them particularly vulnerable when seeking asylum—especially if they are pregnant.
Care needs among asylum seekers commonly arise from psychosocial issues. Government figures show that there is a higher proportion of mental health concerns for asylum seekers than the wider population (UK Visas and Immigration, 2016). These findings are mirrored in research conducted by the Refugee Council and the charity, Maternity Action (Bryant, 2011), which specifically focuses on pregnant women. In the study, midwives reported high levels of maternal mental health concerns, with almost all women reporting high levels of stress and anxiety, and over half the women suffering from mental health conditions.
Descriptive phase
As a third year student, I had the opportunity to spend 2 weeks in an elective placement in a Trust outside of our own. I chose to work with a specialist migrant midwife. The specialist midwife provided antenatal care to women in the community, working from a small clinical room in the initial accommodation provided for those seeking asylum. The role had recently been created and as such, part of her job was to develop the service, identifying the needs of women and adapting the service to meet those needs. The position was created in response to the local demographic, which had seen an increase in women seeking asylum while pregnant, and a recognition that these women required specialist support. The specialist midwife worked closely with a community nurse and health visitor who were also based at the site. Women would come to see the midwife for all antenatal appointments, and receive labour care at the local hospital. Postnatal care was provided by the community midwifery team that covered the accommodation centre. I sat in on all antenatal appointments, including 3-hour bookings, listening to the experiences and stories of these women. I also spent time visiting some women postnatally with the community team. Translation services were used at all times, either face-to-face or through telephone translation services.
Reflective phase
What struck me instantly was the complexity of each individual woman's social and psychological needs. They each had competing priorities, and were navigating the complex asylum system in a language they did not speak, caring for children or elderly family members, worrying about the safety of their family, and making travel arrangements for appointments with no access to finance. This often meant that physical health and pregnancy was not always the first on that list. The midwife was able to provide holistic care that addressed the physical needs of pregnancy, but was also able to support these wider issues.
It became apparent that one reflective account would not be able to address all the many complex needs of each individual. As such, my reflection is in no way exhaustive. I have therefore synthesised a few of my reflections into themes that encompass my main reflections (Table 1): social support, anti-discrimination and communication. These themes are listed as subheadings below, which aims to improve clarity and facilitate the reflective discussion. As this is a reflective account, not a research study with ethical approval, I could not represent the voices of the women from my visit. The women's voices included in the reflection are therefore taken from a study by Lephard and Haith-Cooper (2016), in which quotations were transcribed from audio recordings to aid trustworthiness, and consent for inclusion was gained from participants. They are used here to support and further illuminate the reflections of my observational placement, showing commonalities between my findings and the voices in other publications.
| Psychosocial needs identified | Barriers to needs being met | Ways in which service meets needs | Themes |
|---|---|---|---|
| Support from a social network |
|
|
Social support |
| To feel safe and supported |
|
|
Antidiscrimination |
| To be asked about her care and listened to |
|
|
Communication |
Social support
Women described how they had been moved from all their social networks to accommodation in new cities where they knew no-one. This is a result of Home Office dispersal policy which relocates women across the UK (UK Visas and Immigration, 2016). As in previous studies (Psarros 2014; Lephard and Haith-Cooper 2016), the reality of dispersal policy for the pregnant women I encountered was that they had no control over their lives, had lost social support from family, friends and the community, and often experienced acute social isolation.
‘I have to start again from zero … I was pregnant. And I was sicking [vomiting] all the time. They bring me here … I didn't have nobody here.’
The specialist midwife was able to provide social support in a number of ways. Firstly, she was able to advocate for the women by writing to the Home Office to delay and appeal against decisions that moved women away from their communities (UK Visas and Immigration, 2016). This finding contrasts with qualitative research by Bryant (2011), which documents midwives having little understanding of the asylum system and a lack of confidence in their ability to advocate for women. Significantly, the inclusion criteria for this study meant that midwives did not have specialist roles, highlighting both the need for appropriate training, and the difference that specialist midwifery roles make to the health outcomes and experiences of women.
The specialist midwife was also able to provide continuity of carer throughout the antenatal period. Evidence shows that this improves health outcomes and psychosocial experiences (Dahlberg and Aune 2013; Sandall et al, 2016). The women I observed spoke of how regular visits to their midwives felt like meeting friends. Kirkham (2010) suggests that antenatal care is an ongoing and cumulative process, in which trusting and meaningful relationships are created between midwife and mother. This relationship, as witnessed in my placement, and supported by research (Bryant, 2011), can provide kinship to women at a time when they are feeling acutely isolated.
‘When I see V [community midwife] [had] come [to] see me, I was like, “All my family [has] come to see me!”’
The specialist midwife was also able to signpost women to appropriate local support groups. This helped women to meet others who were experiencing similar things, and who may have shared a language or country of origin. This is not something that is explicitly explored in the literature, which has more commonly evaluated the impact of befriending programmes to provide social support (McCarthy and Haith-Cooper, 2013). Further research in this area could help to determine the significance of signposting as a support strategy.
However, the midwife also recognised that a limitation of her role was her inability to provide this kinship during labour and the postnatal period. It was my feeling that women needed relational continuity that extended into the postnatal period. I felt that this would greatly improve their psychosocial experiences, as is shown in research by Dahlberg and Aune (2013), although I recognised that the specialist midwife could not have provided this alone. The argument for relational continuity is key in the recent National Maternity Review (2016), and seems fundamental in providing quality care for women who are seeking asylum and are often isolated. It may also be worth reflecting on the impact of the professional relationship ending at discharge, as this may be a point of vulnerability for women as they embark on early motherhood. However, as this was not captured in my elective experience, I am unable to comment on women's experience of this particular transition.
Anti discrimination
Asylum seekers are often victims of negative public perceptions (Waugh, 2010). Threadgold (2009) states that this can be partly attributed to attitudes generated by news media, which covers a very narrow portrayal of migration stories and is often keen to imply a burden on public resources. These ideas are further legitimised through political debates on immigration that often evoke the language of ‘invasion’ or ‘foreign threats’, conflated with concepts of crime and terror (Threadgold, 2009). The impact of these misplaced preconceptions was outlined clearly by those whom I observed, who felt victim to discrimination and isolated from the wider community. Findings by Psarros (2014) suggests that these experiences often extend to treatment from health professionals, and those seeking asylum also feel victim to hostility, negative stereotyping and racism.
‘Sometimes I feel like when I used to go in [to see the] GP or … in hospital, I feel like the doctors or nurses … not seen us with same eye like English people.’
The specialist midwife positively affected women's experiences by promoting equality, providing anti discriminatory care and using good continuity to develop trust. Women were regarded positively, and the midwife had a good understanding of asylum issues in a global context. Research by Social Care Institute for Excellence (2015), which is a transferable study and relevant to findings, shows that these factors contribute to a woman's ability to communicate her needs without fear of judgement, and to feel supported and understood. The care I witnessed was in line with the rhetoric of national guidance surrounding care for those seeking asylum, which is of kindness, respect and dignity (National Institute of Health and Care Excellence (NICE), 2010; NMC, 2015). It was my feeling that the midwife was authentic and had deep empathy with the stories of women. My findings are however in conflict with evidence by Phillimore (2014), which suggests that midwives often reflect stereotypes and prejudices in their attitudes towards the women in their care.
‘Asylum seekers are often victims of negative public perceptions, which can be partly attributed to attitudes generated by news media, which is often keen to imply a burden on public resources’
Communication
The women I observed all had low levels of spoken English and literacy. For some, this meant that they did not feel involved in their own care and did not feel listened to, particularly while in hospital. This echoes findings by Psarros (2014) and Feldman (2013).
‘They close [the] door, and started talking.’
The specialist midwife ensured that there was always a registered face-to-face interpreter present for booking appointments, and used telephone translation services for all other appointments. This is in line with NHS policy (NHS England, 2015), which states that if inadequately trained translators (including friends or relatives) are used, neither the health care provider nor the woman can be assured that accurate and effective communication is taking place. During my observation, communication was clear and sensitive, and time was taken to ensure that women understood fully and could ask questions. This also echoes guidance from the (NICE, 2010), which states that women should have access to interpretation services to be able to communicate clearly with health professionals, but contrasts with qualitative research, which has demonstrated that this is not always the case (Lephard and Haith-Cooper, 2016).
Kaur et al (2014) outlined some of the barriers that prevent appropriate use of translations services in health care, including a lack of availability, time constraints, and cost. In my eyes, the quality of the communication was underpinned by the time dedicated to listening, as bookings typically took up to 3 hours. I recognise that this is a luxury not all midwives have, and this further illustrates the need for specialist roles.
Anticipatory and insight phase
From my experience, my reflection is that high quality care in maternity services needs to recognise the complex nature of the psychosocial experiences of pregnant women seeking asylum, which will be unique to each woman. However, there are commonalities that run through the many experiences of those seeking asylum, which midwives can address. It seems fundamental that women need to feel safe and supported, which involves challenging societal prejudices and providing non-judgmental care that promotes equality. Maternity services also need to ensure that women feel involved in care, particularly when there are language barriers. This can be achieved through appropriate use of translation services and good communication skills to ensure that women are listened to, and have the opportunity to make choices. Women also need support from a social network. Good understanding of asylum processes can allow midwives to advocate for women to prevent them being moved away from their communities. This demonstrates a need for midwives to receive mandatory training that uses the evidence-based model, ‘The pregnant woman in a global context’ (Haith-Cooper and Bradshaw, 2013), as per NICE guidelines (2010), and for the development of more specialist roles. Midwives are also well positioned to signpost women to support groups, and to provide kinship and a meaningful relationship through good continuity at a time when women often feel alone.
Conclusion
This reflective account aimed to outline a few of the many factors that affect the pregnancy and birth for women seeking asylum. It has also acted as vehicle for me to better understand my own preconceptions surrounding asylum seekers. Before this placement, I had very little understanding of the experiences of migrant women. Following my visit, I recognise the danger of making assumptions about the health care needs of a group, rather than exploring the specific needs of the individual. It also struck me that often the medical discourse that surrounds those seeking asylum speaks of women's vulnerabilities; yet the enduring impression that I will take with me into my work as a midwife was the strength of those I met. By listening to the many diverse stories, I have a renewed respect for women's ability to endure and overcome adversity.