Evidence suggests that across the UK, forced pregnant migrant women are increasingly becoming destitute (Carter, 2017; Petch et al, 2015). Forced migrants are people who have been coerced or forced to leave their home country for reasons including, but not limited to, a threat to life or livelihood, such as war, conflict, or natural disaster. Forced migrants include persons seeking asylum, refugees and people who have been trafficked (European Commission, 2020). Pregnant migrant women who are destitute are not able to work, legally, and do not receive financial support from the government (Dudhia, 2020). Forced migrants are sometimes living in poverty so acute that they cannot provide for themselves (Carter, 2017). Consequently, they often rely on charities, faith-based organisations or the goodwill of friends to offer them support. In extreme cases, they may become homeless. Many are also at risk of exploitation by traffickers or unscrupulous employers, including in the sex industry (Petch et al, 2015; Ukoko, 2007).
In the UK, pregnant forced migrant women can become destitute for a number of reasons. For example, it is common that asylum seekers entitled to welfare benefits experience administrative errors or delays, leading to a pause on their financial support (Petch et al, 2015). Even women who have been granted refugee status and thus have a legal right to remain in the UK are at risk of destitution because of administrative delays; asylum support ceases 28 days after being granted refugee status but a delay in receiving welfare benefits can mean an individual still fails to receives financial support or accommodation (Carter, 2017; Allsopp et al, 2014a). If a woman's application for asylum is refused or they come to the end of their asylum, they are not entitled to financial support, however they may still be unable to return to their home country (Ukoko, 2007; Allsopp et al, 2014a, Dudhia, 2020). Pregnant forced migrant women who have been denied a right to remain in the UK are considered undocumented migrants and, therefore, have no recourse to public funds. Arguably, forced migrant women fit within the National Institute for Health and Care Excellence (NICE, 2010) definition of women with complex social factors requiring enhanced maternity care. However, they are often charged to use the NHS.
Pregnant forced migrant women in the UK can have underlying poor mental and physical health, leading to more complex pregnancies (Aspinall and Watters, 2010; Asif et al, 2015). They have a higher rate of maternal and perinatal mortality than the general population (Knight et al, 2019) thus it is essential that the underlying causes of this disparity including poor access to services, social and economic disadvantage and lifestyle factors are addressed to maximise the chances of their pregnancy resulting in a positive outcome (Aspinall and Watters, 2010; Higginbottom et al, 2019; Shortall et al, 2015). Ukoko (2007) discusses the potential negative impact of destitution on pregnant women's health. It is important to understand women's experiences of pregnancy and destitution, including their specific needs to maintain their health, to allow for the provision of midwifery care that meets these needs.
A review of the literature revealed little published research around the experiences of forced migrant pregnant women who are destitute. Much of the literature is unpublished reports found on voluntary sector websites. Nyiri and Eling (2012) undertook a survey of 112 attendees to a specialist GP London-based clinic for destitute refugees and asylum seekers. The sample included 10 pregnant women in the second and third trimesters of their pregnancies. The participants received no formal antenatal care and generally had poor physical and mental health. It is estimated that around 20% of maternal deaths in high income countries are the result of women not receiving adequate antenatal care (Downe et al, 2009) and being destitute could influence the decision on whether to attend. It is important to understand women's experiences of accessing midwifery care, so that their needs can be met. In particular, it is necessary to understand how midwives, other health professionals and voluntary sector services can best support women in this position. In addition, evidence is needed to change national and local policy to ensure women and their babies avoid destitution and remain safe and healthy. This article reports on a phenomenological study undertaken with the aims of exploring forced migrant women's lived experience of being pregnant and destitute and understanding the gaps in support for these women, in order to influence local and national policy and address these gaps.
Methods
A hermeneutic phenomenological approach was undertaken to understand how forced migrant women interpret and find meaning from their lived experience of destitution during pregnancy (Jacobsen, 2017). Women were purposefully recruited via local voluntary sector groups, word-of-mouth, and friends and peers. An element of ‘snowballing’ was important to access women who may be hard to reach but fit the study inclusion criteria; women recommended their peers for interview.
The inclusion criteria were forced migrant women who had been destitute at some point in their pregnancy, were over 18 years old and had a baby within the last 2 years. Women who had an adverse pregnancy outcome were not included.
A pilot interview was undertaken with a refugee woman to test the wording and cultural acceptability of the questions. In-depth interviews were then undertaken with six women who had experienced destitution at some time whilst pregnant. Six participants is considered the minimum number to obtain rich data in phenomenological studies (Todres and Holloway, 2011) and because of difficulties finding women to participate, six interviews were considered a pragmatic approach to ensure contemporary data is presented. The interview questions were framed in a way to encourage participants to explore their lived experiences of being pregnant and destitute. Women were asked to broadly discuss their experiences, and the interviewer followed up with additional prompts (Box 1). Interviews were audio recorded and data were transcribed verbatim by the researchers. The interviews were undertaken in a location convenient to the woman either in a voluntary sector office space or her home. The interviewers were two experienced voluntary sector workers (first and second authors) who were known to the women. Although this helped to build trust during the interviews, the interviewers were not migrant women. To ensure the authenticity of the findings, the research team agreed the themes and direct quotes to include within the article.
Box 1.Interview guidePreliminary questionsWhere are you from?When did you arrive in the UK?What has life been like for you in the UK?How many family members do you have over here?How did you feel when you found out you were pregnant?Maternity care and pregnancyDid you see a midwife when you were pregnant?Did you feel you could trust her and tell her about your situation?Did she help? If so, how?How was your health in pregnancy?Were you ever referred to hospital during your pregnancy?Do you think your health was affected by your destitution? If so, how?Living situationWhere were you living when you first became pregnant and what happened next?What stage of pregnancy were you in when you became destitute/had nowhere to live?Was there a specific reason you couldn't get a place to live?What did you do?Where did you stay and what was it like?Was it suitable for a pregnant woman? How?Was there anyone you could turn to for help and, if so, how did they try to help you?Did you know of any person/organisation or community group that could help you?Did you attend a group for pregnant women and, if so, what was that like?Did you meet any women in the same situation as you?Did you share your experiences? Could you help one another?Lack of moneyHow long were you destitute for and at what stage of pregnancy?How much money did you have to live on and how did you spend the money?How did you feel physically?How did it affect you emotionally and mentally?Was there anyone you could talk to? What kept you going?How do you feel destitution affected your pregnancy? Your baby?GeneralWhat did you feel you needed most in your pregnancy and how could we help ensure women in the future receive this?
Ethical issues
Ethical approval was granted by the Chair of the Humanities, Social and Health Sciences Research Ethics Panel at the local University ref E640. Women who expressed an interest received an information sheet and were phoned by the researchers to arrange an interview. English language ability was assessed by an experienced voluntary sector worker familiar to them and an interpreter identified if required.
Prior to the interview, verbal consent was obtained via the audio recorder. A signature was not requested because of the possible fear of it being acquired by the Home Office, influencing their migration status. Anonymity and confidentiality were assured, and it was stressed that the researchers had no link with the Home Office and the data would only be used for research purposes. Audio recordings were destroyed once transcribed, and the transcripts were stored in a password-protected computer file accessible only to the researchers. To enhance anonymity, minimal demographic data were obtained. No quotes were included that would allow a participant to be identified.
As a result of the nature of the subject, the researchers were aware that participants may be describing some difficult experiences. If the participants appeared uneasy or distressed, the researcher offered to pause and wait until the participant felt able to continue or discontinue the interview. In either case, the participant was debriefed and signposted to counselling services, if required. Participants were informed that they could withdraw their consent within four weeks of the interviews and their data would be destroyed.
Data analysis
Thematic analysis was undertaken, guided by Braun and Clarke (2006). Codes were identified from the data then grouped together to form working categories. Similar categories were then merged together to create the final themes. All the research team approved the final themes to ensure rigour in the process.
Results
All women who participated in this study originated from different countries in the African subcontinent. They had lived in the UK for 1–10 years and four of the women required an interpreter. Their sociodemographic characteristics are displayed in Table 2.
Table 2. Sociodemographic information
| Home country | Time in the UK (years) | Interpreter required? | |
|---|---|---|---|
| Woman 1 | Sudan | 1 | Yes |
| Woman 2 | Sierra Leone | 9 | No |
| Woman 3 | Ethiopia | 10 | Yes |
| Woman 4 | Sudan | 1.5 | Yes |
| Woman 5 | Zimbabwe | 2 | No |
| Woman 6 | Eritrea | 9 | Yes |
From the data, four themes emerged that represented the women's lived experiences of destitution in pregnancy: having nothing, a place to call home, suffering mental and physical health issues, and searching for support.
Having nothing
All the participants discussed their experiences of scarcity during their period of destitution. Four women were destitute when their pregnancy was confirmed and the remaining two women became destitute in early pregnancy. In both cases, the women's partner forced them to leave home because of the pregnancy.
‘The relationship with my partner was not working, a bit of violence, and then he broke up with me…and then… I was destitute’.
W2
Every participant interviewed was refused financial support from the Home Office or their local authority. One woman who was seeking asylum was accused of working illegally in a salon and her application for support was refused. Other women had been refused asylum and were appealing the decision. One woman was refused support when she applied for asylum because she told the Home Office she had somewhere to live. In reality, she was only allowed to stay with a friend for two weeks, after which she became destitute until the end of her pregnancy. She was not informed that she could apply for accommodation or financial support once she became homeless. One woman remained destitute until she was 6 months pregnant, whereas the remaining women were destitute until they were term or in the early postnatal period.
Despite having nothing, many of the women discussed their fear of being charged for maternity care because they had no recourse to public funds.
‘…£519, £900, the other one was £1000 something….visit for maternity, visit for the diabetic clinic…I was shocked and I was disturbed and I was frightened. I was thinking how, I don't think I'm going to give birth in the hospital. Where am I going to get the money?’
W5
For each of the women interviewed, the central impact of having nothing was hunger. During their destitution, women went without eating for prolonged periods of time.
‘Sometimes I would live for the whole day I didn't eat’.
W2
This feeling of hunger was exacerbated for women who were exposed to food in different contexts but couldn't eat because of a lack of money. This was also the case for women who were offered food but could not eat it.
‘When she was wanting to eat something, or she will smell it, but she can't get to it because she's got no money’.
W6
‘I vomit a lot, I can't like……keep down…and then because I don't want to disturb people…so whatever they cook I try… I tried to push myself’.
W3
Some of the women accessed small amounts of food through charities.
‘I eat some of the food, and I was poorly, I got a runny tummy, I had a fever, I was really poorly. I had no option, that's the only food I have’.
W2
A place to call home
All the participants discussed their negative experience of living in poor and precarious conditions while they were pregnant and destitute. None of the women interviewed had a permanent living arrangement until they received Section 4 support from the Home Office after week 34 of their pregnancy. In the meantime, they moved around different types of accommodation. One woman had to leave her home when she separated from her partner and became destitute at this point. She slept in the internal stairwell at the entrance to the block of flats in which she had lived. She ensured she was not seen by vacating the flats in the daytime.
‘I wait till people go in, late, a little bit later because you know the fire exits, the stairs, people don't use them that much. They use the lifts before they come in the morning to clean, the council cleaners come and I'm out’.
W2
All the women ‘sofa surfed’, moving around between different friends' houses. This involved living in cramped conditions and sleeping on a settee or even the floor. Despite this, many women described feeling grateful for having somewhere to stay.
‘I can sleep on the floor, it is better for me than to stay in the street’.
W1
However, women also described feeling uncomfortable for intruding on their friends' lives and privacy.
‘Because one of my friends she's night shift working and she sleep in the daytime, and then her house very tiny, and then I don't want to disturb her…and then when I go to toilet her toilet…I am scared to flush because I don't want to disturb her, so I want to stay outside, better for me, I go outside every time’.
W3
As previously stated, all women were eventually provided with accommodation by the Home Office. Their experience of Home Office accommodation varied, and some women told researchers that they did not always feel safe.
‘The lady..she was staying in the opposite room…if I come out the room..she start calling me names…I was shaking like this and, that's the only entrance…I was so scared, she did it once, she did twice, she did it three times, it was what she was screaming, she stands on the stairs blocking me not to pass, not to go down. And then I said ‘what have I done to you… you don't know me, I don't know you’.
W2
Women also discussed how the Home Office accommodation they were provided with was not suitable for a pregnant woman or a woman with a new baby.
‘It was bad, the conditions…the living room, it was smelly…the sofas they were dirty, they stink, they smell, believe me as soon as you enter it was so dirty, the carpet was full of stain’.
W2
Suffering mental and physical health
All of the women who participated in this study reported a deterioration in their mental health. They described feeling scared, lonely, helpless, traumatised, sad, vulnerable, ashamed and angry.
‘I imagine how can I survive with a baby, like more scary, and then at the same time happiest, because I feel, oh I have a baby, and then in the future like you are going to be mum like that I feel, two confusing feelings’.
W3
Other women described feeling very depressed, with thoughts of giving up and committing suicide.
‘I feel weak. I feel tired, I feel hopeless. I feel like there is no hope for me, there is no life. I nearly give up’.
W2
Despite the danger posed back home, one woman described how she was so desperate in her current situation that she wanted to be at home with her parents.
‘I want to go back to my country because there is not anywhere to stay here, there is no house for us, I am crying all the time because I know I don't like to be here’.
W4
One woman was granted section 4 support by the Home Office at the end of her pregnancy and was subsequently dispersed to a new city where she did not know anyone and gave birth alone.
‘It broke me a lot because I was lonely, I had no-one to talk to, I had no-one to say, no-one just to give me just 5 minutes break, “can I just hold the baby for you?” Just for 5 minutes’.
W5
Once their period of destitution ended and their baby was born, most women described an improvement in their mental health.
‘When she gave birth, she was so happy…she didn't forget everything, but she started forgetting some things and that's because she was in a better place, she had just giving birth to a healthy baby and she was healthy….she had a baby and that was hers’.
W6
However, one woman developed postnatal depression, which she felt was a result of the social isolation and loss of healthcare because of being dispersed to a new city.
‘I thought I was a strong woman…I could face anything…But now considering the dispersal to (new city)…it broke me a lot because I was lonely, I had no-one to talk to’.
W5
It is noteworthy that multiple women described being ‘broken’ by their precarious and isolated experiences. Another concern for women throughout their period of destitution was their physical health. Weight loss because of a lack of food, insomnia and headaches were commonly experienced. One woman described how she developed pelvic pain in pregnancy that affected her mobility, to the point that she had to crawl to move around. Another woman developed gestational diabetes that was poorly controlled because of not having the money to eat properly.
‘I was going to the GP, my diabetes was high by then just after giving birth and I was shaking’.
W5
Searching for support
Women discussed their experiences of trying to get support from different places to help them meet their basic needs. Most of the women interviewed understood the Home Office and their local authority to be the main sources of support. However, they were all informed they were not entitled to receive any help until 34 weeks into their pregnancy.
‘Sometimes she take her luggage and everything and they tell her go away straight away and they didn't give her any house and (she) even (had) her bags with her’.
W1
Another woman applied for section 4 support at 34 weeks gestation but did not receive anything until the baby had been born and she was discharged from hospital to new accommodation.
‘Till she has her baby…two days only they give her this house and they didn't have anything, there is no bed, no anything’.
W4
One woman described feeling intimidated by social workers, who had previously stated that they could not help her because of her immigration status.
‘That's the time they start calling me, they start coming around, they start pushing themselves to me they start saying that if I see my ex, they were going to take my baby from me at that time I was pregnant… The time I needed you guys, you said I'm not entitled to, you can't help me. They said at that time you were not entitled to public funds’.
W2
Another woman described how she was left destitute until 37 weeks gestation, when Home Office section 4 support started. She was dispersed to a new city where she knew no-one and lost her social support, midwife and doula.
‘It was a strange city. I haven't been in ***. I didn't know anything and what they did was just give me a couple of papers to look, to find my way through to the new GP, to the hospital….I didn't have a midwife’.
W5
All the women interviewed relied on the voluntary sector to get support when they were destitute. They were signposted to sources of support for food and other basic necessities. Some women were also housed in temporary accommodation. However, the voluntary sector could not always help.
‘They didn't want to host me, that shelter, because I didn't have my UK residency’.
W2
Women discussed how voluntary sector workers, as well as independent members of the community went out of their way to support them. Some helpful individuals wrote to the Home Office about women's circumstances. They also helped one woman by sourcing her and her new born baby furniture for their new empty house, going to buy the food, and picking up medicines.
‘She (voluntary worker) has to go and get me paracetamol. I was not able to go out. She has to go shopping for me and bring food. There was a lady who used to work with her they used to come pick me up and go and help me for shopping’.
W2
The women discussed how they relied on the kindness of friends and neighbours to help them out with food and somewhere to stay.
‘A gentleman called B who used to bring the shopping round every week…that really touched her heart…she classes him as a grandad. He was so nice and he would come round and give her 20 pounds, just so that, you know, it would be a help toward her transportation, because she had no money obviously and yeah, she thinks very highly of him’.
W6
Some women also relied on the local church.
‘I am going to church, and then I meet my other, my country people, and then they help me sometimes because they know I am (have) not nothing..they give me like £5, like that, for bus’.
W3
However, one woman discussed how she avoided relying on friends who were the same ethnic background because of the fear of gossip.
‘There is something, with the African people, you don't want people to know about you, because they gossip. So, there's a point in time I prefer to just struggle on my own, then I go and meet someone who is from the same country or the same colour I was scared of what they would say behind my back’.
W2
Some women described how they attended a specialist antenatal support group run by the voluntary sector which provided them the opportunity to gain support from their peers.
‘They help her and she said she sometime talking to them it make her happy as well’.
W1
The classes included socialising but also learning about pregnancy and childbirth.
‘Chatting and each one themselves they are pregnant…massage, everything, it was very wonderful, and as well..I learn a lot about pregnant, how it will happen, the step’.
W3
Women discussed the support they received from midwifery services. Some women had been referred to specialist migrant women midwives and found the midwives understood their needs beyond the pregnancy.
‘Because when a person gets pregnant, you're an asylum seeker, if you're a refugee and you get pregnant, you're in a certain country, new laws, new policies, new things, no-one, you have no-one. It's like in middle of nowhere in your life but you are with, someone (midwife) comes to you, to your rescue, listens to whatever rubbish you're saying, crying whatever, talking whatever but listens to them, gives you advice.’
W5
However, despite this, midwives could not always help the women overcome their experiences of destitution.
‘My midwife, her name is P, she was very kind and lovely and she tried to help us because every month she came to see me in new house, yeah. And, she tried, but you know that the council say… we can't give you a home now… in the beginning of my pregnancy… where can I stay?’
W4
Experiences of midwifery care in hospital varied, with some women describing a lack of continuity of care in hospital as a negative experience.
‘Yeah, and then I will tell them, because I, my feeling like vomiting, and then they refer me in hospital, and then they have midwife, but every day different midwife, not like the same one.’
W3
Another woman (who was homeless and alone) was advised to return home when her membranes spontaneously ruptured until her contractions became more established.
‘Ah, we don't have bed, you have to go back house,” she said she can't go back, and then she stay downstairs in the…(hospital) coffee shop So painful. Yeah, everyone seeing me’.
W3
However, other women described positive experiences.
‘The midwife in the hospital where I gave birth, they had to tell the social worker to leave me alone, I just went through caesarean, I am not strong enough, they should stay away for the moment. The midwife had to intervene.’
W2
Discussion
This study confirms that migrant women who are destitute in pregnancy face many difficulties that impact their mental and physical health. These difficulties relate to having no money for food, being homeless and having to move around frequently. For the majority of their pregnancies, women could not access support they needed from the Home Office or their local authority. Midwives were generally seen to be kind and helpful. However, the extent to which they could help women in this context was limited. The findings add to the evidence around pregnant migrant women and destitution. It supports previous studies around the impact of destitution on people more generally (Fitzpatrick et al, 2016; Dudhia, 2020; Allsopp et al, 2014b). It also supports previously published research that includes some discussion of destitution in pregnancy (Lephard and Haith-Cooper, 2016), although this study was small and therefore limited in its transferability.
Hunger was the prevailing difficulty for women who didn't have the funds to buy food and relied on charity and friends to feed them. Often the women could not eat the food because of pregnancy nausea and one woman described how eating food past its sell by date made her ill. This reflects previous research around the experiences of destitute people (Fitzpatrick et al, 2016; Allsopp et al, 2014b) where hunger was found to be the biggest issue and food they received from sources, such as charities and friends, was sometimes inadequate. For instance, dried pasta or rice is not appropriate as a donation for those with no access to kitchen facilities. It is well documented that the nutritional status of women in pregnancy, especially in the first trimester, impacts on embryonic development and can lead to small for gestational age and preterm babies (Ramakrishnan et al, 2012). Therefore, it is essential that migrant women who are destitute have access to a well-balanced diet.
In this study, all the women were homeless for the majority of their pregnancy and had to ‘sofa surf’, moving around different homes and often sleeping on the settee or floor. In the daytime, many women felt obliged to leave the house so as not to become a burden on the residents. In addition, when women were provided temporary or permanent housing, this was frequently considered inappropriate and unsafe for a pregnant woman or new mother. Poor living conditions are unlikely to support good health in pregnancy because of poor quality sleep, increased stress and a lack of shelter in the daytime. In this study, unstable living conditions also led to an interruption of maternity care, when the opportunity of accommodation involved moving cities. This reflects findings from previous studies, which focused on the impact of dispersal in pregnancy and the impact on women related to social isolation and interruptions to healthcare (Lephard and Haith-Cooper, 2016; Feldman, 2014). A woman in our study was moved to a new city and had gestational diabetes, and the interruption to her care could have been life threatening.
All the women reported that destitution had a negative impact on their mental health, reflecting previous research (Fitzpatrick et al, 2016, Allsopp et al, 2014b). Forced migrant women can have poor underlying mental health becauase of their experiences of violence and conflict back home, losing their family and support networks and the hostile environment they may face in their host country (Zimmerman et al, 2009, Merry et al, 2017). Poor mental health in pregnancy can lead to preterm birth and low birthweight babies (Stanevaa et al, 2015). Antenatal depression is a risk factor for postnatal depression (Gaillard et al, 2014) and an exacerbation of mental health symptoms because of destitution can only increase the likelihood of women developing severe postnatal depression.
Women in this study sought much of their support from the voluntary sector, reflecting previous work. A Joseph Rowntree Association report found that people who were destitute had positive experiences of the voluntary sector in accessing food, clothes and toiletries (Fitzpatrick et al, 2016). In this study, women reflected on experiences of voluntary sector workers going above and beyond their role to support women in difficult situations. The Home Office and local authority were criticised by the women interviewed in this study as being unhelpful and rigid until they reached 34 weeks gestation. Even then, support should take five days to process. However, women were often left waiting until the early postnatal period before any support began. It is essential that women are healthy in early pregnancy to promote embryonic development, however there is no system in place to support destitute women at this stage in their pregnancy. In addition, support should not include dispersing women to a new city during the Home Office defined protected period of 36–42 weeks gestation (UK Visas and Immigration, 2016). For one woman in the present study, it led to a loss of her midwifery care and she gave birth alone, having lost her doula support. She became socially isolated and developed postnatal depression. Although this study found numerous positive examples of voluntary agencies, religious groups and individuals helping forced migrant women, this help is a poor substitute for the core provisions women need from their local authorities.
This study is limited, with a small sample of women who all originated from the African subcontinent. This was likely because the study was advertised through word of mouth and these women may have been in a similar social network. However, the women had lived in the UK for 1–10 years. More than half the women interviewed required an interpreter, which may have provided an insight into a group of women who are seldom heard because of language barriers. Data were not collected relating to the NHS Trusts in which the women received their midwifery care, and it became apparent that some women had experienced good quality care from specialist midwives but not always from hospital midwives. No other published midwifery research could be found related to destitution in pregnancy, therefore these findings provide an insight to a phenomenon not previously explored.
Implications for midwifery practice
Although this study found examples of positive midwifery care, some women felt that the midwives were limited in what they could do to help. A recent systematic review found that migrant women described positive healthcare professionals as ‘caring, confidential and openly communicative in meeting their medical, emotional, psychological and social needs’ (Higginbottom et al, 2019). In this study, women described experiences where specialist midwives were clearly knowledgeable and caring; for example, midwives offering to write letters of support for women to the Home Office. However, midwives were not always able to meet women's social needs, including the need for a home and funds for food. Further, the evidence suggests that women did not always experience appropriate care from hospital midwives. Clearly, when advising forced migrant women about their care, midwives need to consider the implications of this from a holistic perspective. Advice to return home in early labour if the woman does not have a home is not an appropriate response. A way of considering forced migrant women's holistic needs is by referring to the ‘pregnant woman within the global context model, placing the woman at the centre of her care and considering her wider holistic needs within a local, macro and global context’ (Haith-Cooper and Bradshaw, 2013). In thinking of the women in their care within their wider global context, midwives can better visualise the social and political challenges forced migrant women face, such as destitution. Although midwives are not in a position to change these material outcomes, a greater acknowledgment of forced migrant women's experiences can lead to more sensitive care and support.
A systematic review found that midwives need to provide care underpinned by team work across multiple agencies (Fair et al, 2020). The present study demonstrates how midwives need to work in collaboration with the voluntary sector, the Home Office and local authorities, to ensure destitute migrant women do not fall between the gaps in support. To work with a holistic approach, midwives may benefit from increasing their knowledge of migrant-specific voluntary services to direct women towards. In addition, midwives who are aware of some of the legal issues surrounding migrant women's access to support can be more helpful to vulnerable women, as this study shows, because they can engage with the Home Office to push for support.
There are specialist midwives in areas of the UK who have been trained to understand the wider holistic needs of forced migrant women. Increasing the provision of specialist midwives could improve support for women in other areas. In addition, the voluntary sector antenatal groups run for forced migrant women are an example of good practice where women feel well supported, make friends, and are signposted to other services, such as mental health support and learn about pregnancy and childbirth. In the context of this study, an antenatal group was run by the National Childbirth Trust and similar voluntary sector models could be implemented across the UK to ensure women have the same opportunities.
Conclusions
Being destitute while pregnant is an important issue that can affect forced migrant women's mental health and also the physical health of the mother and baby. There is very little research focusing specifically on pregnancy, forced migrant women and destitution. This study found that women were hungry, had nowhere to live and relied on support from friends and the voluntary sector until they could apply for section four support from the Home office at 34 weeks gestation. It is important that midwives are able to identify specific risk factors in pregnancy experienced by forced migrant women who may be destitute. Also, that all midwives are knowledgeable about destitution and how they can help, which could be achieved by training more specialist midwives. Destitution in pregnancy is a real issue for forced migrant women and their need to be changes to policy to ensure women do not have to wait until 34 weeks gestation before they can apply for Home Office support.
Key points
- Increasingly, forced migrant women are becoming destitute at some point in their pregnancy.
- A dearth of published midwifery research exists that examines migrant women's lived experiences of destitution and the impact on their health and wellbeing.
- This study found that pregnant destitute women do not have enough food, can be homeless and have poor physical and mental health.
- There is a gap in support provided by the local authorities before 34 weeks gestation and midwives need to be active in calling for a change in policy to avoid women becoming destitute.
CPD reflective questions
- Reflecting on a recent experience when you have cared for a forced migrant woman, how did you consider her holistic needs in your care plan?
- How could you tailor your advice about healthy eating when you care for a forced migrant woman?
- How much emphasis do you place on a woman's home environment when you provide care?
- What do you think are some of the risk factors and wider social and political causes of destitution in pregnancy experienced by forced migrant women?
- What voluntary sector services exist in your area to support forced migrant women who are destitute and how would you work with them?