Pregnant migrant women can be held in detention in the UK for a number of reasons. These include on arrival, while awaiting a decision on their right to entry; if they have been refused permission to stay and are awaiting removal; or if they are considered not to have the right of residency, having an expired or no visa or having been refused asylum. Pregnant migrant women are a vulnerable group, who may have fled their home for fear of persecution, having witnessed violence and/or lost family members. They may have been the victims of rape, torture, trafficking, forced marriage and sex working (Tsangarides and Grant, 2013; Public Health England, 2017).
Before 2016, around 100 migrant pregnant women were held each year in detention, often for prolonged periods (Tsangarides and Grant, 2013). Since then, following a Home Office review, women can now only be detained when necessary, for up to 72 hours (or up to a week in exceptional circumstances) (Home Office et al, 2016). However, it is argued that women are still being detained unnecessarily (International Detention Coalition, 2016) and that detention is harmful to their health (Tsangarides and Grant, 2013). Less than 20% of pregnant women who are detained are subsequently deported, a statistic that questions the value of detention in controlling immigration (Shaw, 2016)
Half of detained migrants have claimed asylum at some point in their immigration journey (The Migration Observatory, 2018), and pregnant asylum-seeking women are much more likely to have poor underlying physical and mental health, which leads to complex pregnancies and a proportionally higher risk of maternal and perinatal complications (Cantwell et al, 2011; Asif et al, 2015; Yelland et al, 2015). A case series review found that pregnant migrant women in detention were seven times more likely to have a high-risk pregnancy than the average woman in the UK (Pallotti and Forbes, 2016). In addition, the latest MBRRACE report (Knight et al, 2016) found that non-UK-born women made up one-quarter of maternal deaths in the UK and that 12% of these women were refugees. Stress associated with migration is believed to contribute to the poor health of pregnant women, increasing blood pressure, anxiety and depression (Brunner and Marmot, 2006). Anecdotal evidence suggests that poor conditions in detention centres can further exacerbate women's poor mental and physical health, even for a short stay (International Detention Coalition, 2016)
Pregnant asylum-seeking women are included in the National Institute for Health and Clinical Excellence (NICE) (2010) guidelines to improve maternity services for women with complex social factors. These guidelines, state that, considering their vulnerability, it is especially essential that women in detention receive good quality maternity care to maintain their physical and mental health. A study by the Medical Justice Charity (Tsangarides and Grant, 2013) found that migrant pregnant women held in detention lived in poor conditions and received inadequate healthcare; however, a systematic literature review found little published primary research to support this. Two previous studies have alluded to pregnant migrant women experiencing difficulties accessing healthcare in a detention centre (Feldman, 2014; Lephard and Haith-Cooper, 2016), but there is a lack of published research exploring this issue in more depth. Consequently, the aim of this study was to explore pregnant migrant women's experiences of living in detention, in order to understand maternity care provision and the effect of detention on women's health.
Methodology
A hermeneutic phenomenological approach was adopted (Todres and Holloway, 2011) to understand migrant women's experiences of being detained while pregnant.
Following ethical approval, participants were identified by cascading a request through voluntary sector networks. In addition, snowball sampling occurred through friends and peers. Participants were purposefully selected having had the experience of being held in detention for all or part of their pregnancy (Box 1). There was no budget available for interpreters, but the researcher, who is a senior midwife working in city with a large number of migrant women, assessed that the women had good spoken English language.
Due to difficulties recruiting the minimum sample size considered appropriate for this type of study (n=6) (Todres and Holloway, 2011), the same sampling approach was adopted to recruit two health professionals with working in a voluntary capacity with pregnant migrant women who had been detained.
In-depth interviews were undertaken with four migrant women and two volunteer health professionals. The interview began with an open question that enabled participants to talk through their experiences. Prompts were used to guide the direction of the conversation and further explore specific issues that were raised (Box 2). Each interview lasted around one hour. Interviews were conducted in a neutral, confidential environment, were audio recorded and transcribed verbatim.
Data were thematically analysed using Braun and Clarke's (2006) six-stage approach. This involved reading and re-reading the transcripts, coding the data, then grouping the codes into themes. Theme names and clear working definitions were developed. To reduce the risk of bias, the codes and themes were compared to the original data by the researcher's academic supervisor.
Ethical approval and participant safeguarding
Ethical approval was obtained from the local University Ethics Panel. Women and volunteers who expressed an interest in the study provided their contact details and were referred on to the researcher. A detailed explanation of the study was provided by phone, using the information sheet as a guide. A minimum of 24 hours was provided before contact was made again and a location arranged to undertake the interview. This began with revisiting the information sheet, explaining the consent form and gaining informed consent. Volunteers provided written consent, but verbal consent was obtained from the women due to the possible fear that providing a signature could affect their immigration status. The women were asked to confirm by saying into the audio recorder that they understood the information sheet and consent form and were happy to participate.
Assurances of confidentiality and anonymity were important for this study, and it was made particularly clear that these would be respected unless a concern arose about the safety of the woman or her child. In this case, a referral would be made, most likely through the voluntary sector. Women were reassured that the researcher had no links with the Home Office and that data would only be used for research purposes. Participants were informed that, should they change their mind, they would be able to withdraw their consent up until the writing of the final report. There was the potential that participants might recall upsetting experiences due to the nature of the topic, and so they were offered the opportunity to debrief following the interview and could be signposted to psychological support services if required. Anonymity was maintained by removing names of study participants and any organisations, and by allocating numbers to the women. Transcripts were stored in a password-protected computer file and locked filing box, accessible only to the researcher and her academic supervisor. Once transcribed by the researcher, audio-recordings were destroyed.
Findings
Of the women, two were from central Europe, one was from sub–Saharan Africa and one was from India. They were all experiencing their first pregnancy when held in detention, which lasted between 53-212 days. At the time of data collection, they were living in different towns and cities across the north of England, the Midlands and London. The two volunteers were trained midwives who were experienced volunteers in a detention centre. Four key themes emerged from the data: ‘challenges in accessing maternity care’, ‘exacerbation of mental health conditions’, ‘feeling hungry’ and ‘lack of privacy’. Verbatim quotations have been coded P1-4 for the women and HP1-2 for the volunteer health professionals.
Challenges in accessing maternity care
All participants recalled times when antenatal care had been disrupted due to a lack of available midwives in the detention centre. Midwives provided appointments, but there were not enough to meet demand. Consequently, the volunteers stressed that appropriately-timed care was not always possible. There was a lack of continuity of care, with women seeing a different midwife at every appointment, and women expressed that this was frustrating. In addition, midwives were not available in between appointments if the women had any concerns:
‘I would like to see the midwife because I would like to know what's happening … I just want to hear my baby heart beat … so I would wait all day but the midwife never come back to see me.’
Due to a lack of security staff to escort women to external appointments in the NHS, consultations were frequently cancelled:
‘I remember very well I had to for a scan … and they said, “no we don't have the security, we don't have so many people that can go with you.”’
Women described situations where they felt unwell and were not believed by the staff. One woman described how she felt ill and was made to wait for hours for an appointment:
‘I was feeling sore throat and high temperature … I had bad experience with urinary tract infections … I used to be trafficked woman … I told officer “please can I see doctor?” he told me “doctor will come later” … I feel like I'm dying, I couldn't walk … I feel like they didn't care for me … I feel like they treated me like dog.’
This woman was subsequently hospitalised with pyelonephritis.
One volunteer recalled a time when a woman with a history of ectopic pregnancy experienced vaginal bleeding. Her symptoms were not followed up by a nurse, despite seeing her sanitary pad:
‘She did rupture; she didn't die, but it was close thing.’
Exacerbation of mental health conditions
All the women had a previously diagnosed mental health condition, which they felt was exacerbated due to the circumstances in which they were living in detention.
‘I was depressed, I was stressed … just being isolated, no privacy, men walking in … feeling powerless.’
The volunteers stressed that detention staff did not recognise that mental health could deteriorate in detention as well as in pregnancy, with women not being believed when they expressed concerns about their deteriorating mental health:
‘When it came to mental health, it's only about what someone says; there's little physical to see, so the women were always completely dismissed.’
There also appeared to be situations where women were not given appropriate medication. One woman described how she did not receive her prescribed regular medication in detention, which negatively impacted on her mental health:
‘I feel suicidal … I was scared for my baby … what's going to happen next.’
In addition, appropriate referrals did not appear to be made for women who required support with their mental health:
‘I had a history of depression and you tell them … they are like, “oh yes, we will get in touch with a doctor” … but they never do.’
Feeling hungry
All participants discussed the food in detention. They all felt it was poor quality, unpalatable and did not provide a balanced diet. Not enough food was provided and there was inflexibility in the timing of meals. Participants described how women were offered food not suitable for pregnant women:
‘The food was appalling, like, it was basically just chips. They were supposed to provide a balanced diet but they didn't.’
‘The food was too spicy … I didn't like the food. I was vomiting all the time and just eating to keep surviving for my baby.’
One woman raised this with the staff, but was ignored. All the women felt hungry between meals, especially in the evenings, and were not allowed to take food back to their rooms for snacks. They therefore remained hungry.
‘I requested the manager to keep some food in my room because I get hungry at night … but they refuse … I was so upset … it is just food we are asking for—nothing else.’
Another woman described how she would conceal food such as biscuits in her room to eat during the night when she felt hungry.
Lack of privacy
All participants discussed a lack of privacy in detention centres. Male and female officers would enter women's rooms to perform random checks without any warning. This included when women were having a shower or visiting the toilet:
‘When I go to the toilet I feel scared there because the guards they can just come in at any time … I feel they can come in when I am changing … so I write a note and put it on the door and the male officer took and said I can't put anything like that.’
The women also described situations where there was a lack of privacy when they were taken for appointments in the NHS:
‘When the scan was going on the officer was also in … I kind of felt upset.’
‘We went to the labour ward … the midwife ask the guards to leave because she need to check me … the guard ask her to “leave the door open because we need to know what's happening.”’
There was also a concern about a lack of privacy when receiving care from health professionals in the detention centre. One health professional recalled an experience when a woman requested to be examined due to previous female genital mutilation. The clinic doors would not lock and she received five interruptions while trying to undertake the procedure.
Discussion
This study confirms that pregnant migrant women held in detention are subjected to conditions that can impact on their physical and mental health, and potentially that of their baby, supporting previous work (Tsangarides and Grant, 2013). In this study, women struggled to access timely and appropriate maternity care, and were ignored when they alerted staff to their health concerns. There was no continuity of care provided, and NICE antenatal care guidelines for timing of appointments were not followed (NICE, 2017). External appointments were frequently cancelled due to a lack of guards to escort the women.
Most women stated that they suffered from pre-existing mental health conditions, which were exacerbated by being in detention. These were ignored and medication was withheld. The Centre for Maternal and Child Enquiries (CMACE) report (Cantwell et al, 2011) specifically focused on deteriorating mental health in pregnancy, and recommending counselling and support services. In addition, there is a growing body of evidence to show that children of mothers who are exposed to stress in the antenatal period are more likely to develop childhood and emotional behavioural difficulties (Glover et al, 2010; Capron et al, 2015). It is therefore paramount that women are able to access mental health services.
It was anticipated that women would discuss their experiences of pregnancy through the prompts, and compare their care to the maternity care they subsequently received out of detention. However, in reality, the living conditions that women experienced were at the forefront of their minds, and feeling hungry was discussed by all of the women. Evidence shows that a mother's diet can influence fetal development (Englund-Ogge et al, 2014; Borge et al, 2017), and it is therefore important that migrant woman in detention have access to a healthy balanced diet.
Implications of findings
This study began before the 2016 Home Office review, when length of detention was reduced to a maximum of 72 hours. Women in this study were detained for between 53-212 days, and consequently, one could question the relevance of the findings. The small sample size of this study could also be questioned; however, it is argued that even short periods in detention can have a negative impact on mental and physical health (International Detention Coalition, 2016). If a woman's health does deteriorate while in detention, it is essential that knowledgeable staff act on this is in a timely manner to ensure that potentially life-threatening obstetric emergencies are avoided.
Health professionals and officers need to be trained to understand the health needs of pregnant migrant women and to manage deterioration in health, ensuring immediate access to services as required. They also need to understand the importance of flexibility around food for pregnant women and what foods are appropriate for a healthy diet. There needs to be a better understanding of privacy in detention, using a woman-centred approach and good communication skills.
None of the women in this study were deported following their detention and they continue to live in the UK. This therefore demonstrates the importance of providing good quality, uninterrupted maternity care while pregnant women are in detention, which can be followed-up when they are released back into the community. There has been a drive for improved maternity care in prisons in the UK, for example through the Birth Companions initiative (Marshall, 2010), and NHS providers undertake regular antenatal care that continues once women leave prison. A similar concept in immigration detention centres could ensure that migrant women receive the same level of care, and that they are prepared for community midwifery on leaving detention.
Conclusions
Pregnant migrant women in detention are a vulnerable group with poor underlying mental and physical health, which is exacerbated by the detention process. Vulnerable migrant women have some of the poorest maternal and perinatal outcomes compared to other women. It is essential that midwives who care for women who have been held in detention have an awareness of the experiences that women may have had, to ensure that women's physical and mental health are monitored throughout the remainder of their maternity journey.
Although this is a small study, the participants were living in different locations across the UK and the themes developed were generic, reflecting all participants' experiences. This study therefore adds to the small body of evidence on pregnant migrant women's experiences in detention. It is recommended that maternity care in detention is reviewed and the evidence from the care of pregnant women in prisons used to develop services.