Migrant women experience poorer maternal and perinatal outcomes compared to settled residents in their host country, including 10 times higher mortality (Heslehurst et al, 2018; Gieles et al, 2019; Moore et al, 2019; Rogers et al, 2020). This is driven by language barriers, lack of understanding of the care system, perceived discrimination and lack of cultural sensitivity (Higginbottom et al, 2019; McKnight et al, 2019). While NHS maternity services are freely available to pregnant asylum seekers in the UK, current maternity services are not adequately designed to meet their needs (Phillimore, 2016).
It is nine years since the National Institute for Health and Care Excellence ([NICE], 2011) recognised that in order to create a benchmark of good practice, there was an urgent need for a detailed map of existing service models for migrant women. There remains, however, a lack of detailed knowledge regarding available service models, their interventions, and effectiveness, particularly in a UK context (McKnight et al, 2019, Pangas et al, 2019).
Maternity care at an initial accommodation centre
The NHS specialist migrant maternity service at King's College Hospital London cares for approximately 90 women per year. The service is unique in providing antenatal provision for migrant women within an Initial accommodation (IA) centre.
The Home Office manages seven IA centres in the UK which offer emergency housing to recently arrived asylum seekers (Home Affairs Committee, 2017). They are mixed-sex hostels designed for short-term stays prior to dispersal. Pregnant women, however, are not moved between 34 weeks' gestation and 6 weeks postnatal to avoid disruption to their maternity care. The UK Home Office does not currently have a method for recording pregnancy amongst asylum seekers (Migration Observatory, 2019).
Between 2015–2018, 72% of the women who used the service required interpreters, 56% had mental health needs, 26% were survivors of human trafficking, 69% required obstetric-led care, and 78% booked their pregnancy at over 30 weeks' gestation (Clarkson, unpublished). In order to improve access and outcomes for this complex group, the service has developed a number of innovative features (Table 1).
Table 1. Key features of the specialist migrant maternity service
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While these developments are aimed at improving maternity care and reducing health inequalities, they have not been directly guided by women's experiences and opinions (NICE, 2011). This is due to the practical challenges of language barriers and the dispersal system that this service evaluation attempts to overcome.
Methods
Theoretical framework
This service evaluation set out to establish how well the current service was achieving its aims (National Research Ethics Service, 2013). In-depth, one-to-one interviews using interpreters were chosen to understand vulnerable women's experience of care (van den Muijsenbergh et al, 2016; Fedyuk and Zentai, 2018). This provided confidentiality and overcame significant communication barriers that would make other forms of data collection problematic.
The interviews were semi-structured to provide a clear focus on service provision but allow the women to determine the relevant information (Dexter, 2006).
Setting and participant selection
Recruitment and interviews took place within the IA centre. Purposive sampling was adopted to recruit women who had used the service in the previous three months. There were 12 women this applied to.
Participant information sheets were provided in the women's native language or English. All the women were provided with an opportunity for clarification, questions, and formal written consent. For non-English speakers, this was achieved using the Language Line service, a private company that is contracted by the NHS to provide translation services over the phone, offering 240 languages.
A total of 10 women were recruited, of whom nine had recently had babies with the service, and one was currently pregnant. The participants covered a range of nationalities: Vietnamese, Chinese, Albanian, Nigerian, Afghan and Yemeni. Ages ranged from 23–37 years.
Interviews
A total of eight interviews were conducted face-to-face within the IA centre in a private clinic room and two were conducted over the telephone. The women were aware that the interviewer was a midwife and that she was not employed by the NHS Trust providing their care. The interviewer had never provided care to any of the women.
The interview schedule comprising 17 questions, was based on the NICE (2011) guidelines for ‘Service provision for pregnant women with complex social factors’ and Maternity Action's (2011) ‘Improving care for refugees and asylum seekers’. Interviews were scheduled to last an hour, although the length varied (ranging from 40–90 minutes, 60 minutes on average). A total of four interviews were conducted in English and six in the women's native language using Language Line via a speaker phone in order to translate questions and answers.
Data analysis
A general inductive approach was used to allow a framework of themes and relationships to be generated from the text using NVivo software for data management (Thomas, 2006). Braun and Clarke's six-phase procedure provided a structure for achieving this (Braun and Clarke, 2006).
A total of two researchers coded five transcripts independently (researchers AF and EA) and resolved differences to avoid idiosyncratic coding. The coding framework was then applied to the remaining transcripts and data saturation was reached after six transcripts (Glaser and Strauss, 1967). Collections of codes formed themes and text segments were assigned to these. The lead researcher (AF) then created a thematic map of associations and links. These themes were separated into positive and negative aspects of the service.
Findings
The process described above led to the creation of seven themes as summarised in Figure 1.
Positive themes
1. Accessibility of the midwife and referrals
Antenatal appointments
All the women concurred that having their antenatal care based in the IA centre was convenient and beneficial to their attendance (all women stated they had attended every maternity appointment provided to them). The majority of women were satisfied with the number and length of appointments, and expressed confidence that they could contact the midwife via phone, or in person, as necessary, including impromptu visits to her clinic.
Anytime I had any questions or any needs she were to answer me, even if I had an appointment or not.
Case 4
[The midwife] gave more time to people. I really enjoyed that aspect of it because when I am there, I am able share all my feelings, what I am going through, and she was able to help me.
Case 3
Continuity of care
The major ity of women (eight) appreciated seeing the same midwife for their antenatal appointments and valued the relationship, while two expressed indifference.
You can ask her [the midwife] for everything. She's not, not like mama but she's like big sister. She care about us-the sisterhood.
Case 10
[Interviewer] What did you think of having the same midwife each time?
I don't think it's important; anyone is fine.
Case 9
While it was generally felt that maintaining continuity for intrapartum and postnatal care would have been beneficial, they were realistic that this would be logistically difficult for the maternity service to achieve.
Referrals
Several of the women required obstetric and medical care during their pregnancies for reduced fetal movements, blood-borne infections, fibroids, breech presentation, antepartum haemorrhage and panic attacks. All of the women were positive about accessing this care and their experiences of it.
Women receiving input for mental health issues stated it had been arranged by the midwife at the IA centre, in some cases in their native language, and with follow-ups in their dispersal location if required.
2. Provision of essentials and transport
Attendance at hospital appointments and intrapartum transfer
All the women utilised the free bookable transport service in order to attend their hospital appointments and reported full attendance. All but one of the women (who had required an ambulance) had used the service for intrapartum transfer.
Basic material needs met
All the women were satisfied with the provision of essentials such as nappies, formula and maternity pads at the IA centre, as well as charitable denotations of buggies and additional baby care items. No unmet needs in this respect were identified.
[Interviewer] Have you been able to get all the things you need to care for yourself and your baby?
Yes, everything for the baby: nappies, wipes and also the sanitary towels for women. Everything.
Case 4
3. Respect and kindness
There was general positivity about their clinical experiences and all believed healthcare professionals would act in their best interests. All felt that their views were respected and listened to by healthcare professionals.
Availability of interpreters
All women reported that interpreters were always available at their IA centre and hospital appointments. Satisfaction was expressed at the quality of the Language Line service. There was no clear preference between telephone or in-person interpreters. All the women confirmed that they understood the rationale for all the care they received which reinforced the effective use of interpreters.
Gratitude
Their positive experiences of healthcare professionals engendered a general sense of gratitude that was reflected in their praise of each element of the service.
I am just so glad to all the midwives who attended for me during my pregnancy-they were all so good!
Case 3
I had an infection and I didn't know about it-they actually called me because they wanted to make sure I get my antibiotics and get my test. I mean, they actually wanted me to know about my reports; that's really kind and nice of them!
Case 1
Negative themes
1. Lack of nutritious diet
The women felt very strongly that the food available was not palatable, nor acceptable for pregnant and lactating women. Their lack of agency in being able to feed themselves and their children nutritious food was a major point of frustration.
They give too much of rice, pasta and french fries which are actually not good … I think we should [have] some way of cooking ourselves.
Case 1
The food in the [IA centre] that I'm breastfeeding my baby on, I don't know how, gosh. It's just fish and chips, just, ugh! Well, I don't know! The nursing mothers, what was coming out from our breasts was like water.
Case 3
Really, if we have kitchen, I would make what I need but I can't … I would make Arabian soup; it's good for breastfeeding and my children like it.
Case 10
Several of the women spoke of attending the Happy Baby Group to access fresh fruit and vegetables which they would surreptitiously take back to the IA centre.
So when we go to baby centres like that, or coffee morning, that's when we get fruit to eat, so we pack a lot of fruit! To last us a few days.
Case 3
2. Lack of facilities for hygienic formula preparation and storing breast milk
Women were not allowed to have kettles, fridges or steam sterilisers in their rooms due to health and safety regulations. Those who were formula feeding could access powdered formula and bottles from the IA centre reception, along with tubs and Milton tablets for cold-water sterilising. Boiled water for formula preparation could be accessed at reception and expressed breast milk could be stored in the reception fridge. Reception, however, was often not open when women needed access, particularly during the night.
Some women had secretly purchased kettles, electric sterilising equipment and even fridges to overcome this issue, and did not express any frustration with this arrangement. While others had adopted unhygienic practises, such as leaving breast milk out at room temperature for prolonged periods, making up bottles of formula in advance, or simply expressing their milk directly down the sink as there was nowhere to store it.
[Interviewer] What do you do with your breast milk? I just keep it there [points to chair next to cot] and then I give to him.
[Interviewer] Do you not have access to the communal fridge?
Err … actually there's a timing issue. Expression at night … sometimes when I go, it's locked and nobody opens. In that case, what do I do? It's better to keep it there [gestures to chair again].
Case 1
3. Lack of signposting to services
Lack of clarity about available services and their roles
The specialist service aims to work closely with other agencies relevant to this group. The initial point of contact in the IA centre for financial and asylum status issues should be the migrant help service which is also based on site. However, only two of the women used this service regularly and successfully while some were unclear about its role and others were unaware of the service altogether. The breadth of issues that women presented to migrant help service revealed a general lack of understanding regarding the service's role. If their request was refused, this incited resentment. When they were not directed to alternative services, women expressed anger, frustration and helplessness as a result.
[Interviewer] Who's given you guidance on your entitlements?
Yeah. Honestly, we didn't know who to go to for this problem. There's migrant help—but they wouldn't help, so not so great, and we would want that £300 but how to get it? Where to go? To whom, ask.
Case 1
[Interviewer] Have you required any help with your asylum claim?
I, actually, I would like legal help, or help that is, with my claim but I don't know how to get it or where to go to get some help.
Case 6
[Interviewer] Who's been giving you advice and guidance about getting your son into school?
Nobody. It's not good for him; he needs to go to learn how to write and read. He stays in doing nothing all day and it's bad for him [crying] … I really need [help] but I don't know, [pause] yes, I really need someone-this is the most important.
Case 4
When women were unaware of the migrant help service, they were reliant on forming relationships within the IA centre to find out information.
[Interviewer] How have you found out information about your rights in the UK, access to funds etc?
From the people here. Actually, …migrant help. We were here for a good four months; we didn't know about it. Slowly, slowly, we learn things. People who had stayed here for two months more than, we learn from them.
Case 1
The midwife role was poorly understood by the majority of the women. They were unaware they were receiving a specialised model of care and what this included. As a result, women were hesitant to address topics with the midwife beyond the immediate well-being of their baby and this contributed to not accessing appropriate services.
[Interviewer]What is your understanding of the midwife's role?
To check my baby's heartbeat … that's about it.
Case 7
Honestly … at that time, I thought she was just a midwife and this is something with the Home Office. I didn't know if she could help in that matter; I never asked her actually …
Case 1
While it was generally agreed that there was no expectation for midwives to have in-depth knowledge of exact processes, signposting to appropriate services would have been welcomed. The two women who had approached the Midwife, specifically about housing issues, were positive about the experience.
Lack of communication materials in own language
Women reported that written materials provided during their maternity care were always in English, regardless of their language status. There was a general agreement that the visuals were informative but ultimately the leaflets were of limited use or ignored altogether. All of those requiring an interpreter welcomed the idea of materials in their own language.
Lack of understanding and informed choice
The women stated they always understood the clinical rationale for their care yet six women felt language barriers affected their care negatively. Upon discussion, three women were unable to give a clear reason for their mode of birth. This suggested that understanding was not always achieved, despite the availability of interpreters, thus creating a culture of compliance.
[Interviewer] Do you think the language barrier affected your care?
Yes, of course. It's been an obstacle and I've suffered from that.
Case 8
[Interviewer] Did you ever feel discriminated against by NHS staff?
Yes, just because I don't speak English. So with the language barrier, I feel discriminated a little.
Case 9
Low expectations of service provision
Generally, women had low expectations of the care they were going to receive and were surprised by the quality of the service as a result. None of them articulated expectations beyond basic clinical care. Low expectations were formed by a lack of knowledge of what the maternity system in the UK might offer and a favourable comparison with the care they would have received in their own low- and middle-income countries.
Err … yes. You know this, this was my first baby here in this country so I don't know how it works.
Case 2
Where I was coming from, back home in Nigeria. It's, I think it's, it's … Nigeria is a developing country, you get? … I got something good compared to where I was coming from.
Case 3
I had not expected this much. I feel it is very good.
Case 1
Access to antenatal classes were an example of low expectations. Primiparous women (four out of the 10) were generally ambivalent about the need for them. Some had not received any, nor knew what they were, while others had attended a single session, although not always with an interpreter.
[Interviewer] Did you get any antenatal classes at all?
No.
[Interviewer] Would you have liked to have antenatal classes?
I don't know actually-if they're good?
[Interviewer] When you're a first-time mum, they can be useful…
Yeah, all that's good but now time is gone [laughs]! Yes, they would be useful.
Case 2
[Interviewer] Would you have liked antenatal classes in Albanian?
No. There were, like, pictures and I could get the gist of it.
Case 8
Identifying unmet needs
When asked if they had any unmet needs from their maternity care, women often struggled to think of any. The two women who did mention issues suggested they were to blame for it, again representing their lack of expectation and entitlement.
I think that, um, it was my fault … I hardly got out of the room for the first two weeks-that's how stressed and sad and depressed was I. So, I think it was more me not seeking help than them not offering help.
Case 6
[Interviewer] What did you think about the help and support with breastfeeding?
They couldn't do anything if I didn't have very much milk-they could only give me the advice so no, I am satisfied with that also.
Case 1
4. Lack of social support building
No labour companion
A total of five out of the nine women who had given birth had no labour companion. Those that did, one was with a social worker they had met the day before, two with their partners, and one with a friend they had made in the IA centre.
Unfortunately, I did not have anyone … it was difficult for me, being alone.
Case 6
Here, I felt I was alone because I was alone and I felt that the most because my first pregnancy I had many people around me.
Case 4
The idea of having organised support in labour was generally met with approval and the one woman who had had a social worker with her was very positive about the experience.
Yeah, she helped me a whole lot from the time that I was about to deliver to go in labour, and when I deliver baby, and during my stay in hospital-she helped me a lot.
Case 9
Others however, felt the addition of a stranger to the experience of labour would not have benefited them.
For me, I didn't need it. Maybe someone need it-but me, no. Sometimes when I am sad or something, I just want to stay alone.
Case 2
Childcare provision for labour admission
There were four women living at the IA centre with their other children, all aged under five years old. Arrangements for childcare for when they went into labour had been a source of anxiety and sometimes trauma for these women. Some made arrangements with friends, albeit relatively new acquaintances, or where no arrangement could be made, children were placed in social services for the duration of the mother's stay in hospital. This had a negative impact on the women's care.
A total of two women revealed they had delayed presenting to the labour ward due to last-minute childcare arrangements, with one of these resulting in an emergency caesarean section under general anaesthetic upon admission, and the other experiencing a precipitant birth, delivering 10 minutes after arrival. Both women admitted feeling pressure to leave the hospital prior to discharge in order to return to their children.
The baby was coming from morning but I didn't want to go to hospital because I see my children, how, where, I can put my children and where I can put … I wait, wait to 10 o'clock. Oh, I can't wait!
Case 10)
[Interviewer] Who looked after your children?
My friends here …Yeah, but it's not good, my friends, my friends here are not my real friends. So, I didn't sit in the hospital … I didn't finish 24 hours.
Case 10
When a child was taken into social services, it was traumatic for the parent and the child, notably if the child could not speak English.
I can tell you that after we were united again, together, um, you know, I can tell it has taken a toll on her and on me too, that you know, during those few days … she suffered emotionally while, um, I was separated from her [crying].
Case 6
It was also noted that the postnatal period in hospital could also be difficult for women on their own without a partner.
I forgot nappies for my children … so I ask can you give me nappies, but no, and oh my god, how will I make it? What can I make a nappy with? … It would be good if they have teams for the woman on her own, without husband.
(case 10)
Discussion
The 10 women interviewed conveyed a high level of satisfaction with the specialist migrant maternity service. The accessibility of their healthcare providers is perhaps the most significant as this is a well-established barrier for this vulnerable group (Malebranche et al, 2017). Women reported excellent attendance at appointments at both the IA centre and the hospital, and attributed this to the availability of the midwife and the bookable transport service. This infrastructure was also enhanced by the midwife's effectiveness at referring women to specialist appointments at the hospital and following this up. This is one of the many benefits of a continuity of care model (Homer et al, 2017). The consistent availability of interpreters is well-established as central to addressing barriers facing this group (McKnight, 2019) and assisted women in advocacy and informed choice.
While the positivity about the service is undeniable, it is necessary to consider this in light of the participants' low expectations. Any service that is aimed at this vulnerable group is required to offer holistic care that caters for their complex needs, even if the user may be unaware of them (NICE, 2011). The negative aspects of the service the women identified might seem beyond the remit of maternity care, yet, for a specialist model of care that is attempting to meet their variant needs, it is relevant.
The issue of maternal nutrition and access to infant-feeding essentials, for instance, is ultimately the responsibility of the IA centre. The IA centre was not designed however, to house women and their babies for months during a critical point in their well-being. Nevertheless, adequate nutrition and 24-hour access to hygienic infant-feeding preparation and storage equipment is essential for their health. As advocates for the women they care for, the specialist maternity team have a responsibility to petition the Home Office for the basic needs of these women and their babies, in the same way they advocated for free bookable transport to appointments.
NICE (2011) recommends that services aimed at this client group should provide a multi-agency approach, working with local agencies that provide other services for recent migrants, asylum seekers and refugees. Signposting to specific services however, appears to be a problem, particularly if the women do not approach the midwife with their needs. If women could be informed of the remit of the specialist maternity service at booking, they could perhaps utilise the midwife as an information resource and point of contact. Services, such as migrant help which the midwife can anticipate will be of use to all women, could be clearly communicated and their role explained. Ideally, this should be reinforced in written form in the woman's native language. If an expectation of care is established as early as possible, women may be more likely to desire, and engage with, fundamental elements of their care, such as antenatal classes.
Perhaps the hardest element for the service to achieve is ‘social support building’. Women arrive in the UK isolated and destitute. If women who require labour support and childcare for intrapartum admission can be identified at booking, and then efforts made in advance to address this (establishing a relationship with a social worker, for example), this would surely be beneficial. Additionally, if a true continuity of care model could be supported, women could have a familiar midwife in labour to improve their experience.
Implications for service provision
Seven service recommendations have been made as a result of this evaluation (Table 2).
Table 2. Service recommendations
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Conclusion
There is limited information available of existing service models for migrant women in the UK. While there is qualitative research documenting migrant women's experiences of maternity care in the UK, it focuses on establishing women's needs rather than their experiences of specific services designed for them.
The specialist migrant maternity service has developed unique strategies that successfully overcome potential barriers to care for this vulnerable client group and reduce inequalities in maternal health provision. This is reflected in the satisfaction conveyed by the participants. The negative aspects are, arguably, not within the immediate remit of the maternity team yet they negatively affect the health of the women they serve, and if the service is truly to offer a woman-centred and holistic model of maternity care for vulnerable women, they must be addressed.
Perhaps the most crucial of the service recommendations made from this evaluation is to communicate to women effectively what the service offers in its entirety. By raising women's expectations of the care they are entitled to, they can fully engage and benefit from the services available to them, for the best outcomes for them and their families.
Key points
- The specialist migrant maternity service has developed innovative strategies to overcome potential barriers to care
- Women expressed a high level of satisfaction with the service
- Women generally had low expectations of their care and were unaware of what was available to them
- The service must address the wide-ranging and complex issues raised by this vulnerable group in order to be truly meet their unique needs. A total of seven service recommendations have been made