The number of refugee and asylum-seeking women of reproductive age who have migrated to the UK has considerably increased in the last 60 years (Office for National Statistics, 2013). A refugee is recognised by a country's authorities as an individual who is unable to return to his or her country of nationality for fear of persecution for race, religion, nationality, political opinion or social group (United Nations High Commissioner for Refugees (UNHCR), 1951).
Refugee and asylum-seeking women are often physically, socially and psychologically vulnerable, owing to past experiences (Feldman, 2013). They have a range of social and sexual health needs, which can include suffering from the consequences of female genital mutilation (FGM), sexual violence and exploitation, or sexually transmitted infections (STIs) due to inadequate contraceptive use (Wilson et al, 2007), all of which are issues that frequently result in poor mental health. These women have been highlighted in clinical guidelines as a disadvantaged group needing enhanced maternity care (National Institute for Health and Care Excellence (NICE), 2010). Evidence shows that refugee and asylum-seeking women have a significantly higher rate of maternal mortality and incidence of stillbirths than White British women (Lewis, 2007; Gardosi et al, 2013). This is primarily due to migrant women not engaging with sexual and reproductive health services, or receiving inadequate care, which exacerbates existing problems (Raleigh et al, 2010). Midwives, as part of a wider multidisciplinary team, have the unique opportunity to support this vulnerable group to meet their health needs during pregnancy, promoting the best outcomes for women and babies.
The social context
Migration, the asylum process and resettlement is a complex and distressing experience, which leaves many women destitute (Feldman, 2013). When arriving in the UK, Home Office policy outlines that pregnant women should not be detained in custody for immigration purposes (UK Visas and Immigration, 2015). However, recent research has shown that this is not reflected in practice. Tsangarides and Grant (2013) reported that many women in their sample had a history of torture, rape and trafficking, and experienced inadequate maternity care and poor living conditions while in detention, with very few eventually deported. This research involved a small sample, and because the Home Office does not hold records of pregnant detainees it is difficult to assess how many refugee and asylum-seeking women are affected by this process (UK Visas and Immigration, 2015). However, it is a comprehensive study, utilising and comparing diverse sources of data including health and immigration notes and full interviews with women involved, to analyse their mental and physical health while in detention and the level of care they received (Tsangarides and Grant, 2013). The study has the endorsement of national bodies (Refugee Council, 2013; Griffiths, 2015), as no pregnant woman should experience maternity care that falls so far short of national standards (NICE, 2012).
The poor socioeconomic status of refugee and asylum-seeking women has been highlighted in other research, where women have reported being unable to afford public transport to appointments, food for a healthy diet or necessities such as baby clothes and nappies (Taylor and Newall, 2008; Phillimore, 2015). They are also faced with a number of competing priorities, such as gaining employment and securing housing; consequently, they often neglect their health needs (Hach, 2012). These issues make refugee and asylum-seeking women vulnerable to exploitation and have been linked to high levels of low birth-weight babies (Henderson et al, 2013) and postnatal safeguarding issues (Price and Spencer, 2015). It is clear from research evidence that many refugee and asylum-seeking women lack knowledge regarding their entitlements, but also that these monetary benefits are often inadequate to enable women to support themselves and their families (Taylor and Newall, 2008; Feldman, 2013). Midwives can assist refugee and asylum-seeking women by providing information about their entitlements (Maternity Action, 2015) and by making links with voluntary organisations such as Baby Basics (2015), which provides essentials and equipment to disadvantaged new mothers; by doing so, midwives would be optimising care by meeting the holistic needs of refugee and asylum-seeking women.
The novel and uncertain circumstances of many pregnant refugee and asylum-seeking women mean they often lack knowledge regarding how to navigate a foreign health service and what is available to them, which in turn discourages engagement with services (Phillimore et al, 2011). This was the finding of a qualitative study into migrants' uptake of screening for infectious diseases such as HIV and hepatitis (Seedat et al, 2014). However, this study only sampled community health leads for dominant migrant groups in West London, so may not represent the diverse migrant population in the UK (Seedat et al, 2014). Furthermore, the study was not primarily focused on pregnant women, who are an important group to screen, particularly for STIs that could impact on the development of their unborn babies (UK National Screening Committee, 2013). For example, a UK survey of paediatricians regarding reported cases of congenital syphilis in infants highlighted the impact of the eastern European syphilis epidemic on these statistics (Public Health England (PHE), 2013). It was found that these mothers booked in their third trimester so were not screened for syphilis before 10 weeks, and no treatment was commenced to reduce poor outcomes such as miscarriage or bone deformity (PHE, 2013). The booking appointment is an important opportunity for a midwife to engage a woman in maternity care, assess her social and medical risk factors to plan her care for pregnancy and offer appropriate screening tests (Viccars, 2009). However, evidence has shown only a small proportion of refugee and asylum-seeking women book before 12 weeks (Phillimore, 2015), which is recommended in national policy (NICE, 2010). The knowledge that refugee and asylum-seeking women lack regarding their entitlement to health care should be provided by officials early in their application for asylum, which could enable earlier interventions in pregnancy. However, UK Visas and Immigration (2016) guidelines only stipulate facilitating access to care if a woman has a health need requiring urgent medical attention. Improved information-sharing with women at the point of entry may decrease the large numbers of refugee and asylum-seeking women booking late in their pregnancy (Taylor and Newall, 2008).
Not only do refugee and asylum-seeking women frequently lack knowledge of sexual and reproductive health services, they may also not have had health education regarding the importance of such services (World Health Organization (WHO), 2015). This lack of knowledge has been given as the main reason for the poor uptake of cervical screening among Somali-born women in Camden (Abdullahi et al, 2009); as there is no screening test for cervical cancers in Somalia, many women interviewed were unfamiliar with the concept of preventive health. This large study (Abdullahi et al, 2009) involved 50 participants who were questioned in focus groups and via in-depth interviews, enabling illiterate women to participate; however, the majority of the study was undertaken in the Somali language, therefore discrepancies in translation may have occurred, potentially changing the meaning of some participants' comments. Nevertheless, it is interesting that many women reported being screened following advice given at a postnatal appointment, which shows the importance of discussing cervical screening with refugee and asylum-seeking women after birth (Patnick, 2014).
A lack of knowledge was also highlighted by research involving displaced persons and refugees in Belize (Westhoff et al, 2008). False beliefs and incorrect knowledge regarding HIV and STIs was prevalent among the respondents. However, this study was carried out after Hurricane Mitch in 1998, and sexual health knowledge among refugees may have improved as humanitarian organisations have developed standards for education in emergency situations (UNHCR, 2007). The interviews were carried out by doctors, which may have influenced responses; in addition, no information is documented about how consent was obtained from participants, which is crucial when working with vulnerable displaced persons (Nakkash et al, 2009). These studies (Westhoff et al, 2008; Abdullahi et al, 2009) show the diversity of migrant populations' health education, which has a significant impact on their engagement with services at the site of settlement.
Several initiatives have been set up in the UK to promote sexual and reproductive health knowledge among migrant communities. Such health promotion activities have been carried out by refugee community organisations, health professionals and schools (Wilson et al, 2007). They include antenatal classes specifically developed for pregnant refugee and asylum-seeking women (McCarthy et al, 2013), community radio broadcasts on sexual health topics (Spectrum Radio Network, 2015) and peer-education programmes (Drummond et al, 2011). Publications for educators (Wilson et al, 2007; McCarthy et al, 2013) recommend carrying out an initial needs assessment, addressing language barriers and providing information in a variety of formats. One study (Drummond et al, 2011), which reviewed the effectiveness of a 3-hour sexual health peer-education session for a small group of West African refugees in Australia, revealed positive outcomes and increased knowledge of HIV and STIs. However, this study did not demonstrate whether this new knowledge translated into safe sex practices and reduced the incidence of STIs. Furthermore, the convenience sample of participants may have been more receptive to sexual health messages than those who declined to participate or were not asked (Abbott and McKinney, 2013). Importantly, there is a notable lack of UK-based research into the effectiveness of educational initiatives targeting refugee and asylum-seeking women, or feedback from those accessing them. Further research is also needed to analyse how many women access specialist health promotion services and how to increase engagement.
The cultural context
Cultural norms and expectations can also have an impact on refugee and asylum-seeking women accessing sexual health services, particularly family planning. Researchers have linked sociocultural characteristics with health status and health-seeking behaviours (Carroll et al, 2007; Henderson et al, 2011). In focus group discussions and in-depth interviews for a qualitative study (Rogers and Earnest, 2014), Eritrean and Sudanese migrant women in Australia demonstrated a good level of knowledge regarding contraception; however, women reported a taboo in discussing sexual health issues with their family or partners. The women suggested that men lacked contraceptive knowledge and should be involved in sexual health education (Rogers and Earnest, 2014). Study participants had existing links with a sexual health clinic in Brisbane, and were required to understand and speak English to be involved; this may mean the views of marginalised women who did not access care were under-represented in the findings. Moreover, the psychosocial framework (Psychosocial Working Group, 2003) that was used to underpin the study and analyse the findings was specifically developed for intervention work after complex emergencies, which may not have been appropriate for this non-crisis research. The findings of this study are similar to others (Hach, 2012; Poudel and Dyer, 2013), with women suggesting men need more culturally relevant sexual health education to dispel myths, although some women have expressed concerns that they would not feel able to actively participate in group discussions if men were present (Hach, 2012). Midwives are ideally placed to have private, culturally sensitive discussions about contraception with couples postnatally; informing them of different contraceptive methods, their effectiveness, and services in the local area (Snow, 2013).
It is important that midwives do not make assumptions about refugee and asylum-seeking women due to ‘culture’, such as assuming they will refuse contraception. Descriptions of refugee and asylum-seeking women often portray passive ‘victims’, subject to the control of their families and social norms of their communities (Hach, 2012). Cultural stereotyping, of which midwives can be guilty (Haith-Cooper and Bradshaw, 2013a), may result in a tendency to treat refugee and asylum-seeking women as a homogenous group rather than individual women, which can reduce options offered to these women by midwives, who should be acting as their advocates (NMC, 2015).
When refugee and asylum-seeking women do access maternity care, staff attitudes are particularly important because there can be a power imbalance between midwives and vulnerable women, and a danger of passive acceptance of poor care (Haith-Cooper and Bradshaw, 2013b). Refugee and asylum-seeking women have reported experiencing prejudice and discrimination at sexual and reproductive health appointments (Waugh, 2010; Phillimore, 2015). This is particularly concerning considering the traumatic past experiences that some refugee and asylum-seeking women may have had, including sexual violence and FGM, which may lead to mental health problems (Refugee Council, 2009). Local and national guidelines (Royal College of Obstetricians and Gynaecologists, 2015) stipulate that health professionals should be sensitive and non-judgemental when discussing FGM with women. However, in one study (Straus et al, 2009), women reported a poor experience of care as professionals lacked experience of FGM and did not accept their knowledge of managing the procedure during childbirth. Although this was a small regional study, it used in-depth qualitative interviews with Somali health workers in the UK, who were able to provide perspectives both as professionals and as mothers (Straus et al, 2009).
A lack of professional knowledge has also been highlighted in other research (Zaidi et al, 2007; Relph et al, 2013). Poor experience of care can exacerbate social isolation and further deter refugee and asylum-seeking women from engaging in services (Faculty of Public Health, 2008). Programmes have been set up to empower refugee and asylum-seeking women to have an input in the development of maternity services and cultural education of staff (Haith-Cooper and McCarthy, 2015); the impact of such initiatives has yet to be evaluated. It is important that midwives respond sensitively to refugee and asylum-seeking women to establish relationships of mutual trust, in order to promote positive mental health and encourage them to continue to access sexual and reproductive health care.
National policy stresses the importance of effective communication to promote informed choice for all women in midwifery care (NICE, 2008; NMC, 2015). However, language has been identified as a key barrier for refugee and asylum-seeking women accessing health care services (NICE, 2010). A significant proportion of the women who died from maternal causes in the period 2006–2008 spoke little or no English (Cantwell et al, 2011). There is an obligation for health-care providers to organise translation services (NMC, 2015); however, evidence suggests professionals often fail to book interpreters and, if they do, the interpreters may be unsuitable due to gender, age or ability to articulate sensitive topics using the appropriate vocabulary (Burke, 2011; Phillimore, 2015). The issue of consent is particularly concerning if a woman cannot understand advice and information before agreeing to a medical procedure (Department of Health, 2009). In a 2011 study, Somali Bantu Women in Connecticut reported miscommunication as the principal problem in reproductive care, as they were offered interpreters who spoke a different dialect and were reluctant to talk to a male interpreter (Gurnah et al, 2011). This was a small population study which utilised snowball sampling, identifying participants with the necessary characteristics and asking them to recommend others (Holloway and Wheeler, 2010). This method may be advantageous as the population of women was difficult to determine due to their constant migratory patterns (Gurnah et al, 2011); conversely, it may lead to bias, as subjects are not independent of one another, with focus group discussions potentially exacerbating this bias (Rees, 2011). However, the recommendations of this study are supported elsewhere (Correa-Velez and Ryan, 2012; Bennett and Scammell, 2014)—midwives should arrange longer appointments when an interpreter is needed, and aim to book the same interpreter wherever possible. National guidelines (NICE, 2010) and reports (Taskforce on the Health Aspects of Violence Against Women and Children, 2010; Cantwell et al, 2011) emphasise the importance of not using a family member as an interpreter, which is particularly important when discussing sexual or domestic violence. By addressing language barriers, midwives can empower refugee and asylum-seeking women to make decisions about their care by promoting informed choice.
It is not only communication between midwives and pregnant refugee and asylum-seeking women that should be examined, but also communication among health professionals in the multidisciplinary team. A case review was carried out into perinatal deaths among migrant women in the West Midlands (Cross-Sudworth et al, 2015). The review body highlighted significant social and medical risk factors in the majority of cases, which the GPs and midwives responsible had failed to identify, document and communicate to one another, only referring one mother to additional services. Cross-Sudworth et al (2015) conclude by suggesting that staff lack confidence and need multidisciplinary cultural competency training to improve outcomes. However, this was an audit review which did not qualitatively assess the opinions or experiences of the staff involved, a method that would have better substantiated the study's recommendations (Rees, 2011).
Interestingly, in two qualitative studies (Haith-Cooper and Bradshaw, 2013b; Bennett and Scammell, 2014), midwives and student midwives also highlighted the need for more pre-registration communication and referral training for health professionals. Effective multidisciplinary team working is particularly important in relation to the dispersal of refugee and asylum-seeking women (UK Visas and Immigration, 2016), whereby asylum seekers are sent to various parts of the UK without choice. In a national study involving midwives and dispersed women (Feldman, 2013), the majority of women were subjected to multiple moves in the perinatal period and their antenatal care was disrupted, which was particularly detrimental as many had complex medical conditions that required regular monitoring. This research emphasises the importance of midwives making arrangements for refugee and asylum-seeking women to be received into health care in their dispersal area, which confirms the midwife as the lead professional for the planning, organisation and delivery of care for these vulnerable women within the wider health and social care context (Feldman, 2013).
Overcoming the barriers
In certain areas of the UK, specialist community midwifery teams have been established to caseload women with complex social factors (Sandall, 2014). Specialist refugee midwifery roles have also been established to support refugee and asylum-seeking women and coordinate specialist input in the perinatal period (Ukoko, 2005). Job descriptions for such roles emphasise the importance of multidisciplinary working, including establishing links with emergency care, sexual health, voluntary organisations and housing associations. Specialist roles set an important precedent to promote high standards of enhanced midwifery care for refugee and asylum-seeking women. Initial quantitative research into caseloading midwifery reveals positive outcomes for vulnerable women, including fewer antenatal admissions, fewer caesarean sections and more referrals to mental health and domestic violence support services (Rayment-Jones et al, 2015).
This review of barriers faced by refugee and asylum-seeking women when accessing sexual and reproductive care has demonstrated a complexity of issues. It is clear that these women are not a homogenous group but are differentiated by cultural norms, education and past experiences. This diversity is evident in their social and sexual health backgrounds, such as past experience of FGM and varied levels of contraceptive, STI and screening knowledge.
Refugee and asylum-seeking women are often discouraged from accessing care due to their socioeconomic positon, exacerbated by social policy and poor health literacy. However, during pregnancy, midwives have a unique opportunity to promote access to culturally sensitive services, optimising continuity of care and informed choice by coordinating interpreter services and specialist input from the wider multidisciplinary team. As there is currently an increase in individuals seeking asylum in the UK (Refugee Council, 2015), more research is needed on how best to serve the sexual and reproductive needs of refugee and asylum-seeking women, which includes gaining the views and experiences of this vulnerable group. Refugee and asylum-seeking women's social, physical and psychological needs should be addressed not by a standardised approach but by midwifery-led models of care and service provision that is holistic, non-assumptive and individualised.