Pregnant women seeking asylum in the UK are identified as a vulnerable group in society, with specific concerns relating to their health and wellbeing (Aspinall and Watters, 2010). They may have underlying health issues, suffering the physical and psychological effects of fleeing traumatic situations, and tend to have more complex pregnancies. This has resulted in a higher rate of maternal and perinatal mortality than the general population (Centre for Maternal and Child Enquiries, 2011). It is essential, therefore, that midwives understand the health and social needs of pregnant asylum-seeking women.
In the period 2000–10, studies found that some pregnant women seeking asylum in the UK had poor experiences of maternity care, with midwives and other professionals not meeting their specific health and social care needs (McLeish, 2005; Gaudion and Allotey, 2008; Briscoe and Lavender, 2009; Waugh, 2010). In 2010, the National Institute for Health and Care Excellence (NICE) implemented guidelines to improve maternity services for women with complex social factors, including asylum seekers. A woman-centred approach to care is advocated, underpinned by good communication with the midwife working within a multi-agency context to ensure health and social care needs are met (NICE, 2010).
Despite these guidelines, half a decade later there is evidence that pregnant asylum-seeking women's needs are still not being met, with instances of poor antenatal care and a lack of communication between different health and social care services (Shortall et al, 2015). In addition, midwives have been found to stereotype migrant women and display poor attitudes (Phillimore, 2014; Psarros, 2014). NICE (2010) recommended that midwives undertake training to ensure they understand the specific needs of asylum-seeking women. However, substandard care—including poor use of interpreting services, poor information-sharing with the woman and wider team, and an ad-hoc approach to social care and support—has been linked with an increased risk of perinatal mortality (Cross-Sudworth et al, 2015).
In 2011, the Maternity Stream charity was established to address these issues (Haith-Cooper and McCarthy, 2015). The aim was to facilitate local service providers to develop maternity care that meets asylum-seeking women's needs. Listening to women's stories is key to this and, consequently, a phenomenological study was undertaken with the aim of exploring the maternity care experiences of local asylum-seeking women to inform local services. This article will describe this study and how the findings could be useful across the UK.
A qualitative interpretative approach was adopted to facilitate an understanding of the experiences of women seeking asylum while accessing local maternity services. This approach is in line with the tradition of hermeneutic phenomenology, where the aim is to understand the participant's lived experience and their perception of the meaning of these subjective experiences (Todres and Holloway, 2011).
Posters were displayed and participants recruited purposively through the voluntary sector and a children's centre. In addition, word-of-mouth led to an element of snowball sampling. Inclusion criteria were:
Non-English speaking women were included in the study if an appropriate informal interpreter could be found, of whom the woman approved, as there was no budget to pay for professional interpreters.
Semi-structured interviews were undertaken with six women, the minimum number suggested by Todres and Holloway (2011: 183) to acquire ‘profound in depth insights’. The interviews lasted up to 1 hour, giving participants time and space to explore any detailed aspects of their experience that were important to them, rather than simply answering questions that focused on the researcher's concerns (Green and Browne, 2005). The interview began with an open question encouraging the woman to relate her story. Prompts were only used when required (Table 1). The interviews were audio-recorded with the women's permission. Two women declined, so handwritten notes were made by the researcher while they talked. The audio-recorded interviews were transcribed verbatim and the handwritten notes were added into the data set.
|Main prompt: Tell me about your experience of…|
|Possible specific prompts:||1. Seeking asylum?|
|2. Accessing antenatal care?|
|3. Attending for antenatal care?|
|4. Support you received in pregnancy?|
|5. Health in your pregnancy?|
|6. Birth experience?|
|7. After the baby was born?|
|Was your experience of maternity care what you expected? In what ways…?|
Ethical approval was obtained from the University Ethics Panel 25/02/15, reference E431. Women who expressed an interest in the study received a brief explanation, a cover letter and consent form. One woman who spoke no English had this information translated by a bilingual friend. Contact was made by phone after 24 hours and a venue arranged. The researcher went through the consent form carefully before beginning each interview, and it was made particularly clear that if issues arose concerning the safety of the woman or her child, a referral would be made to an outsider, but that in all other instances confidentiality would be maintained. It was also made clear that the researchers had no links with the Home Office and the data would only be used for research purposes, not affecting the woman's asylum case. Participants were informed that they would be able to withdraw their consent up until the writing of the final report. Anonymity was maintained by removing names of study participants and organisations and allocating numbers to the women. Transcripts were stored in a password-protected computer file and locked filing box accessible only to the researchers. Once transcribed, the audio-recordings were destroyed.
The principles of Burnard's (1991) stages of thematic analysis were adopted. Although somewhat dated, this structured approach was found useful to guide the novice researcher. It involves reading and re-reading to create an overall impression of the data, following set steps to develop themes, coding the data initially, grouping similar codes together, and finally gathering them under headings to form themes. The validity of the themes in light of the original interview data was checked by the research mentor acting as a ‘critical friend’. Some participants were also contacted to ensure that the themes were felt to reflect their experiences.
Four of the six women were from sub-Saharan Africa and two were from Eastern Europe. Four women had been in the UK longer than 1 year before becoming pregnant; the remaining two arrived in the UK when they were already pregnant. Five women were primigravid, one in her second pregnancy. Two women were supported by a partner. Five women had varying degrees of English language skills and one woman spoke no English and had an interpreter for the interview.
Although women were asked about their experiences of maternity care in the UK, it became obvious that they wanted to discuss more broadly their experiences of living in the UK while being pregnant and seeking asylum. This included experiences of maternity care, but not as the main focus. Five key themes emerged from the data on being pregnant while seeking asylum: pre-booking challenges; inappropriate accommodation; being pregnant and dispersed; being alone and pregnant; and not being asked or listened to.
Before accessing maternity services, the women faced difficulties related to being pregnant and an asylum seeker, which led to many of the women booking late for antenatal care. Two women were already pregnant when they arrived in the UK in the back of a lorry. One was in the early stages of her pregnancy and in poor physical health. She was initially sent to a detention centre and struggled to receive any health care:
‘In [the] morning [I sent] my friend downstairs in [to the] office rooms to tell the officer that she's sick, that she have to meet the doctor… and she told me that the doctor will came in [at] 2 o’clock… And I told them I can't wait until 2 o’clock! … Can you bring me a [wheel] chair to go downstairs in [to the] health centre… And they told me, “Why? What happened with your feet? You have to sign that you are disabled to take the [wheel] chair.” I told them, “I’m not disabled, I’m just vomiting… 2, 3 days, I’m very tired, I don't have force to walk.”’ (P5)
The woman waited for a long time in the facility's health centre before eventually being admitted to hospital. She was not referred to a midwife until she was around 20 weeks’ gestation.
Another challenge in early pregnancy experienced by women was registering with a GP, which delayed the initial booking appointment. One woman had been in the UK for 3 years and had never seen a GP until she tried to register when pregnant. She experienced difficulties finding a GP that would accept her.
Some of the women discussed their lack of understanding regarding their entitlement to free health care. One woman talked about how her pregnant friend, who was refused asylum, had no money and thought she was not entitled to access any care.
Accessing maternity services was a challenge for women who had no cash for bus or taxi fares to attend appointments. One woman, who had her asylum claim refused, described how she was given only a ‘butcher card’ (supermarket voucher):
‘Sometime I go in Asda or Sainsbury… [I] saw somebody from Eritrea like me, ask them [for] cash… I needed the cash… Sometimes I have [to ask] her from [our] shared room, I said, “Can you borrow for me bus money?” Sometimes she give me £5…’ (P4)
All but one of the women identified difficulties with their living conditions. One woman discussed how she struggled to keep her newborn baby warm in the accommodation she had been provided. Half of the women said they felt shocked when they first walked into the accommodation they had been allocated:
‘They give me a [hotel] room… [It was] very small, it was smelling of cigarettes. The duvet was very dirty. The bed… the walls… everything was very dirty.’ (P3)
The same woman revealed that, on discharge from hospital with her new baby, she was sent to another unsuitable hotel room:
‘I stayed in the hotel for 2 months—eating sandwiches and I was on crutches. I can't go downstairs ’cause I was on top [floor]. There were scary people. Men smoking, hanging round. So I can't go in dining room.’ (P3)
Arriving at and leaving her accommodation was a problem for another woman:
‘The access with the steps is quite hard, because you'd have to leave your personal belongings outside while you are trying to get the rest of your things… When I’m taking my pushchair out… I take the frame out first, then I go for the rest of… the things… Sometimes I even leave my handbag outside… When the baby is crying I get… confused.’ (P1)
Inappropriate accommodation also had an impact on health professionals who came to do a home visit, with one woman not receiving letters and phone calls and not hearing knocking on the door due to its distance from her room. This woman was sharing a large house with other women and small children. She described how, when she needed to be elsewhere in the house, she found it difficult to ensure her baby was safe, because of the distance between the rooms:
‘Most times I leave him in the room [when cooking]… To take the baby in there is… It's too difficult, because the kitchen isn't spacious… I have to keep running to the bedroom, to just see that he is OK… [You can be] somewhere trying to do, maybe laundry, or cooking, or having a shower and your baby is screaming in the room, without you knowing.’ (P1)
Several of the women talked about the challenges of sharing space with a stranger, particularly those who were given a shared room while pregnant. This caused difficulties such as keeping the room at a comfortable temperature for both women, and worries about disturbing the other woman when getting up to go to the toilet during the night. Many of the women discussed the emotional strain of being forced to live with strangers:
‘If you live with… other women [who] are asylum seeker like us, and everyone have problems like stress… One is cleaning, one not. One is like, shouting, one is quiet. One is like… the TV loud… That's why it's better to stay like, all by your own, or with the people that you know.’ (P5)
Being pregnant and dispersed
Five women were moved by the Home Office to a different area during their pregnancy or in the early days with their baby, which they found particularly stressful. They felt socially isolated, not knowing anyone in the new location:
‘I have to start again from zero… I was pregnant. And I was sicking [vomiting] all the time. They bring me here… I didn't have nobody here.’ (P5)
Women discussed the difficulties associated with the journey to the new area. One woman was heavily pregnant, using crutches and with a suitcase to carry. She was asked to make her own way to her new accommodation, but she could not get there alone. She finally arrived the following evening after waiting for a full day sitting in an office:
‘My head was like to burst. They give me… drink and a sandwich. It was the first time I had eaten all day.’ (P3)
Having eventually arrived at her new accommodation, the woman went into labour.
Other women discussed how they were given very little notice that they were moving, which created practical difficulties in preparing for the move and an interruption to maternity care:
‘I just got a phone call on a Friday morning saying “Oh… we’ve found you an accommodation… we will be picking you up at… ten.” And the phone call came through at just after half past eight in the morning. And that was a week after I had the baby…’ (P1)
Being alone and pregnant
Women identified times when they felt very alone being pregnant or with a new baby in a strange country. This became more apparent in times of stress, such as when in labour or during the early postnatal period:
‘Just crying, just thinking, I have just me… Why [is] my mum not here… Cousin, friends… My sister… nothing.’ (P6)
One woman discussed how being alone in labour and not having the support of a birth partner led to her feeling disempowered:
‘They want to give me epidural and take me to theatre. They could do anything. I was by myself, didn't have anybody. So I just accept what they want to do.’ (P3)
There were times when the women needed and appreciated support, and they discussed how their midwives had supported them in difficult situations. One midwife provided a letter to the Home Office on behalf of a woman who was supposed to be dispersed imminently. Another midwife was a source of constant support throughout a woman's pregnancy:
‘She [community midwife] understand… when I was like… 6 month pregnant as well, they stop my benefit, she tried to call them and explain [to] them about my situation.’ (P2)
For another woman, the community midwife helped her to feel less lonely when she visited her on the postnatal ward at visiting time:
‘When I see V [community midwife] [had] come [to] see me, I was like, all my family [has] come to see me!’ (P6)
Some women discussed how their birth partner was highly valued in labour, providing emotional but also practical support:
‘When I had… back pains… “Oh F—, I have pain!”… she [rubbed] my back all the time. She used to leave her husband, her family, her… kids just for me, and I’m blessed to have her with me in hospital.’ (P5)
Not being asked or listened to
Women described situations where they found communication challenging. There were a number of reasons for this, the language barrier being the most obvious, but there were more subtle reasons. One woman who appeared to speak good English felt she did not fully understand what was being said by the midwife and requested an interpreter to help her to communicate more effectively:
‘I asked them, “[Can] we cancel the meeting until we get an interpreter… I didn't understand you and you didn't understand me.” She said, “No, it's OK, we can go on—you understand English.”’ (P3)
One woman explained how her midwife did not know anything about the situation she was in and the difficulties of being an asylum seeker until part-way through her pregnancy, because she was never asked about her immigration status. On the other hand, some women felt labelled as an asylum seeker, with staff making assumptions about their needs—in one case, this meant a presumed need to terminate the pregnancy:
‘They do me… vaginal scan? To check the baby… They ask me again if you want to take out the baby?’ (P5)
There were examples of labelling and assumptions being made based on a woman's perceived cultural background:
‘I saw a consultant… She was not nice. She was very abrupt. “Did you circumcise?”… I didn't know women can be circumcised! “I’m asking you, are you circumcised?” I don't understand.’ (P3)
Women also described how they felt they were treated differently due to their asylum status:
‘Sometimes I feel like when I used to go in [to see the] GP or… in hospital, I feel like the doctors or nurses… not seen us with same eye like English people.’ (P5)
The feeling of being seen differently was sometimes acute. In one case, a woman attended a walk-in clinic and the receptionist shouted at her asking where her passport was. In another situation, a woman described how she felt as a result of another receptionist's conversation:
‘When we go to register in our nearest GP, the women in reception ask us… you have to bring… bills. And I told her, we don't have bills, we are in NASS [National Asylum Support Service] accommodation… “So you’re not working?”… And I feel like… I didn't choose to not work!… I’m forbidden to… till my case… And I feel… very bad.’ (P5)
There were examples of situations where women did feel they were listened to. One woman discussed how she felt the community midwife was respectful, asking her opinion on her care. Another described how the midwife acted as an advocate, telling other staff to stop a procedure on her behalf. However, some women did not feel listened to. One woman did not agree with the midwife's written record of the conversation they had. Another woman felt ignored during labour:
‘When we reach there [hospital], they take me in [the] toilet and close the door. I open [the] door and baby was coming. They close [the] door, and started talking’ (P3)
This study confirms that women who are seeking asylum in the UK while pregnant face notable difficulties on many levels. Although the aim of the study was to explore women's lived experiences of maternity care as an asylum seeker, in reality this was only a small part of what women wanted to discuss, reflecting findings from previous studies (Kennedy and Murphy-Lawless, 2003; Briscoe and Lavender, 2009). In this context, the difficulties around everyday life in the UK appear to continue to be more significant to women than the maternity care they receive.
Dispersal created major difficulties for most women in this study, supporting findings from previous research (Reynolds and White, 2010; Bryant, 2011; Feldman, 2013). Women's established support networks were effectively removed and they were forced into social isolation. Women and their babies were moved into damp, cold, unhygienic accommodation with physical barriers such as stairs making it difficult to keep physically and mentally healthy and to feel safe. Care was disrupted, exacerbated by the accommodation; with problems such as not receiving notification of appointments, not hearing health professionals arriving and not finding it easy to access the entrance of the building to get to appointments. In 2012, Home Office guidance was introduced stating that women should not be dispersed during a ‘protected period’ of 4 weeks either side of giving birth (UK Visas and Immigration, 2014). Clearly, for these women, the guidelines were ignored.
Accessing health care was difficult for some women in this study and there was also confusion about entitlement to care and whether they would be charged for services. This reflects recent studies where women have had difficulty registering with a GP without a passport, even though this is not actually required (Psarros, 2014; Shortall et al, 2015); where women fear being charged for services, deterring them from accessing care (Psarros, 2014; Shortall et al, 2015); and where there is a lack of understanding about entitlement to travel costs to attend appointments (Da Lomba and Murray, 2014).
Despite the majority of the women's stories focusing on living as a pregnant asylum-seeker in the UK, they did discuss their experiences of maternity care. There were some positive experiences described, with staff being respectful and acting as an advocate. However, there were also situations where women felt their care was poor and they were treated differently to others. There was also evidence of a lack of cultural sensitivity shown around female genital mutilation (FGM). The latest guidelines regarding caring for women who have undergone FGM suggest a sensitive and non-judgemental approach should be adopted (Royal College of Obstetricians and Gynaecologists, 2015).
These findings add to the body of evidence from the last decade where negative experiences of maternity care have been described (Harper Bulman and McCourt, 2002; McLeish, 2002; Lockey and Hart, 2004; Gaudion and Allotey, 2008), along with more recent studies (Phillimore, 2014; Psarros, 2014; Shortall et al, 2015). This suggests that, despite the NICE (2010) guidelines, there remains a lack of understanding from midwives about the needs of pregnant women seeking asylum, and poor attitudes still exist.
Implications for practice
NICE (2010) recommends that midwives undertake training to ensure they understand the specific needs of asylum-seeking women. This should include a woman-centred approach to care, good communication and working within a multi-agency context to ensure health and social care needs are met. The findings from this study support the NICE guidelines in that the training needs are broader than simply focusing on women's maternity care needs.
In 2011, an evidence-based model called ‘the pregnant woman within the global context’ was designed to facilitate midwives to visualise the woman as the centre of her care and consider how factors within the UK and her home contexts will impact on her health and social care needs (Haith-Cooper and Bradshaw, 2013). This is a useful tool for midwives to use when assessing, planning and meeting the needs of pregnant asylum-seeking women. Considering the model and the findings from this study, Table 2 includes suggestions of activities midwives can undertake to support pregnant asylum-seeking women.
|Question the woman about her accommodation and whether it is appropriate for her and a new baby, especially at the postnatal discharge|
|Explain to women their entitlement to free health care and travel expenses for antenatal appointments|
|Write letters to the Home Office to try to prevent women being dispersed|
|Signpost women who have just been dispersed to your area to local refugee organisations|
|Ensure women get the financial support to which they are entitled|
|Be aware of female genital mutilation, but do not assume a woman is affected|
|Refer women to doulas for support|
Women seeking asylum continue to have some of the poorest maternal and perinatal outcomes in the UK. There is a need for midwives to better support these women, and for this to be achieved the women's needs must be understood. Qualitative research can enlighten midwives and policy makers to potential issues of concern (Green and Browne, 2005), and it is hoped that this study will help midwives understand the type of challenges asylum-seeking women may be facing in everyday life, as well as in accessing maternity care. It is clear from the research that the experience of individuals is greatly impacted by wider social factors including housing policies, immigration status and cultural barriers. It is hoped that the voices of the women in this study will add a personal dimension to issues, policy and labelling around asylum, and enable midwives to better ‘act in partnership with those receiving care, helping them to access relevant health and social care, information and support when they need it’ (Nursing and Midwifery Council, 2015: 5). However, this is a small local study and it cannot be assumed that the findings can be generalised across the UK, especially in areas where specialist midwifery services exist. It is suggested that future research could examine the impact of such specialist services on pregnant asylum-seeking women's experiences and outcomes.