Sonia Asif, Nottingham University hospitals NHS Trust, lead author of the review writes…
An article in The Obstetrician & Gynaecologist (TOG) published today (21 October 2015) reviews the current state of obstetric care for women who are asylum seekers and refugees in the UK.
These are a highly vulnerable and socially excluded group of women, often with complex medical histories and psychological needs, and their pregnancies may be quite advanced before they arrive in the UK and receive medical care.
The facts are quite stark. Asylum seekers are three times more likely to die in childbirth and four times more likely to suffer postnatal depression than other women in the UK. Their babies are more likely to be stillborn or born prematurely, to have a low birthweight, or to have birth defects.
The report emphasises the problems and challenges these women face; and suggests ways to improve their experience of obstetric healthcare in the UK and ensure a better outcome for both mother and baby.
The fate of asylum seekers in the UK remains headline news. In 2014 Syria overtook Afghanistan as the biggest source of refugees. More than 4 million Syrians have fled from the current conflict, and three out of four of these are women or children. Over the next four and a half years the UK can expect to resettle some 20,000 refugees and, with opinions divided, the debate about the number of people the UK is in a position to help is set to continue.
Lack of finances are a problem for pregnant asylum seekers, not only in ensuring adequate nutrition but also in paying for transport to clinics, meaning that appointment are not always kept. While they are waiting asylum seekers are not allowed to work (they are however given some financial help - currently 70% of income support with one off extra payments for pregnant women and have access to free NHS care). Poverty and isolation can be a trigger for postnatal depression, which, in a vicious cycle, can lead to further withdrawal from healthcare services.
Compounding this asylum seekers are regularly moved between accommodation centres in a process called dispersal. The Border Agency recommendations say that pregnant women should not be relocated after 36 weeks gestation or until four weeks postpartum. However, this is not always the case leading to women feeling scared, isolated and unsupported.
In each new location the work of healthcare teams in building trust and rapport has to start all over again. Obstetricians and midwives have highlighted the time and resources that they spend trying to contact women or to make sure that the next hospital is aware of investigations and care – especially for women with medical conditions impacting their pregnancy such as HIV, TB and diabetes.
Despite complex medical histories, a woman’s medical history on arrival can be very sketchy. Medical records are often missing, there are language barriers, and indeed many asylum seekers are afraid to reveal medical problems thinking that they might affect their chances of becoming refugees. For women who may not have access to health care in their home countries chronic conditions, such as diabetes or heart disease, may not have been previously diagnosed, vaccination programmes and treatment for infectious diseases may not have existed, while poor nutrition may have led to dental problems.
Women from Africa may also have experienced female genital mutilation (FGM) which increases their risk of perineal tears, obstructed labour and postpartum haemorrhage, and women who arrive in the country already late in pregnancy can have previously undiagnosed pre-eclampsia and placenta praevia.
In addition women can have complex mental health needs due to the experiences which caused them to leave their home countries, including post-traumatic stress disorder (PTSD). This can be exacerbated by rape or torture, and by the isolation and hostility they may experience on arrival. Effective treatment is also hampered by language difficulties and cultural differences, perceived stigma, and because western psychological concepts may not even be relevant. On top of this their risk of postnatal depression is high, especially in women who have undergone dispersal late in pregnancy.
But, the report points out, small changes in care can lead to a big difference to the health of these women. Making care plans that take into account the language, cultural and financial barriers these women face in accessing services, ensuring continuity of service from 34 weeks through to postnatal care, using appropriate translation services, and being aware of mental health needs, including the high risk of postnatal depression, will all help.
In order to achieve this the report recommends education and support of medical and midwifery staff (including emotional support to help them cope with distressing situations), and the development of specialist midwifery care. Better communication between healthcare workers and Border Agency staff, and between healthcare workers and voluntary and other services, will likewise improve continuity and standards of care.
In being advocates for care obstetricians and gynaecologists can help empower pregnant asylum seekers, improve their health, mental wellbeing and quality of life, and that of their babies.