Delivering in the age of super-diversity

Midwives magazine: Issue 1 :: 2012

A quarter of babies born in the UK today have a migrant mother, yet a study by the University of Birmingham has revealed substantial inequalities in the care these women receive. Dave Newall and Dr Jenny Phillimore discuss the findings.

The West Midlands has a super-diverse population. More than 150,000 migrants have arrived in the past five years (Phillimore et al, 2010). The region has high birthrates in its migrant populations and the highest infant mortality rates in England and Wales (Francis et al, 2009). These rates peak in the most super-diverse and asylum-seeker dispersal areas. Given that the Standards for maternity care report (RCOG, 2008) highlights the need for appropriate arrangements for vulnerable women, it is important to understand how healthcare professionals and migrant service users experience maternity care. 

The research
A study by the University of Birmingham looked at the experiences of women and professionals in both rural and urban areas. A desktop study identified data sources, such as the Worker Registration Scheme, to establish the size and nature of the migrant population. Some 82 face-to-face interviews were undertaken with migrant women from 28 countries, who had used UK maternity services, followed by 13 in-depth case studies and 18 interviews with professionals. 

Accessing maternity services
While 67 of the women interviewed had booked by the 12th week of pregnancy, immigration status was an important variable, with asylum-seeking or refugee women first contacting maternity services between 31 and 36 weeks. Almost a fifth of women were unable to attend subsequent appointments because they lacked transport, were in abusive relationships, unable to speak English or had been dispersed in the asylum support system. Only 26% of interviewees accessed antenatal classes for similar reasons. The limited understanding of the purpose and importance of classes also prevented women attending.

Lack of knowledge about entitlement to NHS treatment operated as a barrier to good maternal health. While most migrant women were entitled to register with a GP and receive free primary care services, some were refused or told a GP’s list was full. Entitlement to primary care is not affected by the ‘NHS charges for overseas visitor’ regulations, but confusion created delays in women being referred to a midwife. Department of Health guidance is clear – maternity care should always be considered as urgent.

The system
Professionals were aware of the difficulties migrant women had accessing services and tried to be proactive in engaging them. The process-driven nature of maternity care was problematic. Migrant women without settled lifestyles or with complex needs often fell out of the system when they lost contact. The lack of adequate appointment times was troublesome; more time was needed to explain services and to build trust. Some midwives’ caseloads were between 50% to 75% non-English speaking, but additional pressures were not reflected in their caseload. Many professionals reported that they struggled to signpost women to services to help with financial problems, female genital mutilation (FGM) or postnatal depression.

After birth, women felt follow-up visits focused solely on the baby. Visiting midwives did not pick up on isolated women, or those who were depressed.

Lack of information or advice
A shortage of information available in their own language, or poor-quality interpreting, left women uninformed. Health professionals highlighted communication  problems because interpreters were unreliable or lacked knowledge about maternity issues. 

The impact of abusive relationships emerged as an issue, with some women having no involvement in decisions about their pregnancy. Family members used as interpreters left some without information or an opportunity to discuss their situation. Where women informed midwives of abuse, they were not referred to appropriate organisations, or were given information in English. Midwives pointed to cases where women had miscarried or given birth prematurely as a result of abuse.

Culture and status
Foods provided in hospital didn’t meet cultural needs, and limited discussion about religious needs meant these often went unmet. Poverty, poor housing or homelessness were all identified as complicating factors. Some women were receiving voucher support, but couldn’t purchase travel tickets. Others, such as failed asylum-seekers, had little or no income and were unable to purchase essential items. Several women had their maternity care disrupted when moved by the UK Border Agency, with midwives not receiving notification of dispersal or arrival. 

Overcoming barriers
Changes are needed to help migrant women get more from maternity services. Women wanted longer appointments and greater continuity of care, more translated information and assessment of their situation, more understanding of their cultural needs and maternal postnatal checks. 

Professionals identified several factors that would help improve services for such women. These included receiving training to identify social risk factors, FGM, healthcare entitlements, and cultural competency. Midwives suggested more partnership working to provide translated materials, develop a welcome pack, jointly run antenatal classes or set up support groups or mentoring programmes.

They wanted caseloads to allow extra time where there are communication issues or complex needs. The provision of extended and more flexible appointment times, social risk assessing at the first appointment, adopting caseload approaches for vulnerable women and the use of drop-in services were all thought likely to improve outcomes.

Midwives also recognised the need to stop inappropriate use of family interpretation and ensure women had at least one appointment where they are seen alone.  

The future
Work is underway to address some of these issues. However, this is challenging in an already overstretched, under-resourced, maternity system. 

Good practice

Midwives pointed to some good practice such as a Worcestershire-based Polish translating service and scanning clinic where midwives took evening calls and partly translated hand-held notes into Polish. In South Staffordshire, a team of midwives set up a maternity care pathway for non-English-speaking women, which identified language needs at registration and communicated these to all professionals. In Birmingham, pharmacy staff were trained to do pregnancy tests and refer to a fast-track booking system. Women were given a text number to contact and were called back. In addition a midwife-led FGM service spread information to women and professionals about available procedures.

References
RCOG, RCM, RCA, RCPCH. (2008) Standards for maternity care: report of a working party. RCOG Press: London. See: www.rcog.org.uk/catalog/book/standards-maternity-care-report-working-party (accessed 11 January 2012).

Phillimore J, Thornhill J. (2010) Delivering in the age of superdiversity: West Midlands review of maternity services for migrant women. West Midlands Strategic Migration Partnership and Department of Health: Birmingham.

Francis A, Elsheikh A, Gardesi J. (2009) Stillbirths, infant deaths and social deprivation in the West Midland 1997 to 2007/8. Perinatal Institute: Birmingham.


For further information on the study’s findings, please visit: www.wmleadersboard.gov.uk/migration-documents