1. Child & Maternal Outcomes for Migrant Women Understanding and Responding to the Needs of Vulnerable Migrant Women Monica Tolofari Consultant Midwife 5 th February 2015

2. Objectives Understanding the needs of Migrant women Understanding the barriers to meeting the needs of Migrant women Responding to the need

3. Outcomes Outcomes of Migrant Women are reported to have significantly greater risk of adverse pregnancy outcomes >Stillbirths >Maternal deaths Distinction between women who migrated due to humanitarian & non- humanitarian reason References Gibson-Helm M, Teede H, Block A, Knight M, East C, Wallace EM, Boyle (2014) Maternal health and pregnancy outcomes among women of refugee background from African countries: a retrospective, observational study in Australia J.Gibson-Helm MTeede HBlock AKnight MEast CWallace EMBoyle J

4. Maternal Deaths “Maternal health outcomes are significantly worse amongst migrant women than in the rest of the population. Compared to White women, maternal mortality rates are 3.85 times higher for Black African women, 3.75 times higher for Black Caribbean women, 1.77 times higher for Chinese women and 1.44 times higher for Asian women. Infant mortality is also higher amongst mothers born outside the UK. Evidence suggests that the majority of this is preventable.”

5. Barriers Phase 1. Delay in seeking care – Late bookers Phase 2. Delay in reaching care – Transport, communication geography, basic skills, access to primary care Phase 3. Delay in receiving adequate care – interpreting their needs NHS system eg appointment length, language difficulties Developing and developed country understanding the mindset of the woman Ref:- Maternity World Wide (2014). The Three Delays Model - Saving Lives of Mothers[Available from: http://www.maternityworldwide.org/ [Accessed on 8.9.14] http://www.maternityworldwide.org/

6. Access - Antenatal/Newborn Screening Pathway

7. Responding to the needs of Migrant women Insanity: doing the same thing over and over again and expecting different results. Albert Einstein Albert Einstein Albert Einstein

8. Responding to the Service Users NHS Primary & Secondary Systems + Processes New Design Meeting new demands of the emerging population Registering with a GP - Direct access to a Midwife – 24hr language services (consent to treatment) flexible services, review staffing ratios to meet increasing demands Education of Staff Women’s rights, entitlements, asylum system, legislation, human rights, migrant women’s health needs, challenging attitudes to migrant women, understanding diversity of culture other non UK health care systems

9. Fast Track Midwifery Service An example of good practice + key intervention Commenced in B’ham 2012 Set up to meet some of the maternity services priorites. Identifying the vulnerable migrant women Collaborative working with hospital, Children Centre and local IA unit Mapping current pathway & developing a pathway which meets the women’s needs

10. Fast Track Midwifery Service Continued Midwifery Fast Track Service – encouraging early booking Midwives Working collaboratively with nurses and staff in IA unit - good access to language interpretation services Education of women & staff - NHS + Border Agency/Force – A/N clinic Early bird & or Parentcraft classes in IA unit Antenatal bookings in health room, joint working at IA unit Vulnerable women’s clinic at the local hospital Pharmacy - pregnancy testing - pre-conceptual care information Free direct access to Midwife & GP/Primary care Transport to clinic or funds/bus pass Doula/befriending support – support for labour in absence of birth partner Psychological support – Freedom from Torture Charity etc

11. Conclusion Equipping staff through education to meet the needs of migrant women, understanding the mindset, perspectives, barriers to access of care. Proactive in identifying and tackling health inequalities Removing inequalities & discrimination – Remove NHS Surcharges for those who cannot pay – Eliminate or reduce poverty. Collaborative working across agencies. Redesign & adapt services to meet the needs of new communities and local populations through service user engagement and adequate resources to ensure care is delivered

12. References 1. Maternity Action & Refugee Council (2013) When Pregnancy Doesn’t Matter Dispersing Pregnant Women Seeking Asylum Available Online from: http://www.refugeecouncil.org.uk/assets/0002/6402/When_Maternity_Doesn_t_Matter_- _Ref_Council__Maternity_Action_report_Feb2013.pdf Accessed [9.9.14]http://www.refugeecouncil.org.uk/assets/0002/6402/When_Maternity_Doesn_t_Matter_- _Ref_Council__Maternity_Action_report_Feb2013.pdf 2. Taylor B, Newall D (2008) Maternity Mortality & Migration The impact of New Communities. Available Online from: http://www.wmemployers.org.uk/media/upload/Library/Migration%20Documents/Publications/MMM_Document_FINAL_Webversion. pdf [Accessed 9.9.14] http://www.wmemployers.org.uk/media/upload/Library/Migration%20Documents/Publications/MMM_Document_FINAL_Webversion. pdf 3. Maternity Action (2014). Access to Maternity Care for Vulnerable Migrant Women. Available from: http://www.maternityaction.org.uk/wp/policy-campaigns/campaigns/access-to-nhs-maternity-care-for-vulnerable-migrant-women/ Accessed 9.9.14] http://www.maternityaction.org.uk/wp/policy-campaigns/campaigns/access-to-nhs-maternity-care-for-vulnerable-migrant-women/ 4. The Lancet (2013). Immigration and health in the UK. Lancet 2013; 382: 1459. Full Text | PDF(136KB) | PubMedFull TextPDF(136KB)PubMed Joint Committee on Human Rights. Tenth Report. Provision of healthcare (135—43). www.publications.parliament.uk/pa/jt200607/jtselect/jtrights/81/8107.htm. (Accessed 9.9.14)www.publications.parliament.uk/pa/jt200607/jtselect/jtrights/81/8107.htm 5. The Lancet (2014). Global Burden of Diseases, Injuries, and Risk Factors Study 2013 http://www.thelancet.com/themed/global-burden-of-disease 6. Department of Health. Guidance on implementing the overseas visitors hospital charging regulations, 2012 (pp 43, 48). https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/213015/GUIDANCE-October-2012-FINAL.pdf. (Accessed 9.9.14). https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/213015/GUIDANCE-October-2012-FINAL.pdf 7. NICE (2013). National Institute for Health and Care Excellence. Pregnancy and complex social factors. http://www.nice.org.uk/nicemedia/live/13167/50822/50822.pdf. (Accessed 9.9.14.14). http://www.nice.org.uk/nicemedia/live/13167/50822/50822.pdf 7. Cantwell R, Clutton-Brock T, Cooper G, et al. Saving Mothers' Lives: reviewing maternal deaths to make motherhood safer: 2006—2008. The Eighth Report of the Confidential Enquiries into Maternal Deaths in the United Kingdom. BJOG 2011; 118: 1-203. PubMed PubMed