Home Affairs Committee
Background – Oasis Church Centre has been working with asylum seekers from the local UKBA Hostel in Stone Road Edgbaston which is about 200 yards from our building.
For the last 12 months we have held weekly evening meetings with a meal to welcome and support people from any nation or faith who would like to attend.
Further assistance has been offered to some people who have stayed longer in the Birmingham area and the submission is based on our experiences and observations.
Executive Summary
1. SUBMISSION—concerning the effect of postnatal depression on women who are in the process of claiming asylum. Many women arrive pregnant and the effect of this on their asylum application affects both their ability to give a credible story and giving birth affects the process of claiming asylum particularly with the severe risks of postnatal depression [PND]
2. Post natal depression is a clearly defined illness during the first 12 months after birth.
It can affect 10% of the indigenous population but surveys have shown the diagnosis in up to 42% of asylum seekers. This is often at a key time when they are claiming asylum.
Aetiology—there is little evidence for a biological basis for this illness and the main risk factors are those related to social adversity.
Detection—should present no difficulty if the newly postpartum Mum is seen by the relevant health care professional and has access to appropriate support—often not available for this group of women.
Morbidity –from undiagnosed PND can also affect child development and potentially lead to other costly interventions and cause delay in the assessment process.
3. Two Case Studies are presented to show how the asylum process increases the risk for mental health problems in newly delivered mothers seeking asylum.
4. Recommendations are given
- — concerning support for newly postpartum asylum seekers are given in order to detect and treat this condition and speed up the assessment process.
- — Awareness raising and education programmes are suggested for UKBA hostel staff and for local PHCTs around postnatal care for asylum seekers.
- — Guidelines for the support of new mothers who are asylum seekers would be welcome particularly for the financial provision of the new baby.
5. Conclusion—by offering best practice of care in the immediate postnatal period to asylum seekers there is a better outcome for a satisfactory claim and the welfare of these women.
Factual Information
1. Introduction
- — Definition Post natal depression [PND] ‘an episode of non psychotic depression within a year of giving birth’ 1.
- — The general prevalence of PND in the UK is around 10% 2 but has been shown to be as high as 31.1% in asylum seekers 3.
2. Risk Factors There are many studies into the risk factors for PND
- — MUMSNET [www.mumsnet.com ] outlines 16 common factors 4 of which 8 are commonly prevalent in asylum seekers & all the others maybe present when individuals are questioned.
- — LITERATURE REVIEW 2003 FOR TORONTO PUBLIC HEALTH DEPARTMENT 5 grades predictors into strong, moderate & low risk. ‘Research studies have consistently shown that the following risk factors are strong predictors of postpartum depression: depression or anxiety during pregnancy, stressful recent life events, poor social support and a previous history of depression.’ Without knowing about previous episodes of depression it is obvious that the other 3 listed factors are always present for asylum seekers.
- — ARCHIVES OF WOMENS MENTAL HEALTH 5 summary Findings suggest that PND may affect up to 42% of migrant women, compared to around 10–15% of native-born women. Common risk factors for PND among migrant women include history of stressful life events, lack of social support and cultural factors. With a growing number of babies born to immigrant mothers, greater awareness of PND among this group is needed in order to respond to their particular maternal mental health needs. Maternity care providers should regard all recent immigrants as at high risk of PND and give closer observation and support as necessary.
- — BMJ fortnightly review 1998 6 also concludes ‘the main risk factors are ones indicative of social adversity’.
3. Conclusion—Asylum seekers are at high risk of postnatal depression which may affect their process of claiming asylum and their ability to give a credible story
4. DETECTION—the BMJ article above summarises as follows
Postpartum depression is often missed by primary care teams. Its detection does not, however, present any special problem. The clinical features of the disorder are not distinctive, and its assessment is straightforward. Indeed, a simple brief self report measure, the Edinburgh postnatal depression scale (EPDS) has been developed as a screening device. It has sound psychometric properties. A large community study has revealed a specificity of 92.5% and a sensitivity of 88%. The questionnaire is easy to administer, simple to interpret, and could readily be incorporated within the routine services provided to all postpartum women. Sensitive clinical inquiry in high scorers would be sufficient to confirm the presence of depression.
The use of the EPDS has been validated by many different researchers and is currently recommended in the NICE Guidelines for treatment of antenatal and postnatal depression 7 and it is easily administered by a member of the Primary Community Healthcare Team [PCHT]
5. Effect of postnatal depression on child development the BMJ article concludes
- — Cognitive development in the context of postnatal depression is adversely affected, especially among male children and socioeconomically disadvantaged groups.
- — The children of postnatally depressed mothers tend to have insecure attachments at 18 months, and the boys show a high level of frank behavioral disturbance at 5 years.
- — The adverse child outcome in the context of postnatal depression is related to disturbances in the mother-infant interactions.
- — The Toronto Public health review 5 also concludes ‘Young children of mothers with postpartum depression have greater cognitive, behavioural, and interpersonal problems than children of non-depressed mothers.’
6. Treatment
Turning again to MUMSNET [which must be continually testing, discussing and refining treatment in this condition] 13 possible options are listed. Only one suggests medication/antidepressants and everything else includes support from people, agencies, groups and forms of self help.
Many of these options are unavailable to asylum seekers.
Case Studies
1. S. from the Ivory Coast sought asylum on grounds of severe domestic violence & forced marriage. She became pregnant through the trafficking process. She was illiterate and French speaking with no English. She was placed in a UKBA hostel in Birmingham and gained support from 2 French speaking ladies at a church and was referred by them to the local Doula support service 7. She also had the support of other French speakers in the hostel. She gave birth by Caesarian section for a breech baby and was moved to a shared house in the North of the city away from her previous support. The other 2 women in the house were from different cultures, language and ethnic back grounds. She was given no directions to find support for the postnatal period nor did she understand what to expect. The baby failed to thrive and was taken to Casualty by S who asked one of the original French speaking befrienders from the church to go with her. A very patient paediatrician eventually realised that she was not feeding the baby properly because no advice or follow up had been given.
2. F. from Iran came to London on a years student visa. At the end of her studies she found herself pregnant and decided to arrange an abortion. She was told she was expecting twins and she felt unable to go through with the termination of 2 babies. As she would not be welcomed back home and would bring shame on her family she asked for asylum. 3 weeks after birth she was moved to Birmingham to the UKBA hostel. Fortunately there were other Iranian families there who gave her some support and help. However 3 weeks later she was moved to a single occupancy terraced house around 13 miles away. There were no Farsi speakers in the area and her neighbours were from different cultural backgrounds. No information or directions were given for the local services. She was given a pushchair by the UKBA but it was too wide to fit through her front door. The accommodation was given at Christmas and the weather in the next few weeks made it impossible for her to leave the house.
3. These 2 case studies show
- — Removal of all support structures immediately after birth.
- — No written or verbal help with finding ongoing health service support.
- — Isolation from cultural or ethnic support which maybe vital for a mother from non UK background.
- — Potential increase in worry, anxiety and vulnerability, both for mother and baby.
- — There is a hit & miss system for mothers to find out how to claim further financial benefit when the baby is born.
Recommendations
1. The recent Parliamentary Inquiry into asylum support for children and young people 7 January 2013 recommendation 5 Newly dispersed families should be provided with comprehensive, written information in a language which they understand about their rights and entitlements, as well as practical information about services in their areas and where to get support. The implementation of this recommendation when newly post natal mothers are given fresh accommodation is key.
2. The process of receiving extra financial benefits for the newborn should be an automatic process—financial problems and anxiety being a risk factor for PND. Anecdotal evidence suggests mothers in the asylum process using all their money to buy for the baby and neglecting themselves.
3. A guideline for border agency staff would be helpful with a print off sheet to give to the mother outlining local services, telephone numbers and primary health care centres in her new area. [Availability in different languages].
4. There should be a protocol for networking between midwives and health visitors so that the new mothers who are asylum seekers are highlighted to one member of the local PHCT.
5. A rolling educational programme around health care and postpartum mothers who are refugees or asylum seekers could be developed in all the areas near UKBA hostels. As healthcare staff change posts it is important to raise awareness about this important group of clients with multiple needs and at high risk from postnatal depression where there is poor social support. It is simple to increase the use of the Edinburgh Depression Scale with Asylum seeking mothers.
Bibliography/References
1. literature review for Toronto Public health dept 2003 into postnatal depression
2. C:\Users\margarets\Documents\refugees\Postpartum depression Risk factors—MayoClinic_com.htm
3. Postnatal depression.htmArchives of Women’s Mental Health February 2011
4. http://www.mumsnet.com/babies/postnatal-depression
5. literature review for Toronto Public health dept 2003 into postnatal depression
6. BMJ fortnightly review 20.6.1998
7. doulaproject@bethelnetwork.org.uk
Dr Margaret Hooper
April 2013