Home Affairs Committee

1. Summary

Maternity Action is concerned about the negative impact on health and access to health services for pregnant asylum seeking women as a result of the UKBA policies on dispersal and relocation. Guidance from the National Institute of Health and Clinical Excellence (NICE) states the need for special efforts and provision to reduce levels of maternal and infant mortality. Research undertaken jointly by Maternity Action and the Refugee Council found that dispersal resulted in interruption to women’s antenatal care with potentially serious consequences; required maternity services to duplicate booking appointments, scans and tests; and impacted negatively on women’s mental health. Health service resources were wasted because midwives were not informed by UKBA about travel arrangements. Midwives’ attempts to defer or stop dispersal due to anxieties about the woman’s or baby’s welfare were rarely acknowledged or responded to by UKBA. There is an urgent need for dispersal policies to be reviewed in collaboration with health and refugee experts.

2. About Maternity Action

2.1. Maternity Action is a national charity working to challenge inequality and promote the health and wellbeing of all pregnant women, new mothers and their families.

2.2. Maternity Action provides online information and telephone advice on maternity rights, including rights at work, maternity benefits and asylum support. In 2012, parents downloaded 390 000 information sheets from our website and we answered 2200 telephone advice calls.

2.3. Maternity Action undertakes policy and campaigning work with a particular emphasis on the needs of the most vulnerable women. In 2012, we produced Guidance for commissioning health services for vulnerable migrant women627 in conjunction with the Women’s Health and Equality Consortium. In 2013, we released the report, When maternity doesn’t matter: Dispersing pregnant women seeking asylum628 in a joint project with the Refugee Council.

2.4. Maternity Action provides training to midwives on improving access to maternity care for asylum seekers and for vulnerable migrant women. We also provide training to health and community workers on maternity rights and benefits.

3. Asylum Support: The health impact of dispersal and relocation policies

3.1 Maternity Action is concerned about the negative impact on health and access to health services for pregnant asylum seeking women as a result of the UKBA policies on dispersal and relocation. Maternity Action and the Refugee Council jointly produced a research report on this issue, When maternity doesn’t matter: Dispersing pregnant women seeking asylum in February 2013.629

3.2 The study reviewed UKBA asylum dispersal policies relating to pregnant women and maternity policy and good practice on the care of vulnerable women. Qualitative interviews were undertaken with twenty women who have been dispersed and/or relocated by the UKBA by pregnant. Seventeen midwives were interviewed by phone about their experiences of working with asylum seeking women either before or after they were dispersed. The number of women interviewed is appropriate for qualitative research of this kind.

3.3 Refugees and asylum seekers are an especially vulnerable group in relation to maternity care and pregnancy outcomes. The 2007 Confidential Enquiry into Maternal and Child Health found that Black African women, including asylum seekers and newly-arrived refugees have a mortality rate nearly six times higher than White women.630 Factors contributing to poor maternal health outcomes include poor overall health status including underlying and possibly unrecognized medical conditions; traumatic experiences undergone in conflict and war zones including rape and trafficking for sexual exploitation; reluctance to seek maternity care because of fears about immigration status or shame relating to the pregnancy; and female genital mutilation (FGM), particularly when disclosed late in pregnancy.

3.4 The National Institute for Health and Clinical Excellence (NICE) Guidance, Pregnancy and complex social factors, draws attention to the need for special efforts and service provision for disadvantaged and vulnerable pregnant women in order to reduce levels of maternal and infant mortality.631

3.5 The research found that the UKBA only acknowledged pregnancy as representing a very limited health need unless there is a major pregnancy complication. Its dispersal policies made very little allowance for the healthcare and social needs of pregnant women. This criticism is applied to both the 2009 UKBA Dispersal Guidelines and the revised dispersal guidance introduced in July 2012, Healthcare needs and pregnancy dispersal guidance.

3.6 Most of the women interviewed reported feeling very unwell during their pregnancy. Midwives and women reported serious underlying health conditions including HIV, diabetes, other sexually transmitted diseases, female genital mutilation (FGM), as well as particular problems of pregnancy, such as severe headaches, elevated blood pressures, repeated urinary tract infections. Two-thirds of the women had their first contact with a midwife later than recommended in NICE guidance, which increased their risk for their pregnancies.

3.7 Over half the women described suffering from mental health conditions such as depression, anxiety and flashbacks, and very high levels of stress. Two had attempted suicide during the pregnancy under discussion. Midwives reported a disturbingly high incidence of mental health problems among the dispersed or pre-dispersal women they had looked after.

3.8 All of the women interviewed had been dispersed or relocated during their pregnancy though only two of them were moved away from London and South East England. This is important to note as it is often wrongly assumed that dispersal policies predominantly affect women living in London and the South East. Fourteen women experienced multiple moves during pregnancy or immediately after the birth, including one woman, who was moved six times during her pregnancy and once after delivery before she was found settled accommodation.

3.9 Women were very distressed about being dispersed away from areas in which they had strong social networks and established healthcare provision. In several cases dispersal separated women from the father of their baby. Women were often moved at short notice, without being informed of their destination or the distance to be travelled until the last minute or when they would be picked up. Fourteen women were moved in their final trimester of pregnancy.

3.10 Women reported being moved despite their treating clinician advising against travel.

3.11 Women found that they had insufficient money for essential needs and those worst affected were in receipt of cashless support. This issue is canvassed in some depth in the Refugee Council submission to this inquiry and so is not examined here.

3.12 Midwives attach great importance to regular antenatal contact with vulnerable women, emphasizing especially continuity of care and carer in order to build up trust where there were evident health and social care issues. However, most women’s antenatal care was interrupted as a result of dispersal, often with breaks of several weeks before they could again receive maternity care in the new area, mainly due to difficulties in registering with GPs.

3.13 The interruption in care could have serious consequences for conditions such as diabetes or hepatitis, which required regular monitoring or where treatment needed to be sustained during pregnancy. It also prevented the implementation of multi-agency care packages which were particularly important if children were deemed to be at risk.

3.14 Although nearly all women who had booked into maternity services before they were dispersed, had handheld records, nevertheless, booking appointments, tests and scans often had to be repeated in the new unit to ensure that results were accurate and referred to the right woman. Information on sensitive issues such as domestic violence was not normally stored on handheld records.

3.15 Dispersal had an extremely adverse impact on women’s mental health. At least five women had clinically diagnosed postnatal depression (PND). Many women found themselves in the dispersal area with no social support. They therefore had to make their own arrangements to go into hospital when they went into labour, and in some cases were frightened to call ambulances. They also had anxieties about who would look after their children, and in some cases arranged very ad hoc childcare.

3.16 None of the midwives interviewed were informed by UKBA of when women were being moved, or whether they were fit to travel. This wasted valuable time and public resources looking for them, and prevented planning or information sharing between maternity units. Midwives often asked women due to be dispersed to contact them on arrival at their dispersal destination, so that they could alert the maternity service in the new area, but this left the responsibility for doing this with the woman.

3.17 Where there were anxieties about a woman’s or baby’s welfare, midwives often tried to get a dispersal deferred or stopped, but letters to UKBA were rarely acknowledged or responded to. Midwives frequently spent a great deal of time trying to liaise with UKBA on behalf of a woman about whom they were concerned.

3.18 The 2012 revised guidance on dispersal, Healthcare and Pregnancy Dispersal Guidance, falls far short of addressing the issues identified in interviews with the women and midwives or in the NICE Guidance, Pregnancy and Complex Social Factors.

• — There is no mention of mental health issues or many other health needs arising in pregnancy, nor of many underlying health problems that may affect women during their pregnancies.
• — It does not address women’s need for social support throughout pregnancy and labour.
• — It confines women to Initial Accommodation during the ‘protected period’ of four weeks before the expected date of delivery and four weeks after the birth. The research found that Initial Accommodation is wholly inappropriate for women in advanced pregnancy.
• — The guidance notes some aspects of antenatal care, such as the need not to delay tests or to disrupt a programme of tests, however it does not indicate how its policy can contribute to avoiding such disruption earlier than four weeks before the expected date of delivery.
• — The policy maintains low levels of cashless support, forcing women into poverty and limiting the uses to which the support may be put, especially by denying them cash for public transport.
• — The guidance does not prevent disruption of maternity care.

3.19 Dispersal policies result in increase costs to maternity services. Valuable resources are wasted in searching for women who have been moved without the service being informed, and by generating the need for repeat tests and scans.

4. Recommendations

1. The Home Office should recognise pregnancy in women seeking asylum as involving complex needs and reflect this in its policies and practices.

2. The Home Office should, in collaboration with health and refugee experts, develop dispersal policies for pregnant women and those who have recently delivered, which are compatible with NICE guidance on the maternity care of women with complex social factors.

3. Financial support should be provided in cash during pregnancy and until the end of the postnatal period for women on section 4 support.

4. Pregnant women and new mothers should always be accommodated in safe, suitable housing outside of Initial Accommodation.

Maternity Action

April 2013

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Prepared 11th October 2013