What factors help or hinder refugee women s antenatal care experiences in the Australian public health system? A review of the literature. Last year, Australia accepted approximately 6,500 refugees fleeing persecution approximately half being women, and mostly of childbearing age (Australian Government, 2014). Poorer outcomes amongst refugee women birthing in Australia indicates that this is a significant and important women s health and women s right issue to be explored (Carolan & Cassar, 2010; Yelland et al., 2014). The World Health Assembly has stated migrant health is an identified priority due to the poorer physical and psychological health outcomes and inequities faced by this population (Gagnon et al., 2014). In regards to maternity care in particular, international and local research consistently show refugee women experience physical, mental, emotional and obstetric disadvantages in pregnancy and childbirth (Shafiei, Small, & McLachlan, 2012; Stapleton, Murphy, Correa-Velez, Steel, & Kildea, 2013; Yelland et al., 2014). Specifically, refugees experience higher rates of stillbirth, premature labour, low birth weight babies, and higher rates of maternal and infant mortality. Interestingly, the increased risks cannot be explained by pre-existing risk factors such as malnutrition, parity or age. Alongside pre existing health status, poor outcomes are correlated to resettlement stress, social/financial disadvantage and discrimination faced by refugee women following immigration (Carolan & Cassar, 2010; Stapleton et al., 2013; Yelland et al., 2014). Furthermore, limited or late access to antenatal care is considered a key factor for increased obstetric risk (Carolan, 2010; Gibson-Helm et al., 2015; Yelland et al., 2014) and other evidence suggests that health outcomes for refugees are also affected by social inclusion, accessibility of the health system and interactions with health professionals (Correa-Velez & Ryan, 2012; Shafiei et al., 2012). The literature summarised in this review is both important and relevant to midwifery practice as the evidence directly indicates that midwives are rated as one of the most significant influences on refugee women s maternity care experience (Shafiei et al., 2012). Furthermore, midwives can significantly improve health outcomes for refugee women through the provision of accessible, culturally safe, caring and supportive antenatal care (Carolan & Cassar, 2010; Shafiei et al., 2012; Stapleton et al., 2013). According to Elements 7.2 and 10.1 of the Nursing and Midwifery Board of Australia (2006) competency standards, midwives are responsible to ensure women s individual preferences and cultural needs are taken into consideration and midwives are required to plan, implement and evaluate strategies for providing culturally safe practice for women, their families and colleagues (Nursing and Midwifery Board of Australia, 2006). Despite these professional expectations on midwives, research suggests that midwives feel they do not have the knowledge, skills or support to care appropriately for refugee women (Correa-Velez & Ryan, 2012). In light of the significance of antenatal care for maternal and infant health, the literature review presented here will focus on the antenatal care experiences of refugee women in Australia s public health system, focusing on the factors that help or hinder the experience and the engagement of these women in their antenatal care. The review will focus on three major themes in the literature, including:
- The background factors that lead to increased vulnerability of refugee women - recurrent themes include loneliness and isolation, lack of social support and family separation, history of torture, violence and trauma, and higher rates of mental and physical health problems. - Service design factors, including continuity of care, communication and language barriers, poor health literacy and education, and how social disadvantage creates access issues for antenatal care, and - Factors relating to the role of the midwife and how discrimination and poor cultural awareness versus individualised, supportive and respectful care can impact how refugee women engage with their antenatal care. Search strategy: In order to capture all relevant research on refugee women and antenatal care in Australia, a broad search was carried out on journal articles via the databases Cinahl, Science Direct and Scopus. Although the search terms included refugees, asylum seekers, immigrants and migrants, research was only included where the study examined humanitarian refugees, granted asylum in Australia. This is due to the unique health issues faced by women fleeing persecution, war or other atrocities compared to immigrants in general. Although only articles related to antenatal care were included, the search term maternity care was included, as some relevant studies were not captured when searching for ante- or pre- natal care alone. Australian and NSW government policy and clinical guidelines regarding antenatal care and refugee health was further searched to provide additional perspective and political context on the opportunities and limitations for recommended practice in the future. Inclusion and exclusion criteria: Results were limited to the last 5 years (2010-2015) and depending on the database search capacity, articles were manually or automatically narrowed to English language and Australian based research. Approach to analysis: Due to the influence of local policy, culture and social issues specific to Australia, the literature review focused on Australian research, although only 10 articles fit the search criteria. As international research was much more extensive, particularly regarding the UK and Europe, relevant elements from several international literature reviews will be discussed in order to provide further context for the universal aspects of refugee health and directions for future research. With the majority of relevant research being qualitative, the articles were critically analysed into themes, and the literature review approached with a thematic style. The table below summarises the search strategy and results. Database Search terms limiters Total returns Specific to Australia / Included in literature review Science (Refugee* OR asylum seeker* 2010-2015 34 6
direct OR immigrant* OR migrant*) AND ( antenatal care OR prenatal care OR maternity care ) Search title, abstract, keywords Cinahl (MH Refugees OR asylum seeker* OR *migrant*) AND ( antenatal care OR MH prenatal care OR maternity care ) 2010-2015 English language Search all text (unable to select title, abstract and keyword) 73 6 Scopus Refugee* OR asylum seeker* OR *migrant*) AND ( antenatal care OR prenatal care OR maternity care ) 2010-2015 Journal article Search title, abstract, keywords 237 9 Unique results 10 Background factors The literature highlighted several themes regarding background influences on refugee health and engagement with maternity care. These include physical/mental health issues such as malnutrition, anaemia, infectious disease, post-traumatic stress disorder and depression as well as negative consequences from loneliness and isolation due to the effects of separation from culture, family and social support. Refugee women are at higher risk of experiencing sexual trauma, violence, torture, as well as negative health effects from culturally normative practices such as childhood marriage and female genital mutilation (Correa-Velez & Ryan, 2012; Stapleton et al., 2013). Such trauma creates a potential barrier that could interrupt antenatal care, with refugee women reporting stress associated with male health practitioners or interpreters, lack of continuity of care, and retraumatisation from questions or procedures related to pregnancy (Carolan & Cassar, 2010; Spike, Smith, & Harris, 2011). Sexual trauma such as that mentioned above also has physical and mental health correlates, seen by increased reports of depression, anxiety and post-traumatic stress disorder amongst refugee women (Carolan, 2010). Additionally, the stress of resettlement is correlated to increased mental health issues for refugee women (Yelland et al., 2014). In regards to physical health status, Correa-Velez and Ryan (2012) conducted an audit of refugee women in Australia, finding that these women experienced higher rates of anaemia, female circumcision, hepatitis B and coagulopathies such as thrombocytopenia. In a large study of refugees from Asia, Gibson-Helm et al. (2015) reported additional risk factors to previous research, including higher rates of teenage pregnancies and obesity. The difference in Gibson-Helm et al. s (2015) research is likely due
to the focus on refugees from Asian countries, whereas much of the other research is focused on African refugees. International research further supports findings of increased physical and mental health problems, with higher rates of anaemia, infectious disease, malnutrition, complications from female genital mutilation, depression and post traumatic stress disorder across very large samples of refugee women (Bridle, 2012; Carolan, 2010; Small et al., 2014). Refugee women report higher levels of loneliness and isolation, creating higher risk of mental health issues and stress (Yelland et al., 2014). Separation from the social support and family system specifically impacted on refugee women s experience of antenatal care, particularly where women reported discomfort with the Western practice of having male partners present for childbirth or having to discuss women issues with male health practitioners. The loss of family and social support was also reported to impact refugee women s ability to attend appointments due to difficulties managing transport and childcare requirements (Stapleton et al., 2013; Yelland et al., 2014). Due to the background issues discussed above, it is critical for midwives to focus on safe and compassionate care and to work collaboratively with other health professionals to meet the complex psychosocial and physical needs of refugee women (Correa-Velez & Ryan, 2012; Stapleton et al., 2013). Australian antenatal care clinical practice guidelines and the current refugee health plan policy in the local health system reiterate the vulnerability of refugee women and the importance of tailoring care to the meet the social, cultural, education and language needs of this population (Australian Health Ministers' Advisory Council, 2012; NSW health, 2011). Service design factors Continuity of care for vulnerable groups of women such as refugees has repeatedly been shown to increase satisfaction, improve communication, enhance women s sense of empowerment and promote better engagement of refugee women with the health system (Correa-Velez & Ryan, 2012; Stapleton et al., 2013). Having a known carer was reported to increase antenatal attendance and assisted in enhancing women s understanding of pregnancy, childbirth and breastfeeding (Correa-Velez & Ryan, 2012). Importantly for women with traumatic backgrounds, continuity of care increased trust and helped reduce stress by reducing retraumatisation (Correa-Velez & Ryan, 2012; Stapleton et al., 2013). Continuity of care has also shown to have benefits for midwives, with Yelland et al. (2014) reporting that providing continuity made professionals feel more capable of developing trust and increased understanding of refugee women s needs. Despite the significant research in support of continuity of are, Yelland, Riggs, Small, & Brown (2015) concluded that refugee women s satisfaction of maternity care did not improve over an eight year gap, despite significant efforts to increase continuity of care models. However, the research did not differentiate between immigrant women and refugees, thus further research is required to understand what is the experience of refugee women specifically, and also as to whether the lack of improvement in satisfaction was in fact correlated to continuity of care models or whether other factors such as accessibility of care, waiting time, interpreter availability and perceived lack of cultural sensitivity impacted satisfaction despite continuity of care (Yelland et al., 2015).
A significant number of refugee women speak very little English and are reliant on interpreters or family members for communication (Bridle, 2012; Small et al., 2014; Yelland et al., 2014). Access to an interpreter (and a female interpreter when culturally important) was reported to increase satisfaction and attendance measures amongst African refugee women (Carolan & Cassar, 2010). In a large survey of over 560 refugee women from various backgrounds, language and communication difficulties was listed as a major contributing factor to inequality in health care experience and was also a significant factor impacting women s antenatal care satisfaction (Yelland et al., 2015). Midwives similarly reported that access to interpreters significantly assisted them to provide appropriate education, information and care to refugee women (Stapleton et al., 2013; Yelland et al., 2015). Furthermore, midwives often reported feeling rushed and that there was not enough time in a standard appointment for women with complex history, particularly when interpreters were involved (Stapleton et al., 2013; Yelland et al., 2015). As per recommendations in the NICE clinical guidelines, it would be beneficial to increase antenatal care appointment times when interpreters are required (National institute for Health and Clinical Excellence, 2010). A number of studies found that refugee women reported feeling confused about the health system. Re-occurring themes in Australian and international research include confusion and fear, leading to avoidance of antenatal care or routine tests and general dissatisfaction with care experiences (Carolan, 2010; Carolan & Cassar, 2010; Stapleton et al., 2013). In addition to poor health literacy for the Australian public health system, refugee woman also have higher rates of illiteracy both in English and their native language (Carolan & Cassar, 2010). For women with limited literacy, research indicates there is a paucity of research as to the best way to provide information to these women (Carolan and Casser 2010). In a review of nearly 200 refugee women s experiences of antenatal care, Stapleton et al. (2013) found that these women had different health information needs regarding navigating the health system and also practical information such as where to purchase car seats, maternity pads and other basic products required. As reported in Australian and International literature, refugee women experience greater financial stress and lower socioeconomic status (Carolan, 2010; Small et al., 2014; Yelland et al., 2014). Refugee families have higher rates of unemployment and continue to experience disadvantages of poverty with implications important to pregnancy such as poor nutrition, no access to transport and poorer physical health (Spike et al., 2011; Yelland et al., 2014). Lack of access to a car or difficulty affording public transport was reported as a significant impediment to refugee women accessing antenatal appointments and other routine tests and services related to their maternity care (Correa-Velez & Ryan, 2012; Yelland et al., 2014). Women reported higher satisfaction and greater attendance when the health service was flexible regarding appointment times and when assistance could be provided regarding transport to appointments (Carolan & Cassar, 2010; Stapleton et al., 2013). Furthermore, Yelland et al. (2014) discussed how greater understanding of the social context and stressors present in refugee women s lives resulted in more individualised care to better meet the needs of these families. In summary, satisfaction and engagement in antenatal care depends on accessibility, culturally safe and individualised care, access to known carers and interpreters, assistance
with social determinants of health and provision of information and education addressing the unique needs of refugee women. Midwifery / care provider factors There was a recurring theme in the literature recognising the uniqueness between and within different cultural groups (Carolan & Cassar, 2010). This requires midwives to be adaptable and provide individualised care to meet the social and cultural care needs for each woman. For example, it was recommended that midwives ask about beliefs and cultural practices that matter to each woman rather than assume the needs of women based on their ethnicity (Carolan & Cassar, 2010; Yelland et al., 2014). The concept of individualised care is particularly critical for culturally safe practice as the needs of women can vary within cultures. For example, some research with refugees indicated that access to a female caregiver was critical (Carolan & Cassar, 2010) whilst other research suggested this was less significant (Shafiei et al., 2012). Correa-Velez and Ryan (2012) claimed that whilst culturally competent care was linked to improved satisfaction, there was no strong evidence for increasing attendance or improving health status. In contrast, a large international literature review has drawn a correlation between culturally insensitive care and reluctance of refugees to access maternity care services (Santiago & Figueiredo, 2015). Conflicting information in the literature may be due to difficulty in defining cultural competence or safety, small participant numbers (often focused on one cultural group) and no differentiation made for length of time settled in Australia. Relationship attributes of the midwife have also been highlighted as important to refugee women s satisfaction and likelihood of attending appointments. African refugees reported the importance of feeling welcome and comfortable in appointments (Carolan & Cassar, 2010). In addition, positive experiences was reported when refugee women felt that they were treated with empathy, respect, sensitivity, reassurance and patience by their midwife (Shafiei et al., 2012). In particular, Carolan and Cassar (2010) reported that access to antenatal care was significantly hindered by refugee women s experiences of racism and racial stereotyping by health care providers. This finding is consistent with international literature based on countries with similar refugee intakes and health care systems as Australia (Small et al., 2014). To summarise what is known; refugees experience poorer health prior to immigration and continue to experience physical, social, emotional and psychological disadvantages even once resettled in developed countries such as Australia. Refugees are at greater risk of experiencing violence, trauma and persecution, therefore creating unique and complex health and social needs. Some Australian and extensive international research suggest refugee women are less likely to attend antenatal appointments, have a tendency to book in later in pregnancy, and experience corresponding poorer obstetric outcomes. Refugees face a number of possible barriers to accessing the health system, including difficulties associated with: poor health literacy, communication and language difficulties, poverty, poorer physical/mental health, high levels of stress and discrimination from health professionals. We also know from the literature that factors that help improve access and positive experiences of antenatal care include continuity of care, non-judgemental, supportive and
individualised care from midwives, assistance to attend antenatal appointments and access to interpreters and female staff where required. Although it is recognised that refugees have unique information needs, it is unclear how to best share information and to make educational material accessible. Higher rates of illiteracy in women s native tongue mean it is not as simple as translating written material. It is also relatively unknown as to what differences may exist in the needs of refugee women from different countries or ethnicities. For example Gibson-Helm et al. (2015) found different risks and outcomes for refugees from Asian countries compared to the findings of Carolan and Cassar (2010) of African refugees. These differences need to be explored further in order to inform what services or support systems may be of most benefit to different refugee groups. Although the importance of culturally safe care is well understood, there is very little research on how to efficiently and effectively educate midwives in cultural competence nor on how to provide adequate professional support to improve the confidence of midwives providing care to refugee women. Furthermore, much of the research on refugee women s maternity care in Australia is qualitative, and based on small sample sizes. The quantitative elements of current research are generally self-report surveys or questionnaires. Thus there is little understanding or quantifiable evidence on the correlation between vulnerabilities we are aware of and the magnitude of their impact on obstetric outcomes. Similarly, the research investigated in this literature review did not differentiate between length of time that refugees had been in Australia or attempt to adjust for factors such as education level, English language attainment, household income or other measures that may impact on both the women s experiences and obstetric outcomes. Conclusion Refugee women are at higher risk of experiencing obstetric complications once settled in Australia and these complications cannot be explained by pre existing risk factors alone. Poorer obstetric outcomes are likely correlated to reduced access to antenatal care, and compounded by poverty, poor cultural competence from staff, language barriers, stress and greater physical and mental health issues. Factors that can assist women feel safe and able to access antenatal care include access to interpreters and female staff where possible, practical information and education on how to navigate the health system, and individualised and culturally safe care preferably from a known midwife. Factors that hinder refugee women from positively engaging in antenatal care include judgmental care, poor cultural awareness and inflexibility from staff. Additionally short appointment times and language barriers further hinder refugee women from benefitting adequately from antenatal care. Future research is needed on how continuity of care models might be best adapted to specifically meet the complex needs of refugee women. Future research as to the most effective methods of delivering information and education to refugee women in the antenatal setting would assist service delivery design and help shape midwives future practice. In addition, due to the importance of culturally safe care, it would be beneficial for research to investigate the attitudes and cultural competence of midwives, and how training can most efficiently and effectively be delivered.
The findings from this literature review have several important impacts on how future practice may help refugee women feel safe and encouraged to access antenatal care in Australia. Firstly, the importance of individualised and culturally safe care is now firmly understood and midwives can utilise self-reflection and proactively seek cultural awareness training to ensure the provision of the best care possible. A simple practice recommended for midwives is to ask women of any important cultural practices or needs relating to childbearing and to facilitate these needs where possible. Furthermore, due to the unique information needs of refugee women, midwives are encouraged to ask open ended questions to ascertain whether refugee women have the knowledge often taken for granted, regarding routine tests in pregnancy, what to expect from birthing in Australia and where to purchase basic items such as maternity pads. Lastly, as communication and language issues were frequently cited as barriers to accessing care, midwives are encouraged to ensure appropriate use of interpreters (female if requested) and where possible to allow for additional time to accommodate the potentially increased complex needs of refugee women.
References Australian Government. (2014). Australia s Offshore Humanitarian Programme: 2013 14. Online: Department of Immigration and Border Protection Retrieved from http://www.immi.gov.au/pub-res/documents/statistics/australia-offshore-humanitarianprogram-2013-14.pdf. Australian Health Ministers' Advisory Council. (2012). Clinical Practice Guidelines; Antenatal Care - Module 1. Online: Department of Health and Ageing Retrieved from http://www.health.gov.au/antenatal. Bridle, L. (2012). Asylum seekers and refugees accessing maternity care literature review and discussion. MIDIRS Midwifery Digest, 22(1), 7-12. Carolan, M. (2010). Pregnancy health status of sub-saharan refugee women who have resettled in developed countries: a review of the literature. Midwifery, 26(4), 407-414. doi: http://dx.doi.org/10.1016/j.midw.2008.11.002 Carolan, M., & Cassar, L. (2010). Antenatal care perceptions of pregnant African women attending maternity services in Melbourne, Australia. Midwifery, 26(2), 189-201. doi: http://dx.doi.org/10.1016/j.midw.2008.03.005 Correa-Velez, I., & Ryan, J. (2012). Developing a best practice model of refugee maternity care. Women and Birth, 25(1), 13-22. doi: http://dx.doi.org/10.1016/j.wombi.2011.01.002 Gagnon, A. J., De Bruyn, R., Essén, B., Gissler, M., Heaman, M., Jeambey, Z.,... Vangen, S. (2014). Development of the Migrant Friendly Maternity Care Questionnaire (MFMCQ) for migrants to Western societies: An international Delphi consensus process. BMC Pregnancy and Childbirth, 14(1). doi: 10.1186/1471-2393-14-200 Gibson-Helm, M., Boyle, J., Cheng, I. H., East, C., Knight, M., & Teede, H. (2015). Maternal health and pregnancy outcomes among women of refugee background from Asian countries. International Journal of Gynecology & Obstetrics(0). doi: http://dx.doi.org/10.1016/j.ijgo.2014.10.036 National institute for Health and Clinical Excellence. (2010). Pregnancy and complex social factors. Retrieved 28/03/2015, from http://www.nice.org.uk/guidance/cg110 NSW health. (2011). Refugee Health Plan 2011-2016. (PD2011_014). Online: NSW Government Retrieved from http://www0.health.nsw.gov.au/policies/pd/2011/pdf/pd2011_014.pdf. Nursing and Midwifery Board of Australia. (2006). Midwifery Competency Standards - January 2006. Retrieved 02/08/2014, from http://www.nursingmidwiferyboard.gov.au Santiago, M., & Figueiredo, M. (2015). Immigrant Women's Perspective on Prenatal and Postpartum Care: Systematic Review. Journal of Immigrant & Minority Health, 17(1), 276-284. doi: 10.1007/s10903-013-9915-4 Shafiei, T., Small, R., & McLachlan, H. (2012). Women's views and experiences of maternity care: A study of immigrant Afghan women in Melbourne, Australia. Midwifery, 28(2), 198-203. doi: http://dx.doi.org/10.1016/j.midw.2011.02.008
Small, R., Roth, C., Raval, M., Shafiei, T., Korfker, D., Heaman, M.,... Gagnon, A. (2014). Immigrant and non-immigrant women's experiences of maternity care: a systematic and comparative review of studies in five countries. BMC Pregnancy and Childbirth, 14(1), 152-152. doi: 10.1186/1471-2393-14-152 Spike, E. A., Smith, M. M., & Harris, M. F. (2011). Access to primary health care services by community-based asylum seekers. Medical Journal of Australia, 195(4), 188-191. Stapleton, H., Murphy, R., Correa-Velez, I., Steel, M., & Kildea, S. (2013). Women from refugee backgrounds and their experiences of attending a specialist antenatal clinic. Narratives from an Australian setting. Women and Birth, 26(4), 260-266. doi: http://dx.doi.org/10.1016/j.wombi.2013.07.004 Yelland, J., Riggs, E., Small, R., & Brown, S. (2015). Maternity services are not meeting the needs of immigrant women of non-english speaking background: Results of two consecutive Australian population based studies. Midwifery, In Press. http://www.midwiferyjournal.com/article/s0266-6138(15)00067-4/abstract doi:http://dx.doi.org/10.1016/j.midw.2015.03.001 Yelland, J., Riggs, E., Wahidi, S., Fouladi, F., Casey, S., Szwarc, J.,... Brown, S. (2014). How do Australian maternity and early childhood health services identify and respond to the settlement experience and social context of refugee background families? BMC Pregnancy and Childbirth, 14(1). doi: 10.1186/1471-2393-14-348