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PRACTICE UPDATE - CARE FOR REFUGEE WOMEN
REFUGEE RESETTLEMENT IN AOTEAROA NEW ZEALAND: GUIDE FOR COMMUNITYBASED MIDWIVES AND THE WIDER MATERNITY TEAM
CLAIRE MACDONALD MIDWIFERY ADVISOR CAROL BARTLE POLICY ANALYST The Ministry of Health first published a handbook for health professionals on refugee health care in 2002, designed to support those working in the field to provide culturally safe and effective care across a range of healthcare settings. The handbook was last updated in 2012, and since then Aotearoa has increased its refugee quota, expanding the number of resettlement locations from eight towns/cities to fourteen. Until now, midwifery care of former refugee women has largely been provided by DHB community midwives, but with the quota increase, more LMC midwives will also become involved. In 2020, the Ministry approached the College to research and develop a dedicated chapter about midwifery and maternity care for the 2021 handbook update. Each year, Aotearoa accepts and resettles refugees who have been referred by the UN Refugee Agency (UNHCR) and assessed as having met the appropriate criteria (Government of New Zealand 2018). Under the Refugee Convention, Aotearoa has an obligation to accept refugees, and the annual quota increased from 1,000 to 1,500 places in July 2020. In addition, a smaller number of asylum seekers arrive each year. The human rights of refugees are specified in the 1951 United Nations Convention Relating to the Status of Refugees (the Refugee Convention) and its 1967 protocol. The International Covenant on Civil and Political Rights (ICCPR) and the Convention Against Torture and Other Cruel, Inhumane or Degrading Treatment or Punishment 1984 (CAT) also contain provisions relevant to refugees and New Zealand has ratified all three treaties (Human Rights Commission, 2010). Once people are accepted into Aotearoa as refugees, they become residents and ultimately citizens. Because of their status as New Zealanders, the chapter refers, in most cases, to ‘former refugees’ rather than ‘refugees’.
Our approach to this work was to consult closely with members of the former refugee community and share the development of the chapter as it came together. We undertook focus groups with former refugee women who had experiences of receiving and providing midwifery care in Aotearoa, and they provided feedback on the drafts. We were supported and advised by Sahra Ahmed, Refugee Health Nurse from Pegasus Health, as well as Isabella Smart, Midwife Manager at Counties Manukau Health, who provided valuable insight into the provision of midwifery care to women at Te Āhuru Mōwai by the community midwifery service. The College also engaged a peer reviewer: respected academic Dr Ruth De Souza, who has extensive experience in the areas of cultural safety, maternity, migration and health, and social inclusion. The chapter aims to provide useful information to midwives and other people who might be supporting women from refugee backgrounds. It explores the frameworks and principles for maternity care in Aotearoa as they apply to care for former refugees, follows the woman’s health care journey from offshore to Te Āhuru Mōwai (Mangere Refugee Resettlement Centre), and on to her resettlement region. It identifies the midwife’s role and the specific additional aspects of care and considerations for former refugee women, including interpreting services, clinical assessment, health promotion, cultural considerations and specific health issues. While the chapter is focused on maternity care for women from refugee and asylum seeker backgrounds, much of this information will also be relevant to women who have similar backgrounds to former refugees, for example family reunification migrants, as well as women from other migrant backgrounds and the wider maternity population.
People have refugee status for two years after arrival in Aotearoa, during which time former refugees have the support of refugee resettlement services to facilitate their access to necessary services. For a pregnant woman arriving in Aotearoa on humanitarian grounds following forced migration as a refugee or asylum seeker, maternity care may be the first engagement with the health system in this country. Midwives understand that pregnancy involves significant changes in the lives of women and their families. The growth of a family can signal a new start in a new home for former refugees, but it may also involve the expression of physical, emotional or mental health difficulties reflecting the circumstances that led to the woman’s arrival in Aotearoa. Continuity of midwifery care provides an opportunity for the woman and her family to gain confidence, trust and self-efficacy through positive experiences of the health system in their new home country.
All quota refugees spend time at Te Āhuru Mōwai in Mangere, Auckland, when they arrive in Aotearoa. A health check may have been undertaken offshore prior to arrival, but questions about pregnancy are limited to the estimated due date. A midwife from the Counties Manukau Health
community midwifery team visits the woman onsite at Te Āhuru Mōwai to undertake a full midwifery assessment and commences her maternity record. The Counties Manukau midwifery service undertakes to ensure that all maternity information is transferred to the woman’s chosen GP, once known, in her resettlement area. Prior to departure from Te Āhuru Mōwai, the woman is provided with a copy of her maternity care record-to-date, to take to her next midwifery care provider. Where the need for obstetric or medical involvement in the woman’s maternity care has been identified, a referral to the appropriate service/s is made by Counties Manukau Health to the receiving DHB. At time of writing, the process of navigation from the community midwife at Te Āhuru Mōwai to midwifery care in the woman’s resettlement region is yet to be confirmed.
For women who become pregnant when they are already in their allocated resettlement location, there is a reasonable likelihood they will access maternity care from an LMC midwife, having followed referral pathways from general practice, social services and recommendations from their local community.
As a population group, newly arrived former refugee women have significant and distinct health care needs. It is important to recognise that there is no homogenous refugee experience or reality, and that as with all people, experiences of pregnancy are personal and diverse. Some health conditions are more commonly experienced by former refugee populations than the general population, but as described in this chapter it is important to avoid assumptions. The chapter provides specific information about a number of conditions, including: vitamin D deficiency; anaemia; haemoglobinopathies; parasitic infections and diseases; infectious diseases; mental health and trauma; and the impact of socioeconomic status and racism on health. The section on female genital mutilation (FGM), also known as female genital cutting, has been updated by Nikki Denholm from FGM NZ. Many women with FGM have unique reproductive and sexual health needs and studies on the experiences of women affected by FGM in western countries indicate that these needs are often poorly understood. The chapter details important information about FGM, its potential complications, and considerations for pregnancy, labour and birth, and postnatal care for women affected by it.
Midwives have the potential to be powerful and enabling health care professionals, who provide care, refer to specialist services as necessary, link women to local and non-governmental organisations (NGOs), and help women and families to trust and navigate the health system in their new homes. We hope this chapter provides useful information for midwives, and other health workers, which will lead to former refugee women experiencing the health system positively, with minimal barriers to accessing culturally safe and appropriate care. This level of care should be the expectation for everyone accessing our maternity service. square
When the chapter is published as part of the Refugee Health Care handbook, we will link to it from the College website, www.midwife.org.nz.
