Maternity_mortality_and_Migration_TheImpactOfNewCommunities_Jan2008 by Phit Bhwp

Maternity, mortality and migration: the impact of new communities

January 2008

Dr Beck Taylor Heart of Birmingham Teaching Primary Care Trust Dave Newall West Midlands Strategic Migration Partnership Secretariat

Heart of Birmingham Teaching Primary Care Trust

Maternity, mortality and migration: the impact of new communities

January 2008

Dr Beck Taylor Heart of Birmingham Teaching Primary Care Trust Dave Newall West Midlands Strategic Migration Partnership Secretariat

Heart of Birmingham Teaching Primary Care Trust

Acknowledgements We acknowledge funding support from the Department of Health West Midlands. We wish to thank Birmingham Health and Wellbeing Partnership, the Public Health Information Team, The Perinatal Institute, NHS and social care staff who gave of their time to outline issues that they and their clients face. We wish to acknowledge the assistance given by Karen Saunders (Senior Public Health Manager, Department of Health West Midlands GOWM) in the development of this project, and Dr Jacky Chambers (Director of Public Health HOBtPCT), Michael Swaffield (Head of the Asylum Seeker coordination team at Department of Health), David Barnes (Director of WMSMP) and Clare Daley (Policy Officer WMSMP) for their comments on the final report. We thank the following organisations for providing valuable insight into the nature and scale of the problems facing migrant women and families at the consultation event on 19th October 2007: Coventry Refugee Centre The Childrenâ&#x20AC;&#x2122;s Society Coventry Teaching Primary Care Trust Warwick University Mamta Programme Horn of Africa Women Development Network Terrence Higgins Trust UHCW NHS Trust WMSMP ASIRT British Red Cross Restore Coventry Peace House Finally, we give particular thanks to the service users who shared their experiences of destitution, and to the Red Cross and Restore for putting us in touch with clients who were willing to speak about their situation.

For further information on this report please contact : Dr Jacky Chambers, Director of Public Health HoBtPCT (Jacky.Chambers@hobtpct.nhs.uk ) or Dave Newall, Policy Officer at the West Midlands Strategic Migration Partnership (d.newall@wmlga.gov.uk) Further information on the work of the West Midlands Strategic Migration partnership is available at www.wmlga.gov.uk/asylum, where an electronic copy of this report can also be downloaded. For additional copies of this document please contact Jeanette Davis at Heart of Birmingham Teaching PCT Jeanette.Davis@hobtpct.nhs.uk 0121 224 4693

Maternity, mortality and migration: the impact of new communities

Foreword Maternity, mortality and migration: the impact of new communities presents for the first time a review of the impact of migration on maternal and infant health in Birmingham. The report draws on a wide range of policy documents, information sources, the views of NHS and Local Authority staff, service users and the voluntary sector. The need for this review arose partly from the need to understand more about the rise in infant deaths experienced in Birmingham during the last 5 years, as well as growing confusion, concerns and anecdotal evidence about the needs and entitlements of pregnant women with no recourse to public funds. By assembling evidence about the needs of new migrant women , particularly those who are highly vulnerable and socially excluded , and the challenges faced by front line staff when responding to their needs , this report provides a basis for more informed and objective policy debate. As this report clearly shows, the scale and pace of demographic change in a city like Birmingham are considerable. Given possible changes in legislation and in the funding of maternity services, the need for a more informed policy debate has become urgent. We believe the findings highlight the need for a more flexible, responsive and social model of maternity care which is culturally competent; can provide outreach services, and will promote and support access to benefits, housing and other agencies as an integral part of providing care. The recommendations made in this report identify what can be done by the local health economy and the local authority to commission maternity and child health services which are able to respond effectively to the different needs of new migrant women. We hope this review will be useful for other areas within the region facing similar challenges. We would like to thank all those who have contributed so much to its preparation and production. Dr Jacky Chambers OBE Director of Public Health Heart of Birmingham Teaching Primary Care Trust

Contents Executive summary 1)

Introduction

Policy Context

3) 3.1 3.2 3.3 3.4 3.5

Immigration processes Routes of entry into the UK Asylum seekers process and support Persons with no recourse to public funds Support for individuals with No Recourse to Public Funds Economic migrants

16 16 16 20 23 30

4) 4.1 4.2 4.3

Infant mortality and migration Infant mortality statistics Determinants of infant mortality pertinent to migrants Conclusion

31 31 35 42

5) 5.1 5.2 5.3

Who is giving birth in Birmingham? Birth registration data Births census Summary

43 43 49 52

6) 6.1 6.2 6.3 6.4 6.5 6.6

Health and social care staff perspectives: Community health staff Hospital staff Other staff Examples of good practice cited by those interviewed Key themes/problems identified by most or all groups: Possible solutions

53 53 59 62 64 64 65

Experiences of pregnancy and motherhood in women with No Recourse to Public Funds Health service Health effects of womenâ&#x20AC;&#x2122;s circumstances Other concerns What women would like to change

66 66 68 68 70

7.1 7.2 7.3 7.4

8) Voluntary sector perspective 8.1 Role of agencies consulted in providing support to NRPF and other vulnerable migrant women: 8.2 Agency activity, and the scale of the problem 8.3 Common causes of destitution 8.4 Contributory factors affecting access to health services 8.5 Experiences of destitute clients access to health and social care 8.6 Possible solutions

71 71 71 72 72 74 76

Maternity, mortality and migration: the impact of new communities

Summary of issues identified by all sectors

10) Recommendations 10.1) Health 10.2) Border and Immigration Agency 10.3) Local Authorities 10.4) Recommendations for all stakeholders

80 80 82 83 84

11) Conclusion

Appendix 1: Glossary of terms

Appendix 2: Categories of overseas nationals and migrants workers

Appendix 3: Entitlements to health care for overseas visitors

Appendix 4: Useful documents

Executive summary Background In 2006, 1 in 5 births in the UK were to women born outside Britain. Outcomes in pregnancy are worse in migrant women compared with ‘indigenous’ populations. The West Midlands has a large and expanding migrant population, along with the highest infant mortality rates in the UK, and concerns have been raised about the issues facing migrant women and babies in the region. Infant mortality and child health are key indicators of the overall health of a population, and with this in mind, this project was conducted to examine the impact of migration upon outcomes for migrant groups, and identify areas for action.

Intended audience The information in this report is primarily aimed at informing policymakers, commissioners and heads of service in health, social care and immigration services in the West Midlands. The information may also be of interest to voluntary and private sector stakeholders involved in the care and support of children and families, vulnerable adults and migrants.

Aims and objectives This project seeks to quantify and qualify the impact of migration upon maternal and infant health across the West Midlands, focusing on the situation in Birmingham. Birmingham is the focus as it has particularly high numbers of new migrants, along with high levels of infant mortality. The project identifies the problems faced by service users and organisations, and makes recommendations as to what action might be taken to resolve the issues. There is a particular focus on the issues facing women with No Recourse to Public Funds, as this group was identified as having some of the most acute unmet need. It is hoped that the recommendations will also inform the work of other PCTs with large migrant populations, and in areas of asylum dispersal within the region.

The project has several elements: • • • •

A review of the process of migration and the key issues with respect to maternal and child health A review of infant mortality with respect to migration-related risk Exploration of births in Birmingham, and migrant-related factors A consultation with service users, staff and voluntary sector agencies

Migrants in context Migrants are not a homogenous group. They include economic migrants, asylum seekers, refugees, refused asylum seekers, illegal migrants, and individuals who entered the UK with visa clearance. Visas may be granted to migrants for the purposes of study, tourism, visiting family, employment or marriage. The length of time living in the UK, and immigration status can influence the level of social and economic stability for migrant groups. These factors, in turn, can affect health outcomes. Recently arrived migrants, asylum seekers, and individuals with No Recourse to Public Funds are particularly vulnerable, compared with migrants who moved to the UK decades ago, or those who migrate in order to take up employment.

Maternity, mortality and migration: the impact of new communities

Infant mortality, the scale of the issue locally, and its link to migration Infant deaths are a key indicator of the health of a population. Infant mortality is falling in the UK, although the West Midlands is experiencing a slower decline, and sees the highest rates, with the Heart of Birmingham PCT having the highest rate in England. The areas with poor outcomes generally have high levels of deprivation. These areas also tend to be a focus for migrant populations, and in particular are dispersal areas for asylum seekers. Many of the risk factors for infant mortality are experienced by migrant women and families, including ethnic minority status, material and social deprivation, nutrition, low educational level, abuse, female genital mutilation, consanguinous marriage, mental health disturbance, infection, and antenatal service access issues. In order to tackle infant mortality in the West Midlands, the needs of the migrant population must be addressed alongside those of the indigenous population.

Who is giving birth in Birmingham – headline figures Migration-related factors affecting births in the West Midlands have not been well understood. Two pieces of work were conducted to illustrate the picture in Birmingham: an analysis of birth registration data by country of birth, and a census of women giving birth in Birmingham over the course of a week. Most women giving birth in Birmingham between 2004 and 2006 are born in the UK. However, more than 1 in 4 births are to women who were born abroad. Of these, around 3 out of 5 were born in South Asia, and 1 in 5 in Africa. There are more births to women born in Africa (over 3 times more) and the Middle East than to Caribbean-born women. ‘New’ European Union countries account for only 1.2% of births. Pakistan is by far the most common country of birth of mothers, at 14% of live births. The geographical spread of migrant mothers varies depending upon region of birth. African and Middle Eastern mothers are localised to areas near the City Centre, whereas Eastern European migrants are spread more widely across the whole city. During one week in November 2007, data was collected from women giving birth in 2 of the 3 major maternity units in Birmingham; Heart of England Foundation Trust and Birmingham Women’s Hospital. Data is not available from City Hospital at the time of writing. Of the 219 women identified, almost 1 in 5 reported not being a British citizen. The majority of them reported having ‘leave to remain’. 1.4% were asylum seekers, which over a year could mean up to 150 births to asylum seekers in the hospitals covered alone. This does not include City Hospital, which is the key catchment trust for this population. 68% of women born outside the UK had been in the country for less than 5 years. In terms of ethnicity, the most frequent groups represented after white British (45%) were women of South Asian origin (31% of births, 2/3 of Pakistani origin) and women of Black African origin (6%). One in ten women reported not speaking English. In terms of infant mortality risk factors, 4% reported female genital mutilation (FGM), and 14% reported consanguinity.

Staff and Service User Consultation Staff working in primary and secondary health care, social care and the voluntary sector were consulted regarding the needs of migrant women. Individuals with No Recourse to Public Funds were identified as a particularly vulnerable group, and therefore a small number of women with NRPF were also interviewed. The key themes are highlighted below.

Key themes identified Day-to day issues for migrants: • Poverty and homelessness, particularly in refused asylum seekers and some spousal migrants • Language difficulties • Immigration processes • Inability to work legally • Difficulties with integration • Abuse, exploitation, domestic violence and child protection issues Local service provision issues: i. Language needs are not always met ii. It can be difficult to access housing, benefits and GP services iii. Clients and staff report delays in social care; staff would benefit from more training and awareness iv. Client expectations, health beliefs, and service use behaviour impacts upon capacity, professional-client relationships, and patient satisfaction v. There is scope for more joint working. Service organisation issues: i. Dispersal and relocation disrupts social support, coping ability and continuity of health care ii. Regulations regarding entitlements to health and social care may result in high risk health situations and poor health outcomes

Recommendations Overview : To enhance and develop effective partnership working with Health Services and key Stakeholders from the Statutory, Voluntary and Private Sectors, we suggest the following recommendations should be considered:

Recommendations: 1. 2.

3. 4.

Health Organisations should adopt a core business approach to the identification of the needs and provision of services to migrant women and their infants; Improvement s on information and intelligence gathering currently available in Health Service settings, at a Regional, Sub-Regional and Local level for mothers and infants (Asylum Seekers, refugees and economic migrants) are required; This information should be better utilised in Strategic Health Planning and commissioning within the region. Further work should be undertaken to identify and plan for the training and staff development needs of Health Care personnel in relation to this specific group, and to ensure such training becomes a core element in all NHS Trusts Educational Programmes; Consideration should be given as to how using existing and enhanced Partnership arrangements within the Region could develop a multi-disciplinary approach to training which ensures that medical, cultural, socio-economic and procedural issues re Immigration/ migration are factored in;

Maternity, mortality and migration: the impact of new communities

The impact of Border & Immigration Agency policies and practices, regarding in particular Asylum Seeker Dispersal and the outcomes of Asylum Applications, are taken into account the planning for and the delivery of Health Care provision, particularly at a community level; Local Authorities should develop regionally agreed policies in response to families who have NRPF.

Conclusions Infant mortality is a significant problem in the West Midlands, which contains a number of areas with particularly high rates of infant deaths experience coupled with high levels of deprivation, and often containing large migrant communities. It is known that many of the risk factors for infant mortality are frequently seen in migrant communities. However, the data on migration factors and infant mortality is currently poor, but it is clear that the children of migrants have a higher stillbirth rate than those born to British mothers in Birmingham. Further work is therefore required to clarify the relationship between migrant status and birth outcomes High numbers of babies are being born to mothers who were born outside of the UK: they are thus an important group. Whilst there are many different groups of migrants, and their health needs vary widely, women seeking asylum, and women who have No Recourse to Public Funds are particularly vulnerable, and the latter group is growing: a key cause for concern. Infant mortality strategy must take account of the needs of migrants, including developing methods to systematically monitor the impact of migration and immigration policy upon outcomes, and ensuring that services meet needs. A multi sector approach is required in order to address infant mortality within this group, as so many of the issues relate to the â&#x20AC;&#x2DC;wider determinants of healthâ&#x20AC;&#x2122;. The children of migrants represent a large proportion of our future adult community, and improving outcomes for this group is key to the prosperity of the West Midlands population

1) Introduction Worldwide, an estimated 190 million people are now living outside their countries of birth or citizenship, and the rate of this migration is expected to remain high. About half of this number are women, many of whom will fall pregnant. Pregnancy outcomes in migrant women are known to be poor compared to native population in the England and Wales1. Furthermore, in 2006, just under 21% of births in Britain were to non-UK born women, indicating that this is not an insignificant group2. The care of migrant women throughout pregnancy and childbirth should therefore be a high priority area. In the UK concerns have been raised nationally and locally about the knowledge and attitude of NHS staff with respect to migrant needs and access to healthcare. At a recent West Midlands Women’s event, staff and service users identified a need for more information and understanding around this subject. Similar confusion on entitlement exists within some migrant communities. It appears anecdotally that there are uncertainties about rights to free NHS treatment, and patients may be denied, or excluding themselves from the health system. This issue potentially widens the health inequalities of an already disadvantaged group. Specific concerns have been raised in relation to access to antenatal care and maternity service. The Heart of Birmingham Teaching PCT (HOBTPCT) has the highest perinatal mortality rate in England, and a significant number of new migrants live within the PCT boundaries. Concerns have also been raised in other PCTs about the possible impact of destitute women becoming pregnant with late access to health care and coming to the attention and service provision of Local Authority Children’s Services departments. Research undertaken in London has identified cases of women being asked for payment before antenatal care is provided, and debt recovery proceedings being implemented3 Current work undertaken by the regional PCT asylum lead officers group of the West Midlands Strategic Migration partnership (WMSMP), and with WMSMPs Local Authority “No Recourse to Public Funds” Group has identified some anecdotal examples of late access into maternity services from members of this group, but the extent of the issue is not well documented or understood. There is a need to identify the impact of the asylum process, and destitution at the end of the asylum process, on infant and maternal health and on the NHS itself. Additionally, issues related to EU migrant communities in Birmingham East and North PCT (BENPCT) on child and maternal health have been raised with the strategic partnership. The key objectives of the project were to:

Indicate the current and potential impact of destitution on child and maternal health in the City.

Describe the key issues and events for new destitute mothers in relation to access to primary and secondary care. The aim was to identify destitute mothers through a oneweek ‘census’ of births in Birmingham, and follow them up qualitatively. The census did not identify any women reporting destitution, so instead women were contacted via local voluntary agencies, and consenting clients were interviewed.

Jentsch et al Creating consumer satisfaction in maternity care: the neglected needs of migrants, asylum seekers and refugees. International Journal of Consumer Studies, Volume 31, Number 2, March 2007, pp. 128-134(7) Office of National Statistics. Both UK and foreign’born women contribute to rise in fertility. December 2007. Accessed online at http://www.statistics.gov.uk/pdfdir/fertility1207.pdf Kelley, Nancy; Stevenson, Juliet. First do no harm: denying health care to people whose asylum claims have failed. Refugee Council 2006 pp 11-12

Maternity, mortality and migration: the impact of new communities

Consult with health and social care staff who come into contact with migrants, to identify the issues faced by clients and services.

Consult with key voluntary/community sector organisations working with children and families within the Birmingham area, especially those involved in work with migrant communities and destitution.

This project builds on work already undertaken by Dr Foster on behalf of the Birmingham Health and Wellbeing partnership4, and seeks to quantify and qualify the issue for new migrant communities across Birmingham. The key components of the project are: • • • •

The work explores the problems faced by service users and organisations, and makes recommendations as to what action might be taken to resolve these issues. It is hoped that the recommendations will also inform the work of other PCTs with large migrant populations, and in areas of asylum dispersal within the region. Other asylum dispersal areas include, Coventry, Dudley, Sandwell, Stoke-on-Trent, Walsall and Wolverhampton, who also have high rates of infant mortality.

Dr Foster “Intelligence: Infant Mortality in Birmingham. Birmingham Health and Wellbeing Partnership May 2007.

2) Policy Context Improving maternity services and outcomes are key local and national priorities for the NHS. The NHS in England: the Operating Framework for 2007/85 stated that PCTs should “assess current services, identify gaps and the barriers to service development and set out their local strategy for meeting the maternity commitment in 2009”. There are several key policy areas which highlight the need to improve maternity experiences and outcomes for migrants:

2.1 Public Service Agreement Targets “Starting with children under one year, by 2010 to reduce by at least 10 per cent the gap in mortality between routine and manual groups and the population as a whole”6 Infant mortality is one of the key health problems in the West Midlands. The region continues to have the highest infant mortality and perinatal mortality rate of any other region in England. Infant mortality has featured as a priority in “Choosing Health for the West Midlands”,7 the Chief Medical Officer’s Annual Reports8 and will be included in the anticipated “Regional Health and Wellbeing Strategy”9. The West Midlands Perinatal Institute provides a co-ordinated focus on preventing infant mortality and improving perinatal care in the region and pro-actively addresses the causes of adverse perinatal outcome10. Priorities include patient safety and avoidable perinatal loss. Most perinatal deaths are stillbirths, and the single largest associated factor is intrauterine growth restriction. The only available treatment is timely delivery from an unfavourable intrauterine environment. One intervention is the introduction of customised growth charts which individually adjust the expected growth of a baby. These foetal growth charts customised to maternal characteristics help to empower expectant mothers and take into account individual differences in a multicultural population. There are wide variations in the provision of antenatal screening and the information given about maternal choices. The Institute has standardized the antenatal screening service as better provision and access to screening resonate with reducing health inequalities. Many expectant and new mothers have needs which are currently not met including appropriate family planning services, pre-pregnancy counseling, and preparation for childbirth and motherhood. The West Midlands have high levels of social inequality, teenage pregnancy and smoking rates in pregnancy, and low rates of breastfeeding. Adverse perinatal outcomes are linked to social and ethnic factors, and there is marked variation in access to services. The West Midlands is responding by ensuring routine maternity care is led by well trained midwives based in the community who provide health promotion advice, co-ordinating other professionals and agencies, and working closely with GPs, health visitors, hospital midwives and obstetricians along agreed care pathways.

Department of Health. The NHS in England: the Operating Framework for 2007/8 . December 2006. Accessed online at http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_063267 Department of Health. Health Inequalities PSA target. June 2007. Accessed online at http://www.dh.gov.uk/en/Policyandguidance/Healthandsocialcaretopics/Healthinequalities/Healthinequalitiesguidancepub lications/DH_064183 Government Office West Midlands. Choosing Health for the West Midlands. March 2006. Accessed online at http://www.go-wm.gov.uk/497745/docs/379127/482801/choosinghealth Department of Health. Annual Reports of the Chief Medical Officer. Accessed online at http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/AnnualReports/DH_4115776 West Midlands Regional Assembly Reports and Publications. Accessed online at http://www.wmra.gov.uk/page.asp?id=37 West Midlands Perinatal Institute, website http://www.pi.nhs.uk/

Maternity, mortality and migration: the impact of new communities

2.2 Maternity Matters11 Maternity Matters, published in April 2007, builds on the commitment to improving maternity services outlined in the National Service Framework for Children, Young People and Maternity Services (October 2004) and in the White Paper Our Health, Our Care, Our Say (January 2006). The priority for modern maternity services is to provide a choice of safe, high quality maternity care for all women and their partners. This is to enable pregnancy and birth to be as safe and satisfying as possible for both mother and baby and to support new parents to have a confident start to family life. For some, especially the more vulnerable and disadvantaged, the outcomes are unacceptable. Some women are up to 20 times more likely to die from a pregnancy related complication than other women and infant mortality rates are higher in more deprived areas of the country and in more vulnerable or disadvantaged groups. Future maternity services must be planned to address current challenges including improving outcomes for more vulnerable and disadvantaged families. Commissioners and providers will be able to use a number of the elements of the health reform agenda to facilitate improvements and innovation in the maternity services they offer. The challenge for local commissioners is to ensure that each element is sensitive to the specific nature and requirements of their population, including the migrant population.

2.3 “Recorded delivery: a national survey of women’s experience of maternity care”12 The report is a survey of women’s views about their maternity care. The last national survey of women’s experience of maternity care ‘First class delivery’ was carried out in 1995. The study findings provide a picture of current practice and a way of measuring change over the last ten years and in the future. The data collected and reported can inform policy in maternity care, suggest ways in which maternity care can be improved and provide a point of comparison for local audits of women’s views and experiences in individual Trusts. The research was funded by the Department of Health, the Healthcare Commission and the Information Centre for Health and Social Care. One section of the report examines the care received by four specific groups: women from a Black and Minority Ethnic (BME) background, BME women born outside the UK, women living in the most deprived areas and single women. The findings suggest that women from these groups were more likely to access maternity services later, more likely to report feeling they were not always treated with respect by their carers and that they were not always spoken to in a way they could understand compared with other women. Further analyses are planned to explore the way that possible disadvantage affects women’s access to and experience of maternity care.

Department of Health. Maternity Matters, April 2007. Accessed online at http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_073312 National Perinatal Epidemiology Unit. Recorded delivery: a national survey of women's experience of maternity care, 2006. Accessed online at http://www.npeu.ox.ac.uk/maternitysurveys/report.php

2.4 Health care access rights for migrants The current regulations around entitlements to NHS care for migrants and overseas visitors are, in places, open to interpretation. For example, in primary care, GPs have the discretion to register anyone as a patient, regardless of their immigration status. However guidance states that asylum seekers are entitled to free primary care if they are given leave to remain in the UK, or if they are awaiting the results of an application to remain or appeal. Therefore, by suggestion, failed asylum seekers are not entitled to free NHS primary care. Such ambiguity can present PCTs and GPs with a challenge in terms of knowing who can legally be registered. A table illustrating the current entitlements to NHS treatment for overseas visitors can be found as appendix 3. With regard to hospital maternity services, anyone who is not ordinarily resident in this country is subject to the National Health Service (Charges to Overseas Visitors) Regulations 1989, as amended. These regulations place a legal obligation on NHS Trusts to establish whether a person is ordinarily resident, or exempt from charges under a number of exemption categories, or liable to be charged. Where it is established that charges apply, they cannot be waived for any reason. A person who is found to be liable for charges will be asked to pay in advance of receiving any treatment. However, guidance to the NHS is clear that when, in a clinician’s opinion, medical treatment is immediately necessary it must not be withheld and should go ahead without delay before charging issues are considered. Guidance to the NHS also makes clear that maternity treatment should always be automatically considered as being immediately necessary because of the risks involved to both mother and baby. This includes all antenatal treatment and can include treatment to prevent the transmission of HIV from mother to baby where clinically appropriate. However there has been some uncertainty in the NHS on how to deal with pregnant overseas visitors. Therefore, and following a recommendation by the Health Select Committee in their report New Developments in Sexual Health and HIV/AIDS Policy13, the guidance was reissued to overseas visitors managers on two separate occasions, to bring it more closely to their attention and to stress that pregnant overseas visitors should not be given the impression that if they do not pay the costs of an antenatal appointment, then future maternity treatment will be withheld. Additionally, the rules are not always enforced and they have potentially exacerbated health inequalities. Examples have been cited in London where vulnerable women have ‘disappeared’ following the birth of their child in order to escape debt recovery agencies14. In 2004 the Department of Health launched a consultation, proposing changes to the rules regarding primary medical care for overseas visitors15. A new policy has not yet been finalised, but following the ‘Review of Access to the NHS by foreign nationals’ announced in March 2007, a further consultation document is due to be released in shortly.

Health select committee New Developments in Sexual Health and HIV/Aids Policy accessed online at http://www.publications.parliament.uk/pa/cm200405/cmselect/cmhealth/252/25202.htm Joint Committee in Human Rights. Tenth Report. March 2007. Accessed online at http://www.publications.parliament.uk/pa/jt200607/jtselect/jtrights/81/8102.htm http://www.dh.gov.uk/en/Policyandguidance/International/OverseasVisitors/Browsable/DH_4955486

Maternity, mortality and migration: the impact of new communities

While NHS workers welcome the news that a definitive policy will be available, some concerns have also been raised. The proposed regulations could potentially restrict access to care to unemployed economic migrants, and access to new courses of treatment for illegal migrants or failed asylum seekers, including those who have been in the UK for over 12 months. Primary care access may be subject to further restrictions, and any new rules are likely to be enforced more rigorously. ‘Enforcing the Rules,’ a Home Office report published in 2007, also suggested that the NHS may become more involved in monitoring illegal immigration16. In June 2007 the Parliamentary Joint Committee on Human Rights expressed concerns about the proposed changes to the regulations. Amongst other recommendations, it stated “The arrangements for levying charges on pregnant and nursing mothers lead in many cases to the denial of antenatal care to vulnerable women. This is inconsistent with the principles of common humanity and with the UK’s obligations under ECHR Articles 2, 3 and 8 ECHR. We recommend that the Government suspend all charges for antenatal, maternity and perinatal care. We recommend that all maternity care should be free to those who have claimed asylum, including those whose claim has failed, until voluntary departure or removal from the UK.”17 At the time of writing, an Early Day Motion has been tabled, supporting a “campaign against any measures that would compel general practitioners, and other primary care staff, to be forced to charge refused asylum seekers or other vulnerable foreign nationals for NHS care.”18 The Government is due to release revised regulations for consultation in early 2008.

Home Office. Home Office Enforcing the Rules: A strategy to ensure and enforce compliance with immigration laws. March 2007, London: Home Office House of Commons. Government Response to the Committee's Tenth Report of this Session: The Treatment of Asylum Seekers. July 2007. Accessed online at http://www.publications.parliament.uk/pa/jt200607/jtselect/jtrights/134/134.pdf Gerrard N. Early Day Motion 220, Access to Healthcare. November 2007. Accessed online at http://edmi.parliament.uk/EDMi/EDMDetails.aspx?EDMID=34322&SESSION=891

3) Immigration processes We recognize that the immigration process in the UK is complex area, in this section we have provided a brief outline the different routes of entry into the UK, and the various classifications of migrant. We have also described the current picture in the West Midlands, highlighted the issue and causes of destitution, and options open to individuals in this situation.

3.1 Routes of entry into the UK There are Kingdom, • • •

a range of categories under which an individual may apply to come into the United By applying for formal entry clearance prior to travelling to the country By virtue of being a member of a European Economic Area (EEA) nation By coming and claiming asylum

Individuals from outside the EEA who wish to enter the UK under the following categories require entry clearance to do so: • Students • Au Pairs, Working Holiday makers • Self employed, Businessmen, investors, writers, composers or artists • Retired persons of Independent means • Spouses/civil partners or Fiancé or proposed civil partner of someone who has leave to enter/remain in the UK Immigration officers may impose a number of restrictions on visa applicants as conditions of their entry, one of which may be that a person is required to “maintain and accommodate himself, and any dependents of his, without recourse to public funds.”19 The asylum route generally sits outside of other immigration processes, with the individual being unable to register a claim for asylum outside this country. In some cases people do apply for asylum sometime after arrival in the UK having initially had some form of leave to enter the UK. Individuals from the European Economic Area (EU, Norway, Iceland & Liechtenstein) do not require entry clearance to come into the UK. Some categories of migrant workers will face restrictions to accessing public funds and social housing. Further information can be found on the Border and Immigration Agency website.20

3.2 Asylum seekers 3.2.1 Claiming asylum The UK is a signatory to the United Nations convention relating to the status of refugees (1951), which gives a person the right claim asylum in a country of their choice. The individual claimant is required to demonstrate that they have a well founded fear of persecution in a particular country due to reasons of Race, Religion, Nationality, Political opinion or due to membership of a particular social group, and that they are unable or unwilling to return to their country of origin due to this fear of persecution.

19 20

Home Office accessed online at http://www.ind.homeoffice.gov.uk/lawandpolicy/immigrationrules Home Office www.ind.homeoffice.gov.uk/lawandpolicy/immigrationrules/appendix1

Maternity, mortality and migration: the impact of new communities

An individual arriving in the UK and can either make a claim for asylum at the ‘port of entry’ or as an ‘in country’ applicant at Croydon or Liverpool Asylum Screening Units. Individuals will be given a screening interview where their claim for asylum is recorded along with personal information, a Home Office reference number will also be issued at this point. The asylum decision making process changed in March 2007, since this date all new asylum claims have been processed under the ‘New Asylum Model’. At present, the national asylum caseload consists of individuals in the ‘new’ and ‘old’ systems. Pre New Asylum Model cases are now being resolved by the Case Resolution Directorate in Croydon, who aim to resolve all outstanding cases by 2010. Many of the older cases may have been waiting several years for a final decision on their asylum claim.

3.2.2 New Asylum Model (Now the New Asylum Process) The New Asylum Model has been implemented in order to simplify and improve the decision making process. Since March 2007 the New Asylum Model has been fully operational for all new asylum claims. The process intends to resolve all asylum claims within a 6 month period. It was designed to ensure better access and continuity in the decision making process. This is done by allocating each asylum claim a designated Case Owner who is responsible for the case until the final decision about the claim.21 In the new system, the Statement of Evidence form (SEF), which enabled the claimant to outline their reasons for claiming asylum, is no longer completed by adult claimants. Unaccompanied asylum seeking children are still required to complete this form, and therefore the timescales are slightly extended in their decision making process. The process and timescales are illustrated in fig 1. Day

Activity

0-1

Claim for asylum is made, generally at the port of entry or the Asylum Screening Unit (Croydon or Liverpool). The case will then be routed to one of the regional NAM casework teams

1st Contact with caseworker/ First reporting event (FRE)

7-10

Substantive interview on asylum claim by caseworker

15-30

Decision on asylum claim is made and served within this period

20-100+

Any appeal against the refusal to grant asylum is addressed and resolved

20-100+

Finally refused cases would have support terminated (if single adult or a childless couple), and are passed on for enforcement and removal action

Figure 1. Outline of New Asylum Model decision making process (for adult asylum claims)

West Midlands Strategic Migration Partnership “Regional Migration Scoping Exercise” December 2007)

3.2.3 The Asylum Seeker support process The Immigration and Asylum Act 1999 established the National Asylum Support Service to provide end-to-end support for asylum seekers (who qualified) whilst a decision was being made on their asylum claim. The Act also provided for the dispersal of asylum seekers to other regions of the UK, to be supported in accommodation contracted by the Home Office. Asylum seekers have the option to: • Apply for asylum only, and be self-supporting or reliant on family/friends already within the UK. • Apply for subsistence only (cash) support and stay with family/friends • Apply for support and accommodation under Section 95 of the Immigration and Asylum Act 1999. This accommodation is provided on a no choice basis in any region of the country. When an individual seeker makes a claim for asylum including a request for support and accommodation, they will be routed to ‘Initial Accommodation’ (IA) within one of the Border & Immigration Agency (BIA) regions. All new arrivals of asylum seekers routed to the Midlands and East of England region will be accommodated in Initial Accommodation in Birmingham. Individuals or families will remain in the Initial Accommodation for 2-4 weeks and are then dispersed to accommodation within the West Midlands, East Midlands or the East of England Region. At then end of October 2007 there were around 8300 individuals supported by BIA in the West Midlands region, including those in receipt of a accommodation and support, subsistence only and Section 4 cases. The countries of origin with the largest numbers of asylum seekers receiving full support from BIA in the West Midlands in October 2007 22 were: 1. Iran 2. Zimbabwe 3. Pakistan 4. Somalia 5. Iraq 6. Afghanistan 7. Eritrea It should be noted that currently there are limited possibilities for return to most of these countries of origin. There are in excess of 67 different nationalities being supported within the asylum system within the West Midlands23

22 23

(Information via BIA Midlands & East of England regional office Oct 2007). (West Midlands Strategic Partnership for Asylum & Refugee Support “A Regional Strategy for the Social Inclusion of Refugees and Asylum Seekers in the West Midlands” WMSPARS 2006).

Maternity, mortality and migration: the impact of new communities

The areas where asylum seekers are currently dispersed within the West Midlands region are Birmingham, Coventry, Dudley, Sandwell, Stoke-on-Trent, Walsall, Wolverhampton. These are amongst some of the most deprived Local Authorities within the country, and also contain some of the most deprived (electoral) wards within the UK. Central government has sought to address the levels of deprivation within these areas by the allocation of Neighbourhood Renewal Funding (NRF). NRF is a national programme designed to narrow the gap in outcomes for residents within the most deprived wards and the rest of the country. The accommodation for dispersed asylum seekers is often in NRF receiving wards in this region, and refugees and other newly arrived migrants generally also can only access housing in these areas. Support from BIA continues until the final decision is made on the asylum claim and any appeals have been resolved. If the individual has been granted refugee status or some form of limited leave to remain (e.g. Humanitarian protection or Discretionary leave), then they will be given 28 days after the decision until their support and accommodation is terminated. There is evidence from advice agencies within the region that a number of families are experiencing temporary destitution as a result of being given positive decisions, this is linked to difficulty and delays in accessing benefits and the process of securing alternative accommodation. For those who are refused asylum they are given 21 days until their support and accommodation terminates, except families, who should remain in section 95 support until removal from the UK or return to their country of origin.

3.2.4 Asylum claims: the national picture The number of claims for asylum has reduced markedly over the past 3 years, with the number claiming asylum in the UK for 2006 recorded as 23605, and total numbers up to the 3rd quarter of this year (end of Sept 07), so far totalling 16520. The total number active cases being supported by BIA at the end of the 3rd quarter 2007 was 48740, comprising 10,160 receiving subsistence only, 37660 in dispersal accommodation and 1250 in initial accommodation24. For the same quarter BIA had 9500 cases in receipt of section 4 support, which is provided to refused asylum seekers who meet certain criteria (discussed in further detail later). Removals of failed asylum seekers and their dependents, and including voluntary returns from the UK, for 2006 were 18280. For the first three quarters of 2007 the total of 9900 individuals were removed, compared to 14170 for the same period in 2006, a 30% reduction. The Government’s intention has been to ensure that the asylum system reached a ‘tipping point’ where there were more removals of unsuccessful asylum seekers than new claims where cases are ultimately refused.

New asylum claims

Initial decisions

Removals from the UK

Quarter 1 2006

6455

6245

5085

Quarter 2

5495

4970

5260

Quarter 3

5860

4565

3825

Quarter 4

5795

5150

4110

Quarter 1 2007

5680

6005

3500

Quarter 2

4950

5935

3280

Quarter 3

5890

5230

3120

Period

Figure 2 Comparison of new claims , initial decisions and removals from the UK25

For the third quarter of 2007, 29% of the 5230 initial decisions resulted in granting asylum, humanitarian protection or discretionary leave. A significant number of the remaining individuals went on to win their appeal against the refusal to grant asylum, some 23% in the last quarter 26. This still leaves a high number of individuals who have been refused asylum, and remain in the region where they had been dispersed. These individuals are at risk of destitution. The total number of unsuccessful asylum seekers still remaining in the UK without any legal means of support was estimated by the National Audit Office as between 155,000 and 283,000 in 200627 In June 2007, the Joint Parliamentary Committee for Human Rights stated that “We have been persuaded by the evidence that the Government has indeed been practising a deliberate policy of destitution of this highly vulnerable group [asylum seekers]. We believe that the deliberate use of inhumane treatment is unacceptable. We have seen instances in all cases where the Government’s treatment of asylum seekers and refused asylum seekers falls below the requirements of the common law of humanity and of international human rights law.” However, the Government “Strongly refutes” this claim.28

3.3 Persons with no recourse to public funds Individuals who have been refused asylum and reach the end of the process are deemed to have ‘No Recourse to Public Funds’ (NRPF). Other groups of migrants may also fall into the NRPF category, and they will also be discussed in this section. NRPF individuals are an important group, as they are excluded from certain benefits and services, and may find themselves destitute.

27 28

Home Office - Asylum Statistics United Kingdom 3rd Quarter 2007 – accessed online at www.homeoffcie.gov.uk/rds/immigration.html (Explanatory note – Initial decisions will not necessarily relate to new claims for quarters prior to Q1 2007 when NAM process started. The impact of the governments drive to remove foreign national prisoners has contributed to the reduced levels of enforced removal of asylum seekers since the 3rd Quarter of 2006 Home office - Asylum Statistics United Kingdom 3rd Quarter 2007 – accessed online at www.homeoffice.gov.uk/rds/immigration.html cited in Refugee Action “The Destitution Trap” - Refugee Action November 2006 Joint Council Parliamentary Council for Human Rights accessed online at http://www.publications.parliament.uk/pa/jt200607/jtselect/jtrights/134/134.pdf

Maternity, mortality and migration: the impact of new communities

Within the context of the report, the designation ‘No recourse to public funds’ means: That an individual/ family has no entitlement to a range of public funds or services, generally most forms of Welfare benefits and public sector housing, as a result of their immigration status. This may be as a result of conditions placed on their entry to the UK or by virtue that their leave to enter or remain lawfully in the UK has expired.29

3.3.1 Individuals with No Recourse to Public Funds Unsuccessful asylum seekers An asylum seeker whose claim for asylum has been fully and finally determined and has been refused asylum, or any leave to remain in the UK. All support and/or accommodation from the Border & Immigration Agency (BIA) ceases 21 days after the decision to refuse asylum is been made. Cessation of support and accommodation only applies to single adults or childless couples, as families will continue to receive Section 95 support. (We recognise there may be other reasons why former asylum seeking families may be destitute.) Illegal immigrants Individuals who entered the UK without the necessary entry clearance. ‘Overstayers’ Individuals who previously had formal ‘leave to enter’ or ‘remain’ in the UK but whose period of leave to enter/remain has expired and a fresh application for leave to remain in the UK was not made within the required timescale. Victims of domestic violence who are subject to immigration control These individuals may fall under one of the other forms of immigration status, generally they may be here under a ‘spouse visa’ arrangement. Former unaccompanied asylum seeking children Children who arrived in the UK unaccompanied by a responsible adult and are assessed to be under 18 become the responsibility of the Local Authority in the area where they initially present. In many cases an individual will be entitled to leaving care support, under The Children (Leaving Care) Act 2000, until they are 21 (to 24 if in further education), however this is not always the case and former care leavers may become destitute at either 18 or 21. Local Authorities may support some individuals who turn 18 for a period of time, but at present there is no specific funding for former unaccompanied asylum seeking children whose asylum claim has been refused and turn 18. A8 European Union citizens & A2 countries (See list for these nationalities in appendix 2) Individuals here under the workers registration scheme for the 2004 accession countries are entitled to register for work under the Workers Registration Scheme, their ability to access Public funds is dependant on them having worked within the UK for a specified period of time. In some situations an individual may be injured at work and be unable to return to work, yet not satisfy the entitlement criteria for state benefit etc.30

29 30

See Home Office accessed online at http://www.bia.homeoffice.gov.uk/ukresidency/rights&responsibilities/publicfunds/ Home Office accessed online at www.workingintheuk.gov.uk/working_in_the_uk/en/homepage/schemes_and_programmes/workers_registration.html

3.3.2 Destitution – a definition Destitution has been noted as a growing problem in the UK.31 According to the Immigration and Asylum Act 1999 a person is deemed destitute if: • •

They and their dependants do not have adequate accommodation or any means of obtaining it (irrespective of whether their essential living needs are met) :or They and their dependents have adequate accommodation or the means of obtaining it but cannot meet their essential living needs.

Asylum seekers who have been receiving BIA support already fall into this category by virtue of the fact that they were granted asylum support originally.

3.3.3 Routes into destitution There are several routes into destitution, including, • Ill health, pregnancy or other change in circumstances in economic, illegal or ‘irregular’ migrants • Domestic violence for migrants in the UK under a spousal visa • Turning 18 or 21 for former asylum seeking children • Asylum claim is finally rejected

3.3.4 Impact of the New Asylum Model on destitution With the introduction of the new asylum process from March 07 for all new asylum claims, and within the West Midlands for some cases from April 06, asylum decisions are being made within much shorter timescales. Whilst this is positive for those granted some form of leave to remain in the UK it creates problems for those whose claim is refused and who then quickly become destitute. In the past many of these individuals would have continued under Home Office support for long periods as the asylum process took considerably longer. The BIA asylum refusal letter includes written advice that a claim for Section 4 support may be made, plus information on the Voluntary Returns Programme. We have attempted to identify the impact of the New Asylum Model on the levels of destitution and the volume of approaches to Local Authority social care departments, no clear picture has yet emerged. It is likely that any impact may be seen in the coming 6 -12 months, and further work with BIA and LA’s might be undertaken to ascertain impact on requests for assessment and support from unsuccessful asylum claimants.

Refugee Action - The destitution Trap 2006

Maternity, mortality and migration: the impact of new communities

3.3.5 Destitution within the West Midlands Precise numbers of those destitute and remaining in the region have been hard to quantify, estimates have been proposed of between 5000 - 1000032. The regional destitution steering group undertook a survey of four voluntary organisations assisting clients who were destitute and approached these agencies for advice over a 2 week period in July 2007. They saw 105 individual cases: 14 (13%) of these cases had children. In three cases women identified themselves as being pregnant and destitute. The Children’s Society undertook a piece of research looking at the experience of destitute families within the West Midlands this year33. Focussed interviews were conducted with 13 destitute families and young people, as well as further interviews with professionals working with these clients. The report highlights a number of cases where children are frequently going hungry, in several cases only having one meal a day. It highlights the impact of poor, unsafe accommodation, and the potential for pregnancy to occur as a result of sexual exploitation. Two specific cases of births resulting from exploitative relationships were cited. One key recommendation is for the development of greater regional coordination in responding to this issue.

3.4 Support for individuals with No Recourse to Public Funds A range of options exist for those who come become destitute, all are applicable to those who come to the end of the asylum process, and options a), d) and e) are available to other types of migrants NRPF cases. a) b) c) d) e)

Applying for the voluntary return programme, administered by the International Organisation for Migration. Section 4 support from the Border & Immigration Agency Enforced removal by Border and Immigration Agency Support from Local Authorities under Section 21 of the National Assistance Act 1948, section 17 of the Children Act 1989 or section 117 of the Mental Health Act 1995 Homelessness and destitution within the UK

This section expands upon this, detailing the routes into the various forms of support, and the West Midlands context. We recognise that a significant role is being played in alleviating the effects of destitution for in several parts of this region, this section however focuses on the responsibility of statutory agencies. A comparison of the level of support individuals may receive under these options is given in Fig 7 (page 29) .

“Destitution of asylum seekers in Birmingham” – Richard Malfait & Nick Scott-Flynn 2005 Commissioned by Restore of Birmingham Churches Together & the Church Urban Fund (Source : The Children’s Society “ Destitution among asylum seeking children in the West Midlands” (draft) executive summary – Midlands Refugee Project 2007)

3.4.1 Section 4 Section 4 support is provided under the Immigration and Asylum Act 1999 by the Border and Immigration Agency. It is intended to provide short term support to the most vulnerable refused asylum seekers who are temporarily unable to return to their country of origin. Currently it is not unusual for individuals/ families to be in receipt of section 4 support for over a year. In 2006 Citizens Advice identified that almost 30% of section 4 cases had been in section 4 accommodation for over 12 months, and over 60 % had been in receipt of support for over 6 months.34

3.4.1.1 Section 4 criteria35 : •

• • • •

He or she is taking all reasonable steps to leave the UK, or to place themselves in a position which they are able to leave the UK. This includes the case where applicants have applied for voluntary returns. He or she is unable to leave the UK by reason of physical impediment to travel or for some other medical reason. (this would include being in the late stages of pregnancy) He or she is unable to leave the UK because in the opinion of the Home Secretary there is currently no viable route of return available. He or she has applied to the court s for judicial review of a decision in relation to his or her asylum claim, and a court has granted permission to proceed. The provision of accommodation (and subsistence support) is otherwise necessary to avoid a breach of his or her human rights, within the meaning of the Human Rights Act 1998.This can include where the applicant has made a fresh claim and this is still under consideration by the Home Office, and where the applicant has made a late (i.e. out of time) appeal to the asylum and immigration tribunal (AIT) and the AIT is still considering whether to allow the appeal to proceed.

Currently individuals have to complete an application form for Section 4 support which is processed either in the Case Resolution Directorate in Croydon (for pre-New Asylum Model claimants) or at the regional BIA office for NAM cases. Processing timescales vary: Currently voluntary sector partners indicate that individuals may wait between 2-4 weeks for a decision, and a further period of time before accommodation is provided. It is important to remember that this support was primarily designed for single adults or childless couples. Family units who are refused asylum should normally remain within section 95 support arrangements. Section 4 support consists of accommodation and a flat rate £35 per week in vouchers (for comparisons see figure 7 page 29). Proposals to provide additional support to nursing mothers and young children, reimbursement of some travel costs and a reduced maternity grant made up of vouchers are still under consideration36

34 35 36

“Shaming Destitution” Citizens Advice Bureau June 2006 Home Office accessed online at http://www.ind.homeoffice.gov.uk/asylum/support/apply/section4/ (Border & Immigration Agency "The Immigration and Asylum (Provision of Services or Facilities) Regulations 2007 “(DRAFT) October 2007).

Maternity, mortality and migration: the impact of new communities

In the West Midlands, accommodation is provided under target contracts with BIA by the three private providers. They also provide the accommodation for mainstream section 95 support. The target contract providers have certain duties in relation to their clients, including provision of induction material and assisting clients to register with a GP. Providers should also inform the PCT covering the area of dispersal of any new arrivals of asylum seekers in their area.

3.4.1.2 West Midlands regional picture for Section 4 The numbers receiving section 4 support within this region have increased significantly during the past two years. Information from the Border & Immigration Agency for June 2006 indicated around 1000 individual cases were in receipt of Section 4 Support. The numbers of cases had doubled to 2071 by June 2007, but have remained fairly static since this point as indicated in Figure 4, what does appear to be changing is the composition of the section 4 population, with an increasing number of family units now being supported. This slowing of the rate of increase may be the result of a change in the application section 4 policy by BIA since June 2007. From this period Section 4 accommodation was predominantly offered to applicants outside of the West Midlands, whereas previously applicants were generally accommodated in-region. This change appears liable to have either, â&#x20AC;˘ reduced the numbers of individuals willing to apply for section 4 support, or â&#x20AC;˘ increased the numbers of people who have been unwilling to take the accommodation being offered if their application for section 4 was successful. It is likely that this has resulted in increased numbers of destitute people remaining within the West Midlands. Another consequence of this change has been that women in the late stages of pregnancy and in the early postnatal period may also be asked to travel to section 4 accommodation outside the West Midlands. Total section 4 cases

Single cases

June

2071

1897

174

8.4%

September

2045

1727

318

15.5%

October

2032

1656

376

18.5%

Month (2007)

Families / family % of family members of members total section 4 population

Figure 3 Section 4 cases in the West Midlands, June to October 2007. 37

(Source- BIA regional office October 2007)

The top five nationalities in receipt of section 4 support within the West Midlands October 2007 are indicated in figure 4. Country of Origin

Number of section 4 cases in West Midlands

Iraq

686

Iran

189

Eritrea

145

Sudan

157

Somalia

128

Figure 4 Main nationalities in receipt of Section 4 support within the West Midlands, October 200738

At the end of October Section 4 cases accounted for around 25% of all asylum cases supported by BIA within the West Midlands. The accommodation providers identified 128 section 4 cases with two or more individuals being supported. Information from BIA for the end of the same period showed 111 families within the West Midlands region being supported. A breakdown of case types and location is detailed in the table below (figure 5). Number of persons in household 2

Total sec 4 families with 1 or more child*

Birmingham

42 (50)

Coventry

37 (42)

1 (2)

Sandwell

Stoke-on-Trent

Walsall

Wolverhampton

9 (11)

Total

112 (128)

111

Local Authority

Dudley

BIA identified family cases

Figure 5 West Midlands Section 4 family cases according to accommodation provider and BIA data, October 200739 * Figures in brackets identify the total number of two person households in receipt of section 4 support within the West Midlands as at the end of September 2007. Two person cases where the main applicant is male have been ignored in calculating the number of family units with children.

It is likely that most family units would have initially been supported as single adults or childless couples. This is on the basis that most families refused asylum should automatically remain in receipt Section 95 support from BIA. In a few cases a section 4 family case may have resulted from a former separated child, or child who arrives in the UK subsequent to the parents refusal of asylum and termination of support. It has not been possible to identify the proportion of applications at a regional or national level for section 4 support that are made on the basis of being in the late stages of pregnancy.

38 39

(Source - BIA Midlands & East of England regional office October 2007) (Source - BIA Midlands and East of England regional office October 2007)

Maternity, mortality and migration: the impact of new communities

Further work is required to identify the period of time which pregnant former asylum seeking women waited prior to applying or qualifying for section 4 support and how they may be accessing health services in the intervening period. The quality of active referral and registration with GPs/ other health services for section 4 claimants in the late stages of pregnancy may also benefit form further analysis. This has been beyond the scope of the exercise.

3.4.1.3 Birmingham specific Section 4 statistics The table below (figure 6) indicates the number of cases supported under section 4 by BIA in Birmingham over the period of months, the increase of family numbers as a percentage of the total section 4 caseload is not so marked as the region figures, but still shows a marked increase since June 07. Total section 4 cases

Single cases

June

1136

1077

September

1068

946

122

11.4%

October

1039

892

147

14%

Month (2007)

Families / family % of family members of members total section 4 population

Figure 6 Section 4 cases supported in Birmingham, June to October 200740

Although these figures appear relatively low in context of the population within Birmingham, further work might be undertaken to identify whether these families, or individuals in the late stages of pregnancy are concentrated in certain wards. Development of a clearer understanding of how the referral and low of information between BIA, section 4 accommodation providers and the health sector are working to ensure that women with potentially higher risk factors of Infant Mortality are identified and receive appropriate services for themselves and their babies.

3.4.2 Local Authority Support for individuals with NRPF The rights and entitlements for support from Local Authorities under social care and childrenâ&#x20AC;&#x2122;s legislation have been revised and restricted under successive Immigration Acts, most notably the Immigration and Asylum Act 2002 which introduced restrictions of Local Authority services further with Schedule 3 of the Act. Since this time an increasing number of legal challenges have sought to clarify the current position for Local Authorities, BIA and destitute clients. The volume of litigation around these cases has resulted in an ever changing picture of the duties and support which may be provided in given situations for some groups of destitute individuals, and a constant need to review policy and procedure for assessing the needs of individuals and families who request support from local Authorities.

(Source- BIA Midlands and East of England regional office October 2007)

Local Authorities are generally being requested to provide support to single adults of children and their families under the following acts: The National Assistance Act 1948 • • The Children Act 1989 • Articles 3 & 8 of the European Convention on Human Rights • The Mental Health Act 1995 To qualify for such support individuals are required to demonstrate that their needs are not solely as a result of destitution, the ‘destitution plus criteria’, and in many cases that a failure to provide support would be a breach of their Human Rights (ECHR). The situation is somewhat less complicated for children and their families who are destitute, but varying positions may be adopted in seeking to meet the needs primarily of the child (ren) by Local Authorities within the England. Generally those who are assessed as having an eligibility to support from a Local Authority will receive some form of accommodation and support, comparable to that provided by BIA, although levels vary between authorities. Any assessment will ensure that the specific needs, identified through the assessment process, can be met within an overall care package.

3.4.2.1 NRPF local and national networks The London Borough of Islington has taken a lead role on the “No Recourse to Public Funds” agenda and currently coordinates a national NRPF network, which sits as a sub group within the Association of Directors of Children’s Services/Association of Directors of Adult Social Services asylum task force. They have developed specific work on policy and procedure related to this group of clients.41 From December 2006 a group of Adult Social Service and Children’s Service leads from eight Local Authorities within the West Midlands have been meeting as a regional NRPF group under the coordination of The West Midlands Strategic Migration Partnership. The group also feeds in to the national NRPF network and is working to develop greater a clearer regional response to the issues raised by NRPF cases. The group includes representation from BIA and a regional health lead. Work to identify costs, support packages and development of policy and procedures is ongoing.

3.4.2.2 Regional figures for Local Authority supported cases As at the end of October 2007 the Local Authorities within the Regional NRPF group reported that they were supporting approximately 222 single adult cases and 229 Family cases that have No Recourse to Public Funds (NRPF). It is important to reinforce that the case load of each Local Authority varies in its composition, many having higher numbers of overstayers or victims of domestic violence as a proportion than unsuccessful asylum seekers.

(NRPF network London Borough of Islington accessed online at www.Islington.gov.uk/nrpfnetwork )

Maternity, mortality and migration: the impact of new communities

We have been able to identify specific information from some Local Authorities on the number of individuals who have given birth whilst in receipt of Local Authority support in the past six months. It has not been possible to clarify in each case whether these women were in receipt of support as single adults by the Authority prior to giving birth. The numbers for those authorities who had responded to requests for information were as follows: Number of NRPF cases in receipt of Local Authority support where there had been a new birth in the past 6 months: • • • •

Coventry - 2 Sandwell - 1 Stoke-on-Trent - 3 Walsall - 3

3.4.3 Levels of support for individuals with NRPF Figure 7 illustrates the different levels of support received by individuals in the asylum process, or supported under Section 4 of the Local Authority. Adult asylum seekers receive support equivalent to 70% of Income Support rates. The 30% reduction is accounted for by the fact that asylum seekers do not have to pay utility bills. It is of note that only asylum seekers receive supported under section 95 receive cash support. Section 4 supported clients receive vouchers which are only redeemable on certain products, and individuals on voucher-only support may have difficulties paying for other items, e.g. transport, depending upon what is provided by the Local Authority. In addition, levels of support vary in Local Authority-supported cases, resulting in potential geographical inequality. Support may be paid by way of cash or vouchers, generally family cases receive support for subsistence by way of cash and not vouchers. Category

BIA Section 95 Support

BIA Section 4 Support

Local Authority Support

Type of support

Cash

Vouchers

Cash/Vouchers

Qualifying couple

£69.69

Flat rate of £35 per person in household

Rates vary between authorities, some family cases only receive support for the schild

Single adult (over 25)

£41.41

£35.00

Rates vary between authorities between £21-£40 per week

Single Adult (under 25)

£32.80

£35.00

As above

Child (under 16)

£47.45 (*)

As above (NB some changes have been proposed in the recent consultation document on section 4 (needed))

Rates vary between £21per week and BIA rates

Child (between 16-18)

£35.65

As above

Maternity payments

£300

Nil, although proposal under consultation for £250 payment

Nil

Children under 5 supplements

(*)

Nil although under review

Nil

Figure 7 Current support provided for asylum seekers, as compared with unsuccessful asylum seekers support either by Section 4 or Local Authority Nb – all individuals receive accommodation, in BIA support all utility costs would be paid for, a comparable arrangement would exist with Local Authority support. It is also important to recognise exact rates are difficult to identify as support should be based upon the assessed needs of individual clients. * Additional allowances are provided for a child under 1 (extra £5 per week) and from age 1 -3 (an extra £3 per week)

Other migrants receive support based upon rules related to their specific immigration status. â&#x20AC;˘ Refugees receive support equivalent to British citizens e.g. Job Seekers Allowance. Income Support, Tax Credits etc subject to normal means testing. â&#x20AC;˘ Economic migrants have varying entitlements depending upon country of origin. â&#x20AC;˘ Visa overstayers, illegal immigrants and others have no recourse to public funds, and so are only eligible for Local Authority support, and they must meet the requirements outlined previously before this is granted.

3.5 Economic migrants Economic migrants are generally young individuals in good health, who come to the UK to take up employment. They often bring skills that are in short supply amongst the UK population, and make a significant contribution to the economy. It is difficult to measure economic migration precisely and data on migrant communities is at the early stages of development at a regional and local level. A common method is to look at the number of foreign nationals applying for a National Insurance Number (NINO). However, this does not tell us about self-employed individuals, or the number of dependants accompanying workers. There has been a recent increase in in-migration to the UK, following the expansion of the European Union in 2004 to include Cyprus, Czech Republic, Estonia, Hungary, Latvia, Lithuania, Malta, Poland, Slovakia and Slovenia. On January 1 2007 Bulgaria and Romania also joined the EU. The number of NINO registrations in foreign nationals in the West Midlands was 78% higher in 2005/6 compared with 2002/3, with just over 47000 approved applications in the West Midlands between May 2004 and March 2007. Poland is responsible for the majority, with 3 times more registrants in 2005/6 than the next largest country, India. Migrants are spread across both urban and rural areas.42 Appendix 2 illustrates the differing categories of migrants and migrant workers who may come to the UK. For the purpose of this report we note that some EU Accession state economic migrants and undocumented migrant workers may also fit into the NRPF category, and further work might be undertaken to identify the impact these communities are having on maternity services, and targets linked to infant and maternal health.

http://readingroom.lsc.gov.uk/lsc/WestMidlands/Economic_Impact_of_Migrant_Workers_-_Full_Report_2007.pdf

Maternity, mortality and migration: the impact of new communities

4) Infant mortality and migration Infant mortality (IM) is a well recognised indicator of the health of a population, as its associated factors also influence wider health outcomes. These factors include economic development, general living conditions, social well being, rates of illness and the quality of the environment. This section of the report will outline the regional picture with respect to infant mortality, with a Birmingham focus, and identify the key determinants of IM with respect to migration. Infant mortality is defined as the number of live-born infants dying before 1 year of age. Internationally, infant mortality varies widely, but it is responsible for a large number of global deaths each year, having a huge impact upon average life expectancy. The highest rate in 2006/7 was 184, in Angola, and the lowest was in Singapore at 2.30. In the UK the IMR was 5 in the same period.43

4.1 Infant mortality statistics Infant mortality has declined dramatically in the UK, as a result of improvements in the standard of living, and in care of mothers and babies. The changes seen in the late 20th century are illustrated in figure 10. The decline has continued in England and Wales, albeit at a slower rate, in the early part of the 21st century.

Figure 10 Health inequalities in infant mortality in the UK44

U.S. Census Bureau, International Database. Infant Mortality and Life Expectancy for Selected Countries, 2007. Accessed online at http://www.infoplease.com/ipa/A0004393.html Marsh T. Tackling inequalities in health. 2001. Poverty, 110.

Figure 11 West Midlands infant death rate 3 year moving average45

The West Midlands has unfortunately failed to follow the trajectory of the country as a whole, and has seen only a small decline in the infant mortality rate since the turn of the century (see figure 11). There is a widening inequality gap, and this is a major concern for local health and social care agencies. However, the inequality is not seen across the whole region. There are pockets of high infant mortality across the West Midlands, as illustrated in figure 12. Of note is the fact that the 7 areas with highest IM are also asylum dispersal areas, and Dudley is the only dispersal area with an IM rate below the national average. This is because areas with high levels of deprivation tend also to be areas of as asylum dispersal and refugee settlement. PCT Herefordshire Solihull Shropshire County Warwickshire North Staffordshire Dudley Worcestershire England and Wales South Staffordshire West Midlands Telford and Wrekin South Birmingham Sandwell Coventry Walsall Wolverhampton Birmingham East and North Stoke on Trent HoB

IM rate 2003-2005 4.3 4.5 4.6 4.8 5.0 5.3 5.3 5.5 5.9 6.0 6.4 7.0 7.5 7.6 7.7 7.7 8.6 8.7 10.7

Discrepancy from E&W -1.2 -1.0 -0.9 -0.7 -0.5 -0.2 -0.2 +0.4 +0.5 +0.9 +1.5 +2.0 +2.1 +2.2 +2.2 +3.1 +3.2 +5.2

Figure 12: West Midlands Infant Mortality Rates 3 year moving average 2003-200544 (Asylum dispersal areas in green) 45

West Midlands Perinatal Institute. Key Health Data 2006/07. Accessed online at http://www.pi.nhs.uk/pnm/Keyheathdata2005.pdf

Maternity, mortality and migration: the impact of new communities

Figure 13 West Midlands map of infant mortality by Ward 200446 46

West Midlands Perinatal Institute. Key Health Data 2006/07. Accessed online at http://www.pi.nhs.uk/pnm/Keyheathdata2005.pdf

The IM rate in PCTs across the region is indicated in Figure 13. This project concentrates on the picture in Birmingham, where the highest rates are seen, although many of the issues are pertinent to other parts of the West Midlands region. Babies born to mothers who live in Birmingham have more than double the risk of dying in their first year of life compared to those in other parts of the region such as Solihull and Herefordshire. In England and Wales, babies of mothers born in Pakistan have a death rate that is almost double the overall infant mortality rate.47 The high infant mortality in Heart of Birmingham PCT is the result of many different factors, and some are understood better than others. Some of the key influences in HoB include a high number of mothers in ethnic minority groups, deprivation, and maternal smoking. Local figures for births to non-UK women demonstrate a higher risk of stillbirth in mothers born outside the UK48. Exact figures for infant death are not available due to missing data, but stillbirth rates can be used as a proxy indicator. Figures 14 and 15 illustrates the differences in stillbirth rate by region of birth of mother. Statistically significant differences are only observed in South Asian and Caribbean and Far Eastern mothers, although this may be due to the fact that stillbirth is rare â&#x20AC;&#x201C; there may still be important differences between other groups. Country of Birth

Live births 2004-06

Stillbirths 2004-06

30876

64%

191

54%

South Asia

10149

21%

109

31%

Africa

2870

Middle East

911

Caribbean

785

Far East

762

EU pre 2004

552

EU post 2004

357

Europe other

318

North America

104

Other

South America

Oceania

Unknown

Asia other

EU other

Grand Total

47897

352

Figure 14 Country of birth of mother for live and stillbirths in Birmingham, 2004-06

47 48

Birmingham Health Partnership Life Expectancy and Health Inequalities Project Part One. December 2006. Source: Heart of Birmingham PCT Public Health Information Team

Maternity, mortality and migration: the impact of new communities

Birmingham Stillbirth rate by region of origin of mother 2004-06 30

Rate per 1000 births

0 04 20 st po

04 20 pre

r the eo rop Eu

t as rE Fa

an be rib Ca

st Ea le dd Mi

ica Afr

ia As uth So

-5

Region

Figure 15: Birmingham stillbirth by region of origin of mother 2004-2006, with 95% confidence intervals49

4.2 Determinants of infant mortality pertinent to migrants Infant mortality is a complex subject. It has medical, genetic, behavioural and societal causes, and there is still much work to do before these will be fully understood. However, there are some factors that are linked with poor birth outcomes, or with infant mortality directly, that are pertinent to migrant communities. The following is an overview of the determinants of infant mortality where evidence is available. There are other issues facing migrant women during pregnancy and motherhood, but these are not all covered here.

4.2.1 Demographic factors Ethnicity Evidence demonstrates a higher rate of IM in women born abroad, particularly those from Africa, Pakistan and the Caribbean (see figure 16) 50 Census data from 2001 showed that 7% of people in the â&#x20AC;&#x2DC;routine and manualâ&#x20AC;&#x2122; (R&M) occupational group were from black and minority ethnic groups. However, when looking at the 43 areas with highest numbers of R&M infant deaths, this proportion increases to 14%.

49 50

Source: Heart of Birmingham PCT Public Health Information Team West Midlands Perinatal Institute. Key Health Data 2006/07. Accessed online at http://www.pi.nhs.uk/pnm/Keyheathdata2005.pdf

This suggests that reductions in infant mortality for black and minority ethnic groups could have a greater impact on the target group compared to the population as a whole.51 Local West Midlands figures also suggest inequalities between the different groups. Regional data is not available on certain minority groups (e.g. African), but we can say that babies born to African Caribbean mothers and Pakistani groups have a higher IMR than European groups in the West Midlands.6 There are many factors related to poor birth outcomes that are more common in ethnic minority groups, including migrants, which goes some way to explaining the differences. These include late booking for care, deprivation, female genital mutilation (FGM), consanguinity and lack of social support. These are discussed in more detail below. Infant deaths

Rate

Odds ratio

95% CI

African Caribbean

143

13.25

1.71

1.43 - 2.04

European

1133

7.80

Indian

129

9.35

1.20

1.00 - 1.44

Pakistani

497

12.99

1.68

1.51 - 1.86

Reference

Figure 16: West Midlands infant deaths by ethnic group 1997-2005 average

Figure 17 Infant mortality rates by country of birth, England and Wales 2001-351

Age Maternal age impacts upon infant mortality. Mothers at the extremes of age range tend to have a higher risk, as illustrated in figure 18 below. This is important to consider in any assessment of infant mortality, but it is not a particular concern in migrant women compared with long-term UK residents.

Department of Health. Review of the Health Inequalities Infant Mortality PSA Target February 2007. Accessed online at www.dh.gov.uk/prod_consum_dh/idcplg?IdcService=GET_FILE&dID=116196&Rendition= Web West Midlands Perinatal Institute. Key Health Data 2006/07. Accessed online at http://www.pi.nhs.uk/pnm/Keyheathdata2005.pdf

Maternity, mortality and migration: the impact of new communities

Figure 18: West Midlands infant death rates by maternal age 1997-200553

4.2.2 Environmental influences Deprivation is strongly associated with infant mortality, perinatal mortality, preterm birth, low birth weight, and maternal death.54 One UK study showed a 50% rise in infant mortality and stillbirth according to deprivation.55 All causes of neonatal mortality show a socio-economic gradient and all except one cause of post neonatal deaths (diseases of the nervous system and sense organs) show a socio-economic gradient.56 Figure 19 illustrates the fact that more infant deaths occur in deprived groups in the West Midlands. It shows infant deaths by Index of Multiple Deprivation score, a measure of the level of deprivation in an area. All areas are divided into 5 â&#x20AC;&#x2DC;quintilesâ&#x20AC;&#x2122; depending upon the IMD score, and ranked 1-5 (5 being the most deprived). The graph demonstrates that areas in the most deprived quintile have a higher infant mortality rate than other areas in the region. Migrants tend to have lower (or no) incomes compared with the existing population, and many are amongst the most deprived in our society. Of particular concern are asylum seekers, refused asylum seekers, visa overstayers and illegal immigrants, who are not legally allowed to work, and have little or no income. Economic migrants may also have lower incomes than their established resident counterparts.

55 56

West Midlands Perinatal Institute. Key Health Data 2006/07. Accessed online at http://www.pi.nhs.uk/pnm/Keyheathdata2005.pdf Griffin C, Taylor B, Birmingham Health and Wellbeing Partnership. Review of the evidence of social risk factors in pregnancy. November 2007. Guildea Z E et al. Social Deprivation and the causes of stillbirth and infant mortality. 2001. ArchDisCh 84(4):307-10. Department of Health. Review of the Health Inequalities Infant Mortality PSA Target February 2007. Accessed online at www.dh.gov.uk/prod_consum_dh/idcplg?IdcService=GET_FILE&dID=116196&Rendition= Web

Figure 19: West Midlands infant deaths (3 year moving average) according to Index of Multiple Deprivation (IMD) score57

Figure 20 Distribution of pregnancies in Birmingham and Black Country according to Index of Multiple Deprivation (excluding Solihull and New Cross) 57

Nutrition Maternal nutrition is a concern in deprived groups, both in terms of access to healthy fresh foods, and in relation to total energy intake. Susser has calculated the minimal caloric intake 1750Kcal / 7.3 MJ a day required for optimal growth during pregnancy and if intake is at or below this level, balanced supplements of energy with controlled amounts of protein and other nutrients can increase birthweight.58

West Midlands Perinatal Institute. Key Health Data 2006/07. Accessed online at http://www.pi.nhs.uk/pnm/Keyheathdata2005.pdf Susser, M. Maternal weight gain, infant birth weight, and diet: causal sequences. Am J Clin Nutr 1991;53(6):1384-96

Maternity, mortality and migration: the impact of new communities

Lone mothers from low income households have been described as ‘nutritionally vulnerable’,59 and underweight mothers have been shown to have an increased risk of negative birth outcomes associated with infant mortality.60 Improving maternal nutrition is a key objective of the Department of Health.61 With this in mind, the UK Healthy Start Programme is available to pregnant women and mothers receiving state benefits, providing vouchers for additional fruit, vegetables and milk. However, this scheme is not available to a significant number of vulnerable migrant women and children. In addition, women on asylum seeker support only receive 70% of Income Support in benefits, and those on Section 4 receive only £35 per week in the form of vouchers. Eating a healthy diet is challenging on mainstream Income Support, and it is likely that many women in the asylum process will struggle to meet nutritional requirements.

4.2.3 Social/cultural influences Social support Infant mortality is more common in births where the mother is the sole registrant of the birth, i.e. in lone mothers.60 It has been suggested that the degree of social support a mother receives has an impact upon birth weight and foetal growth.62 Some migrant women will have a large amount of support, for example women who come to the UK to marry may have a large extended family. However, other women may have no friends or relatives, making them particularly vulnerable. Others may find themselves in a failing relationship without any other form of support. This may be exacerbated by frequent moving from place to place, or by compulsory dispersal within the asylum process. Abuse/violence is a problem for some women, and during pregnancy domestic violence tends to escalate. An estimated 30% of cases start or escalate during pregnancy and it is associated with increases in rates of miscarriage, low birth weight, premature birth, foetal injury and foetal death.60 An Indian study it was estimated that 1 in 5 perinatal and neonatal deaths resulted from domestic violence.63 Migrant women are particularly vulnerable as they may be less able to call for help due to a lack of social networks, and less able to access services due to lack of awareness. Trafficked and exploited women are at even greater risk. Educational level Maternal education is associated with negative birth outcomes, including infant mortality.64 Some migrant women have received little or no formal education, and this is likely to impact upon their pregnancy risk. Women with limited or no English language skills may be at even greater risk.

59 60

Dowler E and Calvert C,. Nutrition and diet of in lone-parent families in London. Family Policy Studies Centre. 1995. Sebire NJ et al (2001) Is maternal underweight really a risk factor for adverse pregnancy outcome? A population-based study in London BJOG: An International Journal of Obstetrics and Gynaecology 108 (1), 61–66. Department of Health. Review of the Health Inequalities Infant Mortality PSA Target February 2007. Accessed online at www.dh.gov.uk/prod_consum_dh/idcplg?IdcService=GET_FILE&dID=116196&Rendition= Web Feldman PJ et al. Psychosomatic Medicine 62:715-725 (2000) American Psychosomatic Society Maternal Social Support Predicts Birth Weight and Foetal Growth in Human Pregnancy Ahmed S, Koenig MA, PhD Stephenson R. Effects of Domestic Violence on Perinatal and Early-Childhood Mortality: Evidence From North India August 2006, Vol 96, No. 8 | American Journal of Public Health 1423-1428 Griffin C, Taylor B, Birmingham Health and Wellbeing Partnership. Review of the evidence of social risk factors in pregnancy. November 2007.

Female Genital Mutilation Female genital mutilation (FGM), also known as ‘female circumcision’, is a procedure “involving partial or total removal of the external female genitalia or other injury to the female genital organs whether for cultural, religious or other non-therapeutic reasons.”65 The practice is seen predominantly in Africa, and is estimated to affect around 100 million women and girls worldwide.66 The extent of the procedure varies from excision of the prepuce to infibulation (“excision of part or all of the external genitalia and stitching/narrowing of the vaginal opening”).65 It has significant physical and psychological consequences in many women. The World Health Organisation estimates that FGM results in an additional 1 to 2 perinatal deaths per 100 deliveries, although this is based on research in Africa: rates may differ in the UK.66 FGM is becoming more widespread in Birmingham, due to the recent influx of new migrants from affected areas. At Heartlands Hospital, the specialist FGM midwifery service estimates that approximately 10% of women booking for maternity care have undergone FGM, most with grade 3 FGM (the most extensive), and most from the Somalian community. Consanguinity describes the situation when a child’s parents are blood relatives; cousins, for example. Studies of populations living in European countries suggest an infant death rate between 2.5 and 3.5 times higher in consanguineous couples.67,68 Some new (and not so new) communities in the West Midlands have a higher incidence of consanguinity, for example, the Pakistani population.

4.2.4 Behaviour/lifestyle Smoking is associated with a higher infant mortality rate.69 Some European countries such as the former Yugoslavia have a much higher prevalence of smoking in women that the UK. For example, a recent study in Bosnia Herzegovina found that 46% of female health professionals smoke.70 This will undoubtedly impact upon infant mortality in these populations. Substance and alcohol use both have a negative impact upon birth outcomes.71, 72 These factors are important to consider in any discussion of infant mortality, although they are not covered in any detail here, as other factors are considered to be more pertinent in an assessment of infant mortality in migrant communities.

66 67

World Health Organisation. Female Genital Mutilation. June 2000. Accessed online at http://www.who.int/mediacentre/factsheets/fs241/en/ World Health Organisation. Female Genital Mutilation and Obstetric Outcome. Lancet 2006;367:1835-1841. Stoltenberg C, Magnus P, Lie RT, Daltveit AK, Irgens LM. Influence of consanguinity and maternal education on risk of stillbirth and infant death in Norway, 1967-1993. Am J Epidemiol 1998 148 no.5 : 452 – 458. Bundey S, Alam H, Kaur A et al. Why do UK-born Pakistani babies have high perinatal and neonatal mortality rates? Paediatric Perinatal Epidemiology 1991 5: 101-114. Department of Health. Review of the Health Inequalities Infant Mortality PSA Target February 2007. Accessed online at www.dh.gov.uk/prod_consum_dh/idcplg?IdcService=GET_FILE&dID=116196&Rendition= Web Hodgetts G et al. Smoking behaviour, knowledge and attitudes among Family Medicine physicians and nurses in Bosnia and Herzegovina BMC Family Practice 2004, 5:12. Royal College of Obstetricians and Gynaecologists. Statement on alcohol consumption and the outcomes of pregnancy. 2006. Accessed online at http://www.rcog.org.uk/resources/Public/pdf/alcohol_pregnancy_rcog_statement5a.pdf Hulse GK et al. Assessing the relationship between maternal opiate use and neonatal mortality. Addiction. 1998 Jul;93(7):1033-42

Maternity, mortality and migration: the impact of new communities

4.2.5 Maternal health and access to health care Mental health problems are a significant issue for some migrant women. Experience of violence, rape, conflict, bereavement and separation before arriving in the UK may have had a huge impact upon women’s mental health. Poverty, discrimination, exploitation, abuse and uncertainty about the future are some of the factors that affect women after arriving. Psychological stress has been associated with low birth weight and preterm delivery.73,74 It is likely that mental health problems will in turn impact upon infant mortality rates in vulnerable migrant women. Infection is one of the key causes of infant mortality, responsible for 12.4% of infant deaths in the West Midlands between 2002 and 2005.75 Immunisation may be incomplete or absent in mother or baby, contributing to the risk of infection. Poor housing and nutrition may also be contributory factors. Many types of infection are implicated, although maternal infections such as chlamidya, gonorrhoea and TB can be a source – all of which are seen at higher levels in ethnic minority groups. Late booking Presenting late to antenatal care can delay or prevent screening and identification of problems in pregnancy, which can mean that pregnancies and deliveries become more complicated, with more associated risks. There is no conclusive evidence to link infant mortality with late booking,76 but this may be due to a lack of research, rather than lack of impact. Around 20% of maternal deaths in the UK are in women who booked after 20 weeks or did not book at all.76 It is clear that late booking is associated with negative outcomes, and it is likely to be associated with infant mortality. Women from ethnic minorities are less likely to ‘book’ within 12 weeks of pregnancy in the West Midlands. In particular, 40% fewer women classified as ‘other’ ethnic group booked in time compared to women who described themselves as white. The ‘other’ classification includes Black African women, who are overrepresented in refugee and asylum seeking populations, and form a significant portion of our new community. Continuity of care There is no strong evidence of a positive impact upon infant deaths according to continuity of antenatal care in general maternity patients.77,78 However, the impact may vary depending upon the cause of the disruption in continuity. If a woman’s care is interrupted due to a move to another city, for example, this may have a more detrimental effect on outcomes, particularly if there is limited or no sharing of information between different health services. This is very different to lack of continuity resulting from care delivered in one geographical area by a team of professionals, and may be a significant issue in migrant women who change address frequently. The National Institute for Health and Clinical Excellence recommends the following: “Antenatal care should be provided by a small group of carers with whom the woman feels comfortable. There should be continuity throughout the antenatal period.”79

73 74

Dole N, Savitz DA, Hertz-Piccioto I et al. Maternal stress and preterm birth. 2003: AmJEpi. 157:14-24. Dyan J, Creveuil C, Herlicoviez M et al. Role of anxiety and depression in the onset of spontaneous preterm labour. 200w: AmJEpi. 155:293-301. West Midlands Perinatal Institute. Key Health Data 2006/07. Accessed online at http://www.pi.nhs.uk/pnm/Keyheathdata2005.pdf UCLAN Feb 2007 Access to antenatal care: A systematic Review Tina Lavender, Soo Downe, Kenny Finnlayson, Denis Walsh Waldenstrom U, Turnbull D. A systematic review comparing continuity of midwifery care with standard maternity services. British Journal of Obstetrics and Gynaecology 1998; 105:1160-70. Hodnett ED. Continuity of caregivers for care during pregnancy and childbirth. Cochrane Database of Systematic Reviews 2000, Issue 1. NICE Clinical Guideline. Antenatal Care: Routine Care for the Healthy Pregnant Woman. NICE October 2003

4.3 Conclusion Infant mortality is a significant problem in the region, particularly in Heart of Birmingham PCT. The migrant population is particularly vulnerable, and experiences many of the risks associated with infant death. In order to reduce the inequality between this high-risk population and other parts of the community, it is important that interventions address not only health service improvement, but also the wider determinants of health.

Maternity, mortality and migration: the impact of new communities

5) Who is giving birth in Birmingham? Understanding of the demographics of women giving birth in Birmingham has, to-date, been incomplete with respect to migration-related factors. This means that designing services to meet patients’ needs is challenging. This part of the report attempts to clarify the current picture in Birmingham. It is the amalgamation of two pieces of work. The first is an analysis of the birth registration data from the Office of National Statistics. The second is the result of a ‘census’ of women giving birth in Birmingham hospitals over a one-week period in November 2007.

5.1 Birth registration data Figure 21 shows the spread of maternal country of birth by region for all births between 2004 and 2006 in Birmingham. Most women are born in the UK, but over 1 in 4 births are to women who were born elsewhere. Of these, around 3 out of 5 were born in South Asia, and 1 in 5 in Africa. It is of note that there are more births to women born in Africa (over 3 times more) and the Middle East than to Caribbean-born women, although this probably reflects the fact that the ethnic Caribbean population in Birmingham is ‘older’, in the sense that it has more members who were born in the UK. It is also of note that the ‘new’ European Union countries account for only 1.2% of births, although the total number is 552, a noticeable number for services. Country of Birth

Live births 2004-06

30876

64.5%

South Asia

10149

21.2%

Africa

2870

6.0%

Middle East

911

1.9%

Caribbean

785

1.6%

Far East

762

1.6%

EU pre 2004

552

1.2%

EU post 2004

357

0.7%

Europe other

318

0.7%

North America

104

0.2%

Other

0.2%

South America

0.1%

Oceania

0.1%

Unknown

0.0%

Asia other

0.0%

EU other

0.0%

Grand Total

47897

100%

Figure 21 Live births in Birmingham 2004-06 by region of birth of mother 80

Source: Heart of Birmingham PCT Public Health Information Team

Figure 22 illustrates the top 20 countries of birth for mothers in live births in the City (including the UK). A key point is that after UK-born and South Asia-born women, Somalian women have the highest number of live births in Birmingham (1181, 2.5% of births). This demonstrates the rapid expansion of this population, and why consideration of the needs of Somali residents is important in any service planning in the City. Country of birth of mother

Live births (%)

England and Wales

30585

63.9

Pakistan

6729

14.0

Bangladesh

2060

4.3

India

1311

2.7

Somalia

1181

2.5

Jamaica

722

1.5

Yemen

415

0.9

Philippines

239

0.5

Zimbabwe

228

0.5

Ireland

201

0.4

Scotland

191

0.4

Poland

183

0.4

Iraq

173

0.4

China

173

0.4

Nigeria

158

0.3

Gambia, the

156

0.3

Vietnam

127

0.3

Afghanistan

124

0.3

Germany

122

0.3

South Africa

117

0.2

Grand Total

47897

100

Figure 22 Top 20 countries of birth of women giving birth to live infants in Birmingham, 2004-0681

The following map shows (figure 23) the spread of the information across the city. It is important to note that not all births for 2004-06 are represented on this map resolution due to the fact that some points may be obscured by other overlaying points registered at the same postcode. This is therefore intended as a rough guide to the pattern of distribution only.

Source: Heart of Birmingham PCT Public Health Information Team

Maternity, mortality and migration: the impact of new communities

UK-born mothers are seen in grey. Overall, the map indicates that mothers born outside the UK live closer to the City Centre. South Asian born mothers are concentrated in the West and East/South East. Caribbean-born mothers are spread throughout the city, although more tend to be seen to the West of the Centre. Other large groups are covered in subsequent maps.

Figure 23 Live births in Birmingham, 2004-6, by region of birth of mother by postcode82

The maps on the following pages illustrate the geographical spread of births in 3 groups: women born in Africa, the Middle East, and the EU post-204. Africa was chosen as many asylum seekers or women with no recourse to public funds come from Africa. The Middle East was chosen in order to

Source: Heart of Birmingham PCT Public Health Information Team

identify the growing population of Iraqi, Iranian and other individuals in the city. EU-born mothers were investigated in order to illustrate the impact of economic migration from â&#x20AC;&#x2DC;newâ&#x20AC;&#x2122; EU nations upon the birth rate in the city. Figure 24 below indicates that the majority of Middle-East-born mothers reside to the South of the City Centre. The population is generally quite localised.

Figure 24 Live births in Birmingham 2004-06 to women born in the Middle East, by Super Output Area

Maternity, mortality and migration: the impact of new communities

The spread of African-born mothers is different to that seen in Middle Eastern mothers, with the majority registered as living in and around the centre of Birmingham. For both these populations, there are few or no births registered in most of the peripheral areas of the City: most are within HoBtPCT boundaries.

Figure 25 Live births in Birmingham to mothers born in Africa, 2004-06

In contrast to the two previous region-specific maps, births to women born in â&#x20AC;&#x2DC;newâ&#x20AC;&#x2122; EU countries are spread across the city, with the majority seen in the North West of Birmingham, but in general a wide spread of low numbers in each area. This is shown in figure 26 below.

Figure 26 Live births in Birmingham 2004-06, to mothers born in countries which joined the European Union after 2004

The information in this section illustrates the key geographical areas where different migrant mothers are registered as living. As service planners are already aware, the spread of the different populations is not uniform, and different parts of Birmingham will have different needs in terms of language and culture-appropriate support (for example, female genital mutilation is predominantly seen in the African population).

Maternity, mortality and migration: the impact of new communities

5.2 Births census Information regarding immigration status is not routinely collected and collated in Birmingham hospitals. When considering the maternity and child health needs of migrants, this lack of information presents a problem. This is because the health and social needs of migrant families can vary dramatically depending upon migration status. An economic migrant in full employment is likely to have a lower maternity risk profile than a destitute failed asylum seeker. The following data is the result of a census of women giving birth to live infants in Birmingham hospitals over a 1 week period in November 2007. Women were asked, anonymously and with consent, to disclose their nationality, immigration status, and length of time living in the UK. Information about country of birth and other demographic and clinical factors was obtained from routinely collected information. The data was collected by Pregnancy Outreach Workers employed specifically for this task, as a London-based study had difficulties with completeness of data when collected by mainstream staff as an addition to routine work.83 To-date, data is only available for 219 women who gave birth at Heartlands and Birmingham Women’s Hospitals. It is hoped that information will also become available for City Hospital early in 2008. This is a small project, over a small time frame and cannot claim to present a complete picture of birth in Birmingham. However, it is intended to provide a ‘snapshot’ of what is happening in the city.

5.2.1 Immigration status Figure 27 (following page) presents the self-reported immigration status of the women giving birth in the hospitals covered. The information illustrates very clearly that migration is an important issue for maternity care in Birmingham. Of the two hospitals surveyed, almost 1 in 5 women giving birth were not British citizens. The majority of other women who responded described themselves as having “leave to remain.” 3.7% were European Economic Area or Swiss Nationals, and 3.2% were spouses of British Citizens. Only 1.4% were asylum seekers, although this was over the period of one week in 2 hospitals – extrapolated to a whole year this figure could potentially be around 150, although it is difficult to predict as numbers are so small. For Birmingham as a whole, the figure is likely to be far higher, as the current numbers do not include City Hospital, which is the main catchment area for BIA-accommodated asylum seekers, and many other migrant groups (see maps earlier in this section).

Bohm C. Improving access to maternity services for refugees and asylum seekers in Hackney. Homerton University Hospital Trust, February 2007.

Immigration status of women giving birth in 2 Birmingham Hospitals over 7 days in 2007

Status

) (176 n e z iti sh c Briti 8) in (1 a m o re ve t Lea (8) nal atio N iss /Sw A ) E E n (7 tize i c h ritis is B ) e s u e (5 Spo ons p s e r No ) er (3 eek s lum Asy (1) gee Refu

80.6% 7.9% 3.7% 3.2% 2.3% 1.4% 0.5% 0.5%

(1) visa r o t visi 0% ent/ d u t k/s r o W

20%

40%

60%

80%

Percent

Figure 27 Self-reported immigration status of women giving birth in 2 Birmingham Hospitals over 1 week in November 2007

5.2.2 Country of birth Due to the availability of a larger dataset through ONS, separate analysis was not performed based on country of birth

5.2.3 Length of time living in UK Women who were born outside the UK had been in the country for a variety of durations. The minimum was 2 months and the maximum was 15 years, although most (68%) had been in the country for less than 5 years, and only one for more than 10. Years in the UK

Status

</=1

>1 to 5

>5 to 10

>10

EEA

13%

50%

38%

Visa

83%

17%

Asylum seeker

100%

Refugee

100%

Leave to remain

19%

25%

50%

Donâ&#x20AC;&#x2122;t know

20%

80%

Spousal

40%

60%

Total

1.745833

3.516667

1.675

0.0625

Figure 28 Length of residence in the UK for non-UK born women giving birth over 7 days in 2 Birmingham Hospitals, November 2007.

Maternity, mortality and migration: the impact of new communities

5.2.4 Ethnicity Figure 29 shows that the majority of women surveyed were of White British origin (45%), followed by Pakistani (20%). Overall, South Asians accounted for almost a third of births (30%).

Ethnicity of mothers giving birth in 2 Birmingham hospitals in 1 week in 2007 3% 1%

White British Other white

Mixed Indian Pakistani

6% 4% 45%

1% 5%

Bangladeshi Other Asian Afro Carribean African Black other

20% 5%

Chinese Other Not stated

Figure 29 Ethnicity of mothers giving birth in 2 Birmingham hospitals over 1 week in 2007

5.2.5 Other factors English speaker: 90.3% of the women reported speaking English, i.e. 1 in 10 women did not speak English, even in the hospitals in the more peripheral (and less ethnically diverse) parts of the City. This illustrates the importance of the availability and quality of interpreting and language-appropriate materials in maternity services. GP: 2% had no GP. The true figure over a longer period is difficult to predict, due to small numbers, although this shows that there are women in Birmingham who are not registered with a GP at the time of delivery. Parity: The average number of previous live births was 1.45 (this rose to 3.18 in African women). This suggests differences in family size in different migrant groups, although it is likely that some of the children may not be in the UK, or may have died, particularly in African-born women, due to higher child and infant mortality rates in other parts of the world. FGM: 4% (8) of women reported FGM on booking. 63% (5) were of African origin, 2 “other black” origin (although one identified herself as Somali), and 16.7 “other” (again one was Somali). Consanguininty: 14% (30) of the women reported consanguinity on booking. 73% (22) of these were of Pakistani origin, and the remainder were Bangladeshi (5), African (1), “other” (1) and not stated (1). The numbers here are small, although this does support the assumption that consanguinity is predominantly an issue in the Pakistani community.

5.3 Summary This section provides a picture how migration influences the birth pattern in Birmingham. It is hoped that this will be of use to policy makers in health, but also in other sectors, in planning for the immediate and long term future of the population. These analyses can potentially be repeated, or extended, to meet the needs of service planners.

Maternity, mortality and migration: the impact of new communities

6) Health and social care staff perspectives: Staff from a wide range of health and social care disciplines were asked to share their experiences and knowledge about migrant patients, particularly in relation to pregnancy, birth and infancy. Staff known to be working with patients in this group in key areas of the City were contacted and asked to share their experience. The number and variety of staff interviewed was restricted due to time and capacity constraints of interviewer and staff members, although a broad sample were contacted. The following is an account of the responses from each of the groups. At the end of this section is a summary of key themes identified by those interviewed, good practice, and potential areas for change. It is important to note that the information provided is entirely anecdotal, but it is hoped that it will highlight some of the key issues facing staff working with migrant women.

6.1 Community health staff 6.1.1 Midwives and health visitors Community midwives in Heart of Birmingham and BEN PCT were interviewed regarding their experiences, including one of the midwives based at the dedicated Asylum Seeker and Refugee Centre for Health (ARCH). Health visitors from Washwood Heath (2), Sparkbrook (2), and Ladywood (1) were consulted, along with 2 specialist health visitors from the Birmingham Asylum Seeker Health Outreach Team (BASHOT). Knowledge and immigration questions. The professionals interviewed saw clients from the full range of different immigration categories. Mainstream staff reported no specific training around the issue, but acquired knowledge in an ad hoc fashion from colleagues. They would welcome additional training in this area. The midwives reported asking patients about their status at booking, in order to identify women who may need onward referral or extra help. The midwife from ARCH also reported checking about change of status, due to the impact this may have on the woman’s situation. Referrals came from a variety of routes: from the GP, from Children’s Centre Staff, from women directly and from specialist providers (accommodation providers, BASHOT). Key issues Day-to-Day issues for migrants • Finance Staff reported that some women did not have sufficient money to feed or clothe themselves, or to buy essential items for their babies. Charities were reported to be filling this gap as much as possible, but women were still left in desperate circumstances. Women were walking to appointments as they had no money for transport. • Difficulty accessing benefits Staff reported considerable delays in accessing assessment and financial support from the Local Authority, plus disagreements between authorities about who should support women and children. One respondent reported that clients had felt “disbelieved” at the Local Authority Persons from Overseas centre. The “short” timeframe for accessing the asylum seeker maternity grant (within 1 month before and 2 weeks after delivery) was seen as a barrier to support for women. There was one example of “inappropriate” support, where a client was provided with voucher support by the local authority, but had no cooking facilities.

• Housing was reported to be frequently of poor quality, including private rented accommodation, and BIA/LA provided housing. Patients with no recourse to public funds were reported to be relying on friends or strangers for somewhere to sleep. Families were reported to be frequently accommodated in hostels/B&B, as no appropriate long-term housing was available. • Lack of social support Some women had found themselves in Birmingham without any family or friends, and charitable strangers, churches and voluntary organisations had become their only source of social support. Some of these women were particularly vulnerable, and had experienced exploitation abroad or in the UK. One health visitor described a pregnant patient’s escape from traffickers with her young child. Mobility of individuals • Frequent/rapid relocation was seen as a problem, particularly for women during the immigration process. The eviction/move was reported to be frequently carried out at late notice, and information was not shared with health services about destination. Health professionals had not been consulted regarding the appropriateness of moving patients with ongoing health problems, e.g. one woman was dispersed to Birmingham from London with a pregnancy that was 7 days overdue. Another lady was reported to have been moved into the area while still waiting for the results of an important antenatal test, and health services had not been informed. • Clients disappear There were several reported reasons for ‘disappearance’: dispersal through the asylum process; movement for fear of detection by the authorities; ‘moonlight flits’ by some Roma families as a result of rent arrears. In all these cases, the ‘disappearance’ causes concern for staff as they are not certain what has become of vulnerable women and children. On occasion there child protection concerns were reported, or patients were heavily pregnant. Health specific issues • Language was cited as a problem for patients, as interpreters were not always available. It was seen as a barrier to accessing health services and registering with a GP. • Culture/expectations Migrant women come from a wide range of cultures, and from countries with very different health services. Some respondents felt that certain patients did not see the value in presenting early to services, or attending antenatal follow up, as this was not something that they were used to in their previous country of residence. However, other women were very keen to access services. • ‘DNA’ Some respondents cited ‘did not attend’ rates for appointments as being higher in migrant groups. • FGM was not frequently volunteered as an issue by midwives or health visitors. • Late antenatal booking was frequently stated as a problem, but not necessarily because women present late to services. Due to frequent relocation, women may move before their appointment comes through, or arrive in the area after booking elsewhere. This disrupts the continuity of care. • Out of hospital births The specialist health visiting team recalled 3 out of hospital births in their clients over the past few years. Two cases in the Roma community were mentioned by health visitors in Washwood Health and Sparkbrook. • Stillbirths The specialist health visiting team recalled 2 stillbirths in their clients in recent years. • GP registration was seen as an issue by some respondents. One member of staff felt that registration processes were discriminatory in some surgeries, and that receptionists were more likely to turn away patients who did not speak English, or who were from certain ethnic groups. Some respondents reported that patients were informed that GP lists were full when this was not the case. Others felt that registration procedures were difficult to understand, and registration forms complex. Others did not see GP registration as an issue, and stated that their patients rarely had difficulty finding a GP. • Manipulation of the system was cited as a problem by some. This was reported to be more challenging as it was often difficult to distinguish between “genuine” patients and those who

Maternity, mortality and migration: the impact of new communities

were “working the system”. Some respondents were concerned that some women were falling pregnant in order to improve their immigration case, and that women should be informed at an early stage that pregnancy is unlikely to help their case. Communication between agencies • Lack of communication with caseworkers Staff working in the specialist services stated that they had received little or no contact from New Asylum Model Case Owners, although they had hoped that the workers would be a vital source of continuity. • Information sharing Some staff reported difficulties as a result of little information sharing about client dispersal by immigration services. Several stated that women had been inappropriately moved into/out of their patch during pregnancy or soon after birth. One respondent described an ‘11th hour’ (successful) rush to prevent a patient from being dispersed when in the late stages of pregnancy.

6.1.2 GPs A range of different GPs were consulted: some with particular interest or experience in caring for migrant patients, and others who worked in mainstream practice but had some migrants on their lists. They were asked about the needs of patients, and the issues facing GPs in caring for migrants, plus potential barriers to improving services. The sample of GPs was small (5), but it is hoped that their responses help to identify some of the key issues. Overall, GPs reported little input into maternity care in the current midwife-led system, so their current experience in this area is limited. Registration procedures and access The GPs had looked after the full range of migrants. Registration procedures differed, and ranged from questions regarding length of residence in the UK, to a comprehensive form with various details including substance misuse and immigration status. Proof of address and status requirements also varied, and ranged from referral from a relevant agency (e.g. hostel) to passport and proof of address. The surgeries saw overseas visitors as private patients when required. One GP reported that increasing opening hours had improved access for patients. Language was cited as a barrier to registration and access, and one of the GPs suggested that surgeries should recruit staff with a range of languages to cater for at least some of the need. Two of the GPs reported that patients had been informed that other surgery lists were closed, when they believed that places were in fact available. Key issues Health specific issues • Language was cited by all as a key issue. Interpreting was good in general, although some interpreters were poor quality – one GP reported building relationships with preferred interpreters and requesting bookings with them. Children were sometimes expected to interpret, which was seen as inappropriate. One GP reported that some migrants did not learn English, even several years after arrival, meaning that the problems did not necessarily improve over time. In addition, it was reported that some migrants request an interpreter despite having an apparently good command of English. Rationalising interpreter use was seen as difficult. One GP suggested that improving literacy skills in mothers has been shown to have an impact on outcomes: an effective intervention in Kerala, for example, assisted women to read and write in their own language (not necessarily the main language in use). • Patient expectations were seen as an issue in migrants, as sometimes expectations were high. Patients were reported to expect onward referral to specialists at an early stage, and were not used to a general practice system. This was mentioned by separate practitioners, and appears an issue for both economic migrants and refugees. In addition, it was reported that some migrant patients presented with multiple problems, and some were not happy when asked to

•

• • • •

• •

limit the consultation to one or two problems per visit. Other patients arrived with other family members to a one-person appointment, without realising this was not appropriate. These problems are not specific to migrants, however one practitioner felt that the problem was more widespread in this group, perhaps as a result of lack of understanding of the NHS. One GP stated that patients’ requests for assistance with benefits, immigration etc. were significant in number, and sometimes there was an expectation that the GP can help when, in fact, he can’t. One GP had investigated patient expectations regarding appointments and waiting, and as a result services had been changed from walk-in to booked appointments. 2 of the respondents reported missed appointments were more frequent in migrants compared with the ‘indigenous’ population. Time pressures In migrant patients, lack of English means that consultations can take longer with, or without an interpreter. In addition, some of the health problems that migrants present with are complex, and require a great deal of time, as do requests for medical reports and letters. One GP reported that it took approximately 1.5 hours of their time to complete a medical report at a practice with administrative and clinical expertise: less specialised staff may require further time. This can impact on other work. Training/awareness was felt to be lacking in health professionals. GPs had developed expertise predominantly through experience and their own work. One GP suggested that there was a need to recruit more health care staff from the community which they serve, to improve understanding of the issues, and prevent burnout. Areas where training would be helpful included; rules around entitlements, the immigration system, and the health needs of migrant patients. Lack of funding/staff was mentioned by one interviewee. It was felt that there was a shortage of Health Visitors to meet the needs of an increasingly complex (and expanding) caseload. One respondent reported difficulty in distinguishing between ‘manipulative’ individuals, and patients with genuine medical problems. FGM resulted in some problems for GPs, but these were not frequent. Problems cited included infection and postnatal difficulties. Mental health was identified as a key issue for migrant women, particularly asylum seekers, as a result of experiences before and since arriving in the UK, along with the impact of uncertainty about the future. Accessing psychological support was reported to be difficult, due to language and cultural barriers. One surgery conducted psychological support ‘in-house’ in response to this. Rape/abuse was mentioned by 2 of the GPs interviewed in terms of its physical and psychological consequences for women. Health beliefs were felt to have an impact upon late presentation in pregnancy, as early intervention may not be seen as necessary by some women due to experiences in the country of origin

Day-to-day issues for migrants • Housing was reported as a problem by one of the respondents. Patients were reported to be accommodated in inadequate housing by BIA. Examples included families with adolescent boys and girls being housed together, and several families sharing one toilet. • Destitution was mentioned by one of the GPs as a significant problem, and the doctor had been involved in cases where ‘destitution plus’ support from the Local Authority was not forthcoming. • Occupational issues were identified for economic migrant women. One GP mentioned that women working until late in their pregnancies, or even to term, was a real issue, as women could not afford not to work. Often jobs were demanding, and involved early starts, long journeys to work outside the city, and long hours. • Reasons for pregnancy One GP suggested that it is possible that some women fall pregnant in order to ‘test’ their fertility as a result of the experiences that they have endured before and since arriving in the UK. In addition, a child may be the only relative that a woman has, and

Maternity, mortality and migration: the impact of new communities

this may influence the decision to become pregnant or continue with a pregnancy. Differing attitudes and knowledge regarding contraception may also be an influence. Mobility of individuals • Movement/dispersal was seen as a barrier to effective health care, particularly in asylum cases, where clients may only find out at a late stage that they are to be moved. Two GPs reported success in delaying/preventing dispersal of patients with ongoing health problems by contacting NASS/BIA directly. However, sometimes patients have moved before health services become aware of plans for dispersal.

6.1.3 Pregnancy Outreach Workers Pregnancy Outreach Workers have been introduced in certain wards in Birmingham to provide psychosocial support to pregnant women. They work alongside midwives performing a non-clinical role, supporting and signposting women with a wide range of issues. They focus on vulnerable women, including migrants, and have been working in the community for several months. Three workers in 3 key areas were consulted: Ladywood, Washwood Heath, and Sparkbrook/Springfield. Knowledge and immigration questions Immigration issues came up relatively frequently in the Pregnancy Outreach Workers’ work. Knowledge varied, and where workers did not know all of the issues, they were confident that they were able to draw on others’ knowledge or expertise. However, it was mentioned that further training on these issues would be welcomed in the future. It is worth noting that the workers have recently undergone intensive training prior to commencing their posts, and further sessions are planned as part of their continuing professional development. Pregnancy Outreach Workers reported always asking about or advising re. disclosure of immigration status, as addressing immigration issues was seen as a key role. Also, it was important that clients weren’t promised benefits or entitlements to which they did not have access. Workers did not ask for papers unless the client volunteered to do so. Referrals Patients were referred to the Pregnancy Outreach Workers via midwives, public and voluntary sector agencies and self-referral. Key issues Day-to-day issues for migrants • Poverty is a key issue, and women have difficulty in providing food, clothing and basic equipment. Charities assist by providing this type of support. Women can’t access Healthy Start support (vouchers for food, vitamins and milk provided to families on certain benefits). Patients have to walk miles to appointments as they have no money for transport – Pregnancy Outreach Workers cannot provide lifts to patients, and find it very difficult to see their clients in this situation. • Exploitation was a concern. Patients were reported to be vulnerable to exploitation by landlords and others. This was exacerbated by the fact that women do not know their rights, or where to turn for help, and may have low expectations. • Worklessness Pregnancy Outreach Workers reported that many women wanted to work, and were able bodied. They were prohibited from working, and also from learning English, which left them more vulnerable through isolation and poverty. • Domestic violence had been seen by all of the Pregnancy Outreach Workers, and was perceived as a problem in migrant women as in any vulnerable population. One worker felt that Local Authority advice for women on spousal visas fleeing domestic violence was not always appropriate, for example, one lady was advised to seek refuge with extended family members who she feared would return her to her abusive husband. • Benefits system This was felt to be slow for refugees and others, with language needs not

always met adequately. Clients were reported to have considerable difficulty in accessing benefits, and the presence of a Pregnancy Outreach Worker at an appointment was felt to assist the process. One stated that clients were regularly asked to “Come back tomorrow.” • Poor housing was mentioned as a problem, in terms of both quality and overcrowding. Migrants’ low expectations were felt to make this more of a problem, “They don’t know how to live any other way, and they’re grateful to have a roof over their head.” Mobility of individuals • Movement/disappearance is a problem, with women relocating either by choice or as a result of the immigration process. This disrupts continuity of care, and means that vulnerable women ‘disappear’ • “Women don’t want to be found,” was the response of one of the workers regarding barriers to access. It was felt that there will always be difficulties to a certain extent, so long as women are living here illegally and are afraid of deportation. The issue was seen as a barrier to presenting early in pregnancy, and to reporting crime including domestic violence. Health specific issues • Patient information materials are not always up to date, and workers reported that they would like more resources that are language/culture appropriate • Interpreting & Translation services Interviewees reported that translation services were not available to all Pregnancy Outreach Workers, depending upon the area of the city in which they worked. This caused problems when consultations occurred outside of clinical settings (e.g. home visits) as communication may be almost impossible. In clinics, workers often relied on the interpreters booked via the midwife. • Manipulation One Pregnancy Outreach Worker reported that some women were claiming to be single in order to access more benefits. • Lack of understanding of what is available Pregnancy Outreach Workers felt that clients did not understand what services were available, and thus may not be accessing them. This related to both public and voluntary sector services. • Discrimination Two of the Pregnancy Outreach Workers reported discrimination or lack of understanding on the part of staff who come into contact with migrant women. This included the police, neighbourhood office, housing, children’s services, and hospital. Some staff were reported to make clients feel uncomfortable. One client had requested to be seen at a different hospital for a subsequent pregnancy. General comments • Perception that women are getting pregnant in order to access services This was not felt to be the case • Interim arrangements were cited as a problem by one worker, in that a woman who had been advised to claim asylum following delivery of her baby was sent to the Home Office from a Local Authority provided bed. This was very soon after discharge from hospital, and the client did not have accommodation for that night. A charity paid for her accommodation while she was waiting for BIA support to commence. It is not clear if this situation is isolated or more widespread. • Economic migrants were feared to be at increased risk of poor outcomes due to overwork and working nights. • Long-term illegal immigrants One worker cited the case of a client who had been in the UK since she was a child. She was now a pregnant, and had no immigration documentation. • Spousal immigrants were seen by one worker to be at risk, as they tend to be “Sheltered, and always accompanied.”

Maternity, mortality and migration: the impact of new communities

6.2 Hospital staff 6.2.1 Midwives Midwives from 2 of the maternity units in Birmingham were consulted (City, and Birmingham Women’s Hospital). At Birmingham Women’s Hospital, general midwives were consulted. At City Hospital a senior member of staff discussed her findings from a scoping exercise into the issues around caring for asylum seeking and refugee women, so the findings of this were discussed. Knowledge and immigration questions Midwives did not ask questions regarding immigration status unless the issue arose: the focus was on caring for the patient, regardless of status. The midwives’ knowledge of immigration processes and statuses was, in general, limited. Those asked reported that they would welcome training on this subject. However, training at City Hospital was becoming more systematic, and knowledge was felt to be improving. Key issues Day-today issues for migrants • Patient knowledge Women do not understand the NHS system, which could act as a barrier to care • Domestic violence was reported to be a big issue in maternity services in general. One respondent reported that referrals due to domestic violence had dramatically increased, although this was perhaps due to increased awareness and confidence in community midwives. Asian women were cited as a key group who become victims of physical and verbal abuse, and this may not be at the hands of a spouse, but a sister or mother in law, or other family member. • Poverty was reported to be an issue for some patients, who sometimes had to ask other women on the ward for nappies as the hospital had limited supplies, and they could not provide their own. Midwives mentioned the good work of local organisations in providing charitable support in baby supplies. Health specific issues • Time Midwives only have limited time to spend with patients, which means issues can be missed, and professionals are less able to build trusting relationships with the women. It also means that contact time is more likely to be clinical issue-focused, as midwives are not able to cover clinical and social needs adequately in the time slots given. One respondent suggested that the Pregnancy Outreach Workers were able to fill some of the gaps resulting from lack of time. • Training and knowledge was identified as an issue. The situation was reported to be improving, but the lack of knowledge on professionals’ part was seen as problematic. One respondent mentioned that this may lead to discrimination, or omissions in care due to lack of awareness of women’s situations (e.g. if a woman provides an address to go home to, it may not be appropriate or safe, but this may not be recognised unless questions are asked about who she is staying with, what support she has etc.) • Bed blocking due to destitution/nowhere to go was not identified as a large scale problem, but was significant when it occurred • Language was identified as an important issue by respondents. Interpreting services were not always available, but staff used language line or relatives as a last resort. The sheer number of languages was reported to be a challenge by one midwife. Respondents did report some instances where communication during labour was near impossible due to lack of emergency interpreting services.

• FGM was an issue, but the respondents felt that expertise was growing, and that services were improving their response to the needs of women who had undergone the procedure. Staff welcomed the idea of further training in the issues. Communication between agencies • Information sharing was reported to be an area for improvement. This included communication between different NHS staff in midwifery, and with other disciplines, plus social care and other agencies. • Pathways and safety nets Awareness of support organisations and agencies was reported to be ad-hoc. Staff stated that it was usually possible to find somebody to help patients, but due to the number of different organisations a directory or resource pack would be welcomed. Training and networking events were also identified as sources of awareness-raising.

6.2.2 A&E doctors and nurses Accident and emergency departments are often the safety net for individuals who are having difficulty in accessing services. Free, open twenty four hours a day, and open access to all, A&E is an obvious port of call for people who are uncertain about how to access other forms of healthcare. This is particularly true for those who have previously lived in countries without established general practice services. Therefore, staff in A&E departments across the city were asked about their knowledge and experience. Staff from Heartlands, City and Selly Oak Hospitals were consulted. Knowledge and immigration questions Doctors and nurses (including advanced clinical practitioners) in A&E had varying experience and knowledge relating to migrant patients. None had received specific formal training, but some had learned about the subject through ad hoc or informal opportunities. Many were uncertain about the immigration status of their patients, rights of access to care, and unclear regarding the differences between different groups, e.g. asylum seekers and refugees. Immigration status did sometimes arise during a consultation, but on the whole staff did not ask unless the issue arose. Some felt that raising the subject of status may concern patients and act as a barrier to care. Others expressed a desire to focus on the health needs of patients, regardless of status. Concerns were raised regarding whether or not health staff would be expected to disclose the immigration status of their patients if it was discovered. Checking that women are booked When seeing pregnant patients, most of those consulted reported ‘always’ requesting to see the ‘handheld’ pregnancy notes (others said ‘sometimes’). However, responses were not anonymous, it is possible that staff would be reluctant to admit not requesting to see the notes. There is an indication that women are not asked for the handheld record on at least some occasions, which also suggests that unbooked women may slip through the net. Referral of unbooked women When patients had not ‘booked’, or when there was no GP, staff reported a mixture of actions. Some would advise and signpost regarding registering with a GP, although assistance with registering was not reported. Others would refer to the obstetric on-call. None suggested referring to the midwife or calling the rapid access call centre – some felt that the call centre was not required from an A&E point of view as other routes of referral were available. At City Hospital it was felt that most women presented acutely, and therefore would be referred to obstetric on-call: sending out into the community was not a frequent occurrence.

Maternity, mortality and migration: the impact of new communities

•

Key issues Health specific issues Language was a key concern. Trusts had different arrangements in terms of access to language support. City Hospital and Heartlands Hospital had language line provision, which was reported to be a good service. One staff member described it as ‘superb’. Selly Oak A&E has no facility to use language line in A&E, and the juniors reported that the trust did not have a contract with any organisation to provide this type of service. They found communication very difficult at times, and reported relying on relatives and other staff in the hospital when available. Children had been used as interpreters for adult patients. Internet translation sites had been used by some in extreme circumstances, but internet access was not always available in the departments. Presentation in labour A doctor who had worked at City Hospital reported being in the department when migrant women (Black African) had presented in labour without any antenatal contact. This was during the course of a 6 month placement. On at least one occasion the patient had been circumcised. Language was identified as a key problem as it was near impossible to communicate with the patient. 3 babies had been delivered in the A&E department of City Hospital in the past month. However, this was in part due to the closure of the maternity unit due to staffing pressures, and not always due to late presentation. Eastern European migrants had presented in advanced stages of labour, but it was felt that this was seen in second pregnancies, and due to the fact that the mothers overestimated the time to delivery. Baby born out of hospital At Heartlands Hospital there had been a case of a Romanian patient presenting with a new baby, apparently having had no healthcare input during pregnancy, birth or infancy to-date. This was not viewed as a problem by the mother, and it is suspected that home birth without a midwife does occur in the Roma community. Further investigation with child protection and Children’s Hospital staff suggests that this is not a frequent occurrence, but with the increasing Roma population we may see changes in the future. Concealed pregnancies were mentioned at City Hospital, and were predominantly in the longterm resident population. However, it was reported that some concealed pregnancies had been seen in the Somali and Sudanese community, though not in the South Asian Muslim groups. Access to GP This was not seen as a major problem for pregnant women, although generally respondents reported seeing primary care problems in the department. Local GPs were often reported to be full. Cultural and international expectations of health systems care were also seen as an influence on this. Transfer request City Hospital mentioned that staff referring women who presented to A&E were asked to send them to the booking hospital, e.g. Birmingham Women’s Hospital, although in practice all patients were referred to the City department.

Day-to-day issues for migrants • Destitution was not felt to have a large impact, and staff did not report seeing migrant patients who had nowhere to go (this was more a problem in the traditional homeless community).

6.3 Other staff 6.3.1 Asylum/refugee Outreach Support Service A worker from a pilot project was interviewed. This project is funded by the Community Integration Partnership and Sure Start, and has been in existence since January 2006. It provides outreach to migrant families with children up to the age of 5. This help includes welcome groups, parenting classes, links to English and other training, plus individual and outreach work with families to address their needs. The caseload is around 20 to 25 families, with frequent turnover, but the level of need is reported to be in excess of the capacity of the project. ‘One-off’ interventions are also provided. Asylum seekers, refugees and (more recently) EU nationals are assisted by the scheme. The worker has an in-depth knowledge of the needs of migrant families. Key issues Day-to-day issues for migrants • Domestic violence seems to be on the increase • Housing One BIA housing providers housing was reported to frequently be poorly maintained and potentially dangerous for young children, e.g. exposed wires, damp, vermin, doors not safe, inadequate heating, little action taken when complaints made. Refugees continue to have problems once granted status: little guidance or help to access housing, expected to “go out and find alternative accommodation, and they end up in B&B or a hostel.” Health specific issues • Language is a huge problem. This is particularly true for asylum seekers as they are unable to access ESOL courses, and this affects their ability to integrate, including ability to communicate with services caring for their children (education etc.) Language provision via benefits agencies does not always meet clients’ needs, and some languages are rarely available. Language appropriate leaflets would help – “I have never met a client who cannot read leaflets in her own language,” the interviewee rejected the frequent argument that many non-English speakers cannot read or write in their own language. • Late booking does seem to be a problem in African women, and this is at least in part related to the fact that they don’t understand the need to book. • GP access not felt to be a big problem General comments • Destitute women not presenting to her service – perhaps due to access problems • EU women have been here a long time and suddenly find themselves in trouble as a result of pregnancy

6.3.2 Social care staff Social care staff from the local Persons from Abroad team were interviewed: one from the Adults, and one from the Children and Families teams. These teams are involved in the assessment and support process for Local Authority support for destitute clients under the National Assistance Act and Children’s Act. The following key issues were identified:

Maternity, mortality and migration: the impact of new communities

• Clients The workers described a range of clients. On the families’ side, there was a reported increase in the number of victims of domestic violence presenting. In addition to refused asylum seekers, clients on spousal visas, and visitors from Jamaica were described, amongst others. The majority (70%) of clients were thought to be existing families, i.e. application was not as a result of a single new baby alone. However, it was not possible to provide numbers. The majority of assessments were refused support, and one worker felt that there had been an increase in the number of refusals. • Health and social care access On the whole, access to health was not felt to be a problem. Relationships between health and social care were felt to be good. However, a key concern was the fact that clients with mental health needs cannot access secondary care, and there is no provision of psychological therapies for this group. An example was cited of a client requiring surgery, and uncertainty regarding whether the procedure could go ahead due to immigration status. In addition, one worker indicated that it was not always possible to fulfill the usual social care role as clients may have no rights to services which may help them, and instead are only eligible for voucher support, which does not address their more complex social needs. • Threats to health One of the interviewees identified poverty as a key issue for clients with No Recourse to Public Funds. The current level of support through the Local Authority was described as “inadequate,” and the worker described dealing with “Absolute poverty, not relative poverty, something we haven’t seen since before the reforms of Beveridge and Townsend.” However, the other worker considered that the support provided did meet the needs of families. Uncertainty was described by both respondents in the sense that it was often difficult to identify long-term solutions for clients, and they were likely to continue to be NRPF. • Support provided One worker described the support provided to adults as “Inadequate,” citing the fact that accommodation can be unadapted to meet needs, or overcrowded/inadequate. The worker also stated that the system of voucher support (as opposed to cash) was discriminatory. • Language was identified as a key issue for clients, as cited by other groups of staff • Benefits of the system One worker described the additional services that staff were able to provide for clients, such as one to one support and advice, and in some cases equipment. Clients who ultimately had not been granted support had been assisted to access other support, and one case was cited where baby care equipment had been provided. One worker reported that the assessment system had improved over time. • Pressure on the system Both workers described one of the main limitations of the system as the lack of resources, including time, money and staff. Pressure arose due to the sheer volume of clients, one saying that the workload was “Too high.” One worker also described the challenges faced by the system in dealing with immigration issues in addition to care needs, and stated “I am not an immigration officer.” One worker stated that Home Office responses could be slow, but that individuals had a difficult job to do, and the issues were a result of pressure on the system.

6.4 Examples of good practice cited by those interviewed • • • • • • • • • • • •

A GP practice recruiting staff with a range of languages in order to minimise interpreting costs In house CPN providing counselling in a mainstream practice, reducing secondary care referrals Patient consultation by a GP leading to change in planning of clinics Building relationships with interpreters Welcome group for women Locating multiple services in Children’s Centres Language line (or equivalent) availability with two-way phones in A&E Stillbirth pathway Midwives texting patients to remind about appointments School befriending Excellent work done by charities – ASIRT, Red Cross, Restore and others Joint mental health clinic in midwifery, with staff from other specialties/sectors

6.5 Key themes/problems identified by most or all groups: • • • • • • • •

Poverty and inability to provide for mother or baby Language needs Relocation/dispersal due to the immigration system, or to avoid detection Difficulties/delays in accessing benefits/entitlements Housing access and quality GP registration difficulties Staff training/awareness Patient expectations, health beliefs, and service user behaviour

Maternity, mortality and migration: the impact of new communities

6.6 Possible solutions for the health and social care sector The following were suggested as potential solutions by health and social care staff: • Asylum seekers and other migrants need a central, recognisable service • Staff require more training to understand and deal with issues • Targeted work with communities who present late/don’t engage • Continue to provide and expand support for migrant mothers, especially asylum seekers, at Children’s Centres • Provide education for women to improve outcomes and integration • Develop counseling and mental health services for migrants that are culture- and language-appropriate • Improve GP access, including ensuring clarity about requirements for identification and addressing discrimination • Avoid moving pregnant women where possible • Inform health care providers when moving a pregnant woman • Consider a coordinator role to support community health staff across Birmingham with knowledge and advice • “More health visitors are needed” • Extend opening hours, including weekend midwife access • Recruit more local staff who understand the different communities, and speak appropriate languages • Ensure that staff in acute settings have access to Language Line or equivalent • Expand Healthy Start to asylum seekers and other vulnerable migrants • Reinforce the fact that the Home Office has no link to Health, and maintain this situation • More joint working • “Change legislation” – this was mentioned by several interviewees with respect to current immigration law and rights of asylum seekers and failed asylum seekers • Address the resource issue in funding/staffing NRPF services within Birmingham Local Authority

Experiences of pregnancy and motherhood in women with No Recourse to Public Funds

As a result of preliminary work, women with No Recourse to Public Funds (NRPF) were identified as the group with the highest level of need. This was reinforced through staff and voluntary sector consultations. Five women with NRPF kindly agreed to share their experiences and speak to us about the problems that they face, through semi-structured interviews in November 2007. This builds on the work of Dr Foster, commissioned by the Birmingham Health and Wellbeing Partnership in 2007.84 The women were all of black African origin, and had been through the asylum system. They had been in the UK for between 8 months and 5 years. Most of the women had lived in more than one city: only one had been in Birmingham for the duration of her time in the UK. All women had reached the end of the asylum process. 2 were receiving no support except charity, one had just been granted Section 4 support after a fresh appeal, one was already on Section 4 support and one was being supported by the Local Authority. The women’s families were all different: pregnant and single; pregnant with an existing young child and husband; single, having lost a baby; single, with a newborn, and single with a child under the age of 1. 2 of the women had existing children, although not all were with them in the UK.

7.1.1 Access •

•

The interviewees all sought help from healthcare services once they discovered that they were pregnant. Help was sought at different stages, but generally it was before 12 weeks. Often women had moved during their pregnancies, and ‘rebooked’ with a different health service. Routes of entry to NHS services also varied, and included referral in detention, referral in Initial Accommodation, and signposting by voluntary sector agencies. None of the interviewees reported any difficulty with registering with a GP, and all had a GP in Birmingham. Problems with access centred around distances travelled to appointments, and the logistics of getting there without any money. Women reported walking to appointments when they did not have enough money for the bus, even in the later stages of pregnancy. Bus passes were available from charities, but only for limited periods. Booking an appointment at the GP was reported to be problematic for one lady, in that she had to wait several days to see the doctor. This may reflect the different organisation of healthcare in the UK, with fewer ‘walk-in’ services.

7.1.2 Knowledge and information •

•

The women’s knowledge of the NHS varied. None of the women reported being informed about availability/entitlements systematically (e.g. during the reception period). A midwife explained the system to one lady. Others found out about the system from friends, charities or other migrants. All of the women except one knew that they could access care early on in pregnancy. However, one of them stated that she “Waited until everything was settled,” before seeking help, as she was coping with so many different problems. The remaining lady reported that she had “No idea,” about when to access care. In terms of appointments, the women reported that they would have no problem in finding somebody to translate a letter if it arrived. However, as they moved on frequently, some felt that a phone call would also help, although only if they could speak English. Most had mobile telephones.

Dr Foster “Intelligence: Infant Mortality in Birmingham” Birmingham Health and Wellbeing Partnership. May 2007.

Maternity, mortality and migration: the impact of new communities

7.1.3 Care received The women were generally positive about the care that they had received in the community and in hospital. One respondent said that it was difficult to assess the quality of the care received, as she was not sure what to expect. In addition, the following issues were identified: One reported that her baby’s symptoms were disregarded by her GP. She went to A&E and • the baby was subsequently diagnosed with an infection and prescribed antibiotics. She reported that the GP did not understand the situation in which she and her child were living, and how vulnerable they were. • Another felt that her GP did not assess her properly when she was unwell during pregnancy. She was subsequently admitted and lost her baby. It is impossible to say whether the GP’s actions influenced the outcome, but the lady did not feel like her case was adequately dealt with in primary care. • Two of the interviewees had visited the GP, midwife or A&E during pregnancy, requesting treatment for health concerns (including insomnia, headache and gastrointestinal symptoms). They were dissatisfied with the outcome, and reported that health professionals would not consider prescribing medication, in view of their pregnancy. This practice is routine in the UK, and the professionals had explained the rationale, but the women felt that they had not been treated as they would have been ‘back home’. This reflects the different health beliefs, and expectations of migrant women, and the challenge that patients and health professionals face. • Another reflection of the differing expectations of health services was indicated by one lady’s feeling that the GP did not have enough time for her, and that it was inappropriate to use a policy of ‘one problem per appointment’. The GP was reported to have suggested that it would be good to write a list for the doctor before the appointment, so that he or she would already know what the problems were. • One lady had experienced problems in detention: she had an initial assessment by a midwife, and she reported that subsequently blood tests and scans were not performed, although they had been requested. At nearly 30 weeks pregnant she reported not having had a scan, potentially as a result of being moved to another location. • One of the interviewees was unhappy that, in her view, she had been encouraged to terminate her pregnancy following a potentially abnormal scan. • The GP of the lady who lost her baby was reported not to have followed her up after her stillbirth, despite the patient reporting taking the hospital letter to the surgery in person. At a later date the doctor reportedly enquired about her baby, apparently not knowing about her loss. She said “I was expecting more support.” • There were some reports of treatment which demonstrated either a lack of appreciation of patients’ circumstances, or discrimination: · “You can buy it yourself” A GP’s reported response to a request for a paracetamol prescription · “You are not sick, you just want more attention, go home and see how things go.” A GP’s reported response to a patient. · “Doctor didn’t care about living conditions” · “I am not racist, but I notice that Asian doctors have less time, I find it more difficult.”

7.1.4 Costs and confidentiality Few of the women interviewed reported worries about cost of treatment, or about information-sharing with other agencies (e.g. the immigration services). One lady was concerned initially, but soon realised that she didn’t have to pay for care. One lady was concerned about medication costs, and her HC1 form had expired. She didn’t like having to repeat all of her information and reapply.

7.2 Health effects of women’s circumstances One interviewee described her feelings of helplessness, saying “I only carry on because of my baby.” Women described sleeplessness, crying all the time, and depression. One woman was suffering from chronic back pain and high blood pressure. The long-term effects of experiences before and since arriving in the UK had led to depression in some of the women. One lady had experienced significant mental health problems before her pregnancy, and despite spending time as a mental health inpatient, there was a long delay in securing support from the local authority (support was refused twice before a successful application.)

7.3 Other concerns “Things are just as bad here as [at home].” The women all identified material deprivation as their primary problem, including lack of food, clothing and adequate shelter. There were difficulties in accessing support during pregnancy and after childbirth. Uncertainty about the future was identified as a key issue.

7.3.1 Poverty •

• • • • •

“If my baby is sick it’s because of the circumstances,” a lady with a 4 week-old child sleeping in an unheated living room with no hot water. She cannot wash her baby properly. “If a see another black person in the street, I go and ask them for help. I am begging.” “I have a voucher for food, but nothing else.” “I have a bus pass from the Red Cross, but they only provide for 6 weeks.” “I have nothing to prepare for when the baby comes, no equipment” “The Red Cross gives me wipes, nappies”

7.3.2 Food • • •

“I cannot eat breakfast. I have no food.” A breastfeeding mother. “If I have food and a place to live, then I can think about other things. What can I do now?” A woman who was pregnant at the time of interview. “The vouchers are not enough”

7.3.4 Shelter • • • • •

“I was in the bus stop crying. I had nowhere to go.” “I would prefer to stay there [in detention] and have that security” “Why would they release me from detention when I have nothing?” “My host has asked me to leave but I have nowhere to go.” One mother, sleeping in a living room, had no privacy or security.

7.3.5 Delays and problems in accessing support • • • •

One lady reported being told by Social Services to come back later on in her pregnancy. Another said that she had been asked to “Come back later,” by Social Services and the Red Cross. “Social Services treats me in an inhumane way” One lady reported applying for support one month before birth, but the case had been delayed. 4 weeks after birth she had been assessed by the Local Authority, but still not received any answer or support.

Maternity, mortality and migration: the impact of new communities

Case history A dispute about the responsible authority had resulted in a lady receiving no support for her child for many months, and being housed in inappropriate accommodation. The Local Authority (LA) providing support prior to, and during her pregnancy had declined her application for support for the child, as the family were housed in another LA area. She was forced to share a bed with her baby, as no cot was available, in a room that she described as “small” and “cold.” She was reliant upon charity to support her child, and she was living in shared accommodation. Eventually, support was granted for her child by the LA of residence, but the original LA discontinued her support, stating that the new LA was responsible for supporting the whole family. She is happy with her accommodation, but the voluntary sector have provided her with a washing machine and vacuum as these were not part of her accommodation package from the local authority. However, she now receives support only for her child. This means that she has to support them both on an allowance intended for one child. She is relying on charity to supplement this. There is still no agreement regarding how to support mothers in this situation, and no guarantee that there will not be problems of this type in the future.

7.4 What would you like to change? 7.4.1 Health service “More time” “More friendly doctors” “GP should know patient” “Talk to doctors about living conditions” (i.e. so that they understand patients’ situation).

7.4.2 Situation “Papers to stay” “I just need some time” “I don’t want to rely on charity today, tomorrow, the next day: I want to be able to work” “More help for women like me” “I am only worried about my baby” “Help for when baby comes” In general, women felt that above everything they needed more support in terms of food, clothing and shelter, plus the essential items needed to care for baby. On the whole, the women did not volunteer specific recommendations: the impression of the interviewer was that they were not concerned with how the changes were achieved: they wanted status, material support, and security. One lady summed up her feelings about her current situation by simply stating:

“I want peace.”

Maternity, mortality and migration: the impact of new communities

8) Voluntary sector perspective A voluntary sector consultation was held on 19th October 2007 with representatives from 12 agencies working with destitute asylum seekers and other NRPF cases in the Birmingham and Coventry areas.

8.1 Role of agencies consulted in providing support to NRPF and other vulnerable migrant women: • • • • • • • •

Advocacy and advice Assisting with applications for section 4 support or referral to Local Authority social care / children’s services where appropriate. Temporary accommodation (in some situations) via befrienders the Hope Housing scheme Counselling services Specific work with individuals with HIV Short term payments Food, bedding/ clothing

8.2 Agency activity, and the scale of the problem Those present at the consultation identified a small but significant proportion of their clients who were either single women who were pregnant or who had recently given birth. • Coventry Refugee Centre noted that 40% of the clients they see on a daily basis are destitute. Their specific project working with the most vulnerable clients has a maximum caseload of 40, they indicated that 20 of these cases at any one time were women who were pregnant or who had recently given birth. This project picks up a lot of pregnant women who have no recourse to public funds. The Meridian asylum health practice is also co-located in the same premises as the Refugee Centre. • ASIRT estimate that 5% of their caseload are currently women who are pregnant. They are running a specific women’s group, and report that the majority of those who attend are at the end of the asylum process. There is evidence of referral mechanisms between several of the voluntary sector agencies and some health or Children’s Centres. Again, ASIRT note that 60% of the referrals of pregnant women come from Children’s Centres. • British Red Cross has a specific destitution project operating in Birmingham, Coventry and Stoke-on-Trent. They provide advice and advocacy, and practical assistance with short-term food vouchers and clothing. They also provide training to practitioners working with NRPF cases. • Coventry Peace House has provided interim accommodation for some destitute clients, and provides referral to Coventry refugee Centre. • Restore provide a befriending service and referral for destitute clients, they have also helped find emergency hosting for certain destitute individuals. • Horn of Africa Women’s Development network provide a range of services for women from the Horn of Africa nations. They raised concerns about the hidden nature of destitution that some of the women who use their project experience, their vulnerability and liability to be exploited. They are provided a range of advocacy, support and referral for individuals who are destitute. • Mamta work with a range of individuals from Black & Ethnic Minority groups, providing education and workshops, a proportion of their clients would be destitute. They would generally refer these clients to the Refugee Centre for support.

•

Terrence Higgins Trust in Birmingham are working with individuals from the refugee and asylum seeker community who have HIV. They work with a number of pregnant women with HIV, and women who are identified as having HIV at hospital. A range of advocacy and advice, health promotion and counselling is undertaken, they also work in conjunction with the City council social care team in relation to HIV generally and may make referrals for support for those NRPF cases with HIV. A number of colleagues from the health sector in Coventry attended this event, and cited a range of work which had been undertaken on the issue of infant mortality particularly, including the development of an Infant mortality strategy and more effective signposting and care pathways into the health system for pregnant asylum seekers.

8.3 Common causes of destitution Representative identified the following issues as key causes of destitution for clients they worked with: • • • •

End of the asylum process and resultant removal of support Overstaying leave to remain in the UK Victims of trafficking Relationship breakdown/domestic violence when an individual is here on a spouse visa

It was also noted that some women were identified as falling pregnant as a result of rape or as a result of being pressured into sex for accommodation.

8.4 Contributory factors affecting access to health services The issue of destitution itself is multi-faceted and requires a detailed understanding of the context and factors which may inhibit the process of accessing health care and also result in negative impact on individual/ child’s health. Representatives were asked to identify some of these complicating factors from their experience of work with this group. They suggest the following issues:

8.4.1 The asylum process

•

The process of dispersal and support can create problems in some areas for individuals requiring access to health care. BIA provides short term Initial Accommodation for all new arrived NAM cases, at which individuals may receive some urgent health input, however pregnant women would be there for a short period of time before dispersal into the regions. The level of referral and transfer of health records in these cases would appear to be variable, and the duties on accommodation providers appear to be no more than to provide assistance to clients in registering with a GP.

•

PCTs in differing areas of dispersal approach asylum health care in a number of ways, some have designated projects, others do not. There are risks that maternity care is not adequately followed up for some clients.

•

Additionally, the speed of the process now means refusals of asylum are made at much earlier stages of an individuals’ arrival within a dispersal area. Unless an individual is in the late stages of pregnancy (usually 4 weeks prior to the expected due date of delivery) or until their baby reaches 6 weeks old. The levels of information to PCTs about the dispersal of asylum seekers, section 4 claimants from BIA and the private accommodation companies is not always sufficient or timely.

Maternity, mortality and migration: the impact of new communities

8.4.2 Section 4 •

Agencies reported significant delays in the processing of section 4 applications and any resultant allocation of accommodation. Currently they report the process taking on average of 4 weeks for a decision to be made, with an additional wait of a further 1-2 weeks for accommodation to be allocated.

•

At the time of this project a limited amount of section 4 accommodation was being offered within the West Midlands region. Agencies reported that most of those they were assisting to apply for section 4 support were being offered accommodation in Yorkshire and Humberside, and other regions of the UK. This potentially disrupts maternity and post natal care for women and their babies, and in a number of cases led to women refusing the offer of section 4 support, in preference for the health and community support they had in the region.

•

Representatives reinforced the point that for many clients, section 4 support is only available after extended period of destitution. This would be particularly the case for single pregnant women.

•

Concerns were raised about the level of support and accommodation standards for those provided with section 4 accommodation.

8.4.3 Social care •

There would appear to be significant delays in clients referred to either Adults social services for Children’s services for an assessment of need and a decision as to whether they can be supported under national Assistance Act or Children Act provisions.

•

Agencies also identified a number of cases where individuals remained destitute whilst Local Authorities disputed responsibility for the provision of care between themselves or in some cases different Local Authority departments argued as to who takes responsibility.

8.4.4 Vulnerability of homelessness •

The limited options available to those women who are destitute mean often they are moving around the City in order to accessing accommodation with friends, fellow nationals. This impacts the ability to access regular health care, and a number of colleagues reported that women were particularly vulnerable to sexual exploitation in this situation. There is the suggestion that food/ accommodation are being offered in return for sex in some cases.

•

The new asylum process means it is more likely that unsuccessful asylum applicants will be made homeless and destitute at an earlier stage of living in a particular area and will not have been able to develop appropriate social support networks within their/ refugee community that have been providing temporary relief for large numbers of those who are currently destitute.

•

The impact of homelessness and poverty on health outcomes for infant and maternal health as well as general and mental health is already known. The specific circumstances of these women make these factors even more severe. It was noted that it is often the unrelated issues such as no food or accommodation, problems with access to vouchers for those on section 4 and anxiety about possible removal proceedings or pressure to sign up to section 4 support that mean people find it difficult to make use of health related services.

8.5 Experiences of destitute clients access to health and social care 8.5.1 Primary Care •

Access to GP’s was cited as a problem for many of the NRPF women. The complications of homelessness, lack of relevant documentation, being without official BIA support meant that many found it difficult to register or were refused registration with a GP. In two cases individuals had tried to register at a GP practice in Handsworth , but were refused registration as they were unable to provide a NASS(BIA) support reference. They did not have this information as they had been refused asylum.

•

Some women had reported to agencies that payment had been requested before they could see a GP. As they had no means of support they were unable to do this. It was also reported that the HC2 form was being requested for registration at GP practices and with dentists in some parts of the City.

•

In some cases it appears individuals who did not have a GP and sought to access maternity services at hospital being caught in a cycle between being sent back to register with a GP and the Hospital. Clear processes for accessing maternity/ midwifery services without a GP did not appear to be well known.

•

There appear to be some problems for women who have NRPF obtaining certification of pregnancy. This may result in complications on accessing section 4 or other forms of support.

8.5.2 Secondary Care •

The level of understanding of the vulnerability of patients needs to improve, it was reported that in one case a destitute mother with a new born child was discharged without any resolution on assessment of needs and provision of support from the Local Authority. This mother ended up being supported by a local charity and obtained a temporary place to stay with friends in a small property.

•

Concerns were raised as to the care available for other children of the expectant mother when she entered hospital to have her baby. Agencies report that in some cases other children are being left within unit of accommodation with unrelated individuals whilst the mother goes to hospital. There is a need to consider possible safeguarding issues and to ensure that any older children are identified and their care arrangements are understood by health professionals. The need to ensure better links between Health and Local Authority Social Care services is evident from these incidents.

•

The sector generally felt Hospital care was good for women in these circumstances, there was however one report where a mother was allegedly threatened with the removal of her baby if she was unable to provide any address or money to pay for treatment, although further information was not available at the time of writing.

8.5.3 General health issues •

There appears to be a lack of understanding and application of the charging for overseas visitor regulations. We are aware of one incident where a woman was charged for maternity services and the case was passed to debt collectors for recovery action. Entitlement to GP services and PCT’s specific policy on registration of NRPF clients appear also to be unclear in several areas.

Maternity, mortality and migration: the impact of new communities

•

The attitude of some staff to this group of women, at both a primary and secondary care level was seen as discriminatory. This may reflect a lack of understanding of the circumstances which these women find themselves in. It was suggested that further training around the health needs, entitlements, culture and the influence of racism and the media on perceptions of this group.

•

It does not appear to be well understood within the health sector that destitute individuals, and those supported under section 4 do not have any money for travel. This may mean individuals struggling to arrive for appointments, or having to walk long distances whilst in the late stages of pregnancy.

8.5.4 Mental Health Previous research undertaken on refugee and asylum seeker mental health needs and experiences of health services within the West Midlands has identified a range of impacts and unmet needs for these communities85 The lack of access to lower level mental health services or clear pathways into mental health provision, maybe due to difficulties in accessing a GP, may result in increased levels of depression and mental health problems once individuals become destitute. The state of an individual’s mental health may impact on their ability to access a range of health and other services at later stages.

8.5.5 Social Care •

The response of Local Authority social care teams to the needs of this group of women was raised by several agencies. Common problems were encountered in the referral and assessment process, and concerns were raised as to level and speed of response to referrals that had been made by agencies.

•

It was suggested that coordination between health and social care on this issue needs to improve, specifically in relation to the discharge of NRPF women from hospital post delivery.

(CURS Birmingham University “They do not understand the problem I have – refugee well being and mental health “ Phillimore. J et al Birmingham University 2007)

8.6 Possible solutions There is strong evidence of good referral mechanisms between those who attended the consultation and some children’s centres, asylum health projects, and within the voluntary sector projects. The voluntary sector have been meeting and coordinating their own activities on destitution for a numbers of years, and there has been a regional destitution coordinator in post for over 18 months. These agencies are seeing a significant volume of destitute clients on a weekly basis, and these clients would appear to place trust in these agencies. In considering the solutions raised by the voluntary sector, we suggest that consideration is also given to the reach into this vulnerable group these agencies can offer.

8.6.1 Health • • • • • • • • •

•

Community midwives to ask about care of existing children during labour prior to birth Increase awareness about the issues and available services in health care staff Give consideration as to how NRPF clients might make arrangements to travel to appointments, or hospital for delivery, if they have no means of support. PCTs to consider the likely impact of proposed changes to free entitlement to health services for those with NRPF, and the affect this change could have on public health targets Offer clear guidance to front line workers regarding entitlements to care and assessment PCTs & BIA to consider increasing and improving health information provided in Initial and dispersal accommodation Specific training should be commissioned for frontline staff to provide clarity on the health needs, entitlements and support arrangements to NRPF individuals. Consideration should be given at a PCT level to the development walk-in health facility for NRPF cases, a place where individuals could self refer specifically in the case of pregnancy. Further work should be undertaken to advertise and possible expand venues which can undertake pregnancy tests. The potential for joint work around the HIV and Sexual health agenda, e.g. with Terence Higgins Trust might be explored. Examples of good practice in addressing infant mortality and child and maternal health within this community should be more widely disseminated.

8.6.2 Social Care • •

•

Clearer communication about requirements, assessment timescales and reasons for decisions should be made available. Local Authorities to develop clear guidance within the region as to who takes responsibility for specific NRPF cases when a woman has a baby, including clear protocols for transfer of cases from adults to children and families. Wider involvement with other agencies concerned with the issue of NRPF is required.

8.6.3 BIA We recognise that there proposals are under consideration to provide support to cover travel costs for essential health appointments and to ensure maternity payments are made. •

Currently those in receipt of section 4 receive no maternity payment on the birth of their child. Given that section 4 support is currently being provided for considerable periods of time, we are unclear as to why a reduced voucher aware of £250 is being proposed as a maternity payment. We welcome the recognition that women who have given birth in receipt of section 4 support should receive a maternity award but would ask BIA to reconsider the amount, making it at least comparable to the £300 awarded to those in receipt of mainstream BIA support.

Maternity, mortality and migration: the impact of new communities

•

Agencies would like to see the replacement of a voucher system with cash payments, to enable individuals to purchase culturally appropriate foods, and at least in the interim have some choice as to how paying for travel to appointments. BIA should do more to enforce the standards of care and accommodation provided to section 4 clients, particularly where there are mothers with newborn babies. In light of the increased number of families in section 4, it is suggested that the expectations of standards of contact and care is revisited by BIA in relation to their contracts. Avoid moving women in the late stages or pregnancy/ new mothers to section 4 accommodation outside of the area where their health care is provided. BIA need to have a clearer understanding of the impact on child and maternal health that disruptions in continuity of care and social support networks may have at this stage. BIA should ensure that any dispersals into section 4 accommodation are notified to the receiving PCT by themselves and also the private provider, and that specific attention is paid to moves of pregnant/ new mothers.

8.6.4 General •

•

Expand and develop projects such as that running at Sure Start children’s centre Soho, to improve access of refugee and asylum seeker mothers to Children’s Centre services, including health. The knowledge gained by the designated worker for this project enables timely referral to those voluntary sector agencies providing assistance and advocacy for those who become NRPF. Develop a mechanism to ensure the better coordination of response to the needs of this group at a regional and local level, including clear referral mechanisms and setting of service standards from Health, Local Authority Social Care and the Voluntary sector Given the reach of a number of the voluntary sector agencies, and women’s concerns or inability to access primary health services, it is suggested that the potential of co-location or commissioning within the voluntary sector to provide signposting, referral, or forms of health outreach or promotion amongst this vulnerable group, and women particularly might be explored by PCT’s. All sectors to have a clear understanding of the process for applying for HC2 exemption forms and who might assist in the completion of applications.

8.6.5 Voluntary sector • •

The voluntary sector could provide assistance with training and awareness raising on the NRPF agenda as well as health and cultural needs of this group. ( e.g., British Red Cross ) The voluntary sector could provide further information to health and social care contacts in specific parts of the region as to the current services they provide for NRPF clients.

9) Summary of issues identified by all sectors The following is a summary of the key themes identified by all the sectors which were consulted: •

Poverty and inability to provide for mother or baby, particularly in refused asylum seekers and some spousal migrants

•

Language needs are not always met in health and social care

•

Relocation/dispersal due to the immigration system, or to avoid detection disrupts social support, coping ability and continuity of health care

•

Some clients experience difficulties/delays in accessing benefits/entitlements from BIA and Local Authorities

•

Domestic violence and child protection issues were highlighted as key causes for concern

•

Housing access and quality is variable

•

Migrants are having difficulties with GP registration

•

There are gaps in staff training/awareness

•

Patient expectations, health beliefs, and service use behaviour impacts upon service capacity patient satisfaction

•

Regulations regarding entitlements to health and social care may result in high risk health situations and poor health outcomes

•

There is scope for more joint working across all sectors

9.1.1) Day-to day issues for migrants: • • • • • •

Poverty and homelessness, particularly in refused asylum seekers and some spousal migrants Language difficulties Immigration processes Inability to work legally Difficulties with integration Abuse, exploitation, domestic violence and child protection issues

9.1.2) Local service provision issues: • • • • •

Language needs are not always met It can be difficult to access housing, benefits and GP services Clients and staff report delays in social care; staff would benefit from more training and awareness Client expectations, health beliefs, and service use behaviour impacts upon capacity, professional-client relationships, and patient satisfaction There is scope for more joint working.

Maternity, mortality and migration: the impact of new communities

9.1.3) Service organisation issues: â&#x20AC;˘ â&#x20AC;˘

Dispersal and relocation disrupts social support, coping ability and continuity of health care Regulations regarding entitlements to health and social care may result in high risk health situations and poor health outcomes

10) Recommendations We recognize that there are several distinct sectors and agencies who may be involved in the delivery of services and support to migrant women, and in particular to those who are NRPF. We have sought to identify a number of sector specific recommendations which we hope will be considered in the ongoing service development and delivery work tackling infant mortality. This is followed by a set of overarching recommendations that require consideration by all stakeholders. The recommendations flowing out of this report come from the discussions across a range of sectors and include the experience of NRPF women themselves, this represents a potential starting point in addressing the potential impact on child and maternal health amongst new migrant communities. It is for the agencies who have a stake in the reduction of infant mortality to consider at a local and regional level to how these recommendations should affect their planning and delivery, and what mechanisms might best coordinate at such actions.

10.1) Health 10.1a) Overall health recommendations: i.

Ensure that vulnerable clientsâ&#x20AC;&#x2122; human rights are upheld, regardless of any future changes to legislation around access to health services for migrants, including advocacy on behalf of individuals at particular risk, such as destitute women and families.

ii.

Expand and develop joint working on understanding health needs and inequalities, and commissioning services to address them. This joint approach requires communication and action between different local, regional and national health organisations, plus other statutory and voluntary sector partners.

10.1b) Strategic level

Address the current lack of migration information at a regional level, through working with other â&#x20AC;&#x2DC;sentinelâ&#x20AC;&#x2122; stakeholders who collect such data, and by developing new ways of collecting and collating information within health service settings.

ii.

Ensure that migrants are considered when developing policy and targets, particularly around health inequalities. Migration is a minority issue, and a small part of business for many health organisations. Strategic prioritisation will encourage PCTs and Hospital Trusts to address migrant health needs at a local level.

iii.

Consider the training needs of the medical workforce, and the potential for working with educational institutions, professional bodies, Deaneries and NHS trusts to include migrant health issues in their educational programmes.

iv.

This issue requires leadership at a regional level. We suggest that further discussions take place between those responsible for health and social care at a regional level, with input from the existing strategic groups (including WMSPM), voluntary sector, BIA, and Local Authorities, to determine how this work might be taken forward.

Maternity, mortality and migration: the impact of new communities

10.1c) Primary care and PCT i.

Address the need for training of key staff on the issues migrants face. Priority should be given to training staff who come into contact with migrant mothers and young families, due to the vulnerability of this group. This should include Midwives, Health Visitors and GP receptionists and Practice Managers. Such training should address understanding of patients’ situations, key issues, and entitlements to care. Staff should be aware of the procedures for obtaining HC2 forms, where relevant.

ii.

Improve staff awareness of the agencies and pathways available to support migrant women and families, including the voluntary sector and (in Birmingham) Pregnancy Outreach services. This could be achieved through the development of a database, or extension of existing ‘directories’ such as the ward-based resources put together by the Pregnancy Outreach Workers in Birmingham. The resource could be a generic ‘vulnerable person’s’ directory.

iii.

Consider extending health promotion activities into settings where migrant women and families congregate, in order to build trust, and educate women about availability of services, and what they should expect. Support for healthy lifestyles could also be provided. This should be considered in the Initial Accommodation setting in Birmingham, plus venues for longer term residents. Services could be commissioned through the voluntary sector, where strong links with this community already exist.

iv.

Develop a partnerships approach with other agencies to routinely inform new arrivals, especially women, about the NHS, pregnancy testing, maternity care, and the relationship of pregnancy and motherhood to the success of claims – this could be incorporated with wider health promotion activities, and form part of a wider induction plan for new arrivals.

Identify whether it would be appropriate to supply written resources in different languages, and provide these where necessary.

vi.

Ensure that interpreters’ availability is equitable across geographical areas where possible (e.g. for all Pregnancy Outreach Worker booked appointments and visits).

vii.

Explore reports that migrant patients have been turned away from GP surgeries with ‘open’ lists, and address any problems.

viii.

Ensure that ‘open access’ primary care facilities are promoted, explained and available to vulnerable migrants, particularly pregnant women.

ix.

Develop further work with local emergency departments to develop a pathway for registering vulnerable A&E attendees who do not have a GP.

Consider methods to extend and improve intelligence about migration in local areas.

xi.

Incorporate the needs of migrants when commissioning services for any purpose.

xii.

Reinforce the local networks for specialist and mainstream staff caring for migrants, in order to share knowledge, experience, and provide professional support.

10.1d) Hospital Trusts i.

Hospital trusts with significant migrant populations are strongly encouraged to consider increasing the amount of training that is available to staff around migrant health issues. This is particularly important in the maternity and acute care settings. Junior doctors caring for migrant women in emergency departments should be aware of the need to ensure pregnant women are booked with maternity services. The impact of frequent staff rotation in some areas, necessitates that training should be regular and systematic.

ii.

Emergency departments should consider discharge pathways or referral mechanisms for vulnerable patients who are not registered with a GP, including pregnant women.

iii.

Ensure that translation services (e.g. language line) are universally available and utilized, particularly in acute settings such as emergency departments.

iv.

Trusts should ensure that policies are in place for caring for existing children of single vulnerable women in the perinatal period

Where there are significant, recognised risks associated with childbirth, such as female genital mutilation, Trusts should develop policy, practice and expertise to identify and address the additional complications these may bring, particularly identification at earlier stages of the pregnancy.

10.2) Border and Immigration Agency

Consider transferring families receiving support and accommodation under Section 4 back into Section 95 support. This would eliminate the current inequality in provision of services to refused asylum seekers who become family units before and after the end of process.

ii.

Consider allowing pregnant women to remain in existing accommodation without relocation when applications for section 4 support are made. BIA should consider an extension of the number of weeks before the expected due date at which an individual can apply and qualify for section support, possibly with further discussion with the health sector and in light of what evidence may exist in relation to women in these circumstances giving birth before full term.

iii.

Where this is not possible, BIA should consider dispersing pregnant women and new mothers to Section 4 accommodation within the Local Authority of residence of PCT boundary (both Section 4 and Section 95). This would enable the mother, and child, to maintain effective contact with existing health professionals ensuring continuity of care.

iv.

Ensure that the required standards of support and accommodation (whether sec 95 or section 4) are maintained, effectively monitored and resolved where services are deemed to be unsatisfactory.

Maternity, mortality and migration: the impact of new communities

Explore the potential for Case Owners to a. Identify pregnant women during and at least by the end of the asylum process and that they ensure that such women are informed of their options in relation to healthcare services and support verbally. b. Identify pregnant women to other services (e.g. health) with the consent of clients

vi.

Explore and resolve reported delays in support for Section 4 clients, at the processing of applications and allocation of support stage, and in cases of interrupted support for existing cases, particularly where there are women in late stages of pregnancy or with newborn babies.

vii.

Ensure that clients in detention receive adequate maternity assessment, follow up and continuity of care.

10.3) Local Authorities i.

Evaluate the impact and need to identify/ increase resources devoted to NRPF issues in order to meet current demand. Continue to improve the assessment and decision making process and ensure that such services meet the assessed needs for those for whom the LA has accepted responsibility. (We recognize that LAâ&#x20AC;&#x2122;s are in a difficult position in meeting such needs without any additional funding )

ii.

Ensure that clear guidance on assessment and decision making timescales is provided to individuals who are requesting services but who are NRPF. E.g. average length of time an individual should be expected to wait for a decision after their initial assessment has been conducted.

iii.

Along with other Local Authorities, develop a policy regarding the support of women who give birth (or reside) in one authority, while being supported by another, e.g. because the supporting authority provides accommodation out of area.

iv.

Consideration should be given, where applicable, to providing support to the whole family, and not just the child, when a family is deemed to have care needs, for which the LA is responsible to meet, and is NRPF. (We are aware some LAâ&#x20AC;&#x2122;s already do this), consideration might be given to developing greater regional consistency on this and wider support and assessment issues for NRPF cases.

10.4) Recommendations for all stakeholders

Agencies with responsibility for infant mortality at a local level should consider incorporating the findings of this paper in local plans and strategies.

ii.

Further work is required between agencies to improve understanding of the scale and impact of migration, and to respond to existing and emerging needs. Additional work is required to identify the link between immigration status and infant death, for example through a confidential process, as this was beyond the scope of this work.

iii.

Explore the potential for improved information sharing between immigration services, accommodation providers, primary and secondary care, in order to prevent disruption to maternity care through dispersion of vulnerable women.

iv.

Continue to expand and develop networks within and between organisations, such as the West Midlands Refugee Womenâ&#x20AC;&#x2122;s Issues Group, and Regional NRPF Group to enhance regional strategic coordination on this issue.

Ensure that local and regional policy regarding domestic violence addresses the needs of the migrant communities affected, particularly those with NRPF

vi.

that Local and Regional Safeguarding Children Boards develop policy to address the needs of families in the NRPF group, paying particular attention to information sharing and continuity of care.

Maternity, mortality and migration: the impact of new communities

11) Conclusion This piece of work fills some of the gaps in knowledge about the scale of migration, and its impact upon the health of mothers and babies in the West Midlands. It identifies that many children are born to migrant women each year, and in Birmingham 1 in 4 babies has a mother born outside the UK. Many factors associated with migration carry a risk of poor birth outcomes, and must inevitably impact upon infant mortality rates in the region. It is well-known that infant mortality is a major cause for concern in the West Midlands, where levels are higher than elsewhere in the UK. Current data does not enable adequate linkage between infant deaths and migration factors, although it is clear that the children of migrants have a higher stillbirth rate than those born to British mothers. Further work to clarity the relationship is needed. The report highlights some good practice occurring in the region, but also identifies current challenges, as well as some of the real issues that women in the region are facing. It is clear that migrant women must be a priority in addressing inequalities in maternal and child health. All services have had to adapt to meet the needs of a changing population in recent years, including the immigration services, health, social and voluntary sectors, but there is still work to do. These needs will continue to change as the population develops, and any action will need to be sustained and adapted as necessary. The majority of migrant women giving birth, in Birmingham at least, are of South Asian origin (20%). This is a large group with a substantial risk of infant mortality, and addressing the inequality in this group in likely to deliver the largest overall gains in reducing the gap. However, smaller but significant communities of African-, Caribbean-, Middle Eastern-born and other migrant women are having babies in Birmingham. For example, births to Somali mothers have reached 2.5%, almost equal to those in Indian mothers. These smaller, more disparate groups provide an additional challenge, as some risks and needs will vary widely between the populations. However, these risks are by no means trivial, and services need to respond in order to improve outcomes, for example, by addressing the issues around female genital mutilation in the Somali community. We recognise that infant mortality is a significant issue in local authority areas within the West Midlands where asylum seekers are dispersed. For these areas, the situation may be exacerbated by the dispersal and settlement process of other migrants. At present it is too early to identify the impact of the New Asylum Process on the health and social care sectors, but as this process only started from March 2007, it is likely that clearer indications of impact might be seen in the coming 6 -12 months. Further work is required to identify the actual impact. It is clear that a section of the population is at significant risk due to destitution, and that there are growing numbers of people with no recourse to public funds remaining in our urban areas. This includes increasing numbers of unsuccessful asylum seekers who remain within the region and whose removal is not being effected. Similarly there is a growing numbers of families being supported under section 4 and the health sector should consider what likely impact this, coupled with increasing numbers of destitute individuals may have on wider Public health duties, and on maternity services specifically.

Further work is required to clarify the impact within specific parts of the region, and better methods of data collection and analysis for this specific group of women require development. Destitute individuals experience levels of poverty not witnessed in the UK since the inception of the welfare state. Relative to the childbearing population as a whole, the number of destitute women is small, and it is therefore difficult to measure the impact upon infant mortality in statistical terms, particularly due to limitations in available data. However, the combined risks that these women face are significant, and their social, psychological and physical vulnerability is without question. In public health terms, the ‘NRPF’ population is at the extreme of risk of poor health. In addition, many of the issues that destitute individuals face cannot be resolved through health service input alone: most of the problems arise as a result of the ‘wider determinants’ of health. The problem requires a coordinated multi sector approach, to avoid women and families ‘falling through the gaps’ in society, and this should include the development of clearer regional and local structures to identify the issues, develop clear referral criteria and pathways, better understanding and joint working between all sectors involved in meeting the needs of NRPF clients. We recognise that all sectors work within specific constraints, including legislative, political and other resource driven, but there is a need to recognise , specifically in relation to infant mortality that all have a potential role to play in helping to address current higher than average levels within the region. In addition to existing challenges around destitution, the regulations on charging overseas visitors for NHS care may be about to change. It is hoped that the new regulations will not, as is feared, further restrict access to medical care for this vulnerable group. However, it is up to the local agencies involved to ensure that vulnerable clients’ human rights are upheld, regardless of any changes. A diverse region like the West Midlands cannot afford to ignore the health and social care needs of its migrants if it hopes to compete with other areas in social and economic terms, and such prosperity is essential in order to address the ‘true’ determinants of ill health. There are many practical steps that organisations can take to improve the situation. Training and awareness raising about entitlements, health needs and the support/no support process for this group might help tackle inappropriate denials of service, or improve the use of appropriate referrals between Health and Social care, particularly on discharge from hospital. Local partners will not be able to rise to the challenge of tackling inequality without addressing the needs of migrants. Our current ageing population will only be sustained by inward migration, and the high fertility rate in migrant groups. The children of today’s migrants are tomorrow’s community. We must therefore maximise their opportunities in early life if our population is to prosper in the future. This means addressing their needs before conception, during pregnancy, through birth and beyond.

Maternity, mortality and migration: the impact of new communities

Appendix 1 Glossary of terms AIT

Asylum Immigration Tribunal

ARC

Asylum Registration Card

ARCH

Asylum Seeker and Refugee for Health

ASIRT

Asylum Support and Immigration Resource Team

A&E

Accident and Emergency

BASHOT

Birmingham Asylum Seeker Health Outreach Team

BEN PCT

Birmingham East and North PCT

BIA

Border and Immigration Agency

BME

Black and Minority Ethnic

B&B

Bed and Breakfast (accommodation)

CPN

Community Psychiatric Nurse

ECHR

European Convention on Human Rights

EDM

Early Day Motion

EEA

European Economic Area

ESOL

English for Speakers of Other Languages

European Union

FGM

Female Genital Mutilation

FRE

First Reporting Event

General Practitioner

HIV

Human Immune Deficiency Virus

HoBtPCT

Heart of Birmingham Teaching Primary Care Trust

Initial Accommodation

Infant mortality

IMD

Index of Multiple Deprivation

IMR

Infant Mortality Rate

Local Authority

NAM

New Asylum Model

NASS

National Asylum Support Service (now BIA)

NHS

National Health Service

NINo

National Insurance Number

NRF

Neighbourhood Renewal Fund

NRPF

No Recourse to Public Funds

ONS

Office of National Statistics

PCT

Primary Care Trust

R&M

Routine and Manual

SAWS

Seasonal Agricultural Workers Scheme

SEF

Statement of Evidence Form

United Nations

WMSMP

West Midlands Strategic Migration Partnership

WRS

Worker Registration Scheme

Appendix 2 : Categories of overseas national who may be classed as migrant workers86 Category of migrant

Description

Nationals of the European Economic Area (EEA)

Nationals of the European Economic Area include the 25 European Union (EU) member states and the European Free Trade Countries of Norway, Iceland and Liechtenstein

EU15 Countries

The first 15 European Union member states - no comprehensive statistics are collected upon their entry to the UK

Accession 8 (or A8) Countries

This refers to Central and Eastern European countries that joined the EU in May 2004. No restrictions were imposed to access the UK labour market in the UK, but the Worker Registration Scheme (WRS) was introduced as a transitional measure to regulate labour market access

Accession 2

Romania and Bulgaria joined the EU in January 2007 with additional restrictions placed on these member states in terms of accessing the UK labour market

British Overseas Territories and Nationals Require clearance to enter the UK but do not require a work permit of Switzerland Nationals of all other countries/Work Permit Holders

National of all other countries than those stated above, require a work permit, which is obtained by an employer who is unable to find a suitable national to fill a post, or by applying for one of the many schemed run by Work Permits (UK), which is a part of the Home Office

Commonwealth Working These are Individuals between the ages of 17-30 who can work in the UK for up Holiday Makers to 2 years Students from outside the EEA

These students are allowed to work part-time in the UK whilst enrolled on a course

Refugees and Thirdcountry Nationals

A person who has been granted leave to remain, humanitarian protection or discretionary leave to remain in the UK, in accordance with the 1951 UN Convention on Refugees. Refugees granted status in EU member states also enter the UK, e.g. Somalis from Denmark/Netherlands and are often termed ‘third country nationals’ and have the rights and the documentation to work legally in the UK. An asylum seeker however is I person who has arrived in the UK after fleeing their homeland, has made an application to be granted asylum to the Home Office under the UN Convention and is awaiting the outcome of their decision. The majority are prohibited from working.

Undocumented Workers/individuals

This includes both individuals who have entered the UK legally but are working without a legal right to do so and those who have entered illegally. Failed asylum seekers can also remain in the UK either legally or illegally depending upon their circumstances, but are prohibited from working in the UK

SAWS allow full time students over the age of 18, from outside the EEA, to Seasonal Agricultural provide low-skilled agricultural work for farmers and growers in the UK. Workers Scheme (SAWS) Students are allowed to work in the UK for six months in any year. The Home Office has proposed to phase out this scheme by 2010

Highly Skilled Migrants Programme

This Programme is designed to allow highly skilled people to migrate to the UK to search for work or self-employment opportunities. Unlike the Work Permit Scheme, applicants do not need a specific job offer in the UK to apply. Successful applicants are granted permission to stay in the UK for a year to seek work or self-employment opportunities. If such workers are economically active after one year they can apply to stay longer. After living in the UK continuously for four years with Home Office permission, workers can apply to live in the UK permanently

(Source – “Regional Migration Scoping Exercise” West Midlands Strategic Migration Partnership December 2007)

Maternity, mortality and migration: the impact of new communities

Appendix 3 : Table of entitlement to NHS treatment87

Table of entitlements to NHS services accessed online at http://www.medact.org/content/refugees/DH_077789.pdf

Appendix 4 : Useful documents Bohm.C (2007) Improving access to maternity services for refugees and asylum seekers in Hackney. London: Homerton University Hospital Trust Department of Health (2007) Maternity Matters http://www.dh.gov.uk/en/Publicationsandstatistics/publications/PublicationsPolicyAndGuidnace/DH_073312

Department of Health (2007) Guidance on eligibility for free hospital treatment under the nhs. http://www.dh.gov.uk/en/Policyandguidance/International/OverseasVisitors/Browsable/DH_074373 Home Office (2007) Enforcing the rules: a strategy to ensure and enforce compliance with immigration laws. London: Home Office Home Office (2008) No Recourse to Public Funds. http://www.bia.homeoffice.gov.uk/ukresidency/rightsandresponsibilities/publicfunds.pdf

Kelly, N; Stevenson,J (2006) First do no harm: denying health care to people whose asylum claims have failed. London: Refugee Council West Midlands Public health Group (2006) Choosing Health for the West Midlands http://www.go-wm.gov.uk/gowm/PublicHealth

West Midlands Strategic Migration Partnership (2007) Regional Migration Scoping Exercise. http://www.wmlga.gov.uk/asylum West Midlands Strategic Partnership for Asylum and Refugee support (2006) A Regional Strategy for the Social Inclusion of Refugees and Asylum Seekers in the West Midlands http://www.wmlga.gov.uk/asylum

West Midlands Perinatal Institute Key Health Data 2006/2007 http://www.pi.nhs.uk/pnm/Keyhealthdata2005.pdf

Maternity, mortality and migration: the impact of new communities

For further information on this report please contact: Dr Jacky Chambers, Director of Public Health HoBtPCT (Jacky.Chambers@hobtpct.nhs.uk) or Dave Newall, Policy Officer at the West Midlands Strategic Migration Partnership (d.newall@wmlga.gov.uk) Further information on the work of West Midlands Strategic Migration Partnership is available at www.wmlga.gov.uk/asylum, where an electronic copy of this report can also be downloaded. For additional copies of this document please contact Jeanette Davis at Heart of Birmingham Teaching PCT Jeanette.Davis@hobtpct.nhs.uk 0121 224 4693

Heart of Birmingham Teaching Primary Care Trust