Pregnancy care for migrant and refugee women

While many migrant and refugee women experience healthy pregnancies, issues associated with resettlement can contribute to poorer perinatal outcomes than those experienced by women in general. While the diversity of circumstances and experiences is acknowledged, this chapter highlights general considerations in improving the experience of antenatal care for migrant and refugee women.

The term ‘migrant and refugee’ is used in these Guidelines to refer both to women who are voluntary migrants and women who come to Australia as refugees, humanitarian entrants or asylum seekers. Migrants and refugees are also often referred to as people of culturally and linguistically diverse background, people from non-English–speaking backgrounds or people who speak a language other than English.

4.1 Background to culturally safe antenatal care

Caring for individuals from diverse backgrounds is a daily reality for nurses and midwives, who are expected to provide care which is both clinically safe and culturally sensitive. Williamson & Harrison 2010

Although a third of women who gave birth in Australia in 2014 were not born in Australia AIHW 2016, there is little specific information on the pregnancy outcomes of migrant and refugee women. National data suggest similar rates of perinatal death among babies of women born in Australia and those born overseas (Li et al 2012). However, retrospective studies suggest that outcomes vary with country of birth (Drysdale et al 2012) and use of interpreters, but not refugee status (Thomas et al 2010).

There is significant heterogeneity among migrant and refugee women and their experience of antenatal care. Women bring with them the knowledge and practices from their home countries. Expectations of early antenatal attendance vary between countries. For example, more than half (57%) of women giving birth in New South Wales in 2004 who were originally from a developing country first attended for antenatal care later than 12 weeks in the pregnancy (Trinh & Rubin 2006). In New South Wales in 2006, 64.9% of mothers born in Melanesia, Micronesia and Polynesia and 72.8% of mothers born in the Middle East and Africa commenced antenatal care before 20 weeks gestation, compared with 89.6% of mothers born in English-speaking countries CER 2007. Expectations of the birth experience are also strongly influenced by cultural views and practices (Hoang et al 2009).

An increasing proportion of refugee and humanitarian entrants to Australia come from Africa, the Middle East and Southeast Asia; about 30% are women aged 12–44 years (Correa-Velez & Ryan 2012). Refugee women are more likely than other women to have complex medical and psychosocial problems and may face additional barriers in accessing antenatal care (Correa-Velez & Ryan 2012).

4.1.1 Factors affecting uptake of antenatal care

Migrant and refugee women are diverse, and have differing issues and outcomes. As well as cultural background, women’s experiences differ with migration status, educational level and prior experience of pregnancy and birth. However, there are some common issues that can affect uptake of antenatal care by migrant and refugee women. These include McCarthy & Barnett 1996, Carolan & Cassar 2010, Phiri et al 2010, Murray et al 2011, Boerleider et al 2013:

• migration factors: lack of knowledge of or information about the Western healthcare system (including rights in relation to tests and treatments); arriving in the new country late in pregnancy; history of grief, loss and/or trauma in addition to migration
• cultural factors: adherence to cultural and religious practices, poor language proficiency, lack of assertiveness, partner/family perception of antenatal care, perceiving pregnancy as not requiring health professional involvement, belief that antenatal care is more a burden than a benefit, belief that antenatal classes are not necessary, fear of coming into contact with government agencies
• position in host country: financial problems, unemployment, low or intermediate educational level, social inequality (education, economic resources and residence [rural or urban]), lack of time, lack of childcare, no medical leave from work
• social network: lack of usual female family and community support systems, isolated community
• accessibility: inappropriate timing and incompatible opening hours, transport and mobility problems, indirect discrimination, lack of suitable resources (eg female interpreters)
• expertise: health professional lacking knowledge of cultural practices
• personal treatment and communication: poor communication, perception of having been badly treated by a health professional.

Health care costs and access to health services can be an issue for some women. Women who are asylum seekers may be ineligible for either Medicare or Centrelink Health Care Cards. Women who are skilled migrants and international students may also have restricted health care access because they don't have Medicare entitlements. While overseas students are required to maintain Overseas Student Health Cover for the duration of their time in Australia, pregnancy-related services may not be covered in the first 12 months of membership.

Even when care can be accessed, women who have no previous experience with a western health care system may have limited understanding of reasons for antenatal visits, medical procedures and use of technology. They may not feel confident to ask questions or participate in discussions about their care plan or birth options. Different cultural beliefs may also influence aspects of antenatal care such as involvement of the father in pregnancy and childbirth, acceptance of tests and interventions, willingness to be cared for by a midwife rather than a doctor or a woman rather than a man, understanding of dates and times of appointments, and knowledge about medical aspects of pregnancy.

4.1.2 Issues affecting women from specific groups

Different groups of migrant and refugee women face specific issues that may affect their experience of pregnancy and birth. Increased awareness of such issues and the differences between groups will help to promote better antenatal care of women from migrant and refugee backgrounds.

• Women who arrive in Australia as refugees: Prior to migration, many refugees experience poor health (including oral health, co-existing health issues and inadequate nutrition) and experience poverty, discrimination, trauma and violence in their countries of origin and in countries of displacement. These experiences cause significant psychological distress, manifesting in symptoms of anxiety, depression, post-traumatic stress, poor sleep and concentration. These symptoms can continue to affect women’s lives as they face further emotional challenges in the resettlement period. Early intervention and referral to appropriate counselling services should always be offered and assistance in accessing services provided. Refugee women may fear authority figures, including health professionals, due to past experiences and may also have financial, employment and housing issues. Women in this situation will require reassurance and explanation of the care offered to them, including tests, procedures and pregnancy risks. More time may be needed, and specific strategies used (often in collaboration with other services and migrant agencies) to build necessary confidence and trust.
• Women affected by Female Genital Mutilation/Cutting (FGM/C): FGM/C is the collective term used to describe the cultural practice of cutting or removal of either a part, or the whole external female genitalia. Some of these procedures are minor, while others involve significant change and have an impact during the antenatal period. Depending on the degree of FGM/C, women may require referral to services offering specialised care and support. Some women may need to be deinfibulated to enable ongoing clinical assessment and avoid complications; this is usually performed in the second trimester but the first trimester is the optimum time to discuss the procedure.
• Women in higher risk groups: Some migrant and refugee groups have higher rates of risk factors such as gestational diabetes, smoking in pregnancy and vitamin D deficiency. Lifestyle advice should take cultural issues into account (eg giving culturally relevant nutritional advice on managing gestational diabetes and educating both women and men about passive smoking, as it may be men rather than women who smoke). Domestic violence is high among some communities, and may be hidden within the family structure and/or the community. Screening for conditions endemic in the woman’s country of origin may also be a consideration.

Health professionals are encouraged to develop an understanding of the issues facing families from the migrant and refugee groups that they regularly work with and to use this information to improve the care they provide.

4.2 Providing woman-centred care

Establishing effective communication between a woman and her midwife [or other health professional] is essential for determining how culturally safe care can be instituted. (Carolan & Cassar 2010)

The fundamentals of providing care discussed in Chapter 2 apply to all women. This section discusses issues specific to providing appropriate antenatal care for migrant and refugee women. 

4.2.1 Improving women’s experience of antenatal care

Taking an individualised approach

Factors that may improve the experience of antenatal care for migrant and refugee women include: 

• taking the time to establish rapport and trust with each woman
• being conscious of the need to avoid making assumptions based on a woman's culture, ethnic origin or religious beliefs
• explaining the woman’s entitlement to antenatal care and options for accessing it (eg community clinic or hospital-based setting)
• considering issues that may influence attendance at appointments, such as transport, cost considerations (access to Medicare rebates, need to attend a service that offers bulk billing, cost of procedures such as ultrasounds)
• considering a woman’s support network (eg support from partner, family and friends, and family dynamics)
• consulting the woman about whom she would like to involve in her care and, if necessary, advocating on her behalf so that she receives appropriate care throughout pregnancy
• respectfully exploring cultural and personal understanding and experience of pregnancy and appropriate self-care in pregnancy, and encouraging the woman to discuss anything she is worried or unsure about
• explaining frequently used terms that the woman is likely to hear at antenatal appointments with different health professionals
• explaining confidentiality and that the woman’s privacy will be respected
• checking the woman’s understanding of what has been discussed.

Multicultural health workers

In many states and territories, roles such as multicultural health workers have been developed. Multicultural health workers (also known as bicultural health workers) assist people from migrant and refugee communities to access health services. For example, a multicultural health worker might support a woman to attend antenatal appointments by booking or confirming appointments, helping to fill out forms and questionnaires, assisting with transport and finding clinic locations. They may also provide services that are appropriate to women’s culture and language, such as referral, group work, health education and community development. While the multicultural health worker may communicate with the woman in her preferred language, the role differs from that of an interpreter in that a wider range of services is provided, and a continuing relationship is generally formed between the health worker and the woman and her family. While there is little evidence specific to antenatal care, a systematic review of the literature on culturally appropriate interventions to manage or prevent chronic disease in migrant and refugee communities found that the use of multicultural health workers can promote greater uptake of disease prevention strategies by migrant and refugee communities and translate into greater knowledge and awareness about services (Henderson et al 2011).

Providing information and support so that women can make decisions

It may be necessary to use a variety of means to communicate effectively with women from migrant and refugee backgrounds. Information should be explained carefully and clearly, with the assistance of an accredited health interpreter.

Some words cannot be interpreted easily, and the health professional may need to explain the concept or give examples. It is important to agree on a set of terms that are mutually understood and if necessary use pictures. For example, using charts and models to demonstrate particular body parts can reduce misinterpretation. Acronyms and abbreviations should be avoided, as these can be confusing.

Written information should also be provided; this can serve as a prompt or can be shown to other health professionals who can then remind the woman or explain the information again. Literacy levels in the woman’s own language should not be assumed. Video or audio resources may also be appropriate.

Interpreters

It is the responsibility of the health professional to make sure that communication is clear. Accredited health care interpreters assist by translating the discussion between the health professional and the woman, communicating with the woman in her preferred language either in person or through a telephone service. Involving an accredited interpreter, preferably with training in medical terminology, is recommended for all antenatal appointments if the health professional and the woman have difficulty communicating.

Interpreters accredited by NAATI (National Association of Accreditation for Translators and Interpreters) have been assessed as having a high level of technical competence in both English and one or more other languages and are bound by a code of ethics including strict confidentiality. However, there is a shortage of accredited interpreters, particularly for languages of new and emerging communities. While involvement of female interpreters is preferable in antenatal care, their availability may also be limited.

Non-accredited interpreters, including partners, family and friends, should not be used as they are less able to convey complex medical information in an accurate and non-emotive way. Their involvement may also discourage the woman from disclosing information fully, out of embarrassment or fear of breach of confidentiality. In emergency situations where the timing of decision-making is crucial, it may be necessary for non-accredited interpreters to assist with communication but it is not appropriate to involve people younger than 18 years of age in this role. Staff members who speak the relevant language may provide language assistance but should not be asked to act as interpreters. Organisational policy should be followed at all times and an accredited interpreter (in person or through a telephone service) sought as quickly as possible. Any decision to involve a non-accredited interpreter should be documented in the woman’s antenatal record.

Women may not request an interpreter as they believe there is a cost involved or be unaware that such a service exists. Women may also be sensitive about their level of English proficiency and may have concerns about confidentiality. However, it is important that the onus for using an interpreter is not on the woman.

The use of interpreters can be promoted by CEH 2009:

• having translated information in community languages in the reception area, stating that accredited interpreters are available and free of charge
• advising individual women verbally that interpreters are available and free of charge
• including information about the code of ethics of accredited interpreters regarding confidentiality, accuracy and the procedure for working with interpreters.

Involving an interpreter

• Suggest the use of an interpreter and, if the woman wants an interpreter, provide a female interpreter where possible
• Do not use the woman’s partner, friends or relatives to act as interpreters unless absolutely necessary
• Ask the woman simple questions about her personal details to assess her ability to communicate in English
• A telephone interpreter could be introduced at this point if communication is difficult
• Ask the woman what main language she speaks at home
• Check if a dialect is spoken or if the woman is of a particular ethnicity
• Explain that the use of an interpreter is just as important for your understanding as for her own
• Decide which type of interpreter is going to be most suitable (eg telephone or onsite)
• Consider confidentiality (eg in small communities, the woman may know the interpreter)
• Consider ethnicity of the interpreter (eg when the woman and interpreter come from countries where there has been political or civil unrest)

Source:    Adapted from CEH (2009).

4.3 Service delivery issues for migrant and refugee women

Pregnant women who are recent migrants, asylum seekers or refugees, or who have difficulty reading or speaking English, may not make full use of antenatal care services. This may be because of unfamiliarity with the health service or because they find it hard to communicate with healthcare staff. National Collaborating Centre for Women's and Children's Health 2010

Experiences of antenatal care among migrant and refugee women may be improved through (State Perinatal Reference Group 2008):

• social support, for example through ethnic-specific cultural liaison officers and women’s groups, to maintain cultural connections with the traditions, birthing ceremonies and rituals of women’s countries of origin
• individualised care, informed by cultural awareness and understanding among health professionals, including knowledge of cultural traditions and practices relevant to pregnancy and birth and associated expectations of women, especially of groups in the local community
• a cross-cultural approach to communication based on recognition of the culture of the woman and the health professional
• cultural brokerage, for example through maternity liaison officers/multicultural health workers who can help women understand and navigate the health system, provide education and resources in relation to maternity care, act as a patient advocate and liaise between women and maternity staff, or through partnerships between English-speaking health professionals and multicultural resource centres
• education, including linguistically appropriate information, parenting education workshops, education about accessing the health system, the different models of care available, and education for fathers/partners on antenatal issues
• culturally appropriate resources, including materials available in the woman’s own language, resources in spoken format for women who lack literacy in their own languages, visual resources specifically designed to support antenatal care and access to accredited interpreter services during appointments or important events.

At a local level, individual services can assist health professionals by National Collaborating Centre for Women's and Children's Health 2010:

• monitoring changing local needs and adjusting services accordingly
• maintaining accurate information about each woman’s current address and contact details during her pregnancy
• offering flexible services in the number and length of antenatal appointments when interpreting services are used
• assisting women to book in for their first antenatal appointment, particularly in areas where they are required to telephone a central service and be allocated an appointment at a specific hospital
• ensuring continuity of care wherever possible
• disseminating information about pregnancy and antenatal services, including how to find and use services, in a variety of formats, settings and languages.

4.4 Resources

4.4.1 Consumer resources

• NSW Multicultural Health Communication Service: Pregnancy and postnatal topics

4.4.2 Health professional resources

• (Hach M (2012)) Common Threads: The Sexual and Reproductive Health Experiences of Immigrant and Refugee Women in Australia. MCWH: Melbourne.

• Family Planning Victoria Female Genital Mutilation/Cutting resources
• Mental Health in Multicultural Australia
• Victorian Transcultural Psychiatry Unit (VTPU)

4.4.3 Interpreters

• Telephone Interpreting Service: Free interpreting services for non-English speaking Australian citizens and permanent residents communicating with general practitioners and medical specialists in private practice and their reception staff. (Phone 131 450)
• NSW Health Standards Procedures for Working with Health Care Interpreters PD2017_044.
• Overseas Student Health Cover