Improving care for refugees and asylum seekers Training for midwives PILOT DELIVERY REPORT

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1 Improving care for refugees and asylum seekers Training for midwives PILOT DELIVERY REPORT Maternity Action Featherstone Street London EC1Y 8RT T:

2 Maternity Action received funding from Comic Relief to develop and pilot a training course for midwives on improving care for refugees and asylum seekers. The project ran from June 2010 until March About Maternity Action Maternity Action is a national charity working to challenge inequality and promote wellbeing for all pregnant women, new mothers and their families. Maternity Action provides web-based information and telephone advice on rights and benefits for pregnant women, new mothers and their families. We provide training for midwives, community workers and advisers. Maternity Action undertakes policy and campaigning work to improve the lives of the most vulnerable women and their familes. 2. The Project Overview The Project set out to develop and pilot a training course for midwives on improving care for refugees and asylum seekers. We aimed to develop it in consultation with refugee and asylum seeking women; with specialist refugee and asylum seeker services; with practising midwives and the Royal College of Midwives; and with staff from SHAs and PCTs. The training consists of an Introductory Course (1 day) and an Advanced Course (1 day). While the Introductory Course targets a general midwifery audience, the Advanced Course has targeted midwives with specialist responsibilities in this area or who have a particular interest in working with this group of women. Attendance at the Introductory Course is a pre-requisite for attendance at the Advanced Course. The project built on work undertaken in 2007 with Homerton University NHS Trust where Medact and Maternity Action delivered five sessions of the course, Refugees, asylum seekers and maternity: an introduction. The funder has expressed interest in supporting national roll-out of the training. As part of the pilot process, the project prepared a proposal for roll-out for consideration by the funder. 1

3 3. Project Staff Members Ros Bragg, Director Beba Parker, Trainer Helen Beecher Bryant, Research Assistant 4. Reference Group The Project was overseen by a Reference Group. Two meetings of the Group were held (4 October 2010 and 14 February 2011). The meetings were invaluable in terms of sharing ideas about the course content, relevant contacts, promotion, quality control and moral support. The Reference Group Members Vicky Carne, Head of Midwifery, MIDIRS, Bristol Gerry Hickey, Legal Adviser, Asylum Support Appeal Project, London Gail Johnson, Education and Professional Development Advisor, Royal College of Midwives, London Jacqui McLachlan, Link Midwife for Refugees and Asylum Seekers, Glasgow Dave Newall, Senior Policy Officer, West Midlands Strategic Migration Partnership, Birmingham Debora Singer, Policy and Research Manger, Asylum Aid, London 5. Project Preparation and Research Interviews Helen Beecher Bryant compiled a list of over 200 specialist, community and consultant midwives. After making 432 phone calls, she conducted sixty interviews. Excellent information was gained from the interviews (eg. how services have changed over a period of time to reflect social situation, how they have had to adapt to new communities, etc). The interviews helped identify recurring themes and obstacles and this information informed the training. The majority of case studies used later in the training were a direct result of the interviews. This research is being written up in a separate report. Consultations The consultations were conducted with a range of maternity care staff, NGOs and refugee women. The aim was to meet with those who have direct experiences of working with pregnant refugee women in order to gain a broad overview of relevant issues. It was also good to hear 2

4 personal experiences from refugee women themselves as well as to gain insight into regional variations (eg: Wales, Scotland, etc). The consultations were considered productive and worthwhile as everybody was willing to help by sharing their experiences and giving suggestions. This process helped shape the final version of the training. Ros Bragg and Beba Parker attended a meeting in Birmingham on 18 October 2010 organised by a member of the Reference Group, Dave Newall. The meeting was attended by a mixture of midwives, NGOs and researchers and was very productive, with a lot of input, ideas and suggestions on how to proceed. On 15 December 2010 Beba ran a focus group at the Women Asylum Seekers Together (WAST) in Manchester where she talked to refugee women about their experiences of maternity services. It was a very useful meeting and provided further case studies. The culture of disbelief which many women experience became apparent here. On 13 January 2011 Beba visited Cardiff and met with Karen Jewell (Consultant Midwife in Public Health, Cardiff and Vale Health Board), Jean Saunders (Health Access Team Coordinator, Swansea) and others from their network which was also productive, but unfortunately none were in a position to host training. Beba was advised to organise open training and Karen and Julie offered to promote it. In January, Ros spent two days in Glasgow shadowing Jacqui McLachlan from the Reference Group in various labour wards and in the community. She also visited the initial accommodation centre, which was an unpleasant but useful experience. Ros had sought feedback on the project from Middlesex University students, and from Northwick Park midwives at one of their study days. Beba consulted with the Refugee Council Specialist Team who shared their experiences of helping pregnant clients which provided a good overview of obstacles faced by refugee women as well as health advocates. They were also able to put her in touch with one of their clients whom Beba interviewed at home. 3

5 6. Course design The two training courses were developed after a thorough training needs analysis was conducted through a series of discussions, interviews and meetings outlined above. Whilst the aim of the Introductory Course is to provide an overview of issues relevant when working with refugee and asylum seeking women, the Advanced Course further examines factors that contribute to poor maternal outcomes and takes an in-depth look at the experiences of conflict and violence, mental health issues and obstacles to accessing services. The courses are designed for groups of between 16 and 20 participants. The minimum number of participants is 8. The courses were designed to be interactive and participatory with a lot of different activities (individual, pair and small group work, activities, quizzes, etc) and allow for sharing of experiences, knowledge, examples of good practice and general discussions. The emphasis was on drawing on participants experiences and discussing relevant issues. The course Outline and Programme for both days are at the end of the report. 7. Organising Pilots The original aim was to run one introductory and one advanced session in London, North of England, Wales and Scotland (eight sessions in total). The plan was to get maternity services to host them by providing a room and releasing staff. However, this proved very challenging and time-consuming. The main issue was releasing a sufficient number of staff (at least eight). In London, Newham PCT initially agreed to host a pilot but subsequently withdrew as they could not release sufficient staff. We were unable to identify maternity services in Cardiff and Glasgow which were prepared to host the training. Again, services were concerned about releasing sufficient numbers of staff. University Hospital Coventry agreed to host the Introductory Course but were not able to release the staff for the Advanced Course. It was decided that the best option was to organise open courses in Cardiff, Glasgow and London. Maternity Action would provide the venue and midwives would register individually. A flyer was cascaded through RCM channels, and to those whom Helen had interviewed as part of the research process. The London courses filled up within a couple of days and the waiting list had over 120 midwives (including approximately 15 student midwives) who would have liked to have attended the London course. We used our contacts in Cardiff and Glasgow to promote these two courses. 4

6 8. Supporting materials Training handouts Beba designed a number of handouts to support the training. These were given out to participants. Each participant received a folder of materials at the start of the training. Contact information Helen compiled a list of useful organisations which was included in the folder. Annotated Reading List and Website (see Helen compiled a reading list containing the most relevant and up-to-date research reports with short summaries and divided into categories. It was placed on the website which went live on 21 January The Reference Group provided useful comments on the website and the reading list. New reports continue to be added to the list in order to keep it relevant and up-todate. 9. Summary of Feedback from Pilots The pilots were held as follows: - Cardiff (Introductory and Advanced courses) - Coventry (Introductory course only) - Glasgow (Introductory and Advanced courses) - London (Introductory and Advanced courses) Location No. of participants Intro Adv Cardiff 13 7 Coventry 8 n/a Glasgow London Evaluation forms were distributed to participants at the end of each course. Participants were asked to grade each element of the course as excellent, good, satisfactory or poor. There was supposed to be a section on working with interpreters, which included a hand-out and practical activity, but at each course, timing did not permit, therefore this activity was moved to the Advanced course. Five topics were covered types of immigration status; entitlement to health and other services; the refugee experience; negative attitudes, impact on refugee women and implications for services; case studies. 5

7 At the Introductory courses in Cardiff, Glasgow and Coventry, 100% of the attendees rated each of the five elements of the course as excellent or good. At the London course, 83% rated each of the sections as excellent or good. At the Advanced courses, seven topics were covered: using interpreters; rights and entitlements; gender violence; barriers; referring and signposting; mental health; and promoting early engagement. At the Advanced courses in Cardiff and Glasgow, 100% of the attendees rated each of the seven elements of the course as excellent or good and at the Advanced course in London, 94% of the attendees rated the elements as excellent. Attendees were asked how relevant the training was, and the comments received included the following: Information was clear and useful handouts supported throughout Cardiff introductory participant The course is relevant to practice - Cardiff introductory participant Excellent knowledge. A lot of information to convey therefore timing important - Cardiff introductory participant Very relevant in light of CEMACH findings. Using as part of my Supervisor of Midwives role in line with strategy of Refreshed Maternity Services Framework Glasgow introductory participant Very relevant, very informative, I was clueless before! Glasgow introductory participant Will equip me to deal with issues more effectively - Glasgow introductory participant Excellent. Ties in beautifully with CEMACH / Refreshed Framework for Maternity / Supervisor of Midwives course which I am doing - Glasgow advanced participant Very helpful to know what services are available where, and how to access these services London introductory participant Found the day very interesting and informative. I think that the information gained will help in the care offered to this vulnerable group - London introductory participant I have really enjoyed these two days - having not really known anything about this subject I have learnt loads London introductory participant Found the day very interesting and informative. I think that the information gained will help in the care offered to this vulnerable group - London introductory participant 6

8 It is relevant for midwives to reflect on their own bias when dealing and helping with vulnerable groups. Relevant in understanding refugee and their status and what is available to them London advanced participant The group were asked how well the trainer met the needs of the group. The comments included: The trainer managed the group well, responding to questions and discussions of the group - Cardiff introductory course The administration was well-managed and thoughtful - Glasgow advanced course The trainer was very aware of skills within the group and tapped into them - Glasgow advanced course I think every midwife should have access to this training - Glasgow advanced course The needs of the group were met in a very sensitive way - Glasgow advanced course Trainer was good but didn't allow enough freedom of expression of opposing views - London introductory course I think attitudes could have been explored nearer the beginning of the day - London introductory course The trainer was entertaining and good-humoured, answering questions quite well, however, she had a tendency not to allow individuals to complete their questions - London introductory course Sometimes it felt that we were not treated / respected as intelligent practitioners - London introductory course The trainer was very good at answering all the questions - London advanced course The applicants were also asked if they would recommend the course to a colleague. Of all respondents, one said that they would not recommend the course to a colleague, and two did not answer the question. Therefore, every other midwife (80 in total, including those who attended both courses) said that they would recommend it to a colleague. 7

9 10. Future Maternity Action reported back to Comic Relief in March Feedback was positive and a final decision on further funding is expected by end May Midwives have expressed strong interest in the course. We have pencilled in 21 courses across the UK which can proceed once funding has been confirmed. The possibility of delivering a shorter version of the training at universities is being considered. It could also be turned into an e-learning package, as e-learning is becoming an increasingly popular way of conducting training in the NHS. We are in the process of seeking RCM accreditation for the course. 8

10 Improving care for refugees and asylum seekers - Training for midwives INTRODUCTORY COURSE Overview While the CEMACH report (2007) shows that maternal deaths in the UK are rare, there is a disproportionate number of maternal deaths amongst refugee and asylum seeking women. There are several factors that contribute to this. NICE guidance (2010) identifies asylum seeking and refugee women and those who do not speak or understand English as women with complex social factors who may need additional support. In addition to this, the sheer complexity of the asylum system and legislation can make it very difficult for practitioners to provide appropriate support. This course will examine the issues relevant to pregnant refugee and asylum seeking women and explore strategies that midwives can use to support them effectively. Aim The aim of this course is to provide an overview of issues relevant to refugee and asylum seeking women and to provide midwives with information and tools which can be used to support these groups more effectively. Leaning outcomes After attending this one-day training course and using the resource materials, the participants will be able to: Differentiate between different types of immigration status and entitlements to health and other services and give a basic description of the asylum determination process Describe the experiences of refugee women Identify how negative attitudes impact on individual women and service provision Demonstrate an understanding of key issues when working with refugee women (dispersal, complexity of the asylum process, obstacles to accessing services, communication barriers, sexual violence, FGM, mental health issues, culture, etc) Demonstrate an effective use of own communication skills and interpreters Identify strategies for providing most effective support The course will be participatory and interactive with activities and exercises (individual, in pairs, small and large groups) used throughout the day. All participants will receive a resource pack. 9

11 Programme Improving care for refugees and asylum seekers - Training for midwives INTRODUCTORY COURSE Registration Welcome and introduction Maternal outcomes for refugee and asylum seeking women: latest research findings Terminology: clarifying definitions of different immigration categories The asylum process: a brief overview Rights and entitlements of different immigration groups Break The refugee experience (in the country of origin, during the journey, in the UK) Asylum and migration myths: exploring attitudes, impact on refugee women and implications for services Lunch Providing woman-centered care: case studies Exploring key issues when working with refugee women Identifying strategies for providing effective support Break Providing woman-centered care: case studies (continued) Improving communication Exploring ways of using interpreters effectively and improving own communication skills Summary, evaluation and close 10

12 Improving care for refugees and asylum seekers - Training for midwives ADVANCED COURSE Overview This course will build on the information from the Introductory Course and further examine factors that contribute to poor maternal outcomes for asylum seeking and refugee women. It will take an in-depth look at the relevant issues such as the experiences of conflict and violence, mental health issues, entitlements and obstacles to accessing services. It will also discuss how we can promote early engagement with services and provide woman-centered care in order to provide most effective support. Aim The aim of this course is to provide an in-depth overview of issues relevant to refugee and asylum seeking women and to provide midwives with information and tools for promoting early engagement with services and providing woman-centered care. Leaning outcomes After attending this one-day training course and using the resource materials, the participants will be able to: Differentiate between different types of entitlements to services for different groups (including end of process, fresh claims and further submissions ) Demonstrate an understanding of the barriers to accessing health services (including charging regulations) and ways of overcoming them Describe the experiences of conflict and violence, including gender violence Demonstrate an understanding of mental health issues and the role of mental health services Identify how and where to make most appropriate referral/signpost Identify strategies for promoting early engagement with services and providing womancentered care Suitable for: midwives with specific responsibilities for working with refugee and asylum seeking women or with a special interest in this area. Attendance of the Introductory Course is a pre-requisite for attending the Advanced Course. The course will be participatory and interactive with activities and exercises (individual, in pairs, small and large groups) used throughout the day. All participants will receive a resource pack. 11

13 Programme Improving care refugees and asylum seekers - Training for midwives Registration Welcome and introduction ADVANCED COURSE What do we remember from the last time? Rights and entitlements of different immigration groups Break Experiences of conflict and violence, including gender violence Refugee women in the UK asylum system Barriers to accessing services Exploring ways of overcoming barriers Identifying ways of making appropriate referrals and signposting Examples of good practice Lunch Refugee women and mental health issues: the role of specialist mental health services and the role of midwives offering support Break Exploring strategies for promoting early engagement with services and providing woman-centered care: case studies Summary, evaluation and close 12