Migration into the European Union (EU) has risen over the last decade, with approximately half of the migrants under 30 years old. It is thought that over a third of live births in the EU occur to mothers who are immigrants. About 500,000-650,000 people have come to live in the UK each year in the last decade, with 300,000-400,000 leaving each year. There is evidence from the Confidential Enquiries into Maternal Deaths, the UK Obstetric Surveillance System (UKOSS) and other national reports that morbidity and mortality are higher in migrant mothers. This is not just limited to international migration; migration from rural to inner-city areas is also increasing, and it is thought that mothers who move in this way have similar risks to those who migrate internationally.
Many of the problems exhibited by migrant parturients are not exclusive to migrants; thus there are other vulnerable and disadvantaged groups of women who should also be considered high-risk, including the homeless, the destitute, drug addicts and sex workers. Many will have mental health issues, and many of these groups overlap (see also Chapter 146, Psychiatric disease, and Chapter 147, Substance abuse).
Problems and special considerations
The management of pregnancy and safe delivery of the baby in migrant or disadvantaged women provides a challenge to both midwifery and medical staff, for a number of reasons.
Some mothers may present with poor general health, poor nutrition, obesity or coexisting diseases such as tuberculosis, rheumatic heart disease or HIV infection, which may impact on maternal and neonatal outcome. In certain parts of Asia, Africa and the Middle East, female genital mutilation is commonly practised, and this has implications for delivery options.
Migrant mothers may not be entitled to health care, or they may be unaware that they are entitled to it, during pregnancy. They may therefore seek antenatal care late, if at all, and they may be poor attenders of appointments, making it easy for them to be lost to the system. Thus, any pre-existing medical conditions may go untreated or not optimised until late in pregnancy. Similarly, conditions that develop during pregnancy, such as preeclampsia or fetal growth restriction, may not be detected.
Language may also pose a barrier to women seeking antenatal care, and this has been identified as a major contributory factor to maternal morbidity.
An accurate past medical history may be difficult or impossible to obtain, and there may be little or no medical records to refer to, either because they do not exist or because they have been lost or even concealed.
Certain cultures or religions may mistrust Western medicine and believe that obstetric intervention (e.g. caesarean section) is linked to death. The mother and/or father may therefore be reluctant to follow the advice of staff when any sort of operative delivery is suggested, leading to delay, poor perinatal outcomes and even fetal or maternal demise.
Previous studies have suggested that the uptake of labour neuraxial analgesia is lower in women from some ethnic groups. This may be related to difficulty in establishing the level of the woman’s pain in the presence of a language barrier, the woman’s lack of awareness or understanding of the available options for pain relief, her fear of incurring additional costs for the procedure, or cultural reasons. The absence of an in-situ epidural puts these women at an increased risk of receiving general anaesthesia for emergency interventions and the higher morbidity that may be associated with it.
Management options
A multimodal approach is necessary. As in all cases of good obstetric practice, communication is paramount - both within the team (which should include other specialists and social services as appropriate) and with the patient and her partner (and, if necessary, other members of her family).
If a language barrier prevents good communication, then interpreter services must be provided; it is no longer acceptable to use family or staff members to interpret, as they themselves may have limited English skills.
Proper explanation of antenatal care and the plan for delivery is necessary. It may be prudent antenatally to put forward the analgesic options available for labour and, if necessary, a separate appointment maybe organised with an anaesthetist and an interpreter. If these are not available, other translation aids may be used. The Obstetric Anaesthetists’ Association has leaflets available that may be downloaded, explaining the analgesic options.
Antenatal care should identify any coexisting disease in order that this is optimally managed, and the patient should be advised where to seek help if her symptoms change.
Interpreter services should be available during labour and delivery. Appropriate care and follow-up should also be arranged for the postnatal period.
Key points
• The migrant obstetric population is increasing in number.
• There is a higher morbidity and mortality associated with this group of women, and with other disadvantaged groups.
• Good communication and early antenatal care are paramount in identifying high-risk patients.
• Interpreter services should be available to all women when language is a barrier.
Further reading
Husarova V, Macdarby L, Dicker P, Malone FD, McCaul CL. The use of pain relief during labor among migrant obstetric populations. Int J Gynaecol Obstet 2016; 135: 200-4.
Knight M, Nair M, Tuffnell D, et al.; MBRRACE-UK. Saving Lives, Improving Mothers’ Care:
Surveillance of maternal deaths in the UK 2012-14 and lessons learned to inform maternity care from the UK and Ireland Confidential Enquiries into Maternal Deaths and Morbidity 2009-14. Oxford: National Perinatal Epidemiology Unit, University of Oxford, 2016.
Lindquist A, Knight M, Kurinczuk JJ. Variation in severe maternal morbidity according to socioeconomic position: a UK national case-control study. BMJ Open 2013; 3: e002742.
Nair M, Kurinczuk JJ, Knight M. Ethnic variations in severe maternal morbidity in the UK: a case-control study. PLoS One 2014; 9: e95086.
Royal College of Obstetricians and Gynaecologists. Female Genital Mutilation and its Management. Green-top Guideline 53. London: RCOG, 2015. www.rcog.org.uk/en/guidelines-research-services/ guidelines/gtg53 (accessed December 2018).