On December 4th 2018, about 50 clinicians in the field of obstetrics and gynaecology, researchers, policy makers and ‘experts through experience’, participated in the symposium “Maternal health care for asylum seekers, undocumented migrants and asylum residence permit holders” in Utrecht. The symposium was hosted by the Share-Net ‘Maternal Health’ Community of Practice (CoP) and organized in collaboration with University Medical Centre Utrecht (UMCU), the Royal Tropical Institute (KIT), the Dutch Royal Association of Midwives (KNOV), the University of Amsterdam, the Working Party on International Safe Motherhood & Reproductive Health, the Dutch Society for Obstetrics and Gynaecology (NVOG) and the Central Organ for the reception of Asylum Seekers (COA).
With the arrival of refugees to the Netherlands in the past years, several tailored initiatives in the field of maternity care were developed. Meanwhile, it has become evident that health care experiences and outcomes for mothers and new-borns of this group stay behind. The symposium was set up to strengthen the network of stakeholders involved in maternity care for refugees, to learn from each other’s experiences and identify challenges as well as best practices. Thereby, the aim of the event was to develop recommendations and collectively prepare for the future arrival of pregnant women who seek asylum, have recently obtained a residence status, or who remain undocumented in the Netherlands.
The audience was welcomed by Marcus Rijken (Gynaecologist/Obstetrician AMC and Assistant Professor Global Health), who gave an overview of the ethnic disparities that exist in maternal health outcomes in the Netherlands. Unfortunately, recent research has repeatedly pointed out that asylum seekers and undocumented migrants are at increased risk for adverse outcomes. The “three-delay model” of maternal health was highlighted, which explains how factors related to the decision to seek care (“recognition”), the arrival at the health facility (“referral”) and the provision of adequate care (“responsiveness”) can all cause delay in realizing optimal maternal health worldwide. Dr. Rijken thereafter introduced the aims of the evening, emphasizing that coming together as healthcare professionals with the experiences of the past years fresh in mind, provides a powerful moment to join forces, reflect and develop a comprehensive approach to be well-prepared for the future.
In a keynote lecture, Simone Goosen (policy advisor and epidemiologist) guided the audience through some of the latest evidence from the Netherlands, which demonstrates much higher maternal and perinatal mortality rates in non-western asylum seekers compared to the Dutch population and other immigrants. She then discussed the ‘focus on life course approach’, which is built on three themes: social support, prevention of teenage and unintended pregnancy and family attachment. These themes align with recent findings and consequent priorities for the reproductive health of refugees. In addition, the need for adequate interpretation services was emphasized. Finally, Dr. Goosen highlighted the importance of reflecting on one’s own position as a professional in this field and the strength of sharing personal stories of asylum seekers in maternity care.
Peggy van der Lans (Gynaecologist/Obstetrician at ZGT Almelo and MD Global Health and Tropical Medicine (AIGT) provided a keynote on the implementation of the Dutch continuum-of-care guideline (“ketenrichtlijn”) for maternity care for asylum seekers and shared important insights from the field with the audience. Through collective efforts, the national guideline was operationalized into an integrated pathway of care that could be implemented effectively on a local level in Twente. Essential in this process was to intensify connections between different stakeholders, such as local obstetricians, the associated midwife practices (Verloskundig Samenwerkingsverband, VSV) and the centres for asylum seekers (COA). Through various tools, such as the online platform Kennisnet, sharing information and continuous evaluation of the care path were part of the strategy. Some challenges of the innovative approach were also addressed, such as the need for more engagement and input of women receiving care themselves, the efforts still required to connect care providers in different regions and the fact that women holding a residence permit (status holders) are more difficult to reach.
In the following keynote, Marthe Zeldenrust (MD in Sexual Health, Sexual and Reproductive Health Coordinator at Doctors of the World) reflected on the key messages from the Expert meeting on sexual and reproductive health of undocumented women in the Netherlands organised by Doctors of the World and the Rutgers WPF in November 2018. Her presentation addressed the suboptimal situation for contraceptive and abortion care for undocumented women, with high barriers to care, a large unmet need and the vulnerable position of this group. Doctors of the World has recently presented a report to the government on this situation and has set up a tailored SRH clinic in Amsterdam. Other available resources were highlighted, such as the counselling program “Nu Niet Zwanger” by GGDGHOR and Rutgers WPF. The presentation concluded with an overview of recommendations resulting from the expert meeting. Across health care provision, the need for dialogue with undocumented women was emphasized, as well as the need to improve access and lower barriers, for example by appropriate reimbursement and pro-active (group) counselling programs starting from entry at the asylum seeking centres.
Following the break, Nirmeen Khalal was invited as an “expert by experience” to share some of her experiences with the care she received when arriving pregnant as an asylum seeker from Syria in 2015. Nirmeen expressed her appreciation for the Dutch system of maternity care, and mentioned the fact that her husband was actively involved during her giving birth as an example of what they had valued. On the other side, there were a few issues they encountered, such as when she could not communicate with the postpartum community health care (Kraamzorg) as no Arabic interpreter was available. She missed her family even more at that time, as they are usually very involved in the after-birth care in Syria. A lively dialogue with the audience followed, in which several other cultural differences in maternity care came up, for example with regards to the use of epidural anaesthetics.
Following the input of the first part of the symposium, the audience broke out into small groups to develop recommendations related to research, policy and practice on specific subthemes led by one content expert. The recommendations that each group came up with are listed below this report.
After reconvening, Jelle Stekelenburg (Professor International Aspects of Reproductive Health UMCG) explored the right to health in the context of pregnant asylum seekers in the Netherlands. He explained the concept and history of the right to health as a human right, based on the core principle of dignity and built on the factors of availability, accessibility, acceptability and quality of healthcare. From his talk, it became clear that sexual and reproductive health are part of the human right to health, which comes with certain freedoms and entitlements that a state is bound to respect, protect and fulfil. In the Netherlands, most policies are in correspondence with international treaties, however, problems arise in practice when aspects of communication, culture or knowledge are interfering with the services and facilities that are put in place. He reminded us of “the right to the progressive realization of the highest attainable standard of health”, calling for our joint forces as healthcare providers.
In the last part of the session, Thomas van den Akker (Gynaecologist/Obstetrician at Leiden University Medical Center) facilitated a plenary session dedicated to the recommendations of all subgroups, which are found below this report.
Marcus Rijken concluded with looking back on the evening as a wonderful example of network-strengthening by incorporating voices from the field and sharing experiences across disciplines and expertise. He encouraged the audience to look forward, as learning from the past is needed to prepare ourselves and our systems for the arrival of new asylum seekers, status holders and undocumented migrants, and to ensure safe motherhood for all in the Netherlands.
Share-Net would like to encourage the Community of Practice on ‘Maternal Health’ to take forward and start a discussion on how we can follow-up these recommendations.
For more information and exact numbers see the presentation of Simone