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    The Reaching Out Project:

    Report on preliminary consultations

    May - July 2005

Prepared by Anna Gaudion

    for the Maternity Alliance

The Reaching Out Project

The Reaching Out Project


    The Grayston Centre

    28 Charles Square

    London N1 6HT


Published: June 2006

    The Reaching Out Project aims to improve access to maternity services for highly marginalised Black and minority ethnic women, including refugees, asylum seekers, women with little or no English and women with insecure immigration status.

    The project is based in London and operates on a national basis. The project was undertaken by The Maternity Alliance prior to its insolvency in November 2005. In May 2006, the project was housed with the national charity, Medact.


The Reaching Out Project

Table of Contents

Acknowledgements 4

    Introduction 5

    Background to the project 6 Concurrent Research in London 8 Methodology 9

    ; Strengths of Methodology

    ; Limitations of methodology Findings: The Narrative Report 14

    ; Access to Maternity Services

    ; Regulations Excluding persons from abroad

     Communication ;

    ; Information Needs

    Materials 29

    ; Rationale for Materials Produced Conclusions 33

    References 34

    Appendix 35

    ; Ethnicity of Participants


The Reaching Out Project


    With thanks to all the health professionals, advocates and families in BMER communities within London who contributed to this project:

Firstly, the women from the following communities:

    Black African (Ugandan, Ivory Coast, Nigeria, Democratic Republic of Congo, Sudan); Moroccan, Eritrea, Pakistani, Bengali, Yemeni, Irish Travellers, Albanian, Somali, Chinese and Vietnamese.

Secondly, the gatekeepers in the community:

    Pascale Vassey (Southwark Refugee Forum); Simin Mouvin (Three Boroughs Refugee Team); Ayer Atah (Southwark Day Centre for Refugees); Marion McGuire and Belay Gessesse (Refugee Arrival Team); Lucy Kralj, (Medact); Helen Murshali (Refugee Council); Maryam Jama (Women‟s Health and Family service); Kirsty Shuttle and Anne Marie O‟Brian (Southwark Travellers Action Group); Nabila Ferha and Sarah Hussaine (Womens‟ Relief at the East London Mosque); Bich Nguyen (Vietnamese women‟s‟ group); Vivian Fung (Chinese Healthy Living Centre); Barbara Mickleburgh (Rotherhide Muslim women‟s Group); Mouna El-Ogbani (El-Hasaniya,

    Moroccan Women‟s Group); Priscilla Simpson,( BMER Resource Manager, Hillingdon): Jennifer Bourne (Waltham Forest Somali Outreach FGM Clinic). Rachel Klein (Hansy Josovic Maternity Trust). Gitit Rotenberg (Jewish Maternity Programme). Suj Ahmed (Social Action for Health). Rahmo Ahmed and Essa Ali (Southwark Somali Women‟s Group). Myriam.Cherti (Migrant and Refugee Community Forum). Angela Bell (Westway Development Trust); Lena Spritzer (Norwood Family Centre Rav Tov mother and toddler drop in).

And the health professionals:

    Claire Homeyard Consultant Midwife, Barking Havering and Redbridge NHS Trust; Jane Kennedy Consultant Midwife Hackney University NHS Trust: Jill Demilew, Professional Advisor on Maternity and Family Health, DoH; Marie McDonald (Clinical Director Guys and ST Thomas‟NHS Trust); Lynn Pacanowski, Head of Midwifery, St Marys Hospital, Paddington;

     Pauline Cross, Patient Choice Manager, SE London Strategic Health Authority; Brian Coleman, Diversity Officer, Westminster PCT; and the focus groups of midwives from Kings College Hospital NHS Trust and Barking Havering and Redbridge NHSTrust.


The Reaching Out Project


    This report gives a summary of the methodology and findings from a 3-month information and outreach project targeting pregnant women and new parents from black and minority ethnic and refugee communities to facilitate their access to antenatal and postnatal healthcare, support services and benefits. In particular the project aimed to reach asylum seekers, refugees, homeless families, those with little or no English and women who face additional obstacles to accessing the maternity services.. The aim of the project was to consult with service users, both currently pregnant women and families with a baby under the age of two years. The women were to be recruited through community groups, their needs ascertained and thereafter „information materials‟ to be produced and piloted to improve information and support.

    The stories and experiences expressed by many of the women interviewed resonate with issues broached by recent governmental reports, notably the National Service Framework for children, young people and maternity services (DH, 2004) and Why mothers die 2000-2002(CEMACH, 2004).

    The project was advised by a steering group that includes representatives from the Royal College of Midwives, The Community Practitioners and Health Visitors Association, The Refugee Council, The King‟s Fund, CEMVO, primary care trusts and a Consultant midwife specialising in public health.


The Reaching Out Project

Background to the Project

    In July 2004 the first meeting of the steering group for this project met to share ideas. At that time there were a number of reports, which had highlighted that for some groups in society there were poorer outcomes in terms of morbidity and mortality around childbirth. The Confidential enquiry into Maternal Deaths 2002, Why mothers die, indicated that for

    women from some minority ethnic groups the risk of maternal death was twice that for a white woman. In addition women from ethnic minority groups made initial contact with maternity services later than their white counterparts. A large number of these women spoke little English and in many cases family members acted as interpreters. Since July 2004 a subsequent „Why mothers die‟ report has shown that these issues remain


    “The most disadvantaged women are 20 times more likely to die than those from higher socio-economic backgrounds, and women from ethnic groups other than white are three times more likely to die. Mortality rates among refugees and asylum seekers are particularly high. These problems are related to accessing health care and need to be addressed” (CEMCH,


    Further, in the report, questions are raised as to whether maternity services are inaccessible for reasons such as distance, cost or socio-cultural barriers. The importance of interpreting service and contact with voluntary organisations to offer social support was highlighted (CEMCH, 2004).

In October 2004 the Department of Health published the National Service

    Framework for Children, Young People and Maternity Services. Standard 11

    concerns maternity services. It states that women should have easy access to supportive, high quality maternity services, designed around their individual needs and those of their babies. It stressed that maternity services should be,

    “…Proactive in engaging all women, particularly women from disadvantaged groups and communities early in their pregnancy and maintaining contact before and after birth” (DH, 2004.5).

    Among the cited research finding within the report is that women want,

    To receive adequate information and explanation about their choices for childbirth, including pain relief and hospital practices” (DH, 2004.27).


“Delivering effective ante-natal care is dependent upon effective and

    sensitive provision of non-directive information and support” (DH, 2004.18).


The Reaching Out Project

    Finally it reaffirmed the centrality of options rather than routine, reflecting back to Changing Childbirth (1993) which stipulated that all women should have choice, continuity and control throughout the ante-natal, labour and post-natal period.

    At the end of July, the Healthcare commission published its investigation into the maternity services of North West London Hospitals NHS Trust following the occurrence of nine maternal deaths in three years. Some of the key issues raised by the women were lack of information and support. The report found there was inadequate support for women whose first language is not English, family members were frequently asked to translate information.

    The enquiry reported that staff were unsure about the entitlement to maternity care for overseas visitors, including asylum seekers;

    This was also included in a record of the views expressed by women kept by the maternity services. On at least two occasions, this lack of clarity resulted in women leaving an antenatal clinic without receiving care and treatment. For example, one of the trust‟s documents stated that a female

    asylum seeker was told by the finance department that she would have to pay ?2,300 to have her baby. The woman was in the advanced stages of her pregnancy and said that she had no money and could not pay, or would have her baby at home”. (Commission for Healthcare Audit and Inspection,



The Reaching Out Project

Concurrent Research Projects in London

    There are currently 4 research projects covering the NW, SW, NE, and SE of London. Under the umbrella of the „Pan London Midwifery Review‟ they are

    examining issues of capacity and consumer need. Two of the projects are concentrating on capacity building in recognition of a rising birth rate and a shortage of midwives in the capital. North West London Strategic Health Authority (NWLSHA) and South East London Strategic Health Authority (SELSHA) are looking at issues around access to services and information for all their service users.

    Two of the project leads, Pauline Cross, Midwifery Choice Project Manager for SELSHA and Lynne Pacanowski, Midwifery Project lead for NWLSHA are interested in working in partnership with the ongoing BMER project.


The Reaching Out Project


    This was a pilot project, intended, by definition to explore the best means of consulting with communities and to suggest means of addressing imbalances in needs towards antenatal, birth and postnatal information and support.

Consultations were carried out with a wide range of community groups and

    service providers to determine the key information needs of their pregnant clients. Community groups were sent a short summary of the project‟s aims and a list of possible questions. A project brief was circulated within the consultant midwives e-mail group asking for examples of projects within London where outreach work to BMER women had been tried. Unfortunately there were no replies.

    The first step in engaging with the communities or members of the community groups was to meet the „gate-keepers‟ in person. For a number

    of groups there were 2 3 meetings before an appointment with the women

    was made. The initial discussions with advocacy workers, community group co-ordinators and other „first point of contact‟ personnel about the aims of the project led to the initial working of a storyboard. Most of focus group consultations were conducted after the initial simple 6-page storyboard had been made. Four BMER community consultations/ forums were attended; a Chinese healthy living day, Southwark Community Refugee Forum, a Maternity Conference organised by Social Action for Health and the Ifteen Somali Women‟s Group and a Southwark Travellers Action Group meeting.

Focus group discussions were held on the key messages that women feel

    they need to understand, and on the appropriate mechanisms for disseminating these messages, with women from the following communities: Black African (Ugandan, Ivory Coast, Nigeria, Democratic Republic of Congo, Sudan); Moroccan, Eritrea, Pakistani, Bengali, Yemen, Irish Travellers, Albanian, Somali, Chinese and Vietnamese.

    The participants were recruited through community organisations, and were paid ?10 for their participation. For a few groups refreshments were also provided. In Southwark research was conducted in partnership with Pauline Cross, Midwifery Choice Project Manager and costs shared. Interpreters were used for the sessions where appropriate.

    At the beginning of the interview the project was explained; that the purpose was, to give women from different minority groups a voice to elucidate information needs. Clarification was given that the interviews were voluntary and anonymous but that parts of their stories may be used in the report.

    The initial storyboard, broad based to cover antenatal, birth and the postnatal period facilitated further discussion, comment and laughter. The storyboard was introduced as „work in action‟. Showing a picture of the


The Reaching Out Project

pregnant woman the question would be posed, „what information, support

    and advice do you need when you think you might be pregnant?‟ By enabling women to laugh that the Muslim women pictured looked like a nun or that the young white woman wore the same tracksuit throughout the storyboard fostered a safe and friendly atmosphere. Thereafter the discussion were based around the pictures, women identifies with the pictures and were able to talk about the information that was important to them. During the interviews the women were also engaged in feeding or caring for their babies or young children. Childcare arrangements, appointments, public transport and other issues meant that the women arrived late or had to leave early. For the main part the interviews lasted an hour but this often stretched to 3 hours with a staggered gathering of people and food.

    Service providers in the statutory and voluntary organisation involved were consulted individually or in focus groups. They were not paid, although they would have welcomed chocolate cake.

    ; Strengths of the Methodology

    The main strength of the methodology was that a wide range of women were interviewed across the BMER community. The atmosphere and openness of the consultation with the „link‟ people facilitated the „interface community and refugee organisations to highlight how opaque the maternity services are. This issue was never broached by the project worker but brought up spontaneously by the groups thus stressing the hierarchy of need within the BMER population with regards maternity services; namely initial access.

    The project was an empowering process for the BMER women involved, many of the women were reticent at first but by the end of the session wanted further involvement. Contributing to something tangible, being recognised and respected as women with ideas and knowledge, which could benefit others, was positive and affirming.

    A number of groups were very proactive in their engagement with the project and project worker and expressed interest in being involved in further consultation.

    The project, the campaigning element and the ideas behind the materials suggested has provoked interest and a wish for further involvement by the senior midwives consulted. The materials being formatted were described by one senior midwife as reaching the „nitty gritty‟ of the National Service Framework. Other political viewpoints have been hinted at and may well become louder in nature as the project develops.


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