This submission has been developed by the Multicultural Centre for Women’s Health (MCWH), the national voice for immigrant and refugee women’s health and wellbeing. The term ‘immigrant and refugee’ refers to people who have migrated from overseas, and their children. It includes people who are a part of both newly emerging and longer established communities, and who arrive in Australia on either temporary or permanent visas.
In 2013, 31.6% of mothers who gave birth in Australia were overseas born women (women born in Africa, the Middle East and Asia together accounted for 19.6% of all mothers). However, most of the perinatal health research and data, particularly in relation to perinatal depression, focuses on the mainstream population. The perinatal support needs of immigrant and refugee women and their preferred support interventions have received little attention.
Specifically, this submission highlights the following research findings of the MCWH Sexual and Reproductive Health Data Report 2016 in response to the terms of reference:
(1) The availability, quality and safety of health services delivering services to women and their babies during the perinatal period
Maternal country of birth can be an important risk factor for perinatal outcomes. Available research shows that immigrant and refugee women are at a greater risk of suffering poorer maternal and child health outcomes. The recent cases of Victorian women Akon Goude, Sofina Nikat and Umal Abdurahman have also highlighted the critical need for equitable support of immigrant refugee women during the perinatal period.
(2) The impact that the loss of Commonwealth funding (in particular, the National Perinatal Depression Initiative) will have on Victorian hospitals and medical facilities as well as on the health and wellbeing of Victorian families
Reduced funding would impact negatively on immigrant and refugee women.
A comparative study of the post-childbirth experiences of Australian born and immigrant mothers from non-English speaking backgrounds found that compared with Australian born women, immigrant mothers less proficient in English had a higher prevalence of depression (28.8% vs 15%) and were more likely to report wanting more practical (65.2% vs 55.4%) and emotional (65.2% vs 44.1%) support. They were also more likely to have no ‘time out’ from baby care (47% vs 28%) and to report feeling lonely and isolated (39% vs 17%). The Mothers in a New Country study of Vietnamese, Turkish and Filipino women’s experiences of maternity care and physical and psychological health found the issues most commonly identified by women as contributing to depression were:
- isolation (including homesickness)
- lack of support and marital issues
- physical ill-health and exhaustion
- family-related issues and
- baby-related issues.
Significant associations with depression were seen on at least two of the above measures for mothers who: were under 25 years; had a shorter residence in Australia; spoke little or no English; migrated for marriage; had no relatives in Melbourne. Similar themes and issues were also identified among immigrant Afghan mothers in a further study of immigrant Afghan women’s emotional well-being after birth. This study also found that some women were reluctant to discuss their emotional difficulties with health professionals and did not expect that health professionals could necessarily provide assistance.
(3) The adequacy of the number, location, distribution, quality and safety of health services capable of dealing with high risk and premature births in Victoria; and (4) The quality, safety and effectiveness of current methods to reduce the incidence of maternal and infant mortality and premature births
The Australian perinatal mortality rate in 2013 was ten per 1000 births. In Victoria, the perinatal mortality rate in 2013 (9.9 per 1000 births) was lower than the rate for 2009 (10.7 per 1,000 births). Despite this, perinatal mortality rates remain high for specific migrant groups including babies of women born in North Africa, the Middle East or southern and central Asia (the risk of perinatal death is one and half times higher) (CCOPMM 2016). Australian state-based studies have also shown that:
- Compared with other refugee groups, women from West African humanitarian source countries were found to have the highest stillbirth incidence (4.4% compared to 1.2% and 1.6% from other regions) (Gibson-Helm et al 2014).
- South Asian born women were more than twice as likely to have a late pregnancy antepartum (i.e. not long before birth) stillbirth than either Australian-born or South-East Asian born women (Drysdale et al 2012).
- Lebanese born women had the highest rates of stillbirth (7.2 per 1000 births) compared with low risk women born in Australia and other women born overseas (Dahlen et al 2013).
- According to a Victorian population based study women born in East African countries experienced increased perinatal deaths and other adverse perinatal outcomes compared with Australian-born women. Women from Eritrea and Sudan are particularly at increased risk of adverse outcomes (Belihu et al 2016).
Several studies also suggest that immigrant and refugee women may be at greater risk of adverse perinatal outcomes:
- Compared to African migrant women without a refugee background, African women of refugee background appear to be at greater risk of specific adverse pregnancy outcomes (Gibson-Helm et al 2014).
- Compared to low risk women born in Australia and women from New Zealand, England, China, Vietnam, Lebanon and Philippines (the most common migrant groups at the time of the study), Indian women were found to have the lowest normal birth rate and high rates of low birth weight babies (Dahlen et al 2013).
Antenatal care is associated with better maternal health, fewer interventions in late pregnancy and positive child health outcomes. The World Health Organization recommends receiving antenatal care at least four times during pregnancy and the Australian Antenatal Guidelines recommend that the first antenatal visit occur within the first ten weeks of pregnancy.
Women born overseas who gave birth in Australia in 2013 were found to have attended their first antenatal visit at later gestational ages than Australian born mothers. This finding suggests that immigrant women need to be linked to appropriate health supports and have access to perinatal education
(5) Access to and provision of an appropriately qualified workforce
A systematic and comparative review of studies in five countries (including Australia) of immigrant and non-immigrant’s women’s experiences of maternity care has shown that all women – both immigrant and non-immigrant – want maternity care that is safe, high-quality, attentive and individualised, with adequate information and support (Small et al 2014). However, the same study has also shown that:
- immigrant women were less positive about their care than non-immigrant
- communication problems and lack of familiarity with care systems impacted negatively on immigrant women’s
- immigrant women reported problems with discrimination or prejudice. (Yelland et al 2015)
Other Australian studies (Hennegan et al 2015; Yelland et al 2015; Lansakara et al 2010; Bandyopahyay et al 2010) have also shown that compared with Australian-born mothers, immigrant mothers were:
- less likely to rate overall postnatal physical health positively
- more likely to report relationship problems and to report lower emotional satisfaction with their relationship with the partner
- less likely to be asked about relationship problems by maternal and child health nurses
- less likely to be asked about feeling low or depressed by GPs
- more likely to say that health professionals did not always remember them between visits, or make an effort to get to know the issues that were important to them
- less likely to feel involved in decisions
- less likely to understand their options of care
- more likely to have no ‘time out’ from baby care
- more likely to report feeling lonely and isolated
- more likely to report wanting practical and emotional support
Another systematic review of studies that focused on the views and experiences of immigrant and refugee women in accessing sexual and reproductive health care in Australia (Mengesha et al 2016) similarly found that interactions with health care professionals were critical to immigrant and refugee women’s access to healthcare.
Access to and provision of an appropriately qualified workforce relies on workers being trained to deliver culturally appropriate care that meets the specific needs of immigrant and refugee women.
(6) Disparity in outcomes between rural and regional and metropolitan locations
Immigrant and refugee women in rural and regional areas face multiple disadvantages accessing a range of health services compared to their metropolitan counterparts. Women in rural areas are less likely to obtain health care from medical specialists and more likely to rely on hospital care (‘Women’s Health in Rural Australia’, National Rural Health Alliance 2012). However, for immigrant women, access to mainstream services do not always provide the culturally appropriate care women need.
While the majority of immigrants and refugees live in metropolitan regions of Victoria, the population of new migrants living in rural areas of Victoria is growing, and in many areas, exceeding the population growth of the general population. In the 5 years between 2006 and 2011, the average increase across Victorian rural regions of people who migrated from a non-English speaking country was 18.6%, compared with general population growth of 5.5%. At the 2011 census, the total of immigrants and refugees from non-English speaking countries living in rural and regional Victoria was 77,851, making up 5.4% of the general rural and regional populations (‘Population Diversity in Victoria: 2011 Census Local Government Areas’, OMAC, 2013)
(7) Identification of best practice
MCWH works within an intersectional feminist framework, which recognises that immigrant and refugee women experience multiple and interlocking forms of oppression and discrimination. An intersectional approach recognises that gender alone is not a sufficient lens through which to view women’s health and access to services.
MCWH has published research and best practice guides, which draw on an intersectional framework and recommend culturally responsive health service delivery, such as provision of interpreters, bilingual health professionals and female health professionals.
In summary, MCWH recommends that the Inquiry be attentive to the need for:
- more culturally appropriate and equitable perinatal health services for immigrant and refugee women
- the development of models of maternal health surveillance and primary care support that meet the specific needs of immigrant and refugee women
- bilingual support and education, particularly for newly-arrived women
- the development of an appropriately qualified workforce trained to deliver culturally responsive care
- further research that is inclusive of or focusses on immigrant and refugee women’s perinatal health needs
- the collection, measurement and monitoring of robust data across core areas relating to immigrant and refugee women’s perinatal health, care and wellbeing
Prepared by Dr Adele Murdolo for Multicultural Centre for Women’s Health
MCWH is a Victorian women’s health service established in 1978 that works both nationally and across Victoria to promote the health and wellbeing of immigrant and refugee women through advocacy, social action, multilingual education, research and capacity building. MCWH is partially funded through the Victorian Department of Health and Human Services as a part of the Victorian Women’s Health Program.
MCWH works across Victoria to provide research, expert advice, and professional development to key stakeholders on improving the health and wellbeing of immigrant and refugee women. It does this through research and publication, participation in advisory groups and committees, written submissions, training and seminar programs, and presentations of our work. MCWH also works directly with women in the community providing capacity building and multilingual education on women’s health and wellbeing, across a wide range of issues and topics, through the use of trained, community-based, bilingual health educators.
Given MCWH’s role as a national, community based organisation committed to the achievement of health and wellbeing for and by immigrant and refugee women, this submission focusses on the health, care and wellbeing of mothers and babies in Victoria from immigrant and refugee backgrounds.