We know two things that are proven ingredients to a healthy pregnancy are early booking and continuity of care (that’s regularly seeing a midwife – and ideally the same midwife). The absence of either of these things is seen as a risk.
Women who have recently arrived in Birmingham, such as those seeking asylum, are far less likely to be able to book quickly, due to them not being able to navigate the system in a new country – so being a late booker makes continuity of care even more important.
But continuity of care during pregnancy is difficult when asylum seekers are moved around so often.
The UK Border Agency’s policy of “dispersal” spreads asylum seekers around the country on a “no choice” basis, often moving people many times.
As well as the medical risks for pregnant women, there are the social risks of being moved away from their support networks. This can be socially isolating, but can also have an impact on their ability to get to appointments and understand what they’re being told.
Winta – a refugee from Eritrea – had only been in Birmingham for six months, but this was long enough for her to have formed relationships and make friends. She had joined a local church and her 11-month-old daughter attended a nursery. Winta had a regular midwife and had been going to antenatal classes, where she’d met other mums-to-be.
She shared a house just north of the city centre with another woman, also an asylum seeker. However, just three weeks before Winta was due to give birth, her housing provider decided to shut the accommodation down and move the two women elsewhere.
Under the policy of dispersal, asylum seekers are accommodated wherever there is “a ready supply of housing”. In Winta’s case, she was told that she’d be moving to Wolverhampton – a place she didn’t know at all.
She would have to leave all the support networks she’d formed – and instead start from scratch, finding a new GP, new midwife, new antenatal clinic and new nursery for her 11-month-old, in a city where she knew no-one and struggled with the language, when the baby could come at any time.
“She was due to move on the Monday, but I only found out on the Friday,” says Winta’s Pregnancy Outreach Worker, Jacqui. “So I had to move fast. I phoned the Refugee Council and explained the situation: she was three weeks from her due date – could they help me to find a way for Winta to stay, at least until the baby was born? They said they would do what they could.
“I explained to the housing provider that we were appealing the decision but, initially, they insisted that the move would still go ahead. It was quite a battle to get them to wait for the process to complete. Meanwhile, the Refugee Council had phoned the UK Border Agency, to be told we’d have to appeal in writing. So the Refugee Council had to write a letter and fax it over to them. Once that was done, we just had to hope the UKBA would take it from there. It was a stressful weekend.”
Why did this happen?
A recent report from the Refugee Council concluded that “
the UK Border Agency’s dispersal policies are putting the health of pregnant women and their babies at risk. By moving them to accommodation around the county, women are uprooted from essential healthcare and their support networks, leaving them isolated and vulnerable.”
Guidelines introduced by the UKBA last year already stipulate that
pregnant women should not be dispersed within a protected period; normally from four weeks before the estimated date of delivery until four weeks after the birth. However, it doesn’t look like this is communicated in all circumstances.
Luckily for Winta, Jacqui’s intervention meant that the UKBA were able to act quickly enough to save her from a stressful move. The housing provider told her she could stay in the house until the baby arrived.
A few days after the baby was born, the housing provider told Winta that they still wanted to refurbish the house. But instead of moving her to Wolverhampton, they found her another shared house, just a couple of miles away. Winta now lives with another woman who has a baby – and has been able to keep in touch with the support network she already had.
“I’m so pleased for her – they get on brilliantly,” says Jacqui. “I’m glad she was able to get the continuous support she needed.”
The Dignity In Pregnancy campaign
The Refugee Council has produced a short film about the risks facing pregnant women in the asylum system in the UK: Dignity in Pregnancy for Asylum Seeking Women.
Some of the women our Pregnancy Outreach Workers (POWs) support are what we refer to as “complex clients”. They have many issues – they may be drug users or victims of domestic violence; they may be homeless – and so they tend to have had many interventions, usually over many years, from multiple agencies.
So how does a POW begin to build a relationship with a complex client?
Flexibility, availability, consistency
One of the main benefits of the POW setup is its flexibility. Sarah Samersinghe, a POW who has had some memorably complex clients, explains:
“As a POW, I can go to the client – she doesn’t have to come to me. If it’s not appropriate for me to visit her at home, I can meet her elsewhere, or pick her up in the car and take her out. And I’m always available; I don’t expect to only speak to clients at appointed times.”
Consistency is very important, especially when clients have otherwise chaotic lifestyles. “It’s important to do what I say I’m going to do,” says Sarah. “If I say I’m going to be there, I’ll be there.”
Pitching it right
How does she attempt to connect with women who find it difficult to trust new faces? How does a POW help a frightened woman to make quite dramatic lifestyle changes?
“It’s about trying to read people,” Sarah says. “Pitch it right. Choose your moment. When someone’s ready, they’re ready – you’ll just know. The way I personally do this – and not all POWs do, of course – is to talk about my own family; to find elements of my own life that chime with theirs. It often allows me to identify with the client – to show that we’re human too.”
The flexibility of the role means that the POW isn’t necessarily restricted by a time limit for each case.
“Our aim is a healthy outcome for all concerned,” Sarah says. “So if I can justify it, I’ll keep the case open for as long as I feel is necessary to achieve that. For example, a social worker might have to close a case once a child is placed elsewhere, but I feel fortunate that my role allows me to stay with the mother.”
Case study: Hayley
One of Sarah’s most complex clients is Hayley (not her real name).
“Hayley’s had many issues but, when I met her, the main problem was housing. The flat where she lived was pretty much uninhabitable. It was cold and dark all the time and the building was infested with rats and mice. There was no gas supply, and the wiring was downright dangerous. There was no way of cooking, or even making a hot drink, and there was only cold water to wash in. Not good for anyone, but particularly not for a pregnant woman.”
However, the flat, owned by Hayley’s boyfriend, was her home – and it wasn’t easy for her to make the decision to move away. She was scared.
It took a long time for Sarah to persuade Hayley that she should apply for temporary accommodation elsewhere. One day she finally agreed, largely because the weather had become very cold.
In the video below, Sarah and Hayley are on their way back from the appointment with Housing Services to pick up Hayley’s ID and other paperwork she needed for the move to go through. Hayley reflects on how far she’s come. And, poignantly, she tells Sarah that she thinks this is the type of support she’s always needed.
POWs can support women all the way through their pregnancy and then for a short time post natally (usually a maximum of 8 weeks). In total the support can last for almost a year. This gives the POW the time they need to tackle the woman’s issues, but equally it gives them the opportunity to forge a useful and trusting relationship.
However they always have an eye on when their support will end – and much of what they do is to prepare the woman for this. Ideally she will be on a more stable footing and well able to be independent. For some women the journey is longer so there will still need to be a support network in place that adequately meets her needs. The aim to to ensure there is a seamless transition and that she doesn’t get lost in the system.
Michelle POW Programme Manager explains; “Ideally handover is something that is thought about before baby comes along. We like to ensure that every woman has at least one professional to turn to, should they need them. Frequently the handover is to a Family Support Worker so what we’ll try and do is arrange a visit to the local Children’s Centre while mum is still pregnant. Not only do they get to meet their Family Support Worker and begin to establish a relationship but they see what’s on offer and what they can tap into, so classes, groups etc.”
Michelle continues: “Sometimes mums-to-be, particularly those pregnant with their first baby, may worry about where to get support if they should need it once the POW is no longer around. This shows them that it’s there. It’s one less thing to worry about. It also means that they get familiar with the facilities before baby comes along, which is always a busy time, and it won’t all be new to them.”
Natasha’s coming to the end of her support from Rachael, her POW. She’s made real progress and it’s hoped that in a few months she’ll be ready to apply for her own house so she and her baby can live independently. For now, though, Rachael feels Natasha still needs some extra help – which is why she’s introducing her to what her local Children’s Centre can offer – and Natasha’s already applied to do their Positive Parenting course.
Some of the women we support are going to need more help than others. In many cases the POW has been able to solve the problems the woman was referred to us with, but in some complex cases this isn’t possible. In this situation it’s about working in partnership with other professionals and ensuring that everyone knows the part they have to play.
Miriam, one of our POWs, has concerns about one of the women she’s supporting: “She had her baby six weeks ago but due to some recent changes both she and I feel she needs some specialist help. So I’m going to initiate a CAF (Common Assessment Framework). I’m just filling out the paperwork to get things underway because my aim is to make sure the initial meeting happens before my support ends. I’d like to see who’ll be responsible for doing what and make sure someone takes over the role I’ve been doing which has been sort of co-ordinating things”
Michelle adds: “It depends on the woman. We take a lead from her and how well she’s coping. What is set is that handover must happen. There are things we do as part of it that are standard, like making sure mum knows how to register the birth, that she’s getting the benefits she’s entitled to and that immunisations are booked in, but what support remains is a unique thing; it’s tailored to the individual.”
Helping our clients to give up smoking is an important part of the work we do here at Gateway, but it can be a bit of a challenge.
Of course we, as professionals, know what the risks are for smokers – but sometimes clients just don’t want to make it a priority. Or perhaps the client tells us they do want to address it, but it’s one of a long list of things. It’s quite a skill to support clients in tackling a whole range of issues AND keep smoking cessation on the agenda.
So how do we do it? We tend to find the holistic approach is beneficial for all of our clients. Rather than adding “stop smoking” to a person’s already long “to do” list, we help them to deal with all of the issues they have in a logical order. By helping someone to begin making positive changes in other areas of their life, we often find that they decide to tackle smoking as part of a new routine.
Health Trainer Susan says, “persuading someone to get out of a routine is difficult; it’s scary for them. But once the changes start happening, we see a knock-on effect.”
Sean, another Health Trainer, agrees. “If someone starts exercising, for example, we’ll often find that other positive lifestyle changes come from that, even without much further intervention. They start eating more healthily. They’ll gain confidence. Giving up smoking is one of the things that we continue to talk about as part of that chain reaction.”
Our Health Trainers frequently find that those people who don’t choose smoking as their first priority can be convinced to come back to it. What happens is that they first need to see they can make big changes to their life. So, for example, someone who’s been supported to lose weight sees for themselves what they can achieve with a bit of encouragement. Then, they can decide to tackle something else – maybe something that they felt was out of reach, like smoking.
The Health Trainer is key to this as they’ve already been there in the background helping and supporting them, so they’re trusted to do the same thing again.
For the Pregnancy Outreach Workers, the balancing act can be particularly difficult. Of course, time is of the essence, as the earlier in the pregnancy the woman can stop smoking, the better. However when a woman has a range of issues, some often complex, there can be a lot to tackle in a short time. Team this with the fact that pregnancy is already an emotional and vulnerable time, and women can feel a bit bombarded with do’s and don’ts. We know from experience that this is when behaviour change is far less likely to happen, so it’s vital to deal with the issues with consideration.
“We have to make sure to assess a client’s whole environment before tackling things like smoking,” says POW Sophia. “It’s important to get to know the client and build up a relationship with them – to really understand the bigger picture – before we can suggest it. There are usually lots of other problems that need to be dealt with and giving up smoking is often the last thing they want to do.
“For many clients, smoking is the only link they have to ‘life before baby’ and they see it as a stress relief – a way out. So if we’re going to persuade them to give that up, we have to pick our moment very carefully. It’s tricky, but we always find a way.”
In the last quarter of 2012, 65 babies were born to clients of our Pregnancy Outreach Workers team, and 55 of those women initiated breastfeeding.
That’s 85%, compared to an average of 65% in the wider community*.
In December alone there were 17 births and 16 of the women initiated breastfeeding – a whopping 93%.
Increasing the rate of breastfeeding is something that’s important at both a national and local level, so we’re delighted to be doing our bit to reach the city’s targets.
Most clients want to breastfeed – they know it’s the natural thing to do and the benefits it brings – but sometimes they need just that extra bit of help. That’s why all of our POWs are trained in breastfeeding support as part of
Unicef’s Baby Friendly Initiative.
Before the baby arrives, POWs give their clients lots of information, including leaflets and DVDs from the World Health Organisation and Unicef. Often, POWs will watch the DVD with the client so that they can explain or interpret it, talk about it and answer questions. We also run group sessions where POWs can demonstrate different breastfeeding techniques using dolls.
Sophia and Khadijah run a session at Springfield Children’s Centre. “It’s a six week course, where we show the DVD and give out handouts, as well as giving demonstrations of things like how to help baby latch on,” says Sophia. “We answer questions and discuss worries so that the mums are as prepared as possible. Then, for up to eight weeks postnatally, we visit mum and baby to give some extra support when they need it most.”
In this video of a typical breastfeeding group session run by the POWs, Colette uses a doll to show some different techniques for breastfeeding:
Another POW, Jacqui, says, “At the time of the birth, breastfeeding support is vital. We find that if the mother doesn’t get enough help and encouragement straight away, in the hospital, she’s more likely to start bottle feeding. That’s where POWs can really make a difference.”
Jahanara’s client had her baby on Sunday. “I was her birthing partner,” she explains. “Before the baby was born, the mum had told me that she wanted to breastfeed; this is her second child and she’d already told me how difficult she found it when she bottle fed her first baby. So I knew it’s what she wanted – but, after giving birth, she was so tired, she just didn’t want to do it. She wanted to give the baby a bottle. So I gently reminded her of everything she’d talked about before, and encouraged her to try again. Now she’s very happy to be breastfeeding.”
*published average breastfeeding rates for 2012 in the wards we cover. Source: Birmingham Public Health Health Inequalities Action Plan 2012.
Pre Natal Infection is one of the major causes of infant mortality. Our Pregnancy Outreach Worker Service (POWs) works hard to reduce infant mortality here in Birmingham, so today, the first day of Pre Natal Infection Prevention month seems the ideal time to explain what we do to help.
If women miss their ante natal appointments they and their babies are at more significant risk. We see that part of our role is to get this message across but then it’s about taking practical steps to make sure they get there. Many of the women we work with have missed appointments, in fact this is one of the reasons midwives refer people to us as they know we can be relied upon to tackle this issue. We understand why what appears to be a routine thing can be a problem for some women. Recognising the issues helps us put in place practical steps as Shazia one of our POWs explains:
Over the past 6 months we have supported 150 of the women we work with to attend their ante natal appointments, whether that be by helping them get them booked in, ringing them the day before to remind them, explaining in advance what they can expect, or accompanying them to give them some morale support (even giving them a lift if they’re stuck for transport).
From April, the government will begin making significant changes to the benefit system. Our work is to reduce inequalities and we are concerned that these reforms will further deepen the divide.
Sadly, we are powerless to do anything to prevent these changes. But what we can do is to make sure we help ensure that the people who will be most adversely affected are aware of what’s happening – and that they’re as ready and well-prepared as they can be. This is where outreach workers can play a vital role, families being ‘financially literate’ is so important for families to be able to manage as their income reduces.
Many of the people we work with are in receipt of benefit. Lots of the women our Pregnancy Outreach Workers support claim housing benefit and a large number of our Health Trainer clients are people living with long and short term health conditions, who are supported by the Disability Living Allowance. There are major changes planned to both of these benefits along with the overall benefit cap that will affect all working age claimants.
These are national issues that are due to be phased in area by area over the coming months but here local people will also have to contend with a proposed reduction to Council Tax benefit. In real terms what this means is that many people will have to learn how to live with less.
So where do we come in? Firstly we recognise that many people are currently unaware of what these changes will mean to them and their families, many don’t even know that changes are afoot. So where we begin is by helping them see and understand what this means to them. We are in a unique position, our support staff go into people’s homes, they develop a strong bond with their clients and they are trusted – so who better to help? Over the coming weeks we will be ensuring all our staff have a sound basic understanding of the changes so they can start the conversation, many already help their clients look at basic budgeting so this is a very practical way of them identifying how the essentials will still be afforded.
The second step will be to effectively signpost people for further support. This is about knowing the best organisation to help that person with their specific needs. For example: benefits advice, financial guidance, debt management and how to manage on a low income. The quality and timeliness of advice will be vital so we are pleased to be a partner in the local bid to the Advice Transition Fund (led by Birmingham CAB) which looks at improving the co-ordination of advice in the city, recognising that the advice and guidance sector has already been harshly affected by cuts.
So much of what we do is about improving health and the wider determinants of health, that we see this as a perfect fit. We know that for people to make difficult lifestyle changes – all the pieces matter. How can we tackle the things we need to, like support a pregnant woman stop smoking? or help someone lose weight so they are able to have their operation? when they have to cope with such stressful situations like their income being reduced which makes their already difficult circumstances even worse.
We realise this is just the start of a long term plan. This isn’t something that will be fixed quickly and it will take a range of approaches but we feel by starting now, while there is still time to plan we will help the people we know to at least prepare.
There is a lot less money around at the moment, so what little there is needs to be spent wisely. One of the easiest options is to make cuts to preventative services for people who aren’t in the system… yet.
This may be a quick win for the government, but they’re in danger of leaving a much bigger hole than anyone seems to realise. Cuts to support services may provide a small saving in the short term but, long term, the figures just don’t add up.
Take one of Gateway’s recent clients. Sarah* was referred to Gateway when she became pregnant. Given her troubled background, and the lifestyle that she was leading at the time, it was expected that her new baby would have to be taken into care.
For nine months, during and after her pregnancy, a Pregnancy Outreach Worker helped Sarah to access help from a variety of sources. Homeless, with one child already in care, Sarah needed practical and emotional support. Her POW listened without judging, made it easier for her to attend her appointments, and helped her understand what was happening at case conferences.
We helped Sarah apply for crisis loans to get her through the pregnancy and first few months after the birth. She underwent anger management counselling and drug counselling. We helped her to find local authority housing.
Eventually, after a lot of hard work by both Sarah and her POW, she was able to show that she could provide stability and proper care for her own child. And so, when the baby was born, social services came to the decision that mother and baby would be better off staying together.
I’m not telling you this story in the hope of warming your heart. I’m telling you because:
The approximate cost of taking a child into care for 9 months is £28,000
The approximate cost of the combined preventative services that Sarah accessed over 9 months is £6,000
Preventative services have saved our economy over £20,000. And that’s just for one child.
This theory works across all services, not just for Gateway POWs. Fall prevention, for example – everything from installing grab rails to making little lifestyle changes so that someone uses the stairs less – minimises the chance of someone having a fall. The estimated cost for the first time a person falls is about £40,000, but that £40,000 could pay for fall prevention staff to go into around 200 homes. Yes, that’s £40,000 per person vs £200 per person.
Often there is a perception of voluntary/third sector organisations as “do-gooders”, but we’re not just in this to be nice. Of course there is a moral, emotional, argument that says “people need to be helped”, but there’s also a compelling economic argument: people who are better supported, who are cared-for
before their issues escalate into crises, simply don’t cost as much.
*names have been changed
Sources for figures:
Average cost of child in foster care: The Schools and Families Committee – 2008/9. £774 per week, so 9 months = £27,864. Costs of support services are estimated; based on Gateway FS’s POWs service, which is costed at £20 per hour. First falls costs: Birmingham Local Authority Strategic Shift to Prevention 2012.
Photo: Kriss Szkurlatowski, 12frames.eu
The last few weeks have seen Gateway staff go into overdrive collecting food and other essentials for our food banks. We’ve been overwhelmed by the generosity of our donors, including many of our partner organisations, like Narthex, Healthy Minds and Birmingham Registry Office, as well as our own staff and members of the public.
In the video below you can see how Gateway staff used many of the donations to put together personalised Christmas hampers for their clients. We also hear from Shanaz, with her new baby, talking about what the donations mean for her.
The hampers include food, but also essentials such as toiletries, nappies and baby clothes; and some small wrapped gifts, so that older children have something to open on Christmas day.
The arrival of a baby should be an exciting time and something to celebrate, but financial issues can make it a time of worry. For families below the breadline, having a baby puts a immediate pressure on already unmanageable finances, so we want to do what we can to ease these concerns. Whether the situation is short term or not, a one-off parcel like this provides food and other essential items to bridge a gap.
“Equality of opportunity” doesn’t just refer to having enough money or food; we think everyone has the right to be happy, too. We hope that by providing some practical help, along with the emotional support that our Pregnancy Outreach Workers already offer, we can take away some of the stress and give families the chance to enjoy bonding with baby.