THROUGHOUT her pregnancy, Thusanli Upendran rarely understood the decisions being made about herself and her unborn twins. “But I was really scared to ask questions,” the 34-year-old told The National.
In Sri Lanka, where she lived before claiming asylum in the UK, doctors scolded patients for asking questions. As her pregnancy progressed, there were several instances of miscommunication that caused her unnecessary worry after a traumatised history.
At 35 weeks, Thusanli was told that one of the twins was measuring small and she’d need an emergency Caesarean section, a decision she couldn’t fully comprehend after having requested a vaginal delivery.
A lack of space in Glasgow’s neonatal unit would mean a transfer to Aberdeen, hundreds of miles away from her partner and other child.
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“I told them I was an asylum seeker and couldn’t afford the transport,” she said. “I said I had another child as well, and that I don’t have any help from family or friends.”
The doctor decided to re-scan Thusanli, finding this time that the small twin was now measuring normal. “I thought that because they couldn’t find a hospital, that’s why they told me this,” she said. “I didn’t know if what they were saying was true. I was really scared. I couldn’t enjoy or celebrate my pregnancy.”
Thusanli (below) is one of 100 migrant mothers in Glasgow who participated in Amma Birth Companions’ most recent study, exclusively seen by The National, revealing maternity care disparities faced by migrant mothers over a two-year period.
The final report highlights how systemic racism, inadequate communication, limited choice, and a lack of person-centred care negatively affects the birth experiences of women who already face multiple inequities.
From 2021-22, Amma Birth Companions, a Scottish charity which offers emotional support, practical guidance and a nurturing presence to people who might otherwise give birth alone, noted instances of practice issues and discrimination in 37% of recorded cases, citing issues including delayed pain relief, restricted choice, disrespectful behaviour, and misinformation.
Although 39% of the 100 clients required an interpreter, 74% of the mothers had issues acquiring one due to lack of availability of suitable interpreters, staff understanding and willingness to use interpreters, and technical issues.
From the second trimester of her high-risk pregnancy, “Kadija” attended frequent antenatal appointments in Glasgow to check the growth of her unborn baby. During these, she didn’t have the opportunity to ask questions about her medical care because she had no access to an interpreter.
“The medical staff said that they were trying to get interpreters but they were unable to find,” she said in the report. “It was really difficult, because there were so many things I wanted to ask. I wanted to know what was going on – I wanted to ask but there was no interpreter.”
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At 30 weeks, Kadija became severely unwell and required an emergency Caesarean section. In the aftermath, when she and her baby stayed for an extended period in the hospital, she was never provided with an interpreter to whom she could ask questions about her own or her baby’s care.
Maree Aldam, CEO of Amma Birth Companions, told The National: “It is crucially important that everyone entering maternity services can access information and make and express choices in their preferred language.
“Without adequate interpreting, it simply isn’t possible for individuals to fully understand the information being presented and make informed choices about their care.”
IN some cases, Aldam said, this could lead to interventions such as inductions without mothers fully understanding why they were being offered it, what the procedure involves or the risks, benefits, or alternatives.
Induction rates among the 100 women rose from 46% in 2021 to 48% in 2022, 11 percentage points higher than NHS Greater Glasgow and Clyde figures.
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In 2022, the percentage of Amma clients undergoing Caesarean sections was 18 percentage points higher than the corresponding statistics reported for NHS Greater Glasgow and Clyde.
“Our clients are undergoing inductions and C-sections at a much higher rate than the overall figures reported by Public Health Scotland,” Aldam said. “The stories captured in the report show there are complex dynamics involved in decision-making around interventions – including the balance between patient autonomy and medical recommendations, the impact of effective communication, and the emotional toll of these discussions on pregnant women.”
In the past, Aldam said attempts to reduce racialised disparities and lower risk focused on interventions like induction as the solution.
“It’s important to balance the offer of interventions against other crucial aspects of care, including the potentially negative impact of these interventions on mothers’ and babies’ physical and emotional wellbeing,” she said.
A large percentage of the women from the study grapple with histories of trauma and the stress of the asylum process, and came away from birth feeling re-traumatised and further disempowered.
“Although anyone can be deeply affected by a traumatic birth experience, it’s fair to say the stakes around childbirth are particularly high for our clients,” Aldam said.
“Many of the women we work with lack a support system, access to resources, and financial means to heal after a difficult birth. This is why it’s so important that every effort be made to minimise physiological and psychological stress during childbirth.”
Aldam and her colleagues at Amma Birth Companions “deeply sympathise” with the challenges of working within a strained and underfunded maternity service where staff are grappling with burnout. She made sure to note how many women they work with speak positively about their maternity care.
But the report evidences the impact of systemic racism, poor communication and a lack of person-centred care on asylum-seeking and refugee women and so Amma Birth Companions is calling on the Scottish Government to prioritise greater investment into maternity service reform.
Aldam hopes that by building upon the existing body of evidence of racialised inequalities in maternity care, Amma Birth Companions will contribute to the “ongoing dialogue and support the development of targeted interventions and policies that can address and alleviate these disparities.”
Key recommendations include cultivating anti-racist healthcare practices, increasing awareness of the rights and experiences of people with varied immigration statuses, implementing resources to ensure consistent use of interpreters, provide person-centred and trauma-informed care, and allocate more funding to maternity care.
“Social and cultural factors alone, like race, language, or immigration status, should never determine the choices available during pregnancy and birth,” concluded Aldam. “As one of our clients said, ‘Just because someone is in the asylum system doesn’t mean their bodies are broken, or that they lose their ability to give birth’.”
Mary Ross-Davie, director of midwifery at NHS Greater Glasgow and Clyde, said: “The experiences reported by these women in 2021 and 2022 are deeply disappointing and we are very sorry for the distress caused.
“Over the past two years, we have worked with colleagues to learn from these experiences and to address inequalities for refugee and asylum-seeking pregnant women.
“This includes additional training in trauma-informed care, effective use of interpreters, and addressing unconscious bias.
“We’ll implement the recommendations as they apply to us and will seek to influence those that apply more broadly to the NHS as a whole.”
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