Refugee claimant women and barriers to health and social services post-birth.

Merry, Lisa A. ; Gagnon, Anita J. ; Kalim, Nahid 等

Many who flee their country and seek refugee protection in another country, i.e., asylum seekers/refugee claimants, have suffered abuse and other traumatic experiences. Women are particularly vulnerable and may have been victims of sex and gender-based violence. (1) Once in a new country, their precarious status (not knowing if their application to stay in the country will be accepted), limited or no fluency in official language(s), separation from family members, and unfamiliarity with the country's systems and laws add further stress. (2) In Canada, claimants are covered for emergency and essential health care under the Interim Federal Health Program (IFHP). (3) Benefits covered include prenatal, contraception and obstetrical care; essential prescription medications; emergency dental treatments; and treatment and prevention of serious medical conditions. Other services such as counseling or psychotherapy, diagnostic procedures, ambulance services (unless for emergency) and eyewear are also covered but require pre-approval from Citizenship and Immigration Canada (CIC). (3)

Access to services among vulnerable migrants living in Canada is a major concern. (4) The postpartum period is a time when additional health services and support are needed. Our research to date examining the health and service needs of childbearing migrants has shown that refugee claimant women have a higher number of postpartum health and social concerns not being addressed by the health care system compared to Canadian-born women. (5,6) The current project aimed to gain greater understanding of the barriers refugee claimant women face in accessing health and social services in the post-birth period in Montreal and Toronto, the two Canadian cities that receive the highest number of claimants. (7) Guiding our work is the health capability framework proposed by JP Ruger (8) which suggests it is socially unjust for any individuals to be deprived of capabilities to be healthy as a result of suboptimal health care, inhibited health agency (i.e., ability to engage with and navigate the health care system to prevent mortality and morbidity and to meet health needs) and oppressive social norms.

METHODS

This study was a qualitative subproject of a larger four-year multisite prospective cohort study entitled "The Childbearing Health and Related Service Needs of Newcomers" (CHARSNN). (9) Ethical approval was obtained for CHARSNN from all participating universities and hospitals. For participation in the CHARSNN study, Canadian-born women and migrant women ([less than or equal to] 5 years in Canada, speaking any of the 13 study languages) were recruited from among 12 postpartum units in Montreal, Toronto and Vancouver. All women giving birth during the recruitment period were screened for eligibility (N=58,342 women). Once a refugee or a refugee claimant woman was identified, an immigrant or Canadian-born woman matched by closest date and time of birth was recruited (immigrant and Canadian matches were alternated). All consenting participants were visited by a research nurse at 2 weeks and at 4 months post-birth to assess maternal and infant physical and psychosocial health and to record services received. These data were then independently reviewed by a nurse expert blinded to the research questions, city of residence and immigration status of the participants to determine whether the professionally-identified concerns (determined through the use of screening tools and objective criteria based on standards of care, (10)) were addressed by the health care system. For the current project, CHARSNN records of refugee claimant women in Montreal with [greater than or equal to] 5 'unaddressed' concerns at either 2 weeks or 4 months post-birth and in Toronto women with [greater than or equal to] 3 unaddressed concerns were qualitatively analyzed. Selection criteria differed by city in order to yield a comparable number of records for review. Vancouver was excluded due to too few refugee claimant participants at that site.

The data analyzed mainly included ad hoc notes recorded by the nurses during telephone and home contacts. These were not part of the planned CHARSNN data collection but provided insight regarding women's experiences in accessing and receiving (or not receiving) services. 'Care diaries' (maternal reports of care received between birth and 4 months postpartum and reason for care) provided information on services accessed. An in-depth analysis of these texts was conducted to identify themes related to access barriers. (11,12) A framework for categorizing the data was devised based on the research objective and an initial reading of the records. Ten to fifteen records were then reviewed to test and refine the categories (i.e., main themes) and to ensure consistency in how they were applied. All records were reviewed and text in the form of passages, quotations or single words was extracted and transcribed into a table containing all of the theme headings. The majority of records were coded by NK, the primary coder; the second coder LM reviewed records with French text and also reviewed and recoded a subsample (5-10% from each city) of records coded by NK to test reliability of the analysis. Discrepancies were resolved by discussions between the two coders. Once the coding was complete, the coders jointly reread the text segments within the context of the categories under which they were classified in order to identify patterns and subthemes that best summarized the main themes.

RESULTS

A total of 112 records were reviewed (51 Montreal; 61 Toronto). Background characteristics of the participants are detailed in Table 1. Montreal participants were mainly from Nigeria, Mexico and India; Toronto participants were from Nigeria, Mexico, Colombia and St. Vincent. Women were similar in age to the Canadian average age of women giving birth.13 Most of the women had low levels of education, were living in poverty and were living without the father of their baby.

Six main themes emerged from the data: isolation; difficulties reaching mothers postpartum; language barriers; low health literacy; lacking psychosocial assessments, support and referrals; and IFHP being limited and confusing.

Isolation

The majority of women were new to Canada, having arrived less than two years prior to their baby's birth. Women reported being separated from family and friends and having no access to child care. They therefore felt isolated; they didn't know where to get services, had difficulty getting to services and overall felt they had "no one to help".

One research nurse in Toronto wrote:

"She is here as a refugee. She came alone and left her husband and 2 yr old child in China. She only speaks Mandarin. Mother is living in a small apartment with 4 other families she does not know--Mom claims none of them are her friends and they do not help her. No help, not enough food and not aware of social resources." (24 y.o., China, 1 yr 4 mos in Canada)

Difficulties reaching mothers postpartum

A number of women were living in a shelter or had other temporary accommodation. Women moved frequently and were not easily reachable by phone. Some had no phone or it was out of service or their number had changed. Often women simply did not respond to calls. In other cases, their husband had the cell phone, or their phone was turned off or out of credits.

A research nurse in Toronto describes her experience in trying to contact one mother:

"I called several times. She was unavailable. It was difficult to locate her. A worker states she has left the shelter. 'Jessica', a person who lived at the shelter, knows the client and gave me her phone number."

(35 y.o., Nigeria, 7 mos in Canada)

Language barriers

At four months post-birth, many women could not communicate well in English or French. For women living with the father of the baby, most of the fathers also did not speak English or French well/fluently. Women had difficulty accessing language classes because they had no transportation or child care, did not know where courses were offered or could not afford to attend. Women therefore had communication difficulties when trying to access services. Interpreters were not available and women could not easily express their concerns or understand teaching and information given. Women also reported hesitating to call 911 in the case of an emergency for fear of not being able to communicate.

The research nurses reported:

"Mother wanted to learn French but needs money for bus pass."

(28 y.o., Nigeria, 5 mos in Canada, Montreal)

"The woman claims the social worker told her she has to research [English] classes on the internet herself. The woman paid someone to interpret at her [prenatal] visits. Public health nurse called to check on mom and baby but there was no interpreter so they were not able to communicate."

(26 y.o., Mexico, 8 mos in Canada, Toronto)

"She's been able to access services for learning French and she went but was told she could not go with her baby."

(30 y.o., Nigeria, 10 mos in Canada, Montreal)

Low health literacy

Thirty to forty percent of the mothers were primipara and close to half had experienced a cesarean or operative vaginal birth. As both new mothers and new to the country, women lacked knowledge about self-care and baby care, and due to the language barriers, teaching was poorly understood or not provided.

A Montreal research nurse explains in the following:

"Mother has had no nurse [visit] yet. She is a new mother who has very little info, intensive teaching had to be done ... breastfeeding ... mother does not know why she has to give vitamin D."

(25 y.o., Mexico, 1 yr in Canada)

"Mother doesn't know about 911. She said she would call neighbour or go to hospital.... She also said if there is no time she will pray to God for help.. "

(25 y.o., Pakistan, 6 mos in Canada),

Due to their precarious migration status, women were also hesitant to seek care, especially for themselves. One Toronto research nurse describes two women's experiences:

"Mom will not pursue counseling regarding PTSD until she knows the results of the [refugee claim] hearing ... Her symptoms are stronger than usual due to pending hearing and having to relate stories of her traumatic experiences."

(30 y.o., Colombia, 1 yr in Canada)

"Mom took baby to children's hospital due to respiratory distress. Mom is also sick but was not treated. She did not go to hospital for herself. She was told at the children's hospital that she will be sent a bill for $42 for baby visit. She was unable to find a physician to examine her. Mom said she was afraid to go to the children's hospital but went anyway as she was very worried about baby's health."

(27 y.o., China, 13 mos in Canada)

Lacking psychosocial assessments, support and referrals

Of the 50 participants in Montreal who received a 4-month home visit, 26 women had symptoms of postpartum depression (PPD) and 16 reported skipping meals due to lack of resources. In Toronto, 27 of the 58 women visited at 4 months had symptoms of PPD and 11 reported skipping meals. Many had also experienced abuse within the past year (10 of 36 and 12 of 54 who completed the screen in Montreal and Toronto, respectively). A number of women came from areas of armed conflict and slightly more than 10% had spent time in a Canadian detention centre. Despite their migration histories, rate of psychosocial concerns and low SES, very few of these women were being followed by support programs that exist in Montreal and Toronto and are meant to care for high-risk mothers.14-16

The lack of psychosocial assessment and support was clearly noted by the research nurses:

"She did not mention it [skipping meals] because the [nurse] had not asked."

(33 y.o., Congo, 1.5 yrs in Canada, Montreal)

"She [the mother] was unaware that there are health professionals who deal specifically with this type of abuse. She has never had any counselling."

(25 y.o., Mexico, 11 mos in Canada, Toronto)

"The [family] was told that since they are on welfare then they cannot receive anymore assistance ... they cannot receive any more [food]coupons."

(21 y.o., India, 1 yr 4 mos in Canada, Montreal)

"She was told she would no longer receive milk and egg coupons, they are only for during pregnancy."

(38 y.o., Haiti, 1 yr in Canada, Montreal)

IFHP is limited and confusing

It was unclear to women and health care professionals which services were covered under IFHP and women and their infants were consequently refused care and/or charged fees.

The following research nurse excerpts illustrate these challenges:

"The doctor sent her [mother] for blood tests and did not tell her that they are not covered by insurance."

(35 y.o., Nigeria, 7 mos in Canada, Toronto)

"The family practitioner charged her $50 for baby visit even though she had the form from hospital showing it was the health card for baby."

(32 y.o., India, 4 yrs 8 mos in Canada, Toronto)

"Mom has lost her documentation [IFHP]. Her social worker is helping her to get it replaced, but have not been successful. Mom is concerned she may not have access to healthcare for herself at present ..."

(30 y.o., Nigeria, 10 mos in Canada, Toronto)

"Paediatrician refused to see baby because she had no medicare. One month later the paediatrician gave her an appointment but when mother said she still had no medicare then he cancelled it."

(36 y.o., Mexico, 6 mos in Canada, Montreal)

DISCUSSION

Refusal of care for infants of mothers with IFHP is alarming. Health care providers lacking knowledge of or willingness to accept IFHP is a known issue, (17,18) however the extension of refusal to infants of refugee claimants has not been brought to light. Isolation of new mothers and difficulty for public health nurses to reach women in the postpartum period are also important concerns for this population. Language barriers, hesitance to seek care and confusion related to IFHP (17,18) are similar to what many migrants generally have reported. This includes inaccessibility of interpreter services and not seeking services due to confusion regarding IFHP coverage or for fear it could affect their status. In the postpartum context, hesitance to seek care might also be due to mistrust or cultural inappropriateness of services for certain concerns such as depression or abuse. (19)

Implications for health care therefore include better postpartum screening to identify and refer high-risk mothers, such as women who arrived recently to Canada, those with limited language skills and/or not living with the father of the baby. Requesting additional phone numbers prior to hospital discharge, repeated calls and/or 'drop-in' home visits to women not easily reachable by phone are also recommended.

At the institutional and policy levels, strategies are needed to facilitate the use of interpreters and to educate clinicians on claimants' coverage and eligibility for services. Better teaching of emergency numbers and assessment and support for psychosocial concerns (PPD, abuse and food insecurity) according to maternal-child health best practices (10,20) are also needed. Recommended health literacy approaches for immigrants (e.g., plain language and pictograms) should also be applied in teaching to enhance usability of health information and services by refugee claimant women. (21)

On the immigration side, the addition of psychological services to the benefits covered for refugee claimants without prior approval by CIC could help streamline access to mental health services. Interventions aimed at social determinants (income, housing, social support) underlying health care access issues among childbearing refugee claimants should also be explored. These might include providing access to language courses, social housing and government-sponsored benefits for parents such as subsidized daycare, tax benefits and other child-related subsidies which currently have restrictive eligibility that limit or exclude claimants' access. (22-27)

The main limitation of this study is that it is a subproject of a larger study whose objective did not include understanding health care access barriers. Analysis was therefore limited to maternal reports of services received and ad hoc notes recorded by the nurses; access issues could not be explored in-depth with the women directly. The strength of this study is that it provides further evidence to the growing literature on health care access disparities and highlights concerns specific to childbearing refugee claimant women.

Sources of Funding: Canadian Institutes of Health Research (CIHR); Immigration et metropoles (Centre of Excellence in Immigration Studies--Montreal); Le Fonds de la recherche en sante du Quebec (FRSQ)--Career support for AJ Gagnon. Lisa Merry holds a FRESIQ (Fondation de recherche en sciences infirmieres du Quebec) doctoral bursary through their MELS Universities' program and is also funded by the Strategic Training Program in Global Health Research, a partnership of the Canadian Institutes of Health Research and the Quebec Population Health Research Network;

Acknowledgement: CHARSNN co-investigative team: Cindy-Lee Dennis, Geoffrey Dougherty, Becky Palmer, Jean-Francois Saucier, Elizabeth Stanger, Donna E. Stewart, Olive Wahoush.

Conflict of Interest: None to declare.

Received: December 2, 2010

Accepted: April 8, 2011

REFERENCES

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(2.) Thomas TN. Acculturative stress in the adjustment of immigrant families. J Social Distress and the Homeless 1995;4:131-42.

(3.) Citizenship and Immigration Canada. Interim Federal Health Program, Information Handbook for Health-Care Providers. Edmonton, AB: FAS Benefit Administrators Ltd., 2006.

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(6.) Gagnon AJ. Childbearing Health and Service Needs of Migrants [oral presentation given at the CPHA 2010 conference: Public Health in Canada: Shaping the Future Together]. Archive of the CPHA Centennial Conference, 2010. Available at: http://resources.cpha.ca/CPHA/Conf/Code/Presentations.php?y=2010&l=E&t=1&p= 1&name=gagnon (Accessed May 1, 2011).

(7.) Citizenship and Immigration Canada. Facts and Figures 2008: Immigration Overview--Permanent and Temporary Residents. Ottawa, ON: Minister of Public Works and Government Services Canada, 2009.

(8.) Ruger JP. Rethinking equal access: Agency, quality, and norms. Global Public Health 2007;2(1):78-96.

(9.) Gagnon AJ, Wahoush O, Dougherty G, Saucier JF, Dennis CL, Merry L, et al. The Childbearing Health and Related Service Needs of Newcomers (CHARSNN) study protocol. BMC Pregnancy and Childbirth 2006;6(31). Available at: http://www.biomedcentral.com/1471-2393/6/31 (Accessed May 1, 2011).

(10.) Health Canada. Family-centred Maternity and Newborn Care: National Guidelines. Ottawa: Minister of Public Works and Government Services, 2000.

(11.) Aronson J. A pragmatic view of thematic analysis. The Qualitative Report 1994;2:1-3. Available at: http://www.nova.edu/ssss/QR/BackIssues/QR21/aronson.html (Accessed May 1, 2011).

(12.) Attride-Stirling J. Thematic networks: An analytic tool for qualitative research. Qualitative Research 2001;1(3):385-405.

(13.) Statistics Canada. Mother's Day... by the numbers. 2006. Available at: http://www42.statcan.gc.ca/smr08/2006/smr08_047_2006-eng.htm (Accessed May 1, 2011).

(14.) La Direction des communications du ministere de la Sante et des Services sociaux. Services integres en perinatalite et pour la petite enfance a l'intention des familles vivant en contexte de vulnerabilite, Cadre de reference. Quebec, QC: Bibliotheque nationale du Quebec, 2004.

(15.) La Maison Bleue. 2010. Available at: http://www.maisonbleue.info/ (Accessed May 1, 2011).

(16.) City of Toronto. Healthy Babies, Healthy Children. 2010. Available at: http://www.toronto.ca/health/healthybabieshealthychildren/index.htm (Accessed May 1, 2011).

(17.) ter Kuile S, Rousseau C, Munoz M, Nadeau L, Ouimet MJ. The universality of the Canadian health care system in question: Barriers to services for immigrants and refugees. Int J Migration, Health and Social Care 2007;3:15-26.

(18.) Simich L, Wu F, Nerad S. Status and health security: An exploratory study of irregular immigrants in Toronto. Can J Public Health 2007;98:369-73.

(19.) Gagnon AJ, Carnevale FA, Saucier JF, Clausen C, Jeannotte J, Oxman-Martinez J. Do referrals work? Responses of childbearing newcomers to referrals for care. J Immigrant and Minority Health 2010;12:559-68.

(20.) Registered Nurses' Association of Ontario (RNAO). Interventions for Postpartum Depression. Toronto, ON: RNAO Nursing Best Practice Guidelines Program, 2005.

(21.) Simich L. Health Literacy and Immigrant Populations. Ottawa: Policy brief prepared at the request of the Public Health Agency of Canada, submitted to the Public Health Agency and Metropolis Canada, 2009.

(22.) Canada Revenue Agency. Employment Insurance (EI) and Workers and/or Residents Outside Canada. 2010. Available at: http://www.servicecanada.gc.ca/eng/ei/information/outside_canada.shtml (Accessed May 31, 2011).

(23.) Gouvernement du Quebec. L.R.Q., chapitre A-29.011, Loi sur l'assurance parentale, 2005. Available at: http://www2.publicationsduquebec.gouv.qc.ca/dynamicSearch/ telecharge.php?type=2&file=/A_29_011/A29_011.html (Accessed May 31, 2011).

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(25.) Canadian Council for Refugees. Children's rights, Access to services--Summary by province. Accessibility of Services in Ontario. 2008. Available at: http://www.ccrweb.ca/en/content/ontario [serial online] (Accessed May 31, 2011).

(26.) Canada Revenue Agency. CCTB: Application and Eligibility. 2010. Available at: http://www.cra-arc.gc.ca/bnfts/cctb/fq_qlfyng-eng.html (Accessed May 1, 2011).

(27.) Canada Revenue Agency. UCCB--Application and eligibility. 2009. Available at: http://www.cra-arc.gc.ca/bnfts/uccb-puge/pplctn-eng.html (Accessed May 31, 2011).

Correspondence: Lisa Merry, 2155 Guy St, Suite 400-7, Montreal, QC H3H 2R9, Tel: 514-843-1419, Fax: 514-843-1439, E-mail: [email protected]

Lisa A. Merry, MSc(A), [1] Anita J. Gagnon, PhD, [1,2] Nahid Kalim, MA, [3] Stephanie S. Bouris, BA [1]

Author Affiliations

[1.] Department of Nursing, McGill University, Montreal, QC

[2.] Department of Obstetrics and Gynaecology, McGill University Health Centre, Montreal, QC

[3.] St. Mary's Hospital, Montreal, QC

Table 1. Background Characteristics

                                       Montreal       Toronto
                                        (n=51)        (n=61)

Demographic Variables
Age (years), mean (SD)                29.2, (6.0)   28.5, (5.5)
Income (CDN $)
  <$10,000/yr                             25            26
  [greater than or                        26            35
  equal to] $10,000/yr
Level of education completed
  [less than or equal to] 12 yrs          29            34
  >12 yrs                                 22            27
Living with father of the baby
  Yes                                     32            31
  No                                      19            30
Migration variables
UN region of birth
  Africa                                  14            14
  Asia                                    10            10
  Europe                                   1             2
  Latin America                           26            35
Came from an area of armed
conflict *
  Yes                                     16            19
  No                                      34            37
  Unknown                                  0             2
Spent time in Canadian
immigration detention centre *
  Yes                                      6             6
  No                                      44            50
  Unknown                                  0             2
Length of time in Canada
[less than or equal to] 2 yrs             45            39
[greater than or equal to] 2 yrs           6            22
Spoke English or French at
4 months post-birth *
(could communicate well/fluently)
  Yes                                     25            33
  No                                      25            25
Father of baby (living with
mother and baby) spoke
English or French when                  (n=31)        (n=29)
first arrived in Canada *
  Fluently/Well in one or the other       17            18
  With difficulty/Not at all              14            11
  in both languages

Health variables
Parity
  Primipara                               17            24
  Multipara                               34            37
Type of birth
  Spontaneous vaginal                     29            32
  Vaginal operative                        1             6
  Cesarean                                21            23

* Data collected at 4-month home visit not available for 1 Montreal and
3 Toronto participants (women withdrew after the first home visit).