Title: The Migration And MAternal Health (MAMAH) Study: Identifying clinical and policy interventions to improve maternity care for underserved migrant women in the UK
Funder: Department of Health and Social Care

Abstract: Background:One third of births in England and Wales are to women born outside the UK.1 Some underserved* migrants, including refugees and asylum-seekers, are at high risk of perinatal morbidity owing to various factors including barriers to accessing the NHS, poverty, and poor English language skills.2 Asylum-seekers and refugees are offered free NHS care in England, but undocumented migrants (e.g. refused asylum-seekers) must pay 150% of secondary care costs, including maternity care.8-10 Evidence suggests these women delay seeking NHS pregnancy care due to fears about charging.2 Not all migrant women are from minority ethnic backgrounds, but some are.1 Data suggest that pregnant women from minority ethnic backgrounds have up to a five times higher risk of maternal mortality and twice the risk of stillbirth compared to women from White ethnic backgrounds.3,11,12 Thus, underserved migrant women from minority ethnic groups are likely to face a compounded risk of perinatal mortality and morbidity. Research Gaps:In the UK, there is a lack of quantitative data exploring perinatal outcomes for underserved migrant women. There is also a lack of consensus on the most effective interventions to improve outcomes for these women. This project aims to address these gaps by quantifying the perinatal outcomes of underserved migrant women in the UK, and identifying key clinical and policy interventions to improve perinatal outcomes for these women. Fellowship Proposal:Workstream 1: A systematic review to assess the evidence-base for interventions aiming to improve perinatal outcomes amongst underserved migrant women in high-income countries.Workstream 2: Analysis of NHS perinatal outcome data amongst 40,000 non-EU migrants to England between 2005-2020, with a case note review of approximately 60 migrant women's records who died in pregnancy in the UK between 2009-2019.Workstream 3: Conducting interviews and focus groups to understand what expertsincluding experts by experience**, clinicians, researchers, and policymakersview as acceptable and feasible approaches to improving the perinatal outcomes of underserved migrant women.Workstream 4: Working with stakeholders to create a series of resources and recommendations to improve perinatal outcomes for underserved migrant women in the UK. Patient and Public Involvement:I co-developed this proposal with an expert by experience who was charged for NHS pregnancy care. We engaged with over 40 stakeholders including other experts by experience, clinicians, charities, policymakers, and researchers. Four engagement events, each including experts by experience, were convened to review the proposal. A fellowship Steering Group including experts by experience, and a Patient and Public Involvement Panel will provide input throughout the fellowship. Dissemination and Impact:A likely key output will be recommendations for updated clinical guidance and training resources for those providing maternity care for underserved migrant women in the UK. It is anticipated that videos, infographics, social media, policy briefings, articles, and presentations created throughout the fellowship will be used to improve NHS clinical care and influence policy. * 'Underserved' refers to asylum-seekers, refugees, undocumented refugees (e.g., refused asylum-seekers), and migrant women from low-income backgrounds.**An Expert by Experience refers to someone with lived experience (e.g., a service user)

Lay abstract: What's the problem?One in three births in England and Wales is to a migrant woman*, i.e. a woman who was born outside the UK.1 In the UK, 'underserved' migrant women are more likely to die in pregnancy, and they are less likely to get good pregnancy care.2-6 In this project, underserved migrant women are refugees, asylum-seekers, migrant women with little money, and migrant women without an official visa. There are many reasons for poor pregnancy health amongst underserved migrant women including not having support to access the NHS, not having family nearby, not speaking English well, and experiencing discrimination.In the UK, refugees and asylum-seekers get free NHS care. A refugee or asylum-seeker is someone who the government agrees has come to the UK because it's not safe to go back to their country. However, migrant women without an official visa (e.g., those who are refused the 'asylum-seeker' visa) can be charged 150% of NHS pregnancy costs. A normal birth costs around 8,000 and a complicated birth with a long hospital stay could cost 200,000.7 These women sometimes delay coming to the hospital to get pregnancy check-ups as they are scared the costs may be too high.2 This puts them and their baby at risk.What research is needed?In the UK, we don't fully understand how to help underserved pregnant migrant women because we have not listened to them to understand what they need, and do not have good evidence for what works. We need new research to understand this better.What will this project do?This project will bring together underserved migrant women, midwives, doctors, researchers, charities, and the government to create a plan for action to improve underserved migrant pregnancy care in the UK.The project will have four parts: Evidence Search: To see what has worked to improve pregnancy care for underserved migrants in the UK and in similar countries. NHS Patient Data: Analyse the records of 40,000 migrant women who have given birth in the UK over the past fifteen years, and look in detail at NHS notes from 60 pregnant migrant women who died during this time. We will try to understand what makes underserved migrant women at higher risk of death or illness in pregnancy by comparing them with UK-born women giving birth at the same time. Listen: To understand what underserved migrant women, midwives, doctors, researchers, government, and charities think can improve care. Plan and Resources: Create a plan and tools for improving care for underserved pregnant migrant women, especially those women who pay for NHS care. This may include new guidance, toolkits, factsheets, a video, and social media resources.How will patients and the public be involved?The project has been designed with a migrant woman who is an expert by experience (someone with lived experience of being charged for pregnancy care), and forty other experts including other underserved migrant women, midwives, doctors, charities, researchers, and government workers. Two stakeholder workshops, and two patient groups helped create a plan for the project. A Patient and Public Involvement Panel and a Steering Group have been created; they will provide advice throughout the project and will help in creating an action plan. Factsheets, videos, social media, articles, and presentations will be created with these groups and will help to share the findings with the public and patients.*The term 'woman' is used throughout this application. However, the applicant recognises that not all people who are pregnant and give birth will identify as women, and it is vital that evidence-based care for maternity, perinatal and postnatal health is inclusive.

Research activity codes: 7.1 INDIVIDUAL CARE NEEDS;8.1 ORGANISATION AND DELIVERY OF SERVICES
Health categories: REPRODUCTIVE HEALTH AND CHILDBIRTH