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Interactive Group Education for Pregnant Asylum Seekers
Keywords: asylum seekers antenatal care refugees
Researchers: I.R. Postma Dr. E.I. Feijen-de Jong A. Verschuuren J. Stekelenburg
Nature of the research: This is an already ongoing study, which evaluates Interactive Group Education for Pregnant Asylum Seekers. Questionnaires measuring antenatal knowledge and patient satisfaction have been administered and need to be registered and analyzed.
Fields of study: obstetrics

Background / introduction

With more than 20,000 asylum seekers arriving in the Netherlands per year, health care for this vulnerable population has become an important point of interest. Asylum seekers are refugees whose request for sanctuary has not been processed yet by the country they seek refuge in. Of all asylum seekers, 25 per cent are women of reproductive age. Research suggests that asylum-seeking women are disproportionately affected by health and social problems as compared to men, presumably because they are more vulnerable to physical assault and sexual harassment and they often feel their experiences and fears are not taken seriously. A significant number of the female refugees is pregnant and expected to deliver during their stay in the Netherlands. Research has shown that pregnant asylum seekers have a significantly higher maternal mortality and maternal morbidity. Also, perinatal mortality is two times higher in pregnant asylum seekers as compared to autochthonous women. Currently the same antenatal care is offered to pregnant asylum seekers as to autochthonous women. Several aspects complicate the provision of adequate antenatal care to asylum seekers. Research has shown that the use of antenatal care in the Netherlands is significantly lower in ethnic minority groups as compared to autochthonous women. Especially late entry in antenatal care limits the time to provide these women with sufficient and adequate information. Known factors that contribute to less use of antenatal care and complicate delivery in ethnic minority groups in the Netherlands are inadequate knowledge of the Dutch health system, the language barrier, low educational level and unplanned or unwanted pregnancies. In asylum seekers, the transfer between refugee centers that results in discontinuity of antenatal care adds upon this. Offering antenatal care to asylum seekers as compared to autochthonous Dutch women is also a large time investment for caregivers, due to the language and cultural barrier and little knowledge of the Dutch health system. Pregnant asylum seekers may potentially be a better fit for group health care. Group health care is the provision of care by a health professional to a group of individuals with similar health concerns, while providing education, health assessment and peer support. Women who receive group antenatal care have been found to have less preterm births, have better prenatal knowledge and feel readier for labour and delivery. Women also start breastfeeding after delivery more often after receiving group antenatal care. In addition, women feel more comfortable to share their fears, concerns and experiences in groups, which helped them to feel less alone during pregnancy and to develop a trusting relationship with their care providers. Overall, group antenatal care is associated with better clinical outcomes, maternal satisfaction scores and a greater satisfaction of antenatal care.

Research question / problem definition
1. To measure whether Interactive Group Education, as compared to regular care, improves knowledge about the Dutch maternity care system, (patho)physiology of pregnancy, childbirth and the postpartum period among pregnant asylum seekers. 2. To measure whether patient satisfaction is increased with Interactive Group Education, as compared to regular care.

Workplan

Women are enrolled in the Interactive Group Education if they are pregnant, asylum seeker in Ter Apel and have check-ups at the midwifery practice New Life.
The group antenatal care program consists of two interactive group education sessions in which women will be asked to not only listen but also actively participate in discussion and activities which stimulate the learning process. The groups consist of a minimum of 5 and maximum of 10 women. Women attend these meetings without their partners. These sessions are in addition to the regular midwife visits. The meetings are led by a certified (Dutch speaking) midwife in combination with an official translator. All three meetings are led by the same group leaders. Interactive methods are used (group discussion, audio-visual support, anatomical models and interactive games) to transfer knowledge to the participants. During the sessions, there is time for the group members to ask each other questions or interact. The goal is to create a group-feeling among the participants, so that ideally the interactive part will continue outside of the meetings. It is taken into account that there may be a low educational level or a lack of basic knowledge of the human body. The cultural and religious background is also taken into account by discussing habits and traditions from the participants country.
The main outcome is an increase in knowledge among pregnant asylum seekers after Interactive Group Education as compared to before Interactive Group Education and compared to regular midwife visits, about the following subjects: the Dutch obstetric health care system, (patho)physiology of pregnancy after 34 weeks, delivery and the postpartum period, alarm symptoms and who to call in which case. This is measured using a knowledge questionnaire based on the TNO questionnaire of the Connect-In study evaluating the effects of Centering Pregnancy, with some additional questions about the alarm signal card from the KNOV and the Dutch obstetric health care system.
Patient satisfaction will be measured by the LADY-X questionnaire.
These questionnaires have been administered but now need to be entered into a database and analyzed. You will work together with an MD/PhD student who is currently in her clinical rotations.

References

1. Van Oostrum IE, Goosen S, Uitenbroek D, Koppenaal H, Stronks K. ‘‘Mortality and causes of death among asylum seekers in the Netherlands.’’ J Epidemiol Community Health. 1 June 2010.
2. Zwart JJ, Jonkers MD, Richters A, et al. ‘‘Ethnic disparity in severe acute maternal morbidity: a nationwide cohort study in the Netherlands.’’ Eur J Public Health. 3 June 2010.
3. Simone Goosen, Irene E.A. van Oostrum en Marie-Louise Essink-Bot. ‘‘Zwangerschapsuitkomsten en zorgbehoeften bij asielzoeksters.’’ Nederlands Tijdschrift voor Geneeskunde 15 Nov. 2010
4. Choté, Anushka A., Christianne J.m. De Groot, Marc A. Bruijnzeels, Ken Redekop, Vincent W.v. Jaddoe, Albert Hofman, Eric A.p. Steegers, Johan P. Mackenbach, and Marleen Foets. "Ethnic Differences in Antenatal Care Use in a Large Multi-ethnic Urban Population in the Netherlands." Midwifery 27.1 (2011): 36-41.
5. Zwangerschap En Kraamperiode – Medische Aspecten. Huisarts-Migrant. 23 Nov. 2016. http://www.huisarts-migrant.nl/zwangerschap/.
6. Ickovics, Jeannette R., Trace S. Kershaw, Claire Westdahl, Urania Magriples, Zohar Massey, Heather Reynolds, and Sharon Schindler Rising. Group Prenatal Care and Perinatal Outcomes: A Randomized Controlled Trial. Journal of Obstetrics and Gynecology, 110 (2007), 330–338.
7. Manant, A., Dodgson, J.E. CenteringPregnancy: an integrative literature review. Midwifery & Women's Health 56 (2011), 94–102.
8. Kennedy, H.P., Farrell, T., Paden, R., Hill, S., Joilvet, R., Rising, S.S. “I wasn't alone” – a study of group prenatal care in the military. J. Midwifery Women's Health 51 (2009), 266–272.
9. Novick, G., Sadler, L.S., Kennedy Powell, H., Cohen, S.S., Groce, N.E., Knafl, K.A. Women's experiences of group prenatal care. Qual. Health Res. 21 (2011), 97–116.
10. McNeil, D., Vekved, M., Dolan, S., Siever, J., Horn, S., Tough, S. Getting more than they realized they needed: a qualitative study of women's experience of group prenatal care. BMC Pregnancy Childbirth 12 (2012), 17.
11. Gärtner F.R., de Miranda E., Rijnders M.E., Freeman L.M., Middeldorp J.M., Bloemenkamp K.W. et al. Good reliability and validity for a new utility instrument measuring the birth experience, the Labor and Delivery Index. J Clin Epidemiol. 2015;68:1184-94.

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