Advice and guidance on the health needs of migrant patients for healthcare practitioners.
Be aware of possible religious and cultural sensitivities when discussing sexual and reproductive matters.
Where language is a barrier in discussing sexual or reproductive matters, offer a female interpreter. It is inappropriate to use children as interpreters for adults, particularly when discussing intimate concerns. Have arrangements in place for one-to-one disclosure, and to avoid discussing sensitive topics in front of children.
Those who have experienced forced migration are at increased risk of violence against women and girls. Consider trauma-informed approaches to service provision, and ensure appropriate referrals are made to address the physical and mental health needs of those who have experienced sexual and gender-based violence.
Some cultural practices may expose women to non-infectious environmental hazards.
Use the country pages of the Migrant Health Guide to find out more about sexual and reproductive health indicators for women from specific countries.
Sexual and reproductive health
Different religions and cultures have different beliefs and practices concerning menstruation, pregnancy and childbirth. These can affect a patient’s understanding of and compliance with healthcare professionals’ recommendations.
Explore the individual’s beliefs and understanding. If an individual experiences language barriers, ensure they have access to professional interpreting and translation services.
Enquire about past history of cervical and breast screening (where age appropriate) and provide information about the NHS routine cervical screening and breast screening programmes. Offer girls aged up to 18 immunisation against human papillomavirus (HPV).
A sexual history is an important part of an overall health assessment. Consider whether the patient may require a full sexual health screen for sexually transmitted infections on the basis of country of origin and sexual history.
Sexual health promotion including safer sex advice is important to address with all sexually active people.
Ask migrant women if they feel comfortable to discuss family planning needs as this can be a sensitive topic in some cultures.
Violence against women and girls
Violence against women and girls (VAWG), which is also commonly referred to as sexual and gender-based violence (SGBV), includes:
- rape and sexual assault
- physical, psychological or emotional violence
- forced marriage
- forced sex work
- female genital mutilation (FGM)
- denial of resources, opportunities, services and freedom of movement on the basis of socially ascribed gender roles and norms
Women, especially those who have experienced forced migration, are at increased risk of VAWG. There is evidence of high levels of VAWG prior to, during and following forced migration journeys, and under-reporting of VAWG by survivors is common. Research suggests that SGBV can increase after migration to destination countries like the UK. Perpetrators include family, friends, community members and persons in authority.
The SEREDA project found that while some survivors access healthcare in the UK, the majority receive no support.
It can be challenging for women to talk about experiences of violence. Reasons for this include:
- survivors’ lack of awareness of the types of support services that are available to them, and that disclosure is needed to determine eligibility to these services
- fear of breach of confidentiality
- fear of disclosure impacting on immigration applications (for example, where the main visa applicant is the perpetrator)
- fear of losing family and community relationships as a result of disclosure, including fear of removal of children by social services
- ongoing coercive relationships with perpetrator(s)
- lack of continuity of care and inability to build trusting relationships with service providers (for example, in light of insecure immigration status or dispersal policies)
- mistrust of government officials and services, particularly when women feel that officials and service providers do not believe what they have disclosed
- previous experiences of discrimination in public institutions
Healthcare professionals should:
- facilitate safe space (one-to-one if possible) for women to disclose their experiences of VAWG
- avoid discussing sensitive topics in front of children
- work with female professional interpreters where there are language barriers, and understand that a person with good conversational fluency in English may not be able to understand, discuss or read health-related information proficiently in English
- brief the interpreter thoroughly about the sensitive and traumatic topics that may be disclosed in the session, and the possibility of safeguarding concerns that may arise
- assess for safeguarding concerns and take appropriate actions to prevent harm (refer to the NHS safeguarding policy and the NHS safeguarding app for more information)
- consider trauma-informed approaches and survivor-centred approaches to service provision
- recognise signs of SGBV exposure, such as physical marks and mental health symptoms
- consider development of protocols to identify potential groups at risk of SGBV
- ensure appropriate referrals are made to address physical and mental health needs
- where appropriate, refer or encourage self-referral to sexual assault referral centres (SARCs) that offer confidential and non-judgmental support to victims and survivors of sexual assault and abuse (referrals to SARC is not associated with reporting to the police, unless an individual wishes to do so)
- provide information about available support services to those affected by VAWG
- build awareness about VAWG among peers and support staff to improve communication with survivors
- support women to register for GP services
Charges for sexual and reproductive health services
The following services are free of charge to all individuals regardless of immigration status:
- services provided for routine screening, diagnosis, treatment and vaccination for sexually transmitted infections
- family planning services, including contraceptive services (does not include termination of pregnancy or infertility treatment)
- services for treating a physical or mental condition caused by torture, female genital mutilation, domestic violence or sexual violence (as long as the individual did not travel to the UK for the purpose of seeking this treatment) – this includes maternity services (antenatal, perinatal and postpartum treatment) needed as a consequence of sexual violence or female genital mutilation.
Pregnancy and maternity care
Inform women who are pregnant or planning a pregnancy of their rights to maternity care. Migrant women may have different expectations of maternity care from their country of origin.
Support women to register for GP services.
Encourage anyone who is eligible for the Healthy Start scheme to apply.
If a woman is pregnant or has given birth in the last 12 months and has a valid maternity exemption certificate, they are entitled to free NHS dental treatment and free NHS prescriptions. Help individuals to apply for this certificate.
Some pregnant women may choose to travel back to their country of origin to be with family for their delivery. Refer to the latest foreign travel advice, NaTHNaC’s pregnancy factsheet and NHS Choices advice on travelling in pregnancy. Different airlines have different rules about flying in pregnancy and the woman should be advised to check both with the airline she intends to fly with, and with her insurance company. She may need a letter from her GP stating she is fit to fly.
Infection and disease before, during and after pregnancy
Offer serological testing for Chagas disease to Latin American women of child-bearing age and those who are pregnant. Detection during pre-conception testing can reduce risk of vertical transmission to infants.
HTLV-1 and HTLV-2 can be transmitted from mother to child mainly through breastfeeding but also during pregnancy and birth. Consider serological testing for HTLV in pregnant or breastfeeding migrant women from endemic countries and regions:
- South America
- Australia (Aboriginal and Torres Strait Islander populations)
For further information on testing for HTLV, and how to access specialist HTLV services, refer to the National Centre for Human Retrovirology website.
Listeria infections have been found to be more common in pregnancy among ethnic minority groups in England and Wales. Refer to NHS listeriosis guidance about what advice to give to pregnant women.
Charges for maternity care
While charges may apply for some migrants, maternity care should always be provided and should not be denied or delayed on the basis of immigration status or ability to pay. This includes antenatal care, care in childbirth, postnatal care for the mother and baby. Maternity Action provides guidance on when charges apply for maternity care.
Maternity care should never be refused or delayed even if an individual has not agreed to pay charges, cannot afford to pay, or there is a query about whether an individual is chargeable. If a woman is unable to pay for maternity care, they should inform the NHS Trust. Trusts have a duty to continue maternity care and discuss payment options, such as repayment plans.
NHS Trusts have discretion to write-off debts when it is not cost-effective to pursue. However, debts cannot be waived or cancelled. They will remain in a Trust’s records and can be recovered if an individual’s ability to pay changes.
Pregnancy and maternity care
The Royal College of Midwives has produced ‘Caring for vulnerable migrant women’ which is a pocket guide for midwives and maternity support workers.
Maternity Action is a national charity working to end inequality and promote the health and well-being of all pregnant women, their partners and children. They provide advice on entitlements to maternity care for migrants.
Routine antenatal screening from Patient.info.
Screening tests for you and your baby in English, Easy Read and 12 other languages.
Royal College of Obstetricians and Gynaecologists: Malaria and pregnancy.
Sexual and reproductive health
Family Planning Association guide to contraception.
NHS Cervical Screening Programme leaflets for patients.
Breast screening programme leaflets for patients.
Genital warts and human papillomavirus (HPV) guidance, data and analysis.
VAWG, trafficking, abuse, human rights
See the guidance on forced marriage for professionals protecting, advising, and supporting victims.
Individuals can contact the forced marriage unit (FMU) if they are trying to stop a forced marriage or need help leaving a forced marriage.
Suspected human trafficking and modern slavery can be reported to the National Crime Agency’s Modern Slavery Helpline.
The Asian women, domestic violence and mental health toolkit by EACH (Ethnic Alcohol Counselling in Hounslow) provides background information on Asian women’s experiences of domestic violence, its impact on their health, and how health professionals can respond.
Southall Black Sisters offer specialist support, advocacy and information to Asian and African-Caribbean women suffering abuse.
Imkaan is a women’s organisation dedicated to addressing violence against Black and minority ethnic women and girls.
Muslim Women’s Network offers a national specialist faith and culturally sensitive helpline providing information, guidance and referrals for those at risk of abuse to women of faith and no faith.
Opoka provides a national helpline for Polish women living in the UK.
Refugee Women Connect offers an extensive outreach programme, emotional and practical support and advocacy initiatives.
Refuge runs a number of culturally specific outreach and advocacy programmes.
FORWARD supports African women and girls in the UK who have been affected by violence. They also provide training for professionals and work collaboratively with frontline professionals to provide accessible services to women and girls.
The National FGM Centre supports children and young people affected by FGM, breast flattening and child abuse linked to faith or belief. It has a free online knowledge hub, a directory of FGM services available in the UK, and offers professional training and development.