Fleeing war and claiming asylum should offer healing opportunities to women. Ideally, a refugee’s journey ends with sanctuary and feeling safe (even if uncertainty about the future remains). Reference Begikhani, Hamelink and Weiss1 Uncertain immigration status creates mental health vulnerabilities and carries significant associations with elevated post-traumatic stress disorder (PTSD) scores. Reference Morgan, Melluish and Welham2 For women who achieve refugee status, especially those coming from war and conflict, they still require time to recover and adjust to feel safe. Trauma-informed care places a vital role in treating women seeking psychiatric help. However, although we support trauma-informed care, we propose a reimagined approach to women survivors of conflict-related gender-based violence that is responsive to the particularities of having lived through war and conflict. Such an approach would offer a nuanced and focused treatment model and data categories to take into account the particular needs of this group.
As many readers will not have experienced war or conflict themselves, we illustrate this article’s points using interview extracts from research conducted in 2021 with women in Afghanistan, by the first author’s research team. The research team, Reference Daruwalla, Abas, Ahmad, Bentley, Bhatia and Datta3 funded by the National Institute for Health and Care Research to evaluate mental healthcare packages of women survivors of violence in Afghanistan, India and Sri Lanka, collected life histories from Afghan women in three provinces. We focus on the learning gained from the Afghan cohort, given that the women interviewed were survivors of war and conflict-related gender-based violence.
Women became systematic targets of violence in Afghanistan because of their sex and gendered notions of the land. A systematic war on Afghan women is a tactic to control the land by material analogy. Asylum-seeking and refugee women removed themselves from those forms of physical and symbolic violence, and many live with trauma and PTSD. Wanted pregnancies, in a country where they feel some degree of safety, can therefore offer opportunities for healing and control over their bodies and selves. In the UK, asylum-seeking and refugee women are included in the Black, Asian and Minority Ethnic (BAME) category for reporting maternal health outcomes. This categorisation practice makes it difficult for researchers and service providers to describe the distinctive medical and mental health needs of asylum-seeking and refugee women. This means that journeys of migration of refugee women that harbour the gendered experiences of war as a push factor for seeking asylum are unrecognised. In this sense, we are going beyond the current approach to provide culturally competent care to account for the cultural influences on a patient’s mental health and their psychological state. We are voicing the importance of integrating the narratives of war into trauma-informed perinatal care for refugee women.
Categories of visibility
In the broadest sense, the strategy shift in international and global health to frame care and treatment for mental health in terms of rights underscores the need for asylum-seeking and refugee women to become visible in public health statistics independently of other groups. Statistical invisibility, whether intentional or not, means that a national healthcare system cannot adequately support the mental health needs of asylum-seeking and refugee women who need help with the effects of trauma during the perinatal period, because the State has no evidentiary mechanism for identifying their needs.
Although seemingly obvious, deciding how/whether the national healthcare system will ‘see’ asylum-seeking and refugee women matters tremendously for clinical resources allocations. Rechtman Reference Rechtman4 authored an important article on this point. If clinicians providing mental health support cannot recognise when and how an individual woman’s personal history deviates from the collective distress idioms common in her culture, clinical tools may offer little of value. Knowing the group with which an individual culturally identifies and knowing something about that group and its cultural practices and particularities of communication positions a clinician to identify clinically relevant disclosures that are distinctly shaped by a war narrative rather than a cultural narrative. By this, we mean that although her experiences of war will be interpreted and sensed through her cultural orientation, war is an imposition and not an integration into her culture.
Consider the experiences shared below by an Afghan woman in the context of interviews about the impact of gendered experiences of war on her mental well-being. The following testimonies have been chosen to represent the landscape of women in war, that trauma is a form of territory rather than a defined event: Reference Kaul, Saboor, Ahmad, Mannell, Paphitis and Devakumar5
‘Interviewer: Your husband died in this war. How did it affect you?
Participant 20: My husband was a mechanic so they sent him to fix the car of some people and he was ambushed along with the car. He was killed by the Jehadis. I lost my husband, my father, my three young brothers and I lost my house and my entire life.
Interviewer: I am sure you suffered greatly as a result of all this.
Participant 20: Yes, a lot…. I take a lot of stress and so that affects my health a lot. I lost many people and was left alone to raise my children. We were also poor. All this was because of the war. Schools and mosques were destroyed. Houses were reduced to rubble.
Interviewer: Did you seek help from someone for these negative feelings?
Participant 20: I used to be able to talk to people who had suffered like me. People who had lost their husbands and seen pain and suffering like I had. … My mother-in-law would start hitting me on my head when she saw me talking to people. She would ask me what we were discussing and what we had plotted.’
Psychiatry can support healing from the traumas of conflict-related gender-based violence during pregnancy and birth. However, a clinician not deeply familiar with the particular conflict (e.g. Afghanistan), the woman’s culture and its idioms of distress along with the shared experiences of the specific conflict may struggle to support good perinatal outcomes for her. Productive interventions on behalf of her mental health become harder.
Seeking sanctuary in the UK from war means becoming a category – migrant, asylum seeker or refugee. For health services, these labelling mechanisms define such women’s pregnancies as high risk, and therefore correlated with high levels of maternal psychological distress. Reference Isaacs and Andipatin6 However, little provision exists in this system for conceptualising pregnant migrant survivors of conflict-related gender-based violence in other ways. Reductive methods of evaluating perinatal mental health conditions allow little scope for women to experience their pregnancies as sanctuaries. BAME categorisation contributes further confusion by reassigning and reframing the relevant collective history of the woman into a statistical catch-all. It functionally erases the starting point for clinical engagement and potential healing by failing to recognise the influence of the gendered experiences of war and conflict-related violence even if pregnancy-related risks are shared with other women in the BAME group.
Although we think it is critical to recognise the impact of trauma exposure, neither trauma alone nor statistical categories informed by vague sociology ought to provide the primary framework for understanding mental health vulnerabilities. In the section below, we suggest that a trauma-informed awareness and approach to forming supportive relationships with pregnant asylum-seeking and refugee women can reflect an understanding of trauma that goes beyond the typical definition of the psychological wound. Doing so means carefully applying all the dimensions of the Trauma-Informed Care model, thus taking care to avoid meaningless and generalised claims about experience.
Trauma-informed care
The multifaceted health needs that arise during pregnancy often challenge the generalised and economic approaches to health services delivery. Trauma-informed approaches to perinatal care for asylum-seeking and refugee women are important interventions for preventing maternal and neonatal health inequities. Additionally, the perinatal period creates an opportunity for transforming negative and harmful experiences relating to the body into forms of healing that are meaningful for the individual. The nature of engagement with perinatal healthcare settings offers opportunities for fostering the well-being of asylum-seeking and refugee women when settling into new environments and new healthcare systems and values:
‘Yes, I have seen war. We were forced to flee. Women had children in their arms as they fled through mountains and deserts. People were running away. I saw a woman who gave birth on the way and throw her child in the river and run. I saw this with my own eyes. She was right in front of me. People were killed with bullets, houses were brought down with rockets. I saw a woman whose child was killed and she threw the dead body behind a wall and continued running. These are things I saw with my own eyes.’ (Participant 20)
Preventing adverse pregnancy outcomes means addressing both the physical and mental health requirements of a woman during the perinatal period. Sperlich et al Reference Sperlich, Seng, Li, Taylor and Bradbury‐Jones7 published a foundational article that established the mental health effects of adverse events before pregnancy on maternal birth outcomes and during the period of gestation. For women of war who have embodied the symbolisms inherent in gendered violence during conflict, and the shared witnessing of traumatic experiences such as those recounted by Participant 20, the perinatal period is a time that garners reflective memory on the tragedies of how women suffer in war.
The Trauma-Informed Care model consists of three dimensions and goes beyond simple definitions or guidelines (see Table 1). Known as the three Es, four Rs and six principles, the framework establishes trauma in individuals as resulting from an event or events that one experiences as physically or emotionally harmful and that has lasting effects on an individual’s well-being and physical/mental health. This recognition ought to sit within a structure that takes a stance toward trauma that:
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(a) Realises the widespread impact of trauma and understands potential paths for recovery
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(b) Recognises the signs and symptoms of trauma in clients, families, staff and others;
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(c) Responds by fully integrating knowledge about trauma into policies, procedures and practices; and
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(d) Seeks to actively resist retraumatisation. Reference Rechtman4
Recommendations for perinatal psychiatrists who work with asylum-seeking and refugee women with war/conflict trauma indications
This applied values-based approach then integrates six broad principles: (a) safety; (b) trustworthiness and transparency; (c) peer support; (d) collaboration and mutuality; (e) empowerment, voice and choice; and (f) cultural, historical and gender issues. 8 Tailoring a Trauma-Informed Care framework to integrate voices of women who have experienced war would create a narrative-based foundation for developing and supporting discourses, dialogue and disclosures about their traumas.
Although we ought not generalise trauma and its sequelae, by integrating the above values and practices with awareness of how individual expressions of distress can stand out in relief from specific collective and cultural idioms, asylum-seeking and refugee women can view and live their pregnancies differently. The use of clinical tools and techniques in such a setting with a perinatal asylum-seeking and refugee woman opens the possibility for such women who present with a history of direct/indirect gender-based violence experienced in contexts of war and conflict to potentially experience better mental health outcomes.
In our work, we help prepare expert witness statements on behalf of women claiming asylum. We work with clinical psychologists and psychiatrists who evaluate women asylee’s mental health and propose treatments. Many of these women have diagnosed mental disorders from exposure to conflict-related violence. Furthermore, past (and sometimes current) exposure to direct and/or indirect forms of gender-based violence often complicate these diagnoses. Commonly, treatment cannot commence until the asylum-seeking and refugee woman’s immigration status has been settled. Healing for refugee women survivors of conflict-related gender-based violence remains in silence, akin to the stories that they live and carry. Although the care that obstetricians provide can help to strengthen the perinatal experiences for a survivor of violence, there is an important role for psychiatry to unravel the signifiers of war within the minds and bodies of ‘travelling’ women:
‘When there is peace. When there are no rockets and suicide attacks I feel at peace. I feel light. I sleep well and spend my day at peace. Those days I am very happy. When there is a blast and I hear that school children have been killed or pedestrians, or shopkeepers or journalists or other innocent people, I feel very sad. I keep thinking that the war has just not stopped. That it is still ongoing. People are so tired. Every person in this country is tired.’ (Participant 20)
Ahmad Reference Ahmad9 describes how ‘war is a silencing shroud’, yet ‘women as storytellers of suffering are the epitome for understanding the lived spaces of war’. The chasms created by the ways war fuels the isolation that women survivors of conflict-related gender-based violence are symbolic of the targeted intentions of the perpetrators. To describe further, ‘words and silence are weaponized in war, meaning that a woman’s story is silenced because of what she has the power to reveal; but she is never silent; stories are living breathing vessels of the self and surrounding world’. Spaces need to exist – to be created – for stories of suffering and of healing to provide the sanctuary that pregnant refugee women of war seek when they themselves are creating new stories of new life – that of their child and that of their own. Pregnancy often reveals that which needs to be told/understood and that which remains to be told/understood, and for pregnant refugee women there is still tremendous scope for both to improve perinatal mental healthcare.
Author contributions
A.A. was a member of the research group that conducted the research cited in the article. Both authors collaborated on the conceptualisation of the article, and conducted a literature review and analysis. R.R. produced the article structure and article draft. A.A. edited the draft and produced the analysis of the interview. A.A. wrote the conclusion. Both authors contributed to the finalised version of the article and in the discussion and addressing of the reviewer’s comments.
Funding
This research received no specific grant from any funding agency, commercial or not-for-profit sectors.
Declaration of interest
None.
Ethical standards
The interview data reported here was collected from 2018 to 2021 under a National Institute for Health and Care Research grant (number 17/63/47), and received ethics approval from University College London Research Ethics Committee (ethics approval reference 2744/007); the London School of Hygiene and Tropical Medicine Research Ethics Committee (ethics approval reference 22818) and the Islamic Republic of Afghanistan, Ministry of Public Health (ethics approval reference IRB. 1902.0007). Participants gave informed consent to participate in the study before taking part. Verbal consent was formally recorded by the local researcher.
eLetters
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