The project “ORAMMA: Operational Refugee And Migrant Maternal Approach” has a vision to develop an operational and strategic approach in order to promote safe motherhood, to improve access and delivery of maternal healthcare for refugee and migrant women and to improve maternal health equality within European Union. Moreover the project will increase awareness, commitment and action towards improving maternal health of refugees in EU. There is an increasing need for a prompt, coordinated, and effective response for all migrant and refugee pregnant and lactating women with newborn babies. Migrant and refugee women face specific health risks and challenges during perinatal period that need to be dealt by well-trained multidisciplinary teams of health professional experts since they are characterized by a complex physical, psychological and mental state of health.
The majority of the refugee pregnant women, their families and their communities are not empowered to be healthy, do not always have adequate capacities to provide appropriate care during pregnancy or when the new baby has arrived, neither are they able to make healthy decisions and act upon those decisions, including the decision to seek care when needed. There is a lack of empower manifest in a number of levels while additionally gender constraints may prevent some refugee women from expressing the need for and obtaining care during perinatal period.
The ORAMMA project will develop, pilot implement and evaluate by comparative analysis an integrated and cost-effective approach on safe motherhood provision for migrant and refugee women, taking into consideration (a) best practices, (b) the special risks and characteristics of the target group and (c) the transferability of the model in different healthcare systems across EU: from camps sites in Greece, to National Health Services in the UK and to community-based model in Netherlands.The project “ORAMMA: Operational Refugee And Migrant Maternal Approach” has a vision to develop an operational and strategic approach in order to promote safe motherhood, to improve access and delivery of maternal healthcare for refugee and migrant women and to improve maternal health equality within European Union. Moreover the project will increase awareness, commitment and action towards improving maternal health of refugees in EU.
Safe journey to motherhood
The ORAMMA project develops an integrated, mother and woman centered, culturally oriented and evidence based approach for all phases of the migrant and refugee women perinatal healthcare, including detection of pregnancy, care during pregnancy and birth, as well as support after birth. This approach implemented by multidisciplinary teams of experts, namely midwives, social workers and general practitioners, with the active participation of women from migrants and refugee communities, ensures a safe journey to motherhood.
a) Guidelines for perinatal care for migrant and refugee women
The guidelines will be addressed to health providers, individual health professionals working with the target group and other community-based services that the target group visits. The aim of the Guidelines is to be used both as a practice tool for health professionals but also as an informative and educational tool for all stakeholders involved in health assessment of migrant and refugee women and other related services.
b) ORAMMA approach development
This approach includes all the characteristics of the approach, description and role of the multidisciplinary team, description of phases and specifications on each phase, decision trees and/or algorithms for the implementation of the model.
c) Perinatal Personal operational plan
The Perinatal Personal Operational Plan (general health, psychosocial, perinatal assessment and plan) will be the basic tool of the perinatal healthcare provision for migrant and refugee women. It will provide all the necessary information both for the woman and the team treating her such as personal information, medical history related to pregnancy and childbirth, the perinatal care plan, the assessment of the professionals of the team, as well as useful information for the women, such as the benefits and impact of the PPOP for her and her family.
d) Pilot and recommendations.
The ORAMMA approach and tools will be pilot tested and assessed in different European settings (UK, the Netherlands and Greece), in order to provide recommendations on the perinatal healthcare of migrant and refugee women and feedback on its effectiveness and efficacy.
e) Mapping of perinatal healthcare for migrants and refugee women in Europe.
The ORAMMA project gathers information on the present situation and the current size of the migrant and refugee population, the needs of the target groups and the needs of health professionals, the existing practices, social services and operational structures of healthcare provision, as well as special issues as legislation or other country specific issues to be taken into consideration. As a result, a summative Report on EU and national context on perinatal healthcare for migrant and refugee women will be used for the development of the model, the pilot implementation and the design of the training course.
Cultural awareness across the borders
Involvement of women from the target population and their training in order to assist and act as advocates for pregnant women during the whole perinatal and antenatal period as intercultural mediators is a key aspect of the ORAMMA project. A highly innovative concept enabling these women to have more encompassing role not only as an interpreter but truly mediate, actively assist and provide support to migrant and refugee pregnant women. Through developing an education/package this will facilitate two-way knowledge transfer and learning between health professionals and community increasing cultural awareness.
Working together for a better community
The implementation of the ORAMMA approach refers to communities with migrant and refugee populations. Selected key members or active players from these communities will propagate and diffuse the perinatal approach into the communities and motivate them to actively participate. The project combines close cooperation of health professionals and migrant and refugee communities. In this framework training activities on both target groups will be implemented as well as raise awareness of migrant and refugee women on a rights-based knowledge.
Health care with compassion
The ORAMMA project develops an integrated, mother centered, culturally oriented and evidence based approach for all phases of the migrant and refugee women perinatal healthcare. The ORAMMA approach supports a compassionate holistic treatment of these vulnerable groups focusing on their needs, addressing in a compassionate way the challenges migrant and refugee women face.
Work Package 1
Coordination of the project by lead TEI-A
Start month:1 – End month: 24
The coordination WP runs throughout the duration of the project and seeks to support and define the relationships among the partners; the co-operation; and co-ordination processes, in order to ensure smooth progress of the project activities, efficient handling of any problems that may appear and risk management.
In addition, a detailed planning for the project management has been developed, which might readjust according to the needs of the project. Apart from defining the level of responsibility and authority of each person /institution involved and describing the governance structure of the project management, clear and appropriate reporting mechanisms are included. Thus, defined roles, functions, scopes of authority and systems that will help all members of the partnership to ensure effective management and monitoring of the project, will be in place.
On a 6- month base, a technical report will be prepared by all partners, as well as an interim and a final report by the Project Coordinator. The interim and final report will summarize the completed activities of the project and the ongoing ones, as well as a short action plan of the next period. This reporting method will enable all partners to be aware of what has been achieved so far, to early identify and manage potential risks and to control any upcoming internal or external issues.
Finally, at the early stages of the project a detailed internal communication plan will be drafted and be delivered to all partners. It will describe the project’s mechanisms and tools for internal communication, in order to assure effective and on time communication between the project partners. The relative tools will include emails, online meetings, telephones in a systematic time base, which will be determined at the kick- off meeting.
The everyday communication of the project will take advantage of teleconferences and email, while four main project meetings will take place:
a. Kick-off meeting in Luxembourg: the kick-off meeting will take place in Luxembourg in the beginning of the project. The meeting will signalize the launch of the project and will clarify the roles and tasks of different partners for the remainder of the project. All partners will attend.
b. 1st progress meeting in Athens: The 1st progress meeting will take place in Athens in month 9 of the project. The 1st progress meeting will focus on the finalization of the details of the proposed model and the developed tools while it will set the discussion for the training work package and the pilot implementation work package. oreover, partners will assess the progress of the project up to that point and discuss key issues for the interim project report. Remedial actions will be discussed and agreed in case of any divergence from the original plan. All partners will attend the meeting.
c. 2nd progress meeting in UK: The 2nd progress meeting will take place in UK in month 15 of the project. The 2nd progress meeting will focus on the specifications and the organization of the pilot implementation of the proposed model. Especially the partners from the countries that will implement the pilots (GR, UK, NL) will agree on the general framework of the group and/or individual sessions with the target groups, the reporting and documentation of the pilots, the questionnaires that will be used and the ass
Work Package 2
Dissemination of the project by lead EMA
Start month:1 – End month: 24
The partnership will create lists containing medical associations, potentially interested organizations and experts on the field, in each participating country. During the project they will be informed on a regular basis about the project’s progress and results (e.g. development of the model and perinatal personal operation plan, piloting implementation, health professionals trained etc). Moreover, partners plan to participate to annual health related conferences in national and European level address informative letters to scientific communities and health professionals of different target groups (midwives, social workers and GPs etc.), organize consultation meetings and presentation of the results in a conference conducted by project’s coordinator and finally scientific papers with the results arising from pilot sessions.
– E-newsletters. Electronic newsletters will be periodically produced and disseminated to stakeholders through the web site and the project’s mailing list of stakeholders (three newsletter in total). The newsletters are targeted at the direct target groups of the project, but mainly to health professionals, policy makers, and other interested stakeholders who want to be informed about the project, the expected benefits, the learning opportunities offered to them, and how they could utilize it to improve their practices as professionals.
– Final conference, will take place in Brussels at the end of the project. A range of stakeholders will be invited, such as health professionals, policy makers etc. This event will be the formal public launch of project’s finalized materials and products, and will offer presentations of lessons learned from the project experience and the significant issues that have emerged. During the event, the partnership will present project’s results, will distribute project’s deliverables in order to promote the need of specialized healthcare for the target group of migrant and refugee pregnant women.
2.2 Presentations in external events. Besides the project’s conferences and meetings, all partners will present the project at external conferences, workshops, seminars or meetings nationally or internationally (at least 5 events). Each partner will draft minutes from his/her external event participation. These presentations would be delivered throughout the duration of the project and results will be delivered according to the progress reports.
2.3 Reporting on dissemination activities. All partners will be responsible of reporting on the dissemination activities and submit to the WP leader adequate documentation (as dissemination stakeholder lists, recipients’ lists, participants’ lists, photos from events, etc.). A final dissemination report will be developed.
Work Package 3
Evaluation by lead CMT PROOPTIKI
Start month:1 – End month: 24
The partnership will develop an evaluation and quality assurance plan at the early stages of the project. This plan will specify the procedures and standards for implementation, monitoring and evaluation of the project. Moreover, the partnership will develop a relevant evaluation tool (evaluation questionnaire). The overall evaluation of the project will be performed in two phases: a) in the middle of the project and b) at the end of the project, leading to an interim and final evaluation report, respectively. An external evaluator will be subcontracted, providing an additional and independent evaluation of project’s results and outcomes.
Specifically, this WP includes the following tasks for the internal evaluation of the project:
3.1 Evaluation methodology: CMT (P3) will develop the evaluation plan with projected activities, timeline, expected results and framework of performance indicators and design evaluation methods (questionnaires, interview tools, and other methods to be specified). Important activities of the evaluation WP which will be specialized further are:
– Design of the assessment tools: Based on the developed assessment methodology, the evaluation tools will be designed (both quantitative such as questionnaires and qualitative such as interview guides).
– Interviews and/or focus group with stakeholders: A number of interviews/focus groups will be conducted in each participating country (Greece, UK and NL). The target group of the interviews will be various stakeholders as health professionals, migrant and refugee women and other relevant stakeholders.
– Analysis of the results and reporting of the assessment findings: The collected data (both quantitative and qualitative) will be analysed accordingly. The approach assessment report will include the results from the assessment of the model and the pilot sessions, recommendations for the improvement of implementation of the proposed model, policy recommendations related to the field of perinatal healthcare for migrant and refugee women and other key finding resulting from the whole experience that will be gained throughout the project.
3.2 Interim Evaluation: Partners will evaluate the progress at the interim phase of the project (interim progress meeting, formative evaluation of input processes and outputs until that moment); CMT (P3) will develop an interim evaluation report.
3.3 Final Evaluation: Partners will evaluate the progress at the end of the project (final progress meeting, summative evaluation of outputs and outcomes); CMT (P3) will develop final evaluation report
3.4 Target users evaluation: The target user evaluation (including stakeholders, visitors of the project’s web site, participants in the project’s conference and trainees), will also evaluate the project at the end of the project. CMT (P3) will collate and analyse the responses to generate a report and include it in the final evaluation report.
3.5 External evaluation of main project deliverables: As a general methodology for the evaluation of the developed refugee and migrant maternal care approach, assessment models developed by major health organizations, such as the Tanahasi model developed by WHO, will be used. Such models are used for evaluating the health service delivery performance by considering the dimensions as availability, accessibility, acceptability and quality of the targeted health outcome. The main evaluation questions will be specified and the key issues to be explored. The evaluation methodology will be further developed and specified in order to produce indicators such as:
• Comparative assessment (analysis to different health systems of member countries participating in the project)
• Economic analysis
• Perinatal health assessment on public health indicators: morbidity and mortality rate, breastfeeding rate, perinatal mental health disorders (anxiety, depression, panic attacks)
• Referrals to social services (domestic abuse, welfare benefits etc.)
Work Package 4
State of the art & ORAMMA approach development by lead TEI-A
Start month:1 – End month: 11
State of the art activities: The overall aim of the State of the art activities is to gain a holistic knowledge of (a) the current settings & situation in Europe on addressing migrants’/refugees’ women health needs, (b) the best practices in perinatal healthcare for migrant & refugee women and (c) the emerging needs in healthcare provision & in healthcare capacity building for the healthcare professionals. In order for the partnership to identify and assess the recent progress in the field of perinatal healthcare for refugee and migrant women the following tasks will be undertaken:
4.1 EU and national context review on perinatal healthcare for migrant and refugee women. Conduct of field assessment/ mapping of healthcare provision in the different European settings in order to identify (a) The present situation and estimation of the current size of the population, (b) needs of the target groups and the needs of health professionals, (c) existing practices, social services and operational structures of healthcare provision, (d) special issues as legislation or other country specific issues to be taken into consideration. The field assessment will be conducted through:
a) A desk research for the national contexts of Greece, UK and Netherlands and
b) A European qualitative research in the national midwifery schools and/or associations that will focus on the aforementioned issues. The qualitative research through semi-constructive interviews with health professionals will be conducted through the extensive network of midwife organizations of the “European Midwifery Association” (EMA) and will be addressed mainly to European countries with high migrant and refugee population.
The produced deliverable from both the researches will be a Summative Report on EU and national context on perinatal healthcare for migrant and refugee women which will include key findings and recommendations that will be used for the development of the model, the pilot implementation and the design of the training course. The EU and national context review is essential in order to avoid duplicating existing actions /efforts at the EU level in terms of addressing migrants’/ refugees’ women health.
4.2 Development of Practice Guide for migrant and refugee women. Conduct of literature review of scientific papers and reports from major health organization (such as WHO) and medical journals on perinatal healthcare of migrant and refugee women (special risks, best practices, case studies, implementing tools, social issues etc.). The aim of the literature review is to provide evidence-based research to form the base of sound clinical practice guidelines and recommendations on perinatal healthcare of migrant and refugee women. The produced deliverable will be a Practice Guide for Perinatal care for migrant and refugee women. The Practice Guide will be widely disseminated to health professionals and health organizations throughout Europe, thought the partners’ networks, especially through the extended network of the European Midwives Association and the European Forum for Primary Care, as well as the wide network of organizations of the supporting and collaborating partners of the project
4.3 ORAMMA approach development. The ORAMMA approach on perinatal healthcare for migrant and refugee women will be characterised by four main elements in order to be “an integrated approach”: (1) it will be co-ordinated by a multidisciplinary team of experts, (2) it will be gender-approached, (3) it will be culturally-appropriate and (4) it will be mother-centred. More specifically:
(1) The multidisciplinary team of experts will consist of (a) a midwife, (b) a GP or other medical practitioner, (c) a social worker and (d) an intercultural mediator or maternity peer supporter. The team will act in a collaborative way in order to provide co-ordinated care for the migrant or refugee pregnant woman. Each professional will provide a separate assessment of the mother, but all together will plan and treat the mothers synergistically. The GP, who will also probably detect the pregnancy, will provide assessment and clinical actions on health issues related to chronic diseases, communicable diseases and other conditions to be noticed; the midwife will treat the mother during pregnancy and mother and new-born after birth as well; and the social worker will provide counselling mainly after birth to the mother and the whole family. One important element of the multidisciplinary team is the maternity peer supporter. The maternity peer suporters are women coming from the target population (communities of migrants and refugees) that are or will be trained to assist the mothers during birth
and act supportively for the mothers during the whole perinatal period as intercultural mediators. The maternity peer supporters is a highly innovative concept, so far implemented mainly in Scandinavian countries that has the ability to enhance and redesign the role of cultural mediators to a maternity peer supporter who not only translate but truly mediate, actively assist and provide support to this highly vulnerable target group of migrant and refugee pregnant women.
(2) The team will also be gender-approached, meaning consisting of women professionals, in order to address the religious needs of the target group and moreover to ensure that all the women will feel comfortable and safe (considering the special risks of the target group as GBV or abuse).
(3) The approach will be culturally appropriate, meaning that the care protocols to be developed will ensure that the professionals involved will respect and take into consideration specific cultural issues when treating the women.
(4) The approach will be mother-centred and will have as an ultimate purpose to ensure that the treatment of each mother will be personalized, customized to her needs and taking into account her preferences.
The ORAMMA approach will also include community capacity building and empowering of the migrant and refugee women and their communities in order to be successfully implemented. Moreover, the proposed model will include 3 phases: (Phase 0) The detection of pregnancy, (Phase 1) the healthcare during pregnancy and (Phase 2) the support after birth for the mother and the new-born. The expected outcomes of the development of such a model are:
(1) A co-ordinated, culturally-appropriate, gendered approached and mother-centred approach on perinatal healthcare for migrant and refugee women
(2) Prepared and proactive multidisciplinary teams of professionals
(3) Informed, empowered women and family
The ORAMMA approach will be developed by working groups of experts and the deliverable produced will be a guide/ protocol containing the rationale and all the characteristics of the approach, description and role of the multidisciplinary team, description of phases and specifications on each phase, decision trees and/or algorithms for the implementation of the model.
4.4 Development of the Perinatal Personal Operational Plan (PPOP) for migrant and refugee women. The Perinatal Personal Operational Plan will be a tool (booklet template) to be used by health professionals as an individualized health care plan for each woman they treat. It will provide all the necessary information both for the woman and the team of health professionals treating her: (a) personal information and contact details, (b) medical history related to pregnancy and childbirth as well as chronic and communicable diseases, (c) the perinatal care plan (conditions, medicines, preferences for birth, etc.), (d) the assessment of the professionals of the multidisciplinary team, (e) useful information for the women, such as the benefits and impact of the PPOP for her and her family.
Work Package 5
Community capacity building, propagating key members and empowering migrant and refugee women by lead SHU
Start month:8 – End month: 24
The process of implementing a community-based health care model, especially for migrant and refugee populations, requires a process of empowering the communities through partnerships, collaborative planning, community actions and overall community capacity building. This work package will organise and implement activities with the overall aim to prepare and empower the communities that the developed approach will be implemented. Including the community itself into the healthcare approach will facilitate the implementation, enhance the participation and increased the health benefits for the target group. The activities to be undertaken are:
5.2 Set the pilot specifications for the organization, implementation, coordination and monitoring of the pilot sessions. According to the Community Capacity Building Action Plan that was developed in the previous WP, a SOP document will be developed that will specialize the action plan for the pilot implementation in Greece, UK and the Netherlands, will include organizational guidelines for the three different settings and will describe in detail the way the pilot sessions will be conducted. Moreover the pilot specifications SOP will include guidelines for reporting and documentation of the pilots. Additionally the partners will select the specific migrant and refugee communities in GR, UK and NL to pilot implement the approach. The current migrant and refugee crisis is ongoing and dynamic. Thus, the partners will choose the most appropriate communities to implement the approach the months beforehand. In order to select the communities a number of criteria will be taken into consideration as the needs of the communities, the size of the target group, the access to the target group and the recruitments possibilities of health professionals to participate in the pilot sessions.
5.3 Recruitment of health professionals and development of the multidisciplinary teams that will conduct the pilot sessions in each country. The multidisciplinary teams of experts will be developed prior to the beginning of the sessions. In each country at least on team consisted of one midwife, one GP or medical practitioner (as obstetrician or gynaecologist), one social worker, one intercultural mediator or maternity peer supporter when applicable and one team coordinator will be selected so to carry out the pilot sessions with the pregnant migrant and refugee women, apply the ORAMMA approach and collect data/ report from the pilot sessions.
5.4 Recruiting of maternity peer supporters. The multidisciplinary team of health professionals is important to include a maternity peer supporter. According to a number of recent studies, doulas can greatly aid migrant and refugee mothers in gaining access to effective care by acting as advocates, cultural brokers, and emotional and social support . More emphasis on cultural self-awareness in doula training, expanding community doula programs, and more integration of doula services in health-care settings are highly recommended. In this context, before the beginning of the pilots, the team coordinator in each setting will recruit migrant and refugee women for the role of doulas and train them to support and assist the mother during the visits with the health professionals, the birth and the ante-natal period.
5.5 Training of health professionals and maternity peer supporters for the pilot implementation. The multidisciplinary teams of health professionals who will treat and monitor the migrant and refugee mothers, according to the ORAMMA approach, will need to make use of the developed tools and act in a coordinating way. In order to facilitate the process, a training toolkit of the developed model and tools will be developed in the form of self-learning e-course that will be available to all health professionals in a European level. The e-course will remain open, available and accessible after the end of the project for every health professionals who wishes to acquire knowledge on the ORAMMA approach and developed tools.
5.6 Capacity building workshops. Capacity building workshops will be organised to the selected communities with health professionals and maternity peer supporters. The capacity building workshops will allow for sufficient time and opportunity for trainees to learn; they will give the right of publishing opinions and interacting with other professional stakeholders through the discussion forums.
5.7 Community Coaching and support during the pilot implementation and risk management. For each country that the model will be pilot implemented (GR, UK, NL), team coordinators will be in place. The team coordinators (health professional experts /researchers of the project) will coordinate, monitor and support the teams of health professionals who will participate in the pilot sessions. The team coordinators will arrange frequent meetings with the teams of health professionals, will provide them with the reporting documents, the pilot evaluation tools and ensure that the pilot sessions are running without any problems.
Work Package 6
Pilot implementation and assessment by lead TEI-A
Start month:12 – End month: 24
The pilot implementation of the proposed model will be conducted in three different European settings: in camps/hotspots in Greece, through the NHS in the UK and in municipality-based services in Netherlands. The purpose of the three settings has been made in order pilot test the model in the much different health systems throughout Europe.
The tasks to be undertaken for the pilot implementation are:
6.1 Conduct of pilot sessions. The pilot implementation of the proposed model will be conducted in three different European settings: in camps/hotspots in Greece, through the NHS in the UK and in community-based services in Netherlands and will include the following activities:
1. Detection of pregnant women: The first activity for the beginning of the pilot sessions will be for the health professionals to identify the pregnant migrant and refugee women. This activity (phase 0 of the ORAMMA approach) will be coordinated by the GPs-researchers. The GPs will be responsible for detecting the pregnancies, perform all the necessary medical action to screen the health of the women and make the referral to the midwife-coordinator.
2. Care during pregnancy: The second activity for the pilot sessions will be the pregnancy care of the migrant and refugee women, coordinated by the midwife-researcher of the project (phase 1 of the ORAMMA approach). The midwives will perform all the necessaries visits with the mothers either individually or in groups. Moreover, an important role in this phase will have the cultural doulas, since they will act both as mediators and as supporters for the mother during all the clinical tests and decision for their birth plan.
3. Support after birth: The third activity of the pilot sessions will be the support after the migrant and refugee women will have given birth (phase 2 of the ORAMMA approach). This phase will be coordinated by the social worker-researcher who will provide psychosocial support to the mothers and provide useful information about social benefits and other important issues for the family. In this phase, the midwives will also perform the post-natal check for the mother and the newborns.
In every phase each health professional will perform an evaluation of the mother that will be included in the Personal Operational Plan of each women. Each migrant or refugee woman that will be treated via the proposed model will monitored for at least a six-month period. Approximately a minimum 20-30 migrant or refugee pregnant women per country/health system will participate in the pilot sessions. More specifically a minimum number of visits with the multidisciplinary team is foreseen, unless more visits are needed due to the conditions of the woman:
• 4 midwife visits (3 ante and 1 post-natal): 150 midwife visits per country
• 1 social worker visit: 30 social worker visits per country
• 1 general physician visit: 30 general physician visits per country
The visits with the health professionals will be made either individually or in groups.
6.2 Reporting on the pilot sessions. A final report will be produced after the pilot sessions are finished that will include all the quantitative and qualitative data from the pilot sessions in order to be used for the evaluation of the pilot sessions.