According to the United Nations High Commission for Refugees (UNHCR), there are 13 million refugees globally, 10 million stateless people and, by mid-2014, 1.2 million people were seeking asylum.1 In the global context, the Oceania region has relatively small numbers of refugees and asylum seekers.2 In Australia, it is difficult to elucidate exact numbers of resident refugees, although the numbers of those currently in community detention, immigration detention centres or regional processing centres is published by the Australian Government.
Currently, there are 1914 asylum seekers in immigration detention centres, either on the Australian mainland or on Christmas Island. A further 2091 people are living in the community after being approved for residence determination and 27 675 are doing so on bridging visas. There are 1648 individuals in regional processing centres, either on Manus Island or the Republic of Nauru. Only men are held on Manus Island while out of the 469 people in detention on Nauru, 113 are women and 95 are children.3
In terms of definitions, asylum seekers are defined as individuals who have sought international protection and whose claims for refugee status have not yet been determined.4 The individuals within immigration detention centres and regional processing centres are almost universally seeking asylum and are therefore not yet technically refugees.
The human rights of asylum seekers under the care of the Australian Government, particularly those of asylum seekers in regional processing centres, has been the focus of intense media and public scrutiny. Reproductive health has been formally recognised as a human right for the past 20 years and, like all other human rights, it applies to refugees and asylum seekers regardless of whether they reside in the community or are detained in a processing centre. To realise this right, these people must have access to comprehensive reproductive health information and services such that they are free to make informed choices about their health and wellbeing. These services have been defined by the Inter-agency Working Group on Reproductive Health in Crises (see Box 1).
Management of pre-existing issues
Many of the following issues vary depending upon the origin of the asylum seeker and the route and conditions they have experienced before their presentation to health services. Hence, the following paragraphs are general and global in nature and may not be representative of all the cohorts in immigration detention and regional processing centres managed by the Australian Government.
As with most socially disadvantaged groups, asylum seekers may be at a higher risk of chronic illnesses, infectious diseases, mental illness and prior gender-based violence.Many, but not all, of these women are from populations that experience low nutritional status, endemic infectious diseases (such as malaria or HIV) and poor access to healthcare facilities. Some will also be fleeing conflict zones where sexual violence was commonplace.
The effect of the situation that leads to becoming a refugee (be it war, disaster or persecution) on an individual depends upon their capacity to withstand complex social, political and economic changes. As an individual’s resilience to manage these changes decreases, their vulnerability to detriment increases. Hence, the most vulnerable are at the most risk.
Box 1. Reproductive health services required for human rights
- family planning, counselling, information, education, communication and services;
- education and services for prenatal care, safe delivery and postnatal care, and infant and women’s healthcare;
- prevention and appropriate treatment of infertility;
- prevention of abortion and the management of the consequences of abortion;
- treatment of reproductive tract infections, sexually transmitted diseases, including HIV/ AIDS;
- prevention, early detection and treatment of breast cancer and cancers of the reproductive system and other reproductive health conditions; and
- active discouragement of harmful traditional practices, such as female genital 5
While women are not an intrinsically vulnerable group, there is a potential for increased vulnerability as in some societies women continue to hold low social status or are the targets for acts of violence.Paired with the loss of normal social and family structures this often removes established coping strategies and supports.
This potential for increased vulnerability is often reflected in reproductive health outcomes during displacement, placing refugee and asylum seeker women in a high-risk group for adverse outcomes. This has been recognised recently and data collected by the National Maternal Death Reporting form have been amended to include this information.6
Initial assessment of these women involves screening for and managing pre-existing conditions. The exact regime will depend upon their country of origin and the countries through which their transit to Australia occurred (see Box 2).
Management of issues in detention
Access to healthcare
While healthcare is easily accessible within immigration detention centres run by the Australian Government, access to healthcare is a complex issue within immigration detention centres globally. In other countries, it has been documented that women, especially pregnant women, held in immigration detention centres have poor access to medical care.7 For women in immigration detention centres or regional processing centres, the only way they can access reproductive healthcare services is through the sole provider of medical services in these centres. While all of these services are offered, they require culturally appropriate education to inform detainees of their availability. It is also important that these services are seen to be independent from government immigration services.The incorrect perception of a lack of confidentiality may cause fear that accessing medical services could adversely affect refugee status determinations. This incorrect perception could potentially act as a barrier to accessing reproductive healthcare services within the detention or processing centres. Similarly, in some cases, asylum seekers seek to positively affect refugee determinations or location of detention by using specific medical conditions.
One of the immigration detention centres and both of the regional processing centres are in remote locations and therefore available medical services are akin to those accessible in rural or remote Australia. This means that some gynaecological surgical services, services for the care of severely preterm infants and complex obstetric services require transfer to facilities in major cities. An effective system to facilitate timely transfer is important, as a significant proportion of displaced women will encounter a potentially life-threatening obstetric complication.8
Mental health is an important issue for those in detention centres and regional processing centres and much has been published on this issue, particularly the mental health of men and children in detention. While exact figures are difficult to ascertain, a significant proportion of detainees receive a mental health diagnosis.9 There is a recognised association of antenatal depression with miscarriage, preterm labour and low birthweight. Postnatal depression also has important effects on bonding and attachment, with potential deleterious effects on the mental and physical development of the child.
Clearly, the provision of adequate mental health services, as an adjunct to reproductive health services, is crucial, particularly during the provision of antenatal and postnatal care. These services are universally provided within immigration centres and regional processing centres run by the Australian Government.
Antenatal services on Nauru
As part of a group of obstetricians, I am involved in providing an antenatal service to asylum seekers in the regional processing centre on Nauru. Within the limits of working within the centre, we aim to deliver antenatal care equivalent to that available on the Australian mainland.
Maternity care is provided from the diagnosis of pregnancy until a six-week postnatal check. This includes the delivery of routine assessments, pathology, imaging and referrals as per the existing Australian standards. At a practical level, this care is delivered via monthly appointments with subspecialist or specialist obstetricians as well as by midwives or general practitioners. Mental health services are also provided to all antenatal and postnatal patients within the immigration detention centres and regional processing centres.
Given that these women are asylum seekers and mindful of the well-documented effects of the detention centre setting, all are treated as ‘high risk’ patients.10 Therefore, specialist sonographers perform an obstetric ultrasound at every visit in addition to the routine ultrasounds for the combined first trimester screen and the fetal morphology assessment. This is done in concert with their antenatal appointments.
Box 2. Initial assessment
- Health induction assessment upon arrival into detention*:
- Public health screening questionnaire
- Screening for infection:
- Chest x-ray
- Hepatitis B, hepatitis C, HIV and syphilis serology
- Mental health screen
- Full assessment by general practitioner, including additional investigations where necessary
- Additional assessment after diagnosis of pregnancy:
- Assessment of nutritional status:
- Body mass index, micronutrient deficiencies such as iron, folate, iodine, vitamin B12 and vitamin D
- Mental health screen
- Including opportunities for safe and sensitive discussion of gender based violence.
- Female genital mutilation, where relevant
- Assessment of nutritional status:
* Health induction assessment currently used by International Health and Medical Services
Non-invasive prenatal testing has also been made available to the detainees. All consultations are done with a gender- appropriate interpreter facilitating communication and explanation. This specialist care complements the primary care delivered by resident general practitioners, midwives and nurses. Mental health support is readily accessible for all patients, especially during pregnancy and the postnatal period.
Owing to the remoteness of the facilities on Nauru, currently all antenatal patients are transferred for labour and delivery. This translates to transfer at 28 weeks for those women in the regional processing centre on Nauru. This occurs due to a lack of permanent obstetric and neonatal services on Nauru and this policy may change in the future once appropriate services are established. Transfers occur earlier for those that require emergency care or who have higher risk pregnancies.
Limited gynaecological services are also available. During our monthly visits to Nauru, women referred for gynaecological review are also seen. While assessment, including ultrasonographic imaging and basic medical management, is available, surgical interventions are limited by the available facilities and the remoteness of the processing centre and often require further referral to a mainland service. Again, this may change once appropriate services are established on Nauru.
The ethics of providing care
No discussion of the provision of healthcare to patients within immigration detention centres or regional processing centres would be complete without considering the ethical aspects of this practice. There has been commentary regarding the ethical challenges for doctors working in the immigration detention system, with some authors suggesting that doctors should boycott the provision of services in immigration detention centres and regional processing centres.11 This has been the focus of renewed attention now that the Australian Parliament has passed the Australian Border Force Act 2015.
Some claim that this Act means that doctors and teachers working in immigration detention facilities could face up to two years in prison if they speak out against conditions in the centres or provide information to journalists. If this were correct this could potentially leave doctors in a difficult moral situation and may impair their ability to provide broader, public health type advocacy on behalf of detainees.
Recent media statements by the Department of Immigration and Border Protection have countered these claims and reinforced that medical professionals, teachers and other professionals employed by and on behalf of the Department of Immigration and Border Protection are not inhibited from reporting matters in line with their professional obligations. The same media statement stated that claims that the provisions of the Border Force Act would prevent reporting or scrutiny of conditions in immigration detention were misleading.12 It remains to be seen what impact, if any, this new legislation will have upon the delivery of care within Australian immigration detention centres and regional processing centres.
The provision of care to asylum seekers within detention centres and regional processing centres is complex, both owing to the intrinsic vulnerability of this population and because of the environment in which the care is delivered. Ethical challenges add another dimension to care delivery in this complex, highly politicised environment.
Despite these challenges, care within detention centres continues to be provided with care and compassion, and at a standard consistent with the healthcare afforded to others within Australia.
Disclosure of interests
I am employed by Arrivals Obstetric Centre who are contracted by International Health and Medical Services to provide obstetric and gynaecological services to asylum seekers in the Nauru regional processing centre.
Obstetric and gynaecological services to asylum seekers in the Nauru regional processing centre are also provided by Dr Paul Bretz, A/Prof Greg Duncombe, Dr Megan Castner and Dr David Watson. I would like to thank them for their editorial advice and support.