Care For Pregnant Illegal Immigrants By The Multidisciplinary Out-Of-Hospital Team


In recent years there has been an increase in the immigrant population, especially among pregnant African women who generally arrive on our coastlines on pateras (a Spanish word used to describe a small boat used by immigrants to cross the Mediterranean). This impacts on the professionals who care for women during childbirth, and for this reason we need a wide range of knowledge to improve the care of this vulnerable group. OBJECTIVES: Develop an action protocol for the multidisciplinary out-of-hospital team for the comprehensive care of pregnant woman who arrive illegally on pateras. Comprehensively assess other actions relevant to this emergency through scientific publications in addition to childbirth care in a multicultural environment. METHOD: An exhaustive systematic bibliographical review of the last eight years was carried out, in Pubmed, in physical libraries, by way of recommendations of the WHO and protocols. Compilation of journals by SciELO, where there are references relating to Italy. RESULTS: They found an abundance of these boats in Andalusia. Extensive out-of-hospital medical deployment and expertise is required to offer quality care until their transfer to hospital. After the analysis we verified the need to develop a protocol for childbirth care, due to the fact that there are no basic care protocols in this environment. CONCLUSION: Given their sociocultural differences, there is a need to individualise the care. Therefore, it is very important to make the intervention team aware of the required tools and skills, in addition to expanding future research with relevant examples in Europe.

Keywords: Carechildbirthemergencyimmigrantmulticulturalismnursing


The nursing profession in Mediterranean countries is bring presented with new challenges now that immigration in recent decades has taken on a greater relevance in public health due to its gravity, complexity and difficulty in establishing an optimal service. The arrival of pateras and the continuous flow of African immigrants, especially women, have been increasing. Anxiety, impotence, anger, anguish, hunger, misery ... in a word: despair; is what drives them to make the journey of their life.

According to Madeleine Leininger, author of Transcultural Nursing, our care towards a patient must be culturally appropriate, meaning caring for their needs holistically as a biological, social and cultural being, thus we will encourage tailoring the care to the person and their family (Leininger & Marilyn, 2002).

Spain has become a host country for those people who come to live and establish their life, work and family project. The healthcare system is free, with universal coverage, for pregnant women and children, even those with illegal immigrant status (Valverde et al, 2015). In Spain, Andalusian ports are the most popular for these boats, followed by the Canary Islands, Murcia and Alicante (Artigas & Bennasar, 2009). Data disseminated by the Italian Ministry of Foreign Affairs and Cooperation has also been collected which reveals that during 2016 Italy saved almost half of all immigrants found in the Mediterranean Sea. About 25% of those arriving in the country are women and unaccompanied minors, which are the most vulnerable categories (Caponio & Graziano, 2011).

An exhaustive review of the relevant literature in Spain has failed to find a specialized protocol for childbirth care for women who arrive on pateras, and from there stems my interest to develop one so it may be of use to the whole medical team who work in out-of-hospital care.

QUESTION: What are the basic care needs of a pregnant African woman, or one giving birth, who arrives on a patera?

Problem Statement

The significant migratory flow that our country has experienced in recent decades, the age of the immigrants, the vulnerable population and the use of the healthcare services is justification enough to carry out this work. However, more than that, the quality of the healthcare system, the security and the comprehensive care of patients in vulnerable situations is one of the priorities for nursing, with it being a qualified profession with the necessary expertise to act as the front line in the provision of these types of services, prioritizing vulnerable groups.

Research Questions

General: Creating an action protocol for the multidisciplinary out-of- hospital team for the comprehensive care of pregnant women who arrive illegally. Comprehensively assess other actions relevant to this emergency through scientific publications in addition to childbirth care in a multicultural environment.

Specific: Provide medical assistance through on site first aid and perform stabilization routines, and transport those pregnant women to the closest hospital.

Purpose of the Study

The subjects of the study are pregnant African women who come to our shores on pateras. As healthcare professionals we must aware of the importance of this phenomenon, and work through it, with protocol, towards an improvement in the care of this group through quality interventions. Prevention plays an important role, especially with this group who feel vulnerable when faced with an unfamiliar society with different customs, beliefs, laws, etc. This protocol offers an improvement in the quality of the care provided to women in the process of birth, based on the latest scientific evidence. Since in this area there was no protocol as such or its recommendations were obsolete.

Research Methods

Type of investigation: It is a descriptive bibliographic review.

Information gathering: To devise the protocol, a bibliographic review was carried out in physical libraries as well as in databases: Pubmed, journals from SciELO, searches in official guides for pregnant women, textbooks, and the World Health Organisation. To keep the review up-to-date, the search was limited to studies in Spanish and English published after 2010. We want this protocol to be an instrument which guides the healthcare centres and professionals who start to work in the support of normal childbirth outside of the hospital setting, with minimal resources, in the hope of developing a practical clinical guide in accordance with international scientific standards.


The Spanish Red Cross carry out various tasks on foot on the beaches or at the ports:

  • Humanitarian Support: provide food and drink, hygiene products, dry clothes or maternal-infantile kits (food, clothes and footwear)

  • Medical Care: dispense first aid, basic care and life support or stabilization measures, preparation and transfer to a hospital if required.

  • Social Mediation: Interpretation tasks between recently arrived immigrants and the medical team, psychological support, information and orientation, with special attention paid to women and minors.

  • Integrate the activities of Maritime Rescue, the Red Cross and Civil Protection to provide specialist medical care according to the needs of the victims (Cabrera, 2009).

When making a comparison between sexes it is clear and obvious to see that there is a marked flow of 90% male immigrants. At the other end of the scale, we find that women represent 15-25% of the immigrants. It is on the coastlines of Andalusia that we find an increase in pateras with the corresponding out-of-hospital health team offering care until they can be transferred to the nearest hospital (Awad, 2009).

The next section deals with the protocol that I am developing based on the results found in the various sources, which will help the out-of-hospital team improve the care of women who are in labour, who come to our main ports and coasts from the Mediterranean basin.

Protocol for childbirth care in the out-of-hospital setting

The limited pregnancy monitoring offered in the country of origin greatly influences the delivery and can sometimes lead to a series of complications. The focus of childbirth care is to treat the mother and give initial care to the new born baby. It is best to transport the pregnant mother, unless the birth is imminent. In the interview we will have to assert ourselves using non-verbal language (gestures and mime), use guides or questionnaires translated into the most needed languages or fall back on the help of a translator to carry out follow up tests, which can be of great assistance in cases of doubt or at least to rule out some of the most serious diseases (WHO, 2016; Protocolos Clínico Terapéuticos en Urgencias Extrahospitalarias Instituto Nacional de Gestión Sanitaria, 2013).

Instruments for data collection: Semi-structured interview with personal and gynaecological history, in addition to carrying out a physical examination and the taking of vital signs.

Materials: In an out-of-hospital situation where we lack specific instruments or devices, it would be conveniently obtaining towels or blankets for drying, cleaning and covering the new born baby and wrapping up the postpartum woman, in addition to a birthing care kit with the following materials: Two sterile Kocher clamps (to clamp the umbilical cord), sterile scissors or surgical knife, umbilical clamps, gloves, dressings, sterilized wipes, neonatal breathing lines: numbers 8 and 10, infusion instruments, a baby hat, mother and baby identification and security bracelet, and as medication: it would be desirable to have oxytocin (“Syntocinon”®).

Figure 1: Figure 01. Childbirth care kit
 Figure 01. Childbirth care kit
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Figure 2: Figure 02. Identification bracelet and clamp
 Figure 02. Identification bracelet and clamp
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Definition, objectives and activity: A normal birth is defined as one which is initiated spontaneously, at between 37 and 42 weeks, with the expectant mother at low risk, ending with the birth of a new born baby, in vertex presentation, who adapts normally to life outside the uterus.

Objectives : Define the interventions of the nurse or team based on the correct actions when faced with a normal birth and to prevent any possible complications.

Consider that you are in the active phase of delivery, where the established dynamic is a minimum of 3 contractions in 10 minutes, neck cleared, and dilation of 4cm. The origin of the pushing is a reflex that is triggered by the compression exerted by the foetal head on the pelvic floor; this indicates that the birth is imminent. The evaluation of the progress of childbirth is done observing the woman; her appearance, behaviour, contractions and the descent of the foetal head. Steps to follow:

  • Take blood pressure, pulse, temperature and blood glucose, as they may have implications for the outcome of the labour.

  • When the head is crowning, place the woman in a comfortable and intimate position and prepare for delivery. Encourage the expectant mother to push.

  • The expulsion of the foetal head should be allowed with a progressive distension of the vaginal introitus and the perineum avoiding a rapid and uncontrolled expulsion that produces perineal tears.

  • Delivery of the shoulders is facilitated by the release of the anterior shoulder, pulling in a downward direction from the foetal head, placing both hands around the head at the cervical and parietal level.

  • Then the posterior shoulder is released with the same manoeuvre, but in the opposite direction and protecting the perineum. The rest of the body comes out easily. Place the new born on the mother's abdomen (skin with skin) and record the time of birth.

  • Dry the baby well, put on a hat, cover it with dry cloths and with a thermal blanket to keep it warm as they can experience marked drops in body temperature which can lead to metabolic problems. The process of drying the baby stimulates it, making it cry and thus it begins to breathe. A normal Apgar test would be 7 to 10 points, in the first minute of life, if it is less than 7, the baby should be stimulated by vigorously drying the body and gently giving small blows to the soles of the feet.

Once the heartbeat stops (in the cord), pinch it 5cm from the baby's body with the forceps to make it permanent, place a Kocher clamp about 2cm from the cord clip and cut the cord with sterile scissors between the two clamps. In 95% of deliveries the time interval between the birth of the newborn and the expulsion of the placenta is 15 to 30 min. Never pull the umbilical cord to remove the placenta (Protocolos Clínico Terapéuticos en Urgencias Extrahospitalarias Instituto Nacional de Gestión Sanitaria, 2013).

Precautions : Ensure that both the mother and the newborn are well, keeping them at a suitable temperature until their arrival at the nearest hospital. It is recommended that the new mother is accompanied at all times by a family member or person of trust and provide them with emotional support. Encourage breastfeeding (the suckling of the mother's nipple by the newborn produces a release of oxytocin in the mother).

Monitor the constants, postpartum bleeding and uterine contraction every 15 minutes (for at least two hours).


The objective of this bibliographic review was to collectively analyse women in a pregnant state or with birth imminent who arrive on pateras and to identify the possible nursing interventions with the aim of providing assistance and quality care until they can be transferred to a hospital. Although there have been few studies on immigration, health and risk factors, it is our obligation as professionals to keep investigating and to allow nursing to mature.

Healthcare staff are welcoming the results but their training in this respect is not well regulated and is mostly voluntary, in coastal areas. For this reason, the need exists to have health care protocols formalized.

Nursing care for the immigrant population must be based on the application of comprehensive care based on cultural knowledge and must follow a scientific methodology. The protocol developed in this paper is hoping to deliver a tool which contributes to the improvement of the healthcare of out-of-hospital emergencies, with the purpose of improving the work and the satisfaction on the part of the patient after being treated.

In conclusion, and without forgetting the context in which we find ourselves, where the multicultural reality is a fact which cannot be reversed, nursing staff must take a holistic approach to care, in which all the needs of the immigrant patients are covered to the highest quality, hence the importance of the action protocols.


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09 April 2019

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Multicultural education, education, personal health, public health, social discrimination,social inequality

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Salvador, A. G., & Baeza, M. M. R. (2019). Care For Pregnant Illegal Immigrants By The Multidisciplinary Out-Of-Hospital Team. In E. Soriano, C. Sleeter, M. Antonia Casanova, R. M. Zapata, & V. C. Cala (Eds.), The Value of Education and Health for a Global, Transcultural World, vol 60. European Proceedings of Social and Behavioural Sciences (pp. 794-799). Future Academy.