Human Trafficking: An emerging and critical challenge for maternity and health care

This week’s EBN Blog is written by Sam Nightingale (@mwsamnight), a clinical academic midwife from UHCW NHS Trust (Coventry). Sam’s research interests lie in vulnerable women in pregnancy and she has recently completed and NIHR MRes on the topic of human trafficking and pregnancy. Sam will be leading the @EBNursingBMJ Twitter chat on Weds 8th Jan (8pm UK time) along with @liz8ailey. To join in add #ebnjc to your tweets; to follow the discussion during the chat search for #ebnjc (latest).

Human trafficking, a form of modern-day slavery, is a brutal abuse which denies people their dignity and safety1 and is linked to poor mental and physical health outcomes 2. Human trafficking is a growing problem, but due to its illegal nature it is difficult to know the exact figures3. However, statistics for the National Referral Mechanism (NRM)4 report that in the third-year quarter of 2019, 2808 potential victims of modern slavery were referred to the NRM; a 21% increase from the previous quarter and a 61% increase from the same quarter in 2018. The statistics around known human trafficking victims have been described as the “tip of the iceberg”5.

The ILO1 points out that trafficking affects every country of the world, and estimates that, in 2016, 40.3 million people were victims of trafficking. Women and girls were disproportionately affected by forced labour and made up 99% of victims in the commercial sex industry, 58% of victims in other sectors, and 71% being of childbearing age6 .One in four women become pregnant while trafficked7, and maternity services being able to appropriately identify and respond to victims of human trafficking and offer appropriate referral and care is of high imprtance2,7.

Given that sexual abuse and physical violence are associated with human trafficking8 these are also potential risks associated with maternal and neonatal morbidity and mortality for women within a trafficking context. 9,10.

Emerging research links human trafficking to poor physical and mental health outcomes2-8-11. These studies show that mental health is especially poor, with suicidality and post-traumatic stress disorder (PTSD) the most common mental health issues. Stanley et al.2 discuss that chronic illnesses and symptoms from physical injuries are also a major issue.

Barriers to accessing health care for victims of trafficking include restrictions to liberty, language difficulties, fear for own safety, and navigating the perceived complex “gatekeeping” barriers such as accessing a GP without identification and address2.

Midwives and nurses need to be aware of signs that their patient may be a victim of trafficking:

  • Have they presented late for treatment or care;
  • Are they accompanied by someone who appears controlling, or are nervous of;
  • Does this person talk for them, not giving them opportunity to speak;
  • Does the patient appear unkempt, in inappropriate clothing for the weather or situation;
  • Does the patient have multiple or untreated injuries;
  • Have they had multiple sexually transmitted infections;
  • Do they have a chronic poorly or untreated physical, sexual or mental health condition?

If you have suspicions, ask gentle questions considering if the patient feels safe, if they have supportive people around them, who they live with, do they have access to their own money and identification documents? These questions need to be asked sensitively and away from people accompanying them. Ensure that interpreters, face to face if possible, are used where needed.

The rise of human trafficking and modern slavery has made this a is a key issue for nursing and midwifery education as a global and immediate problem.

Questions for the Twitter chat (Weds 8th Jan 2020 8pm-9pm GMT)

  1. Do you feel prepared to spot the signs of human trafficking/modern slavery?
  2. Do you feel confident to respond to suspicions of human trafficking/modern slavery?
  3. Does your employer have policies for responding to, and referral for victims of human trafficking?
  4. What education or support do you think is needed to improve spotting the signs and responding to suspicions or disclosures?


1 International Labour Organization (2017) Forced labour, modern slavery and human trafficking. [online] available from–en/index.htm [01/12/17].

2 Stanley, N., Oram, S., Jakobowitz, S., Westwood, J., Borschmann, R., Zimmerman, C. and Howard, L.M., (2016) The health needs and healthcare experiences of young people trafficked into the UK. Child abuse & neglect, 59, pp. 100-110.

3 Zimmerman, C., Stöckl, H., (2012) Understanding and addressing violence against women: Human trafficking. [online] available from;jsessionid=32106071F408E95A99FF3E91341E84E0?sequence=1  [11/07/18].

4 Home Office (2019) National Referral Mechanism Statistics UK, Quarter 3 2019 – July to September [online] available from [31/12/ 2019]

5 Breaking the Cycle (2019) Modern Day Slavery Human Trafficking. [online] available from [18/04/ 2019].

6 Human Rights First (2017) Human Trafficking by the Numbers [online] available from [23/08/ 2018].

7 Bick, D., Howard, L.M., Oram, S., Zimmerman, C. (2017) Maternity care for trafficked women: Survivor experiences and clinicians’ perspectives in the United Kingdom’s National Health Service. PLoS ONE12 (11): e0187856.

8 Oram, S., Stöckl, H., Busza, J., Howard, L. M., Zimmerman, C., Oram, S., Stöckl, H., Busza, J., Howard, L. M., and Zimmerman, C. (2012) Prevalence and Risk of Violence and the Physical, Mental, and Sexual Health Problems Associated with Human Trafficking: Systematic Review. PLoS Medicine 9 (5), e1001224.

9 Gisladottir, A., Luque-Fernandez, M. A., Harlow, B. L., Gudmundsdotti, B., Jonsdotti, E., Bjarnadottir, R. I., Hauksdottir, A., Aspelun, T., Cnattingius, S., and Valdimarsdotti, U. A. (2016) Obstetric Outcomes of Mothers Previously Exposed to Sexual Violence. PLoSONE 11 (3), e0150726.

10 Alhusen, J.L., Ray, E., Sharps, P., Bullock, L. Intimate Partner Violence During Pregnancy: Maternal and Neonatal Outcomes. Journal of Women’s Health. (2015) 24(1):100-106. doi:10.1089/jwh.2014.4872.

11 Kiss, L., Pocock, N. S., Naisanguansri, V., Suos, S., Dickson, B., Thuy, D., Koehler, J., Sirisup, K., Pongrungsee, N., Nguyen, V. A., Borland, R., Dhavan, P., and Zimmerman, C. (2015) Health of Men, Women, and Children in Post-Trafficking Services in Cambodia, Thailand, and Vietnam: An Observational Cross-Sectional Study. The Lancet Global Health 3 (3), e161.




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