One in four births in the UK is to foreign-born women. In 2016, the figure was 28.2%, the highest figure on record, with maternal and perinatal mortality also disproportionately higher for some immigrant women. Our objective was to examine issues of access and experience of maternity care by immigrant women based on a systematic review and narrative synthesis of empirical research.
Review methods A research librarian designed the search strategies (retrieving literature published from 1990 to end June 2017). We retrieved 45 954 citations and used a screening tool to identify relevance. We searched for grey literature reported in databases/websites. We contacted stakeholders with expertise to identify additional research.
Results We identified 40 studies for inclusion: 22 qualitative, 8 quantitative and 10 mixed methods. Immigrant women, particularly asylum-seekers, often booked and accessed antenatal care later than the recommended first 10 weeks. Primary factors included limited English language proficiency, lack of awareness of availability of the services, lack of understanding of the purpose of antenatal appointments, immigration status and income barriers. Maternity care experiences were both positive and negative. Women with positive perceptions described healthcare professionals as caring, confidential and openly communicative in meeting their medical, emotional, psychological and social needs. Those with negative views perceived health professionals as rude, discriminatory and insensitive to their cultural and social needs. These women therefore avoided continuously utilising maternity care.
We found few interventions focused on improving maternity care, and the effectiveness of existing interventions have not been scientifically evaluated.
Conclusions The experiences of immigrant women in accessing and using maternity care services were both positive and negative. Further education and training of health professionals in meeting the challenges of a super-diverse population may enhance quality of care, and the perceptions and experiences of maternity care by immigrant women.
- systematic review
- narrative synthesis
- immigrant women
- maternity care
- navigation and access
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Strengths and limitations of this study
Immigration is an international phenomenon, and this review increases understanding of how immigrant women navigate maternity services in the UK.
The review systematically maps the positive and negative aspects of maternity care provision as experienced by immigrant women.
The review provides strategic direction for enhancement of maternity care services.
The review does not address the experiences of maternity care for second-generation women (eg, women of black and minority origin born in the UK).
The UK is in a period of superdiversity that is characterised by ‘an increased number of new, small and scattered, multiple-origin, transnationally connected, socio-economically differentiated and legally stratified immigrants’.(Vertovec, p1024)1 This presents challenges for the delivery and configuration of maternity services in achieving equality of provision which forms a key aim of the National Health Service (NHS) in the UK.2 One in four births in the UK is to foreign-born women.3 Indeed some immigrant women (depending of country of origin) appear disproportionately in confidential inquiries into maternal and perinatal mortality,4 perhaps indicating possible deficits in the delivery of care, access and utilisation. Our review contributes to amelioration of this situation by synthesising knowledge related to maternity care access and interventions so as to configure appropriate interventions as identified per the NHS Midwifery 2020 vision to guide professional development of healthcare professionals (HCPs).5 Reshaping care to ensure culturally safe and congruent maternity care that will not only benefit immigrant women but also improve the health of future generations in the UK.3 4 6 Without the delivery of culturally appropriate and culturally safe maternal care, negative event trajectories may occur that range from simple miscommunications to life-threatening incidents,7–9 risking increased maternal and perinatal mortality. While recent reviews have focused on specific aspects of maternity care,10 11 they have not considered a comprehensive conceptualisation of access or the current super diversity and redesign of NHS maternal services to meet the needs of immigrant women which requires integration of all these aspects.2 We have addressed this deficit in our current review which utilises Gulliford et al’s theory of access to care.12
Considering the global context, some commonality exists between high income nations in the maternity care experiences of immigrant women: studies in the USA,13 ,Canada,11 Australia,14 15 Sweden16 17 and Germany,8 18 all provided evidence of this in earlier international reviews led by Higginbottom et al 7 19 and Gagnon et al.11 However, the international comparative reviews by Gagnon focused on specific populations of South Asian and Somali women in the UK11 which form established immigrant groups rather than the more recent super diverse patterns of migration. We have addressed this deficit in our current review. We have addressed this deficit in our current review.
There is no consensus definition in the UK regarding the definition of the term immigrant20 with the terms immigrant and migrant which are frequently used interchangeably across different data sources and datasets whilst conveying the same meaning. Country of birth is used by The Annual Population Survey of workers and Labour Force Survey as a precursor for defining a ‘migrant’. This survey therefore declares a person born outside the UK is classified as a ‘migrant’. Noteworthy is the fact that workers born outside the UK may become British citizens with increasing residence in the UK.
A second source of data on migrants is applications made to obtain a National Insurance Number. This differs from the former in that the term migrant is conferred on the basis of nationality. All applicants who hold nationality other than the UK are therefore considered migrants. However, the situation is dynamic in that the nationality of a person may also to change over time and in some cases individuals may acquire dual citizenship involving several nation states.
A third and significant source of data on migrants is the Office for National Statistics (ONS). ONS utilises a different strategy classification which focuses on the notion of short-term international migrant and long-term international migrant. In this definition, the term ‘long-term’ refers to holding the intention of residing longer than a year, whereas short-term is intention of residing less than a year. The implication of this is that the ONS considers length of stay of a person in the UK as critical in determining migrant status which reflects the United Nations (UN) recommended classification of migrant into short and long term. Additionally, ONS utilises the UN definition of long-term international migrant. Accordingly, ‘a migrant is someone who changes his or her country of usual residence for a period of at least a year, so that the country of destination effectively becomes the country of usual residence’.20 In long-term international migration data, students and asylum-seekers are also included which differs for example from the situation in the USA.
Immigrants and the UK NHS
In respect of service provision, the NHS adheres to the mandates set by central government that determines immigrant’s entitlement to free NHS care. These mandates are concerned with the immigrant status and the type of service provision.21 Within these mandates, an asylum-seeker woman may not be entitled to full maternity care because of immigration status.22 Moreover, data collection by the NHS on this topic is not well established or comprehensive. Currently, the NHS usually collects data on ethnicity and nationality and not on migration-related variables such as length of stay, country of origin and so on.
The National Institute for Health and Care Excellence (NICE) which provides clinical guidelines for healthcare practice in the UK see NICE (2010)23 identified recent migrant women as having complex social needs in its guidelines on Pregnancy and complex social factors: a model for service provision for pregnant women with complex social factors identified recent migrant women having complex social needs. Within the NICE definition, a recent migrant woman is a woman has who moved to the UK within the previous 12 months. This generic definition of the term migrant conflates migrant women of all classifications (eg, economic migrants, asylum-seekers, refugees and those lacking English language proficiency). This suggests that there is implicit acceptance of the term migrant women in healthcare in respect of being born outside the UK, and being subject to immigration regulations, together with possible challenges in English language proficiency.
The operational definition of an immigrant women used in this review
The preceding paragraphs suggests that the term ‘immigrant’ is defined in various ways in different countries and by different authors. However, two features are frequently referred to in these definitions, namely ‘country of birth’ and ‘length of stay’. These factors are noted by the NICE guidelines23 on the provision of maternity care as important in entitlement, access and ability to use healthcare in the UK. For example, if you are born outside the UK, it is unlikely that you are knowledgeable about the UK healthcare provision.
We adopted the following definition of an immigrant woman for the purposes of our review, and most importantly, to inform our inclusion and exclusion criteria. We defined a woman as an immigrant if she was:
Born outside the UK.
Living in the UK for more than 12 months or had the intention to live in the UK for 12 (or more) months when first entered.
We therefore included studies on immigrant women where the population studied fulfils these two characteristics and included population groups of foreign students, asylum-seekers, recent legal refugees and immigrants, and illegal immigrants. In cases where the study populations/sample was not accurately or fully described, we employed the criteria of linguistic ability, as demonstrated by the need for an interpreter as a proxy for immigrant status. Notwithstanding all of these perspectives, we acknowledge that the term ‘immigrant women’ is generic and refers to a highly heterogeneous group of individuals with a complex and vast array of ethnocultural groups.
Aim and rationale
We consider in this paper how accessibility and acceptability manifest, as important dimensions of access to maternity care services in terms of women’s perception about availability of services and their experiences of accessing these services. We also consider whether evaluated interventions exist that challenge inequalities in maternity healthcare provision.
Our review employed two theoretical frameworks. These are Gulliford and colleagues’ theory of access and second the concept of cultural safety.
Utilisation of services and barriers to access (which includes personal, financial and organisational barriers).
Relevance, effectiveness and access.
Equity and access.
We used this theoretical model in our systematic review which was based on a synthesis project funded by the National Institute for Health Research. Unlike most access models in the USA, this framework reflects the philosophy of the NHS in that its key principles are to provide horizontal access in terms of ensuring equality of access in the population and to achieve vertical access in terms of meeting the needs of particular groups in the population, such as minority ethnic groups. The application of these principles is influenced by availability, accessibility and acceptability. The Gulliford model12 has been widely used in empirical research, with the main paper cited over 730 times. This model with its emphasis on accessibility, acceptability, relevance and effectiveness, is entirely appropriate for assessing the provision of maternity services to minority ethnic groups and was employed in this review to assist in initial theme development and to examine how this access model intersected with our evidence.
Second, concepts of cultural safety provided a theoretical lens for the production of recommendations. Cultural safety is a theory that aims to assist the understanding of deficits in care by considering the historical and social processes that impact power relationships within and beyond healthcare.24 Cultural safety is achieved when programmes, instruments, procedures, methods and actions are implemented in ways that do not harm any members of the culture or ethnocultural group who are the recipients of care. Those within the culture are best placed to know what is or is not safe for their culture which suggests the need for increased dialogue about immigrant and partner approaches.25–29
We employed Popay’s approach to Narrative Synthesis (NS)30 which consists of four elements (for a comprehensive explanation please see our published protocol.31 The unique feature of this approach is that it provides highly specified steps.
Team members have successfully employed NS previously and have vast expertise in its usage.7
Element 1: Developing a theory of why and for whom.
Element 2: Developing a preliminary synthesis of the findings of the included studies, following implementation of the search strategy.
Element 3: Exploring relationships in the data.
Element 4: Assessing the robustness of the synthesis.
The NS approach relies primarily on text to summarise the findings and produce a synthesis of the narrative findings of included papers. NS may be used with all paradigms of research quantitative, qualitative studies and mixed methods research studies, as the emphasis is on an interpretive synthesis of the narrative findings of research rather than on a metadata analysis.30
Search strategy refinement and implementation
The search strategy employed key terms used in consistently formulated text-based queries and search statements. These terms were based on subject headings, thesaurus terms or related indexing and categorisation terms appropriate for each literature database. An example of a detailed final search strategy is given in online supplementary file 1. First, we searched 10 electronic databases using the aforementioned strategies (online supplementary file 2 ). Following this, we searched for appropriate grey literature in SI Web of Knowledge Conference Proceedings Citation Index (Science 1990–), ISI Web of Knowledge Conference Proceedings Citation Index (Social Science and Humanities 1990–), ProQuest Dissertations and Theses, and the Cochrane Methodology Register. We also searched using Google and Google Scholar and consulted with the study expert advisory group. In conclusion, we hand searched the reference list of all included studies and relevant systematic reviews. Citations were downloaded into an ENDNOTE library, and following this all duplicates removed. The bibliographic databases that we searched are listed in box 1.
Ovid MEDLINE 1948– and MEDLINE in-process and other non-indexed citations to daily update
Ovid EMBASE 1980–2017 week 11
Ovid PsycINFO 1972–March week 3 2017
CINAHL Plus with full text/EBSCOHost to 2017
MIDIRS on Ovid 1971 to April 2017
Thomson Reuters Web of Science* 1900–2017
ASSIA on ProQuest 1987–current
HMIC on Ovid 1979–January 2017
POPline (via http://www.popline.org/) 1970 to the present
Thomson Reuters Web of Science 1900–2017 includes the following:
Science Citation Index Expanded 1900–2017
Social Sciences Citation Index 1956–2017
Conference Proceedings Citation Index-Science 1990–2017
Conference Proceedings Citation Index-Social Science and Humanities 1990–2017
Book Citation Index-Science 2008–2017
Book Citation Index-Social Science and Humanities 2008–2017
Emerging Sources Citation Index - 2015–2017
We adopted the PICO approach to implement the search strategy as follows:
C=non-immigrant women—implicit comparator emerging in the results
O=experience of care
Our search strategy development was therefore based on:
Search concept 1=pregnancy, childbirth (implicitly females requiring maternity care), explicit terms covering women/females requiring all types of maternity care (antenatal, perinatal, postnatal, etc).
Search concept 2=immigrant populations (which would not fully distinguish between ‘new’ and ‘second-generation’ immigrants—this would be done at the selection stage).
Search concept 3=terms used to identify access to, use of, deficiencies in and so on, service provision (to help identify groups with poorer health outcomes or vulnerabilities)
This comprehensive search strategy generated high rates of retrieval of records, however many were not pertinent.
Screening for relevance
In many cases, the study populations/sample was not fully described. In this situation, we contacted the authors for further clarification and in some cases used linguistic ability, for example, the need for an interpreter as a proxy for immigrant status. Our focus was on first-generation immigrant women regardless of their phenotype which led to inclusion of women of white ethnicities, although we encountered few studies that focusing on these groups. Study screening was undertaken independently by two team members (GH & BH) who employed our screening tool to assess the relevance of titles and abstracts in respect of our screening tool. The entire team reviewed papers classified as ambiguous papers in order to achieve a consensus agreement and where necessary full text papers of potentially included studies were retrieved and appraised. The exclusion and inclusion criteria can be found in online supplementary file 3. When we retrieved full-text papers which were later rejected, we have documented these excluded papers and presented a rationale for exclusion. These can be found in online supplementary file 4.
Studies included in the review, findings and evidence
Our systematic review identified 40 empirical research studies in the scientific and grey literature. The included studies embraced a broad range of ethnocultural groups and methodological genres (see table 1 for master table of included studies and online supplementary file 5). The search outcomes are comprehensively detailed in figure 2, the Preferred Reporting Items for Systematic Reviews and Meta-Analyses flow chart.32 The distribution of the studies across the themes are shown in figure 3 and publication dates in figure 4.
Data extraction and assessment of relevance
We conducted the following foundational activities in order to extract data (discussed in detail later).
1) Textual description. A systematic textual narrative was written for each study. We used headings adapted from Popay et al
Setting, Participants, Aim, Sampling and Recruitment, Method, Analysis, Results.30
(2) Tabulation and summarisation of all studies to be included. These tables described the attributes of the studies and the results. Information was extracted from the textual description using the same headings as above and additional headings as necessary. Papers in the PDF format were imported into ATLAS.ti qualitative data analysis software (ATLAS.ti Scientific Software Development, Berlin) using the ‘Attributes’ option to allow the tabulation of relevant data.
In element 4, we conducted the quality appraisal (see tables 2 and 3).33 All included studies were critically appraised by two reviewers using tools from the Center for Evidence-Based Management (CEBMa).34 We used Good Reporting of A Mixed Method study (GRAMM)35 for the mixed-methods studies. Differences were resolved in our reflective team meetings. We also used high, medium and low as appraisal categories (discussed in table 2) This is approach is congruent with recent publications from the Cochrane Qualitative Research Group’s Confidence in the Evidence from Reviews of Qualitative research (CERQUAL) publications and was previously used by in published studies by Higginbottom and colleagues.7 9 Studies were classified in three into domains, high, medium and low, to enable a ‘macro’ evaluation.
High was assigned to studies that used a rigorous and robust scientific approach that largely met all CEBMa benchmarks, perhaps equal to or exceeding 7 out of 10 for qualitative studies, 9 out of 12 for cross-sectional surveys or 5 out of 6 for mixed-methods research.
Medium was assigned to studies that had some flaws but that did not seriously undermine the quality and scientific value of the research conducted, perhaps scoring 5 or 6 out of 10 for qualitative studies, 6 to 8 out of 12 for cross-sectional surveys or 4 out of 6 for mixed-methods research.
Low was assigned to studies that had serious or fatal flaws and poor scientific value and scored below the numbers of benchmarks listed above for medium-level appraisals in each type of research.
The past decade has witnessed a growth in approaches to assessing quality and Popay et al 30 recommends evaluating not only the scientific quality of studies but also the ‘richness’ of studies, defined as ‘the extent to which study findings provide in-depth explanatory insights that are transferable to other settings’ (Popay et al, p230)30 ‘Thick’ papers create or draw on theory to provide in-depth explanatory insights that can potentially be transferable to other contexts. By contrast, ‘thin’ papers provide a limited or superficial description and offer little opportunity for generalising. Each paper was assessed against the criteria as set out in Higginbottom et al (p5)28 33 and categorised as either ‘thick’ or ‘thin’ (see table 2).
Analysis and synthesis
Following construction of the preliminary themes, we produced code/narrative theme tables to demonstrate how the basic meaning units related to the theme. This involved utilising the codes produced in ATLAS.ti and aligning these to the manually extracted key findings (see figure 5). We reviewed all these processes in our reflective team meetings to ensure the rigour and robustness of our analytical steps. This iterative process is similar to the process of qualitative research and involved grouping the narrative findings into meaning units and social processes as they manifested in the maternity care experiences of immigrant women. Individual team members engaged in independent theming of tabular and coded data. We subsequently merged these individual perspectives to form the final harmonised themes representing a ‘meta-inference’ which is a term used in mixed methods research to describe merging of findings from the positivistic and the interpretative paradigms. Tashakorri and Teddlie (p101)36 describe meta-inference as ‘an overall conclusion, explanation of understanding developed from the integration of inferences obtained from the qualitative and quantitative strands’.
Following construction of the preliminary themes, we produced code/narrative theme tables to demonstrate how the basic meaning units related to the theme. Utilising the codes produced in ATLAS.ti and aligning these to the manually extracted key findings (see figure 5 ).
During the analytical processes we interrogated the data identifying using the concept suggested by Roper and Shapira.37 We have constructed the themes in a policy directive fashion in terms of containing implicit indications in order to provide tangible guidance for policy and practice that might be developed into relevant strategies that benefit immigrant women and the NHS.
Rigour, reflexivity and the quality of the synthesis
Reflexivity in the review process requires a self-conscious and explicit acknowledgement of the impact of the researcher on the research processes, interpretations and research products. Reflexivity therefore demands acknowledgement of inherent power dimensions, hierarchies and prevailing ideologies that might shape and determine interpretations and the consequent knowledge production and research products. Gender, sexuality, professional socialisation, ethnocultural orientation and political lenses as these impact on social identities further coalescing to provide a specific perspective on any given phenomena. The review team members are imbued with a strong personal and professional commitment to the eradication of inequalities and allegiance to contemporary equality and diversity agendas. From a reflexive perspective, this is important given that immigration is global phenomena and the inherent vulnerability of some immigrant women.
Reflexive analysis alerts us as researchers to emergent themes and informs the formal and systematic process of analysis, with reflexivity defined as:
sensitivity to the ways in which the researcher’s presence in the research setting has contributed to the data collected and their own a priori assumptions have shaped the data analysis (Murphy et al , p188)38
Our collaborative decisions required constant review and reading and, in some cases, reviewing the theme allocation and evidence to reach consensus. Therefore, we believe we achieved a nuanced and comprehensive approach. Higginbottom et al have successfully employed this review genre previously and have vast expertise in its usage.39
Within the published NS reviews, we have not given great attention to the issue of publication bias. However, we strove to eradicate any potential bias by undertaking a comprehensive and exhaustive literature review that included grey literature and follow-up emails with authors seeking greater clarity and explanation of opaque issues. A number of the included research studies were identified via ProQuest and E-theses and do not appear as publications in peer reviewed scientific journals.
We also held a national stakeholder event during which we presented our preliminary findings to a wide range of health professions (obstetrician, general practitioner and midwives), academics, voluntary and community workers. Possibly this approach may be considered contentious in the respect of systematic review, as attendees had no previous knowledge of the original included papers although they held deep topic knowledge. Notwithstanding this, we found broad support for our findings and facilitated groups work activities in order to challenge our initial interpretations. These challenges resulted in the construction of Theme 5: Discrimination, racism, stereotyping, cultural sensitivity, inaction and cultural clash in maternity care for immigrant women. These focused activities collectively contribute to the confidence in the review findings, providing verification and validation of the themes.
We identified 40 research studies that met our inclusion criteria, and we extracted and synthesised key findings into five themes (see table 4) for the publications informing each theme.
We identified eight quantitative studies that all used a questionnaire for data collection.40–47 These population-based studies and cohort surveys were all cross-sectional: none were longitudinal.
We identified 10 mixed-methods studies that employed both qualitative and quantitative dimensions.2 48–56 For example, Duff et al 49 reported a two-stage psychometric study in which focus groups and interviews were used in the first stage to develop a questionnaire for an ethnocultural group (Sylheti) In the second stage, quantitative methods were used to test and evaluate the acceptability, reliability and validity of the questionnaire. Other mixed-methods designs included (a) interviewing a small sample of the participants after collecting data from a large-scale survey; (b) conducting semistructured interviews with a small sample of participants based on quantitative data routinely collected from a large group of participants; and (c) using face-to-face, postal and online questionnaires to collect data. One of the studies used Q methodology which uses questionnaires with structured and unstructured questions.
Of the 40 studies included in this review, we identified 22 as qualitative research studies employing a range of qualitative methodologies and approaches.17 57–77 However, many of these studies did not specify a qualitative methodological genre but instead employed a more generic qualitative approach and described only the data collection tools used. For example, some presented multiple longitudinal case studies of participants (asylum-seekers and refugees) about their maternity care experiences that included photographs taken by the participants, field notes and observations in addition to researcher interviews. Another example was a case study of an ethnocultural group, immigrant women of Somali origin, that used semistructured interviews and focus groups. Some studies used focus groups and interviews conducted in the language of the population group; for example, Bengali, Sylheti, Urdu and Arabic. Others used in-depth interviews, open-ended questions, group story-sharing sessions and individual biographical life-narrative interviews. In contrast, a few studies specified a qualitative interpretive approach that used hermeneutic phenomenology and focused ethnography.
Studies focusing on specific ethnocultural groups
The chosen studies included participants from a wide range of ethnocultural groups that originated in diverse countries in different continents, including Asia (eg, Bangladesh and Pakistan), Africa (eg, Somalia and Ghana) and Europe (eg, Poland). In some cases, the sample was drawn from a single ethnocultural group, such as Pakistani.72 However, most of the studies were undertaken with mixed samples of immigrant women originating from different countries (eg, Somalia, Bangladesh and Eastern Europe) (see online supplementary file 6).
Studies focusing on immigrant women without a clearly specified ethnocultural group
We identified 16 studies that used the term immigrant women generically and not clearly specify an ethnocultural group. In deciding to include these studies, we believed that legitimate proxies for immigrant status could be the specified use of an interpreter or the participants having countries of origin or birth outside the UK. Some studies reported immigrant women arriving from 14 different countries but did not specify the country of birth. Without clearly specified ethnic group, these studies were still included.
Theme 1: access and utilisation of maternity care services by immigrant women
Late booking emerged as an important dimension in this theme with immigrant women study participants often booking and accessing antenatal care later than the recommended timeframe of during the first 10 weeks of pregnancy. This delayed utilisation was found to be multifactorial in nature with influencing factors including the effects of limited English language proficiency, immigration status, lack of awareness of the services, lack of understanding of the purpose of the services, income barriers, the presence of female genital mutilation (FGM), factors associated with differences between the maternity care systems of their countries of origin and the UK, arrival in the UK late in the pregnancy, frequent relocations after arrival, the poor reputations of antenatal services in specific communities and perceptions of regarding antenatal care as a facet of medicalisation of childbirth. The range of factors affecting the access and utilisation of postnatal services were similar to those reported for antenatal services.
Theme 2: maternity care relationships between immigrant women and HCPs
Our included studies identified the perception of service users in this group and their interactions and therapeutic encounters with HCPs as significant in understanding access, utilisation, outcomes and the quality of their maternity care experience.
Included studies identified both positive and negative perceptions of study participants regarding the ways HCPs delivered maternity care services were both positive and negative. A number of studies illustrated positive relationships between HCPs and immigrant women with the HCPs described as caring, respecting confidentiality and communicating openly in meeting their medical as well as emotional, psychological and social needs. Conversely, some studies provided evidence of negative relationships between participants and HCPs, with HCPs described from the perspective of immigrant women as being rude, discriminatory or insensitive to the cultural and social needs of the women. The end result of these negative encounters was that these women tended to avoid accessing utilising maternity care services consistently.
Theme 3: communication challenges experienced by immigrant women in maternity care
It is axiomatic that limited English language fluency presents verbal communication challenges between HCP and their patients, families and carers. Moreover, this is compounded when HCPs use complex medical or professional language that is difficult to comprehend. Nonverbal communication is culturally defined and challenges can occur through misunderstandings of facial expressions, gestures or pictorial representations. Poor communications result as illustrated in our included studies in limited awareness of available services in addition to miscommunication with HCPs. Study participants often expressed challenges in accessing services, failed to understand procedures and their outcomes and were constrained in their ability to articulate their health or maternity needs to healthcare providers and disempowered in respect of their involvement in decision-making. They therefore sometimes gave consent for clinical procedures without fully comprehending the risks and benefits, and did not always understand advice on baby care. Studies also identified communication as not reciprocal with HCPs often misunderstanding participants. These issues of communication were described as leading to feelings of isolation, fear and a perception of being ignored.
Theme 4: organisation and legal entitlements and their impacts on the maternity care experiences of immigrant women
The study participants in our included studies had mixed experiences with the maternity care services in the UK. Positive and commendable experiences included feeling safe in giving birth at hospital rather than at home, being able to register a complaint if poor healthcare was received, being close to a hospital facility, not being denied access to a maternity service, and having good experiences with postnatal care. Conversely, negative experiences included lack of continuity (eg, not being able to see same maternity care providers each time) and being unaware of the configuration of maternity services work that limited appropriate use. Participants in our included studies found services bureaucratic and perceived within the UK maternity care model as having a propensity towards medical/obstetric intervention and lower segment caesarean section births.
The legal status of an immigrant women in the UK has a profound influence on their on their access to maternity care. Women without entitlement to free maternity care services in the UK were deterred from accessing timely antenatal care by the costs and by the confidentiality of their legal status. Moreover, some women arrived in the UK during the final phase of their pregnancies that resulted in interruptions in the care process, loss of their social networks, reduced control over their lives, increased mental stress and increased vulnerability to domestic violence.
Positive experiences included receiving information from their midwives on the benefits of breastfeeding together with demonstrations on how to position the baby. Negative experiences included poor support from hospital staff on how to breastfeed their babies consequently these reported experiences are mixed.
Theme 5: cultural sensitivity, inaction and cultural clash in maternity care for immigrant women
Inequalities in access, navigation, utilisation and the subsequent maternity care outcomes are influenced by discrimination and cultural insensitivity in maternity care services according to the perspectives of women in several included studies. Although discrimination is often subtle and difficult to identify, direct and overt discrimination was reported in some studies.
Specifically, study participants of Muslim faiths challenged assumptions held by HCPs, including those held regarding Muslim food practices and that their partners or husbands should help the women during labour. Moreover, HCPs were reported in some studies to lack cultural sensitivity and cultural understanding. For example, these women did not optimally benefit from antenatal classes facilitated by a non-Muslim educator who had no knowledge of the relationships of Muslim culture to maternity.
Furthermore, Muslim participants often expressed dissatisfaction with antenatal classes having a gender mix, which contravened religious edicts. Studies illustrated that some women of Muslim faith also regarded their cultural and religious needs were not met, and they felt that the staff lacked insight, knowledge and understanding of FGM.
Evidence from our included studies suggests some immigrant women perceived that the staff did not treat them with respect or attended fully to their healthcare needs, and they felt devalued, unsupported and fearful while receiving maternity care. Our findings also identified instances of cultural clash and conflicting advice during pregnancy and maternity care, mostly resulting from differences between the cultural practices and medical systems of the home countries of the immigrant women and those in the UK. In a few cases, however, midwives were happy to meet the cultural and religious needs of the study participants in our included studies in both antenatal and postnatal settings which is a positive finding.
We conceptualise the findings graphically in figure 5.
Patient and public involvement
The systematic review questions were developed in consultation with our project advisory group including service users’ priorities experience and preferences. This systematic review did not include empirical research therefore there were no human participants.
Discussion and conclusions
The UK is in a period of superdiversity, defined as being ‘distinguished by a dynamic interplay of variables among an increased number of new, small and scattered, multiple-origin, transnationally connected, socio-economically differentiated and legally stratified immigrants’. (Vertovec, p1024).1 Responding to this level of diversity is challenging for UK maternity care health services and may require the development of new and innovative strategies.
The experiences of immigrant women in accessing, navigating and utilising maternity care services in the UK are both positive and negative. In order to enhance services, it is essential that strategies are developed to overcome the negative experiences reported. The experience of maternity care services is multifactorial in nature with a number of issues appearing to coalesce to determine the poorer experience reported by some immigrant women. Important factors identified by the review included a lack of language support, cultural insensitivity, discrimination, poor relationships between immigrant women and HCPs, and a lack of legal entitlements and guidelines on the provision of welfare support and maternity care to immigrants.
Implications of findings and recommendations for maternity care policy, practice and service delivery
Inequitable access appeared to be a consequence of the immigration and legal status of asylum-seeking women which has a profound impact on healthcare experiences and consequently health, and was also influenced by language fluency. We concluded that addressing language barriers and ensuring culturally sensitive care are essential elements of providing optimal maternal care for immigrant women. The issue of confidentiality may be compromised by having known interpreters in small communities. One solution may be the setting up of a national-level website offering standard information on maternity care and the option of translation in a wide range of languages. Additionally, the identification of best language practices should be identified in order to improve the current language service model.
The knowledge, understandings and attitudes of maternity care healthcare providers is a critical determinant of care. Ethno-culturally based stereotypes, racism, judgemental views and direct and indirect discrimination require eradication requires challenging discrimination and racism at all levels: individual, institutional, clinical and societal Interventions to improve maternity care for immigrant women are scant, and formal evaluations of these interventions were largely absent. Increasing the social capital available to immigrant, health literacy and advocacy resources may empower women to access and use maternity care services appropriately.
Maternity care staff require a greater level of mandated education to have better cultural awareness of needs of diverse client groups including newcomers to the UK. Our findings highlight the importance of demonstrating compassion, empathy and warmth in their relationships with these women to reinforce positive attitudes among immigrant women.
It is contingent on maternity care providers to value diversity among service users and to offer individualised and culturally congruent care. One way to achieve this goal would be through birth plans that can be jointly agreed and discussed in advance by the maternity care staff and recently arrived newcomers and immigrant women. Maternity care staff should seek to empower immigrant women by providing comprehensible information and better education concerning the configuration of the maternity system in the UK, conveying accurate information about care delivery. Central to these suggestions may be to enable volunteer and third-sector organisations to work as links between the statutory maternity services and immigrant women. We found evidence (though not scientifically evaluated) of such links in our national networking event.
Representatives of immigration control agencies may feel obligated to adheres to immigrant rules and consider the maternity care needs of immigrant women’s and baby’s health as a secondary issue. The policy context regarding data protection and sharing information with the Home Office about the immigrant status of women was at issue as well, especially since variabilities have been seen in the policies for sharing this information. The results suggest that the legal and policy context is important in addressing the maternity care needs of immigrant women.
It would seem imperative, as reflected in current policy directives, to adopt a universal of aim of achieving optimal maternity care for all and not just for immigrant women. However, maternity care services should strive to give more information to immigrant women about their rights to care, the availability and configuration of maternity services, and how to navigate maternity care systems. The child in utero of an immigrant is a future UK citizen and optimising maternity care is a dimension of securing the future health of the nation. In a period of super diversity is incumbent on health professional to have an awareness of immigrant women’s legal rights and perhaps education on this topic should be mandated for maternity HCPs. Continuity in maternity caregivers and compulsory provision of interpreters would also help to improve the experiences of these women.
Decision-makers and healthcare leaders should address the findings at a strategic level. A focus on diversity, equality and the needs of immigrant women could reasonably be embedded in the role and responsibility of ‘Board level Maternity Champion’ and of ‘Maternity Clinical Networks’. Maternity service providers could consider the appointment of one obstetrician and one midwife jointly responsible for championing maternity care provision to immigrant women in their organisation. As these dimensions feature within the ‘Bespoke Maternity Safety Improvement Plan’,78 key areas of action include:
Focus on learning and best practice: issues of equality and diversity should be featured in the Saving Babies’ Lives care bundle for use by maternity commissioners and providers.
Focus on multiprofessional team working: continuous personal and professional training.
Focus on data: greater focus on ethnicity and immigration within the Maternity Services Dataset and other key data sets.
Focus on innovation: create space for accelerated improvement and innovation at local level.
Gaps in the evidence
Some locally developed and locally based interventions to address inequalities in access and quality in maternity care for immigrant women were described during the final feedback meeting. However, there are very few interventions to address these issues in the published literature and their effectiveness has not been evaluated robustly. None of the interventions had also included economic evaluation of the intervention. Studies of the usual 6 weeks postnatal checks by a general practitioner were not identified nor studies that focused on the intrapartum period. As mentioned earlier, we found few studies that focused on immigrant women with ‘white ethnicity’ in our review time period, for example, women of Eastern European origin.
Strengths and limitations
We were challenged and constrained by the lack of consistency in describing immigrant population sin the published literature. There exists a great deal of variation and no unified approach within the UK literature.
Immigration is an international phenomenon, and this review increases understanding of how immigrant women navigate maternity services in the UK,
The review systematically maps our positive and negative aspects of maternity care provision as experienced by immigrant.
The review provides strategic policy-level direction for enhancement of maternity care services.
The review does not address the experiences of maternity care for second-generation women (eg, women of black and minority origin born in the UK) nor does it consider refugee and asylum seeking women as a separate group.
Implications for future research
More research is required into how the term ‘immigrant’ is used, and the changes in its use over time that may affect immigrant women’s care. At present, the term is used very broadly and simplistically which masks its inherent heterogeneity. Furthermore, more research is required to understand how the intersections of particular characteristics—such as gender, education status, time in the UK, immigration status, wealth and country of origin—may influence or alter the experiences of these women in their maternity. Research is also required that focuses on developing and evaluating specific interventions to improve maternity care for immigrant women.
We gratefully acknowledge valuable input from the members of our Project Advisory Group. Their input has been very helpful in making possible the successful completion and the high quality of this review. The following people kindly consented to be members: Jim Thornton, Professor of Obstetrics and Gynaecology, Faculty of Medicine and Health Sciences, University of Nottingham, Dr Caroline Mitchell, General Practitioner/Senior Clinical Lecturer, Clinical Academic Training Programme Lead, Academic Unit of Primary Medical Care (AUPMC), University of Sheffield. Dr Jane Mischenko, Commissioning Lead: Children and Maternity Services, NHS Leeds, Carol McCormack, Specialist Midwife, NUH Trust. We also thank following immigrant women for their input in the conceptualisation of this review: Ms Valentine Nkoyo, Director of Mojatu, Nottingham Kinsi Clarke, Nottingham Refugee Forum
Twitter @Awoko1, @Catrin_notts
Contributors GH (Professor, School of |Health Sciences) was principal investigator. Initiated the project and oversaw all stages. Led the interpretation/synthesis phases and draft-ed the manuscript. BH (Senior Research Fellow) contributed to all stages of the review. Led the data extraction, coding, and quality appraisal and contributed to the manuscript. CE (Associate Professor of Nursing, Director of the Centre for Evidence Based Health Care) contributed to all stages of the review, provided expert methodological advice, acted as second reviewer for quality appraisal and development of the synthesis. She contributed to the review of the final version of the manuscript. MM (Professor Emeritus King’s College London) contributed to all stages of the review, provided expert methodological advice, acted as second reviewer for quality appraisal and development of the synthesis. She contributed to the review of the manuscript. KB (Retired Director of Midwifery, University of Leeds) contributed to all stages of the review, provided clinical and policy perspectives, contributed to formulation of the implications and recommendation in the manuscript. JE (Information Specialist) designed the literature search strategy, advised the team on all aspects of information retrieval, undertook the main database searches and contributed to the development of the manuscript.
Funding This project was funded by the UK National Institute for Health Research (NIHR) Health Services and Delivery Research Programme (Grant No. HS&DR-15/55/03). Along with this funding, NIHR also contributed by peer reviewing the funding proposal.
Competing interests None declared.
Patient consent for publication Not required.
Provenance and peer review Not commissioned; externally peer reviewed.
Data availability statement Data are available upon reasonable request.
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