Experience of and access to maternity care in the UK by immigrant women: a narrative synthesis systematic review

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.

3 ((birth* or matern* or mother* or pregnan* or childbearing or child-bearing or prenatal or pre-natal or postnatal or post-natal or perinatal or peri-natal or preconception or pre-conception or antenatal or ante-natal or postpartum or puerperium) adj3 (health* or nurs* or care or service*)).ti,ab. 5 and (matern* or child* or baby or babies or fetus* or fetal* or embryo* or obstetric* or birth* or mother* or pregnan* or childbearing or childbearing or prenatal or pre-natal or postnatal or post-natal or perinatal or peri-natal or preconception or pre-conception or antenatal or ante-natal or postpartum or puerperium).ti,ab.

14965
Revised to focus on established or new immigrant groups; Field modified from .mp. to .ti,ab.
14 ("non-UK-born" or "born outside the UK" or "length of residence in the UK" or (("not lawful*" or "not legal*" or unlawful* or illegal* or unauthori#ed* or "not authori#ed" or uncertain or insecure or illegal or legal or irregular* or refused or undocumented) adj3 (residen* or immigrant* or imigrat* or migrant* or migrat*))).ti,ab. 1375 Multi-level ecological models.
All but four interviews were in the participants' homes.
The study recruited from diabetes and antenatal services in two deprived London boroughs 45 women of Bangladeshi, Indian, Sri Lankan, or Pakistani origin aged 21-45 years with histories of diabetes in pregnancy. Overall, 17 women shared their experiences of diabetes, pregnancy, and health services in group discussions, and 28 women gave individual narrative interviews (facilitated by multilingual researchers). All were audiotaped, translated, and transcribed.

9
To understand the nature of need in superdiverse areas and to examine the emergent challenges for effective maternity service delivery in an era of superdiversity.

West
Midlands.
Mixed methods: the study used a semi-structured questionnaire and held narrative interviews of newcomer women. The findings were then triangulated with interviews of professionals who regularly worked with such women.
Not specified. Not specified. Qualitative: systematic thematic analysis. Quantitative: triangulation of findings.
Sampling was not described clearly. However, the study used a semi-structured questionnaire that was designed in collaboration with maternity professionals and community researchers to explore the views and maternity experiences of newcomer women. Experienced multilingual female community researchers completed 82 of these questionnaires with interviewees in a range of different languages. Narrative interviews were also held with 13 women to further explore issues. The findings were triangulated with 18 interviews of professionals who regularly worked with migrant women.

98
To explore how Somali women with FGM experienced and perceived antenatal and intrapartum care in England.

Birmingham.
Qualitative: a descriptive, exploratory study using face-to-face semi-structured interviews that were audiorecorded.
The study used convenience and snowball sampling of ten Somali women in Birmingham who had received antenatal care in England in the past 5 years.

100
To explore differences in infant thermal care beliefs between mothers of South Asian and white British origin in Bradford, UK.

Bradford
District, West Yorkshire.
Mixed methods: mothers were interviewed using a questionnaire with structured and unstructured questions.
Not specified. The women chose the location of the interview.
A total of 102 mothers (51 South Asian and 51 white British) were recruited in Bradford District, West Yorkshire, UK. The inclusion criteria specified infants aged 13 months or less with a parent of South Asian or white British cultural origin who lived in the Bradford District. South Asia was defined as including the countries of Pakistan, India, Afghanistan, Sri Lanka and Nepal. Recruitment was aided by local community organisations, children's centres, and community contacts. Urdu-and Punjabispeaking interpreters were requested and provided for 69 per cent of the firstgeneration South Asian mothers (n = 26) in the sample.

97
To gain an understanding of infant feeding practices among a group of UKbased refugee mothers.
Liverpool and Manchester.
Qualitative: two focus group discussions and 15 semi-structured interviews.
Not specified. HCPs: private offices or clinics Refugee women: private rooms or discrete areas at the support venue (community centre or church hall).
The study purposively selected 30 refugee mothers from 19 countries who now resided in Liverpool or Manchester and were at least 6 months pregnant or had a child who had been born in the UK in the last 4 years. Of these 30, 19 were HIV-negative and 11 were HIV-positive.

119
To provide insights into possible causes of poor maternity outcomes for new migrants in the West Midlands region of the UK and to develop recommendations that could help improve maternity services for these migrants.

West
Midlands.