Introduction
The aim of this study was to map out the experiences of immigrant women accessing maternity care in the UK, and to identify the existence of interventions that were focused on enhancing the accessibility and acceptability of maternity care services for these women. Although there are many pertinent issues that might impact on the experience, the nature of a systematic review means that we can only report on those issues and factors that have been investigated and appear in the scientific journals. For example, we did not encounter studies that featured solely on ‘white ethnicities’. The primary focus was on the perspectives of women. As the UK is in a period of superdiversity (see Chapter 1, Background), the navigation of health services for many is challenging. The level of superdiversity presents challenges for the NHS in the provision of optimal and individualised maternity care. We consider these challenges framed by the theoretical perspectives of cultural safety62 and cultural competence.51,61,157 Midwives and obstetricians predominantly provide maternity care in the UK; however, virtually none of the studies we identified and included in this review focused on the role of obstetricians and the care they provided. However, we did find evidence of perspectives from women regarding the maternity care provided by GPs, health visitors, community midwives, linkworkers, care assistants and breastfeeding support workers in primary and secondary care.
We reported findings from all three phases of maternity care: antenatal, intrapartum and postnatal. The immigrant population categories studied included asylum seekers, refugees, and spousal and economic immigrants. The ethnocultural groups mentioned include immigrant women of Bangladeshi, Pakistani, European and Middle Eastern origins; black African women from unspecified countries; and women from specific African countries (from Somalia, Ghana, Senegal, Eritrea, Gambia, Sierra Leone, Ivory Coast, Algeria, Congo, Angola and Nigeria).
This NS review identified 61,638 papers (after removal of duplicates), following implementation of our search strategy. We excluded 15,684 papers, meaning that only 0.06% of papers met our inclusion and exclusion criteria. We appraised the quality of each study using the CEBMa tools for the qualitative and quantitative studies and GRAMMS103 for the mixed-methods studies. Following appraisal and organisation into themes as described earlier, we established five significant themes; providing definitions, the scope and parameters of the theme, and exemplars in the form of verbatim comments from included studies and constructing a meta-inference.
Summary of findings
Our themes were as follows:
- access and utilisation of maternity care services by immigrant women
- maternity care relationships between immigrant women and health-care professionals
- communication challenges experienced by immigrant women in maternity care
- organisation of maternity care, legal entitlements and their impact on the maternity care experiences of immigrant women
- discrimination, racism, stereotyping, cultural sensitivity, inaction and cultural clash in maternity care for immigrant women.
Our review established strong and robust evidence for three themes presented above (themes 1, 2 and 3).
Although we found evidence to support our theme development for themes 4 and 5, the evidence was less comprehensive. Nevertheless, themes 4 and 5 highlight important critical dimensions of care. Please see Appendix 6 for an overview of the studies supporting each theme.
Theme 1: access and utilisation of maternity care services by immigrant women
Late booking emerged as an important dimension in this theme, that is that immigrant women study participants tended to book and access antenatal care later than the recommended time frame (during the first 10 weeks of pregnancy). This issue was found to be multifactorial in nature, including issues such as 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 FGM, 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 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 health-care professionals
Our included studies evidenced the perception of service users in this group and their interactions and therapeutic encounters with HCPs. These interactions were significant in understanding access, utilisation, outcomes and the quality of their maternity care experience.
Included studies in this theme demonstrated that the perceptions of study participants regarding the ways in which HCPs delivered maternity care services were both positive and negative. A number of studies illustrated positive relationships between HCPs and immigrant women. Study participants asserted that the HCPs were caring, respected confidentiality and communicated openly in meeting their medical, as well as emotional, psychological and social, needs. Conversely, studies showed evidence of negative relationships between participants and HCPs. Studies showed HCPs, from the perspective of immigrants, as being rude, discriminatory, or insensitive to the cultural and social needs of the women. Consequently, women tended to avoid accessing/utilising maternity care services consistently.
In our included studies, participants expressed a desire for the HCPs to be empathetic, respectful, culturally congruent and professional when providing maternity care services. Some women also suggested employing HCPs from the immigrant population.
Theme 3: communication challenges experienced by immigrant women in maternity care
It is axiomatic that limited English-language fluency presents verbal communication challenges between the HCPs and their patients, families and carers. Moreover, this is compounded when HCPs use complex medical or professional language that is difficult to comprehend. Non-verbal communication is culturally defined and challenges can occur through misunderstandings of facial expressions, gestures or pictorial representations. Our evidence shows that poor communications result in limited awareness of available services. Communication challenges also create miscommunication with HCPs. Study participants often expressed challenges accessing services; failed to understand procedures and their outcomes; were constrained in their ability to articulate their health or maternity needs to health-care providers; were disempowered in respect of their involvement in decision-making; often gave consent for clinical procedures without fully comprehending the risks and benefits; and did not receive understandable advice on baby care. Studies identified that communication was not reciprocal and HCPs often misunderstood participants. This created feelings of isolation, fear and a perception of being ignored. Interventions to address the language challenges included the provision of formal and informal services, bilingual support workers and written maternity care information in the necessary languages.
Theme 4: organisation of maternity care, legal entitlements and their impact on the maternity care experiences of immigrant women
The legal status of immigrant women in the UK has a profound influence 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, which resulted in fractures in the care process, loss of their social networks, reduced control over their lives, increased mental stress and increased vulnerability to domestic violence.
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 a hospital, rather than at home; being able to register a complaint if poor health care 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 (e.g. not being able to see the same maternity care providers each time and being unaware of the configuration of maternity services work, limiting navigation). Participants in our included studies found services within the UK maternity care model to be bureaucratic, and perceived a propensity towards medical and obstetric intervention and lower segment caesarean section births.
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: discrimination, racism, stereotyping, 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 established in our included studies. Discrimination was often subtle and difficult to identify, but direct and overt discrimination was reported in some studies. The findings informing this theme arise from 12 of the 40 included 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. In addition, evidence from our included studies suggested that they also felt that they were regarded as different and dangerous people. 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, studies reported participant dissatisfaction of antenatal classes with a gender mix, which contravened religious edicts. Studies illustrated that some women of Muslim faith felt that their cultural and religious needs for breastfeeding were not met on the postnatal wards and they felt that the staff lacked insight, knowledge and understanding of FGM.
Evidence from our included studies suggest that immigrant women perceived that the staff did not treat them with respect or full attention. They felt devalued, unsupported and fearful when receiving maternity care. 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; this is a positive finding.
Our findings also identified instances of cultural clash and conflicting advice during pregnancy and maternity care, mostly resulting from differences between the home countries of the immigrants and the UK in their cultural practices and medical systems.
A theory or model is a postulation of reality and provides a systematic and logical explanation for the meta-inferences and observed phenomena in our included studies. We present a conceptual model of our findings, embedding the key drivers and influences. These key drivers and influences form the critical domains or foci that require interventions and service enhancement to enhance the maternity care experiences of women in the UK maternity care services. Policy and practice development focusing on these domains can therefore bring about benefits and enhancements to maternity care (Figure 9).
FIGURE 9 Maternity care experiences of immigrant women. Reproduced from Higginbottom et al.24 © Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY. Published by BMJ. This is an open access article distributed in accordance with the Creative Commons Attribution 4.0 Unported (CC BY 4.0) license, which permits others to copy, redistribute, remix, transform and build upon this work for any purpose, provided the original work is properly cited, a link to the licence is given, and indication of whether changes were made. See: https://creativecommons.org/licenses/by/4.0/. The figure includes minor additions and formatting changes to the original figure. (Figure not reproduced here; see the original article.)
Policy context
Maternity services are essentially public health services that play an important role in improving health and reducing inequalities. Recently policy recommendations that call for modernisation of maternity service, for example National Maternity Review. Better Births; Improving Outcomes of Maternity Services in England,6 A Maternity Strategy for Northern Ireland 2012–2018,158 Refreshed Framework for Maternity Care in Scotland159 and A Strategic Vision for Maternity Services in Wales.160 The overall vision for the maternity services in the UK is to improve the safety and quality of maternity care. National Maternity Review. Better Births; Improving Outcomes of Maternity Services in England6 set out a 5-year vision for improving the quality of maternity care, providing women and newborn infants with safer, more personalised, kinder, more professional and more-family friendly care, ‘where every woman has access to information to enable her to make decisions about her care; and where she and her baby can access support that is centred around their individual needs and circumstances’ (contains public sector information licensed under the Open Government Licence v3.0).6 These goals and aspirations match many of the concerns identified by women in our included studies.
The premise behind this vision in the UK is that the services should be flexible and individualised, designed to fit around the needs of the woman and newborn infant, and her family’s journey through pregnancy, childbirth and parenthood. Women and their partners should be supported and encouraged to have as normal a pregnancy and birth as possible. This ambition with regard to the provision of individualised care intersects very well with the findings of this review in respect of immigrant women and maternity care services.
Safety features throughout the Maternity Transformation Programme (this programme is responsible for achieving the vision set out in Better Births) aims to drive improvement in maternity services. Likewise, proposals in the government’s Safer Maternity Care: Next Steps Towards the National Maternity Ambition146 focus on five key drivers for delivering safer maternity care, which are ‘leadership’, ‘learning and best practice’, ‘multi-professional team working’, ‘intelligent use of data’ and ‘innovation’.
Consideration might be given to maternity services improving interagency arrangements (through clinical and local social services networks), including protocols for information sharing and a lead professional, to ensure that women from disadvantaged groups have adequate support and benefit from other agencies (such as housing), referring women, with consent, to local maternity services.
Our findings highlight the criticality that interpreting services are provided for women for whom English is not their first language. Relatives should not act as interpreters. It is paramount in terms of addressing inequalities that funding must be made available for interpreting services in the community, especially in emergency or acute situations.
Successfully providing appropriate maternity care requires the legitimisation and incorporation of the pervasive traditional beliefs and practices of immigrant women, to which these women often adhere despite their new milieu. Their beliefs on maternity care may differ considerably from Western biomedical perspectives. However, a recognition is required that beliefs may change over time due to acculturation. Care provision based on a rigid perception of ethnocultural orientation may lead to stereotyping, and therefore a nuanced strategy of care is required. Overcoming migration issues and language barriers will also be a major factor.
In a diverse pluralistic society, maternity service, care provision and delivery to immigrant women should be everyone’s business. Consideration to addressing the findings from this review might be addressed via the following mechanisms, as articulated in the Transforming Maternity Care programme.
Decision-makers and health-care 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 champions’ 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 in the bespoke maternity safety improvement plan.161
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 data set and other key data sets
- focus on innovation, create space for accelerated improvement and innovation at local level.
In Table 5 we provide a summary of the review implications, illustrating their relationship to the review themes and the underpinning evidence from the review.
| Domain | Implication | Theme evidence | Key points derived from review evidence |
|---|---|---|---|
| Service delivery | Focus on strategies to facilitate early booking for immigrants (the evidence in respect of early booking and the potential outcomes is comprehensive and well known) | 1, 2, 3, 5 | Difference in care model from country of origin Gender of provider FGM Religious/food needs Gender mix in antenatal classes Fear of creating trouble in the system Accessibility of HCPs Understanding of antenatal care Late booking Antenatal class: no attendance Conflicts with antenatal appointments Deference to HCPs Lack of continuity of care Knowledge of emergency health care Rejecting antenatal care and health advice Community midwifes visits too short |
| Focus on the development of personalised care, continuity of care and named midwives could help to address inequalities in maternity care services | 1, 2, 3, 5 | Women need both knowledge and understanding of the services that are available to them and need to be made aware of how they can make contact; however, in the absence or limited provision of such information, effective access is not possible Cultural dissonance, stereotyping, racism, and language and communication contribute to women’s inability to access maternity services Issues of access to and within the services (delay in accessing maternity service and limited use of other preventative services) | |
| Communication | Development of early communication strategies in languages understood by the immigrant women, in geographical locations where cohorts of women are large enough to make this economically viable. Use of a variety of modes of communication: website, videos, text message, social media groups | 2, 3, 5 | Language and communication issues coupled with the availability/quality of interpreters was one of the most commonly reported barriers to service access and utilisation (e.g. informed consent is not a reality; cause for dissatisfaction; issue of supply not meeting the demand; diversity of languages spoken by migrant women appears to be a problem for service providers) Women who have inadequate language support are unable to consume spoken and written information effectively and as a result are unable to access and/or utilise maternity services adequately and appropriately Communication issues are a cause for concern. Language and communication barriers are perceived by many migrant women as a cause of their stereotyping by HCPs, coupled with their racist attitudes and behaviours The provision of interpreters: inadequate provision of effective translation support; use of informal interpreters is common Service expectation was that women should provide their own language support and they are required/asked to bring someone who would translate for them. Informal interpreters appear to be used (e.g. family members or acquaintances, children used too – can be a cause of embarrassment and might hinder information-seeking concerning sensitive issues). Children may miss school in order to accompany a woman to a consultation, or women may be unable to attend their appointment if they cannot make arrangements with a suitable family member or acquaintance. Informal interpreters may lack the skills required to translate medical language or translate women’s health needs into the English language and facilitate effective communication Provision of formal interpreters lead to migrant women’s satisfaction with care and have a tendency for a positive maternity services experience Interpreter service support was inefficient or non-existent; leads to poor involvement of women with decision-making Interpreter service provision if on an ad hoc basis: limited flexibility and are unable to adapt to women’s changing short-term needs Immediate interpreting support may experience considerable anxiety and dissatisfaction when the service is unable to respond quickly and flexibly |
| Outreach strategies with immigrant women in their communities and provision of the necessary maternity care education holds the potential to improve access | 4, 5 | Personal barriers/issues Anxiety/depression Stress Enduring trauma from prior migration/refugee experiences Loneliness | |
| Existing networks and mechanisms exist via immigrant support agencies and ethnocultural group community associations. Potential exists to use these avenues as vehicles for outreach to immigrant women | Allopathic vs. biomedical understandings of health/ill health Different expectations of care due to cultural differences or differences in health-care systems Lack of understanding of fear of caesareans/interventions and of new tests and technologies Community/family role in decision-making | ||
| The NHS in the UK has a hugely diverse ethnocultural workforce with a vast untapped linguistic resource. Strategies could be developed to harness this resource in a non-exploitative way for the benefit for patients, families and HCPs, with, of course, due regard for remuneration and non-exploitative strategies | 1, 3 | ||
| Service organisation and reconfiguration | Asylum-seeking women and refugees with wider circumstances and legal position impinging on access and utilisation of maternity care. Specific strategies are required for these groups to use maternity care services effectively | 1, 4, 5 | Lone migrant women, in particular those seeking asylum (dispersal, separated from partners, etc.) with restricted social support, appeared to be particularly vulnerable to poor maternity care experiences and expressed dissatisfaction with care. Many felt powerless and helpless and following birth, many women describe feeling very isolated on the postnatal ward and their postnatal support needs appeared to be the least met Structural barriers to care leads to disempowerment Immigration policies, payment systems, dispersal, transient lifestyles (disrupts continuity of care among other issues) Poor-quality housing affects newborn’s health and mother’s health Spouses’ lack of rights/entitlements Multiple more immediate problems than health (housing, money, etc.): health deprioritised Lack of transport or lack of money for transport Lack of familiarity with UK health system (lack of cultural health capital) and what to expect from different stages of maternity care (e.g. lack of knowledge/familiarity with antenatal classes) |
| Geographically responsive maternity care services are required, as there is a vast difference in demography throughout the UK | All themes | Organisational/cultural issues Lack of culturally specific services (e.g. classes just for women or single rooms or female providers; more of an issue for Muslim families) No extra time provided for women with complex needs Organisation structures and systems based on needs of white British women, rather than reality of existing (super-diverse) patient groups Social barriers to care Isolation/lack of support Loneliness Lack of practical help especially in postnatal period | |
| Responding to geographical need the provision of permanent linkworkers and a 24-hour interpretation service | 1, 2, 3 | Recommendations for improvement from the evidence reviewed studies: permanent linkworker and a 24/7 interpreter availability | |
| Generic issues exist that all maternity care users experience; for example, need for greater support, lack of continuity, reducing appointment times, which may reflect both service organisation and scarcity/pressure on services. Therefore, general policies and directives could be utilised to improve the experience of minority immigrant women | All themes | Expectations of maternity services Immigrant women want maternity care that is respectful, kind and compassionate, dignified and sensitive Women want to be treated as a person; HCPs who they trust; time and attention from midwives; continuity of carer (care); individualised and culturally sensitive care; and professionalisation Although the above ingredients are a recipe for ‘good’ care, factors such as lack of cultural sensitivity care and HCPs inability to meet the needs of the women were perceived as ‘poor’ care Although issues of ethnicity and gender of HCPs matter to some women, the above issues, for many, took precedence These issues may be considered common to all service users | |
| Our findings have indicated a lack of interventions focused on maternity care and immigrant women. Therefore, a policy focus on the development of interventions, implementation and evaluation of such interventions might be considered | All themes | Interventions focused on improving maternity care for immigrant women: link worker; interpreting support; and availability of information on maternity in a multitude of languages Possible interventions/strategies: very few reported interventions to improve access to, or experiences of, maternity care and social support. Possible role for link workers and possible evidence for benefit of support groups/peer support | |
| Evidence from the review suggests that the current maternity care service structure is often rigid and repeats what was tried unsuccessfully in the past. Maternity care services need more flexibility to meet the needs of our super-diverse population | 4 | The organisation of the NHS/maternity services was found to be difficult to understand; this was problematic for women who need to access maternity services before they are registered with a GP. Once women book for maternity care, the main source of information during the antenatal period is the community midwife. However, information needs are not always met. Information can be inadequate, with limited or no information about antenatal screening and antenatal processes, breastfeeding or nutrition, labour, the birth process and analgesia Migrant women journey through childbirth without adequate information about services that are available to them and, as a result, their choices are limited because they are unaware of all the options available to them and therefore their choice menu is restricted. Thus, migrant women are not empowered to make informed decisions about the care that they want and indeed need Issues of cultural and religious insensitivity in the delivery of maternity care. Cultural dissonance between the understandings of migrant Somali women and UK-based maternity care professionals. Differing understandings of the need for operative delivery lead to tensions and dissatisfaction in both women and their carers. Migrant women’s understanding of caesarean sections was associated with high mortality (in their country of origin) and were fearful of UK practices, they approached childbirth with aspirations to achieve a natural birth and to avoid caesarean deliveries, whereas UK-based maternity services understand caesarean sections essentially prevent maternal and/or fetal mortality. This dissonance lead to women’s distrust in the maternity care that they received; made active choices to delay care or be non-compliant in order to improve their chance of a vaginal birth; contributing to loss of trust and dissatisfaction with maternity services | |
| Education and training | Improving relationships of patient–health-care provider, includes addressing discrimination/racism and the provision of culturally appropriate care. Increasing the cultural sensitivity of services and providers emerges from this review as a paramount concern | 1, 2, 5 | Multiple interlinking issues/challenges at different levels intersect to produce specific outcomes and experiences Variable experiences of care Perceived good care: respectful; explains; person centred, gets to know you, treats you as an individual; takes time; listens; encourages choice/involvement; does not judge; shows cultural sensitivity; has cultural knowledge; kind; compassionate; gives useful appropriate advice; reassuring; choice over gender of health professional; continuity; being proactive (talking about sensitive topics, e.g. FGM) Perceived poor care: stereotypes; judges; no time; lack of cultural sensitivity or sensitivity to complex needs; being ignored/talked over or talked about; feeling unable to express needs/feeling silenced and/or powerless; rude/offensive attitudes; lack of practical help (especially in postnatal period); lack of knowledge of certain issues (e.g. management of FGM) leads to fear/poor outcomes/inconsistent care |
| Greater education and training of all maternity care professions, regarding caring for women who have experienced FGM. A focus on all elements of care (e.g. antenatal, intrapartum and postpartum) | All themes | Immigrant women who had experienced FGM expressed concern regards lay deinfibulation Negative experiences intrapartum Accessibility of all maternity care services Accessibility of antenatal clinics Stated antenatal deinfibulation was not preferred Needed more booking information Needed more care from midwife Deinfibulation Limited language fluency and access Midwifes cultural and FGM knowledge Their mode of delivery choice Modes of information transfer Mother/midwife relationship Their experience of birth care during labour | |
| Specifically focusing on immigrant groups sometimes results in stereotyping and further discrimination and a focus of attention might be ‘mainstreaming’ in the context of maternity care | All themes | Noted in a number of studies that women reported a display of stereotypical and judgemental attitudes towards some groups of migrant women. Such attitudes of being ‘ignorant’ and ‘rude’ have adversely affected the interactions between migrant women and HCPs |
What is the value of this synthesis for the education and training of health-care professionals?
To improve maternity care experiences for immigrant women, we need to improve these women’s access to the services and increase the acceptability of these services. We suggest that the education and training of HCPs needs to take into account the dimensions shown in Box 7, both in the core education programme and in ongoing professional development.
The reality of the UK context as a super-diverse society demands health-care providers who are culturally competent and culturally safe so that they will be able to communicate effectively with immigrant women and their families. The goal is the delivery of high-quality maternity care for immigrant women who are from diverse sociocultural, economic and environmental backgrounds and provide them with quality health care.164 A number of different definitions, typologies and models have evolved55 to assist in the identification of the key components of culturally safe and competent care as well as ways in which practitioners and organisations can enhance their performance and delivery of care in this area. Prior to embarking on a learning path to develop skills in culturally safe and competent care provision, a theoretical grounding is imperative. Moreover, cultural safety and competence improves patient satisfaction, as many ethnocultural groups value relational quality (as established in this review) and the resultant individualised care.
We suggest that a focus on cultural safety and competence could provide vehicles and mechanisms for improving maternity care services for immigrant women in the UK.
Limitations of the review
This review was challenging to undertake because of the great variation in language and diversity of terminology used by researchers to describe ethnocultural and immigrant groups in the UK. We worked closely with our information scientist to ensure that we had selected the correct terms and to develop robust inclusion and exclusion criteria. In the UK, researchers most frequently use the terms BME or specify the ethnocultural group without an indication of the immigrant status. As noted in this report, reductionism in the terminology creates a mix of approaches to reducing immigrant women and their complex cultures, ethnicities and lives to particular contexts or situations. Although a range of identifiers are used, we noted a pattern of identifying immigrant women by their situation or context (such as the use of ‘asylum seeking’), as well as the use of ‘immigrant’ woman as a generic demarcation of a non-British or non-white woman. In sociological terms, this creates a process of ‘othering’ of some of the most vulnerable women in UK society.
Specific challenges existed in extrapolating the findings specifically for immigrant women, when studies used mixed samples of immigrants and non-immigrants. We rejected papers in which no clear findings were presented about the immigrant women in mixed population samples. We also employed as a ‘proxy’ for immigrant status, the use of an interpreter in the data collection processes, or the clear identification of a place of origin for the participants that was outside the UK.
Most of the included studies focused on women’s perspectives on maternity care service, as women’s views were critical in understanding the access and acceptability of maternity care services delivered in the UK. We also included a small number of studies that captured the perspectives of both HCPs and immigrant women, but we largely excluded studies that provided only the views of HCPs on the topic.
Some challenges existed in determining the temporal dimensions of all the included studies. It was not always clear in which phase of maternity the data were collected (e.g. antenatal, intranatal or postnatal). The included studies focusing on the postnatal period also presented a challenge; our operational definition of the postnatal period concluded at 6 weeks, whereas one study included the postnatal phase as the period immediately following birth until 13 months post partum.
The number of interventions evaluated by rigorous research methodologies was quite limited. Although we became aware of a wide range of interventions through our key stakeholder events, most of these have not been subjected to scientific appraisal.
A review of this nature does not include a meta-synthesis data analysis as might occur in a classical systematic review. However, Popay et al.’s 86 original work included conducting a review using a classical genre and a NS review on one topic; and the findings of both reviews were highly congruent in their conclusions.
We experienced technical challenges with the shared use of EndNote, which created a time lag requiring remedial actions. These problems have been relayed to the producers of EndNote.
Priority and key areas for future research
Studies are needed regarding interventions and their effectiveness in enhancing the accessibility to, and the utilisation of, maternity care for immigrant women. We also need studies that address the factors associated with negative and positive relationships between HCPs and immigrant women by using social and psychological theories of ‘otherness’ and ‘difference’. Additionally, there is a lack of research emphasis on the structural dynamics within health systems that may encourage or even foster negative relationships between service users and HCPs. The high-risk intrapartum phase is a critical phase of maternity, but studies focusing on communication challenges and interventions in this phase are almost absent. Many of the existing studies regarding communication were conducted several decades ago. In the current period of superdiversity with new and more diverse ethnocultural groups in the UK, more contemporary evidence is required. We also see a lack of complete strategies, at scale, that consider interventions as part of an integrated system of approaches and care. Most immigrant women come from countries where breastfeeding is a cultural norm, but more research is needed on how we can maintain their existing breastfeeding practices in the UK; the health benefits are substantial and contribute to the health of the nation. The impact of limited legal rights on the health of the mother and infant also needs more study. To our knowledge, no intervention has been reported that focuses on addressing discrimination and stereotyping, eradicating racism, and reducing cultural insensitively to improve maternity care for immigrant women.
Development and evaluation of online antenatal education resources in multiple languages could be explored and obviate the need for written materials and expensive interpreter time. Software exists that will translate online materials into different languages. Development and appraisal of education packages for HCPs, focused on the provision of culturally safe maternity care for the UK’s diverse population, should also be considered.
Significantly, the NHS in the UK has a hugely diverse workforce, with a vast untapped linguistic resource. Strategies might be developed to harness this resource in a non-exploitative fashion, ensuring that NHS staff are correctly remunerated for this activity.
More research is required into the term ‘immigrant’, how it 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 needed 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 care.
Review conclusions
The experiences of immigrant women in accessing and using maternity care services in the UK are mixed; however, these women often have poor experiences. Factors contributing to poor experiences include lack of language support, cultural insensitivity, discrimination, poor relationships between immigrant women and HCPs, legal entitlements and guidelines on the provision of welfare support to immigrants.
The evidence indicates that very few evaluated interventions have been implemented to address inequalities in access to, and quality in, maternity care for immigrant women. However, participants in our national research symposium shared details of many local initiatives not evaluated by rigorous research methodologies. To our knowledge no single study exists on economic evaluations of interventions, which is an important requirement for implementation. Likewise, to our knowledge, postnatal checks by a GP have also not been studied. Researchers may be missing opportunities to connect maternal care with a future holistic approach to improve the mental and physical health of immigrant women and ultimately the health and well-being of future UK citizens.
We suggest that a focus on cultural safety and competence could provide vehicles and mechanisms for improving maternity care services for immigrant women in the UK.
Gaps in the evidence in this review
In the current period of superdiversity in the UK, more contemporary evidence is required. We need complete strategies, at scale, that see interventions as part of an integrated system of approaches and care. In concluding, and as noted earlier, studies are lacking on interventions and their effectiveness in enhancing accessibility and utilisation of maternity care for immigrant women. Studies addressing factors associated with negative and positive relationships between HCPs and immigrant women using social and psychological theories of ‘otherness’ and ‘difference’ are also needed.
Intrapartum/delivery is high risk and is a critical phase of maternity, but studies focusing on communication challenges and interventions are almost absent. Many of the existing studies on such communication were conducted several decades ago. Most immigrant women come from countries in which breastfeeding is a cultural norm, but it is not in the UK. Therefore, more research is needed on how to maintain their existing breastfeeding practices, as the health benefits are substantial and contribute to the health of the nation. For asylum-seeking mothers, the impact of limited legal rights on the health of the mother and infant also needs more study. No intervention has been reported that focuses on addressing discrimination and stereotyping, eradicating racism and reducing cultural insensitivity to improve maternity care for immigrant women.
Additionally, the structural dynamics within health systems have not been emphasised as yet, even though they may encourage or even foster negative relationships between service users and HCPs.
Knowledge transfer
Who should know the implications?
The target list includes policy-makers, commissioners, women in communities, academics, midwives, clinical trainers, HCPs, maternity action groups, migrant women’s rights services, GPs, students in health-care programmes, volunteer and community services organisations, organisations working with migrant women, maternity voice partnerships, the Department of Health and Social Care, UK Visas and Immigration, the Royal College of Midwives, the Royal College of Nursing, Public Health England, the World Health Organization, support agencies in other countries, migrant refugee organisations, religious leaders, local councils, pressure groups, Unite Community Practitioners and Health Visitors Association and, indeed, everyone.
Activities undertaken
- Publication of the review protocol.
- National research symposium with key stakeholders.
- Oral presentation at the Healthy Mothers and Babies Conference, Vancouver, Canada, 1 March 2018.
- Oral presentation to GPs and primary care nurses at the Academic Unit of Primary Care, University of Sheffield, Sheffield, UK, 19 September 2018.
Further activities
Publication of the findings paper in an academic journal. Contributions to theory and practice will occur via publication of findings in high-impact international journals, such as the Journal of Immigrant and Minority Health, Sociology of Health and Illness, Journal of Health Services Research and Policy and Social Science and Medicine, as well as open-access journals such as BMC Pregnancy and Childbirth and BMJ Open Access. The PAG will be invited as co-authors.
Knowledge translation and impact
GH is invited to participate in a multidisciplinary, international Delphi Expert Panel that will select a core set of validated items that can measure mistreatment in medium and high resource countries and align with the World Health Organization Quality of Maternal and Newborn Care framework.
Supported by the Canadian Institutes of Health Research 5-year grant we will study respectful maternity care and mistreatment of pregnant families across Canada, using a participatory research methodology.
GH is invited to participate as an external (independent) International Advisory Group member for the recently funded NIHR Research Global Health Research Group on Preterm Birth, University of Sheffield, along with PAG member Dr Caroline Mitchell. Principal investigator Professor Dilly Anumba. Funding: £2M. Capacity building has resulted from this review as CM (PAG member) is leading the knowledge synthesis strand of this significant study.
GH is invited to provide a methodological workshop on NS at the University of Middlesex on the 16 October 2018.