In the following narrative, we present our synthesis of evidence in a thematic form derived from the systematic review process (Figure 8). We define each by scoping out the parameters of the theme. We then examine the context and the mitigating factors, enablers and barriers in the maternity care pathway. Finally, we establish the distribution of themes across the included studies (see Appendix 6 and Figure 7). This contributes towards an evaluation and understanding of the weight of evidence in each theme.
FIGURE 8 Flow chart of the NS review processes. 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.)
To organise our themes, we used the theoretical framework adopted by Gulliford et al.23 and the associated four domains of access:
- service availability
- personal barriers
- financial barriers
- organisational barriers.
In our review, we found research evidence in all four domains that determined access to maternity care. It is worth noting that utilisation of maternity care services is determined not just by adequacy of supply, but also by social or cultural obstacles, financial hurdles and organisational issues, such as the acceptability of services.
These four dimensions proved to be extremely useful for providing a theoretical lens to organise our evidence and investigate the experience of immigrant women. The NHS seeks to provide a universal and egalitarian service; consequently, this might be the most profound and significant dimension of access. Though complex, our review has provided the opportunity for a nuanced and comprehensive exploration of the four facets of access. This stance also interfaces well with NICE research recommendations25 on access and models of service provision.
Theme 1: access and utilisation of maternity care services by immigrant women
Theme 1 maps out and describes the factors that affect immigrant women’s access to and utilisation of formal health-care services relating to their maternity needs, including services delivered through primary care and community settings, in addition to hospital settings. The women received three types of maternity care services: antenatal, intrapartum/delivery and postnatal. Findings in this theme arise from the following ethnocultural groups: women from specific countries in Africa (Somalia, Ghana, Nigeria, Senegal, Eritrea, The Gambia, Ghana and Sudan), Asia (Bangladesh, India, Sri Lanka, Pakistan, Afghanistan and Nepal), Europe (Poland), as well as women from the Middle East and black women from unspecified countries in Africa. The categories of immigrants studied included asylum seekers, refugees, and economic and spousal migrants.
Antenatal services: accessibility and utilisation by immigrant women
Access to antenatal services
The findings identified late antenatal bookings and low rates of attendance for parent education classes among the immigrant women.121 For example, a study conducted in London found that, out of 29 women, only five (17%) had their first antenatal appointment before the recommended 10 weeks’ gestation.47 The study noted that 11 out of 29 (38%) women had their first antenatal appointments during their first 12 weeks of pregnancy, whereas 10 (34%) did not visit antenatal services until after 20 weeks’ gestation or even later in their pregnancies. The study noted that 50% of the sample (17/34) attended fewer than the minimum recommended number of antenatal appointments.47 Late booking among immigrant women was also noted in large studies across England49 and in the West Midlands.3
Immigrants who had been placed in the category of ‘no recourse to public funds’ (NRPF) (not entitled to welfare benefits), failed asylum seekers, and spousal and economic migrants with short-term employment contacts were less likely to attend antenatal classes or follow-up appointments.3 Attending follow-up appointments posed a significant challenge for new migrants, who frequently changed address at short notice and then would forget or did not have time to share the new address with maternity services.3
The legal status of the immigrant women could influence their choice to register with maternity services. For example, women with immigration challenges did not register with maternity services because they feared that immigration authorities would access the data, track them and then remove them from the UK.3 As a host of systems and services that are geared towards immigration status engage in increasing levels of scrutiny of residency or citizenship documentation, this concern should be seen as emblematic of the health-care system’s role within a wider system of surveillance. Some women were not clear about the purpose of the antenatal appointments121 and reported that the duplication of activities within the antenatal appointments was frustrating.111
Many immigrant women were not aware of parent education classes, particularly asylum seekers and those with low levels of English.121 Women with female genital mutilation (FGM) coupled with low levels of English were also identified as more likely to experience difficulties in accessing antenatal services.117 Some immigrant women also mentioned that they were not aware of the content of parent education classes.121
A study exploring experiences of maternity care in the UK by women of Muslim faith noted that HCPs tended to assume that immigrant women (in this case of Asian origin) were not interested in attending parent education classes.121
Other reasons cited for not accessing antenatal services are lack of transport and not being able to afford transport.3 Some immigrant women did not attend antenatal care because they feared that they would be required to pay.47
Immigrant women of Somali, non-Somali African and Eastern European origin had much higher rates of late booking than native British women.47 However, the ability of immigrant women to access antenatal services increased over time.117 Additional time spent in England improved the English-language skills and social support networks of immigrant women, and both these factors helped to improve their access to antenatal services. A study117 also noted that if these services had a bad reputation in the community, informal communication via social networks can discourage immigrant women from accessing the services. Other factors affecting their access to antenatal services included family size, the number of young children, the financial conditions of the women, the ability to drive or to use public transport, the geographical proximity of the health services and the marital status of the women.117
Immigrant women in the asylum-seeking category did not receive formal support to understand the configuration and delivery of maternity care, these women only became aware of the availability, processes and practices of maternity services through informal social networks of other asylum seekers.118 These challenges delayed their initial booking visits for antenatal care.118 A study3 conducted in the Midlands found that half of the immigrant women in the sample did not have the name of the midwife to contact when they were in need of support or advice.
Legal requirements governing the asylum-seeking process also hampered some women in accessing antenatal care. For example, a study3 reported a case of a human immunodeficiency virus (HIV)-positive asylum-seeking African woman who was detained for 2 months and barred from accessing maternity care:
The Home Office put me in detention centre so I could not attend my appointments. There were no maternity services there for me for the 2 months I was there. I was offered appointments, but they were cancelled at short notice without anyone telling me why.
Asylum-seeking women were also noted to be heavily engaged with their asylum-seeking cases, the legal process involved and their fundamental needs (e.g. acquiring housing), all of which were more important to them than attending antenatal care and follow-up appointments.3 Some women in the economic immigrant class feared that their employers would not give them time off to attend follow-up appointments and consequently skipped these appointments.3 Some new immigrant women did not have access to a telephone and so could not book an antenatal appointment.3 The new immigrant women also experienced difficulties in locating the hospital and in finding the correct public transport to access antenatal care.3 The findings noted that, in the UK maternity care system, procedures and processes are based on the assumption that the service users have the cultural health capital required to navigate and access relevant services; however, this may not be true for immigrant women.
The evidence suggests that immigrant women of Somali and Bangladeshi origin perceived antenatal classes as a medicalisation of childbirth, which for them is a natural process. This perception is a barrier to antenatal care uptake.3 However, a study focusing on preventing adverse obstetric outcomes among Somali women found that the women did have knowledge of emergency health care and the NHS emergency telephone number, which was reassuring.4
Utilisation of services
Some immigrant women stopped attending antenatal appointments because they perceived that their husbands, who were being used as interpreters, were not communicating their concerns and the care procedures.3 Many women avoided going to parent education classes because they were offered only in English.20 The evidence in the studies indicated that Muslim male partners did not find it appropriate to attend antenatal care classes that were composed of Muslim and non-Muslim women.121 A few women in the study also felt that the male presence in parent education classes was inappropriate and argued that childbirth should be a women-only sphere.121 Other women in the study wanted their husbands to take part in the classes so that the women could get support from them:121
If they are going be there at the birth, then they need to know.
I just felt that my husband could have been better prepared if he knew, you know, what area to support me in.
You know, like you have to tell him everything. It is better that someone tells him before you have the baby that this is the kind of support she will need, because then you feel like a nag.
In one study, some immigrant women were not clear about the value of routine ultrasound scans; hence, they stopped attending antenatal visits.111 Other women in the study111 considered seeing an obstetrician even for low-risk pregnancies. Immigrant Somali women with FGM indicated their disapproval for deinfibulation in the antenatal period.117
The culturally defined health behaviour of immigrant women is an important facet of their access to and navigation of maternity care services. Some studies reported findings related to cultural influences on women’s health behaviour. For example, a qualitative study115 exploring sociocultural influences on the behaviour of South Asian women with diabetes in pregnancy noted an absence of personal coping strategies and a lack of intention to make changes in lifestyle, such as diet and exercise, to reduce the risks.
What would a good antenatal service encompass?
This review evidenced new models for antenatal care for immigrant women in the UK.121 For example, in a study soliciting views of immigrant women and HCPs, the findings suggested the provision of community-based antenatal services that are culturally and religiously sensitive and that involve local community and volunteer groups along with midwives and other HCPs.121 Some women were of the view that male-only antenatal care might encourage their Muslim husbands to attend these classes so that they would be better able to help them in their pregnancies.121 The women in this study121 further suggested that the antenatal care classes for Muslim women should include a Muslim educator who could provide culturally and religiously sensitive explanations on pregnancy and childbirth.
To increase awareness of antenatal services, Somali immigrant women in one study117 suggested that graphic representations in a ‘comic book-style brochure’ on health education could be helpful. Such brochures could present the advantages of prepregnancy deinfibulation. Some immigrant women found that receiving text messages from antenatal clinics on their mobile telephones to remind them of their appointments was also helpful.111
Intrapartum care services: accessibility and utilisation
Findings from a review by Gorman et al.131 indicated that Polish immigrant mothers had higher rates of instrumental delivery in Scotland than in their country of origin. Somali immigrant women perceived hospital birth to be safer and they had a strong preference for this over home birth.117 However, they expressed mixed views on the need for a caesarean compared with normal birth.
Somali immigrant women who anticipated an episiotomy preferred to have deinfibulation in the final stages of labour stage to prevent experiencing surgical interventions twice.117 Some Somali women delayed accessing intrapartum services because they feared creating trouble in the system, which may not be helpful in preventing adverse obstetric outcomes:4
My husband and I were waiting to see if the pain got worse. We did not want to cause trouble in the system.
Although we note that such statements could be interpreted to mean that the women did not wish to cause undue fuss and attention by announcing any problems or issues to their practitioners, we also note that women who had already had high levels of stress and agency interaction, such as asylum-seeking pregnant women, may be especially concerned about being ‘in trouble’ within the system.
Pictorial representations in health education brochures were found to be a useful tool for increasing the knowledge of immigrant Somali women regarding emergency caesarean sections.117
Postnatal services: accessibility and utilisation
Evidence from included studies suggested that participants found that their hospital stays were longer than they expected. For example, one study47 found that 24 out of the 35 immigrant women sampled (68.57%) reported inpatient stays that were 2–11 days longer than they expected. The reasons for longer stays related to both the baby and the mother, such as the baby requiring antibiotics, the mother having high blood pressure, or the mother recovering from a caesarean section and loss of blood.
Lack of money limited the opportunities of many of the participants in our included studies to access and utilise postnatal services. Women from the asylum-seeking and refugee categories were often unable to buy clothes and pushchairs or to attend baby health-check appointments with health visitors.20 Evidence suggested that immigrant women with no access to welfare benefits found it challenging to manage the expense of feeding their babies with formula milk.116 Sometimes these mothers prioritised their child’s dietary and health needs over their own:
It is so hard to live on vouchers only. I can’t go for an appointment.
One study demonstrated that participants were not well informed about the amenities available at the hospitals, such as baby changing and feeding facilities.139 For example, an immigrant woman from the Middle East was not aware of the toilet facilities and she did not ask about it owing to her limited English-language ability. In addition, some women were not aware that a male circumcision facility was available in the hospital.
Acceptability of baby care
A study on the evaluation of postnatal care found that immigrant women of Middle Eastern and European origin received adequate and appropriate information, as well as practical demonstrations from hospital staff, on a wide range of information about caring for their baby,139 for example how to carry the baby, bathe the baby, change nappies, clean the baby’s navel area, settle the baby, massage the baby’s stomach, clean a baby’s sticky eye, maintain safe sleeping positions, control the room temperature, burp the baby, immunise the baby and address the baby’s jaundice. The women from the Middle East rated the baby support that they received in the UK more positively than that in their home country.
A study evaluating bilingual peer support for breastfeeding noted that the support worker did not inform the immigrant women about the breastfeeding classes and none of the women from the study sample attended such classes.135
Advice on infant nutrition
Evidence regarding advice on infant nutrition was reported by one study.140 The women reported being confused and disoriented when they were attempting to balance the information received from NHS literature, from health visitors, and from their own social and ethnic network:140
In Africa I was observing what my mothers were doing, what another woman are doing. I introduced solid food to my kids when they were at 4 months. Here information is different. It is confusion because my mother-in-law is telling one thing and a health visitor is telling other.
The evidence from that study also indicates that the midwife can play a very important role in advising women on infant nutrition:140
When I was pregnant, midwife visited me. She left me some leaflets, some of them were in Polish language so it was very helpful. It was very useful . . . It was my first contact with NHS.
Suggestions for improvement in antenatal care included setting up a local community-based ethnicity-specific (e.g. Asian) parent support group, with targeted marketing to increase attendance.121 These women found their support group helpful in terms of learning how to better care for their children. The women mentioned that they would not have attended if the group had been held in a health-care clinic.
Conclusion
Evidence from our included studies indicated that many participants experienced several accessibility barriers to maternity care. They also faced many challenges in uptake and continuing to utilise these services because of perceived insensitivity to their culture and religious needs. The system was also reported as being designed primarily for the general population and not for immigrant women, highlighting the ways that the health-care system may not currently accommodate diversity.
Gaps in the evidence
More studies are needed relating to interventions and their effectiveness in enhancing accessibility and utilisation of maternity care for immigrant women.
Theme 2: maternity care relationships between immigrant women and health-care professionals
Maternity care relationships in the context of this review mean interpersonal relationships between HCPs and immigrant women during the provision of technical or physical maternity care, and emotional, physical, and psychological support. The relationships between service users and maternity care professionals, such as midwives, GPs and health visitors, are significant in determining the accessibility and quality of maternity care. This theme discusses in more detail the dynamics of building positive relationships between immigrant women and HCPs in maternity care. The findings were mixed, suggesting both positive and negative relationships between maternity care professionals and immigrant women. Positive relationships facilitated a safe environment in which women were able to engage with maternity care professionals in identifying their care and many had a positive experience with maternity services. Positive relationships had good communication, cultural sensitivity and no stereotyping or cultural humility.148 By contrast, negative relationships are the opposite and may manifest in negative behaviours, such as lack of respect, dismissive communication, failure to respect cultural norms and poor or ineffective communication.
The following subsections give critical accounts of various dimensions of a positive relationship.
Relationships with midwives
From the perspective of immigrant women, a good relationship with the midwife is established when the midwife is caring, kind and helpful in enabling the needs of the immigrant women to be met.127 However, we identified substantive evidence indicating that the immigrant women born outside the UK continue to be unclear on the role of the midwife in meeting their maternity care needs.138 This lack of clarity may be due to different perceptions of doctors and midwives in the birth countries of the participants. For example, most of the maternity care needs during the antenatal phase in the UK are provided by midwives, whereas pregnant women with physiologically uncomplicated pregnancies in some other countries (e.g. South Korea and Pakistan) visit gynaecologists and medical doctors for maternal check-ups and medical tests.127
We identified variability in the quality of, and perceived satisfaction with, the relationships between midwives and immigrant women in different maternity care settings. For example, in a study110 involving asylum-seeking women and maternity care services, high levels of satisfaction with antenatal care were expressed and some of the women had good relationships with their community and specialist midwives:
I received information about depression that women may have after having baby. This gives me some comfort that this may happen to all of us. It was important for me not to feel ashamed that I feel depressed and where I get support. It was very useful for me.
However, relationships during labour and postnatal periods were sometimes reported to be poor, with some, but not all, women experiencing perceived racism, indifference, rudeness and disrespect, as well as feelings of being powerless and coerced.110 When seen through the lens of the previous considerations of surveillance, racism and causing ‘trouble’ within the system, these issues suggest that more systemic dynamics may be at play, which are less to do with the insensitivities of some, but not all, individual members of staff and more indicative of a system-wide framing of service delivery and care for immigrant women who may disadvantage them because of assumptions about their experiences and capabilities.
The findings suggested that asylum-seeking black women of unspecified African origin perceived that some of the care and health-care practices were coercive. For example, decisions about commencing an induction or a caesarean section appeared to be taken exclusively by the staff.109 To highlight such coercion, McLeish109 cited a participant quotation:
When they wanted me to stay in hospital because of my high blood pressure I refused . . . I went home . . . They took me by force. They rang the police and told them to bring me back to the hospital.
When combined with the potential instability and uncertainty in some immigrant women’s lives, especially due to their immigration status and social circumstances, the participation of the health-care system in what appears to be violent and compulsory practices is concerning. Rather than taking sides, however, we see this participant’s perspective as crucial to spurring a reassessment of the practice of service and the challenges of properly communicating procedures and risks, especially within circumstances that may already be fraught with tension and mistrust of authority figures (which would include the NHS from the perspective of some of the mothers).
In cases when women did not have open communication with their midwives (e.g. feeling comfortable in disclosing their FGM), they were unable to share all their concerns and cultural needs.117 Some immigrant women perceived their midwives to be cruel,108 and a woman in one study124 reported a very bad experience during labour. The midwife asked this woman to walk to the labour ward with her membranes ruptured, shouted at her during labour, refused to hold her hand and argued with the woman’s birthing partner about the practice of FGM.
During the postnatal phase some immigrant women reported that the midwives were angry with them when they approached midwives for help.108 Midwives were also reported as being unkind, unfriendly and uncaring.107 For example, an African immigrant woman complained that, after she had undergone a caesarean birth, the midwife did not look after her vomiting baby and left her alone at night.107
Clearly, some women felt that their interactions with the midwives were devoid of cultural safety. These situations can occur when the demands of the system on the birth practitioners are translated by the women as culturally insensitive care:
I do not think the midwives were friendly with me. When I was delivering him, without my mum . . . I took one of their hands she said to me ‘Don’t touch me!’ I had to say to her ‘Sorry!’ . . . I thought she might hate me she might not help me.
Although the study107 did not identify the maternity care setting clearly (such as antenatal, postnatal, or labour suites), the event was in a hospital setting. Furthermore, immigrant women feel midwives are too busy in hospitals and they lack support from midwives, particularly if the women had undergone caesarean deliveries.107
Some women described experiencing more positive birth experiences in their countries of origin than in the UK.123 This view often developed from poor treatment by midwives. However, this result conflicts with evidence we presented earlier that Middle Eastern women preferred UK birth experiences:
I am so disappointed that I delivered here, in spite of the midwife was nice, but she did not compensate for the general way [I was dealt with]. I maintain that delivery in Jordan is much better – there is no comparison . . . ‘Third World’, they empathise . . . here the indifference is perceptible.
Some women felt that community midwife visits were too short and were not helpful or congruent with the level of support they needed.139 These women also expressed that the midwives engaged in poor communication, although the study did not explain how this poor communication manifested.139 By contrast, a few women from the same study thought that their community midwives were most helpful and that the midwives offered them and their babies optimal maternity care and clinical support.139 Instances of positive relationships with midwives postnatally also included new mothers reporting ‘very good’ support and education on baby care.139
Immigrant women from the asylum-seeking category felt that midwives did not know their difficulties and never asked them about their immigration status.118 The midwives also did not take into account their poverty and living conditions when giving maternity advice; therefore, such advice was not helpful for these women because it was not tailored to their specific situation.118
Factors promoting satisfactory and positive relationships
When the midwives and immigrant women reported an open, comfortable and safe relationship, the women were able to discuss sensitive issues such as FGM,139 asylum-seeking and parenting.137 Awareness of the immigrant women’s religion and culture played an important role for the midwives in developing positive relationships.117 It indicated a high level of cultural sensitivity55,65,149 and an appropriate regard for the cultural safety51 of the immigrant women. The analysis identified positive examples of midwives who offered wider treatment options to immigrant women as a matter of course, and showed respect for their cultural and religious needs. In a study108 based in West London, the participating women reported that they had received helpful information on pregnancy and labour from their midwives. In a qualitative study,107 mothers also reported positive and trusting relationships with their midwives during labour and postnatally. Factors that strengthened a trusting relationship with the midwives and increased the quality of communication included maintaining a continuous presence during labour (which was seen as a comfort for the women) and keeping the husband fully informed and aware of the situation.
In some instances, midwives intervened to improve the living circumstances and the access to benefits of asylum-seeking women by referring them to the appropriate services. For example, one study118 reported how a midwife supported an asylum-seeking woman by writing a letter to the Home Office to prevent her dispersal (forced relocation to another area). Another community midwife helped an asylum-seeking woman to get her benefits, and a community midwife visited a woman on the postnatal ward to provide additional support to reduce her isolation and loneliness. In this same study, immigrant women felt that more time and attention, rather than less, was needed from the midwives during the postnatal period, because they lacked sufficient energy and resources to look after their baby properly after giving birth.139
Rather than receiving ‘orders’ from midwives, the women understandably wanted to be actively involved, have choices and receive explanations of procedures:
She [the midwife] was asking me, ‘Why do you want this medication? You have a sour stomach now?’ . . . the doctor always gives me Zantac with any medication. If you are not convinced, call the doctor. But she would not listen to me.
Improved staffing levels on the postnatal ward (a universal theme) were needed to improve the quality and experience of care.107 Although women preferred early discharge, they expected that the postnatal home midwifery care would replicate the care offered in a hospital setting.110
Relationships with general practitioners and medical staff
Some findings related to the relationships between immigrant women and GPs and other medical staff. Immigrant women complained that often they were not treated with respect and sometimes misunderstood communications articulated by medical staff.133 Some immigrant women reported experiencing aggressive behaviour from health professionals (unspecified), and one service user even reported a breach of confidentiality by her GP who was also a family friend.126 Some immigrant women reported a lack of communication from doctors.139 Overall, GPs were perceived to have a minimal role to play in antenatal care, which reflects the midwifery-led UK model of maternity care. However, this lack of medical input may contrast with the care women received in their country of origin.111
Evidence of negative relationships was found when doctors did not explain to the immigrant women why they would not get the medicines they were normally prescribed for minor illnesses.124 The studies highlighted differences in prescribing practices between the UK and the immigrant women’s countries of origin that led to unmet expectations. This negative perception was attributed to the UK emphasis on ‘self-management’ and ‘over-the-counter’ medicines, rather than prescribed remedies, for treating minor illnesses when compared with countries such as Pakistan127 and South Korea.124 Consequently, the immigrant women reported feelings of insecurity and perceived that this lack of medical treatment might increase their risk of complications during their pregnancy.124
Some immigrant women experienced racism or stereotypical comments and attitudes from some medical staff.107 One study that provided an example of a racist attitude included the use of the term ‘Asian woman syndrome’, suggesting that the professionals perceived that women from an Asian background commonly exaggerated their symptoms and complained too much about minor illnesses.121 These cultural assumptions were expressed in ways that the mothers felt were not only unprofessional but also may have jeopardised their care. Evidence arising from one study suggests that the negative attitudes and behaviour of some but not all GPs resulted in poorer access to care for the immigrant women and non-adherence to health-care advice.111 In some cases, women (in this case Muslim women) would compromise on their cultural needs to avoid insensitive treatment from maternity care professionals:121
When I was referred, I was given the choice of a woman consultant, but the woman consultant is a nightmare. She’s really, really insensitive, so I chose to be referred to the man because of the insensitivity of the female.
Relationships with health-care professionals
Under this subtheme, we present findings from studies that used the terms HCPs or maternity care providers, but did not make clear which professional group they studied. Health visitors are included here because they are registered nurses or midwives who have undergone further training and gained additional qualifications.
The findings highlighted the relationships between immigrant women and health visitors and the ways in which these relationships affected care. Health visitors were reported by some women to be the best professionals they saw in the community setting, these professionals were keen to help the women and provided health-care support, emotional support and childcare needs. However, other immigrant women reported superficial engagement and a lack of thoroughness by health visitors who, for example, failed to explore their postnatal mental health in sufficient depth.126
The women from the asylum-seeking category perceived feeling ‘labelled’ as asylum seekers and consequently felt that they experienced poorer and different care. In one instance, staff made assumptions about the woman’s health-care needs, such as undertaking a vaginal scan and asking her, unprompted, if she would like to terminate the pregnancy:118
They do me . . . vaginal scan? To check the baby . . . They ask me again if you want to take out the baby?
The asylum-seeking women were distressed by being treated differently when accessing care. For example, a receptionist in a walk-in clinic shouted at a woman when asking her to provide her passport. Another woman had a negative experience when she encountered a receptionist who made derogatory comments about her non-working status, demonstrating her ignorance of the ineligibility for employment of asylum-seeking women:118
To register in our nearest GP . . . reception ask us . . . You have to bring . . . bills. And I told her, we don’t have bills ‘So you’re not working?’ . . . And I feel like! . . . I’m forbidden to . . . I feel . . . very bad.
The immigrant women noted both subtle and direct forms of discrimination from the staff.121 Subtle discrimination was by non-verbal communication and by addressing immigrant women’s requests and questions in angry and inappropriate ways. Direct discrimination included unfair, racist and stereotypical comments and assumptions being made based on a woman’s perceived cultural background:
I saw a consultant . . . She was not nice. She was very abrupt. ‘Did you circumcise?’ . . . I didn’t know women can be circumcised! ‘I’m asking you, are you circumcised?’ I don’t understand.
No one offered me any antenatal classes . . . Nobody mentioned it to me . . . I really wanted to go but they [health professionals] don’t mention it to you. That’s the thing . . . [They think] Asian people don’t want to come to these antenatal classes.
Some professionals were found to be stereotyping immigrant African women as having an abnormally high pain threshold.20 The stereotypes held by professionals on pain negatively affected the care received by the immigrant women, who perceived that they were not offered timely and sufficient pain relief. Some women also complained about a lack of emotional involvement by the HCPs.123 That lack, together with discrimination, was felt to impair them from providing proper explanations and committing to shared decision-making during the care of immigrant women.3,110
One study139 noted that a few immigrant European and Middle Eastern women felt that the professionals at the hospitals were easily accessible to them all the time, and they could ask them for prompt explanations and information at ‘the press of a button’:
If I ask them about something, they always told me what to do and they show me how to do this . . . Actually, they were everywhere, so it was easier for me to ask . . . if I press the button. They came to check what is wrong.139
The women from European and Middle Eastern backgrounds also perceived community HCPs to be accessible, including by telephone. Some women were less satisfied with the telephone contacts because of their limited English-language skills.139 Even though language was a barrier,108 the immigrant women in the asylum-seeking and refugees categories in many instances felt welcomed by ‘the staff’,110 cared for,122 and offered good service coupled with high attention, consideration123 and equal care.139
The findings identified a lack of trust between maternity care providers and some immigrant women, especially on the need for caesarean section as a mode of delivery.107 Mistrust between the maternity care professionals and the immigrant women can negatively affect the ability of the professionals to provide the expected quality in service.113 If sufficient mistrust exists between the professionals and the immigrant women, some of the women might get their maternity care outside the UK.4
To improve these relationships, the immigrant women highlighted that empathy and culturally congruent care from the professionals would help them to feel more positive about their experience of maternity care.111 For some immigrant women, employing maternity care professionals of similar ethnocultural origin was important in building trust and enhancing communication. An alternative view argued that qualities such as being respectful and professional were more important than ethnocultural similarity.113
Conclusion
This theme identified that positive relationships between immigrant women and maternity HCPs was critical in the access to and uptake of maternity care. Multiple factors influenced these relationships positively or negatively. Being respectful, caring and professional were key dimensions in developing positive relationships with immigrant women and these positive dimensions are reported in a number of studies. Conversely, stereotyping, racism and disrespect from maternity care professionals discouraged immigrant women from obtaining equitable access to the services and impeded adherence to professional advice.
Gaps in the evidence
Studies using social and psychological theories of ‘otherness’ and ‘difference’ are needed to more completely address the factors associated with negative and positive relationships between HCPs and immigrant women. Additional studies are needed, emphasising the structural dynamics within health systems that may encourage negative relationships between service users and health professionals.
Theme 3: communication challenges experienced by immigrant women in maternity care
Communication extends beyond articulated words; therefore, this theme covers both verbal and non-verbal types of communication. It also includes written information on maternity care offered by health-care services in antenatal, intrapartum and postnatal care settings in the UK. Verbal communication occurs through words of a shared language among individuals. English is the language of everyday business for maternity care services in the UK. Therefore, immigrant women with low levels of English-language proficiency find it difficult to communicate with and understand their service providers, particularly if medical or professional language is used,150 and this can result in inability to access maternity care and a lack of interaction within it. This theme is central, as the findings have identified that ‘language is really the key to everything’117 in maternity care.
Non-verbal communication occurs without words and it includes facial expressions, gestures and pictorials.151 It can be explicit or non-explicit. Importantly, non-verbal communications are culturally defined; for example, a particular gesture can have different meanings for different ethnocultural groups.
Studies included in this theme also report findings on how verbal and non-verbal communication can affect the abilities of immigrant women to access and utilise maternity care services equally. Some studies reported interventions and their effectiveness in improving direct communication between HCPs and immigrant women. This theme also covers interventions to enhance the accessibility and uptake of printed and digital information for immigrant women.
The HCPs with whom immigrant women communicated in these various studies included midwives, GPs, community midwives working in primary and secondary care, obstetricians and sonographers.111
Findings in this theme relate to the following ethnocultural groups: Indian (Punjabi, Gujarati, Urdu and Tamil speakers), black African and Caribbean women of unspecified origin, African (Somalian, Sudanese, Gambian, Ghanaian and Eritrean), Pakistani, Bangladeshi, Middle Eastern (Arabic and Kurdish speakers) and Eastern European (Polish and Czech). The participants were either asylum seekers, refugees, or spousal or economic migrants.
Impacts of language and communication barriers to access and utilisation of maternity care
The findings indicated that some immigrant women were able to neither speak nor write in English.132 Women with limited levels of English-language proficiency used gestures to express their needs:110
I waved my hands [to communicate].
Lack of proficiency in understanding, speaking and reading English resulted in many challenges for immigrant women in maternity care services, including a limited awareness of available services, an inability to access services, an inability to articulate their health and maternity needs to service providers, and an inability to be understood by HCPs. Importantly, abuse and safeguarding issues may not be noticed without proper language support. These issues can be especially important in countries in which patriarchy is the cultural norm, such as India and Pakistan. One study3 reported the following situation from their sample:
One ‘No Recourse to Public Funds’ South Asian respondent, raped by her husband, told us she had wanted an abortion. However, her husband attended every appointment speaking directly with maternity professionals while clearly excluding her from decisions. She explained that she wanted an interpreter to report the abuse.
Language fluency and communication play an important role in developing maternity care relationships. Lack of mutual understanding between immigrant women and HCPs led to visible frustration and anger on the part of the HCPs, hindering relationship development:113
The problem we Somalis have here as a refugee or as foreigners or as immigrants is the language . . . Everyone will be fed up with you if you can’t understand what they are saying – if you can’t talk to them . . . sometimes they will just ignore you.
Before they discharge me, the midwife came to me, my husband was there. She tried to explain a few things how to lie down the baby in bed and how to register his birth and how to look after the baby, how to feed him. But he didn’t understand.
Lack of speaking and understanding the English language often resulted in miscommunication between immigrant women and HCPs.20 Often the immigrant women did not understand care procedures and their outcomes, discouraging them from fully taking advantage of maternity care services111 and negatively affecting their experience with the health professionals.126
Language and communication barriers affected almost all phases of maternity care. In terms of antenatal care, language and communication barriers are cited as reasons for immigrant women booking late3 and therefore failing to access the recommended minimum number of antenatal appointments.47 In a multivariable model of a quantitative study,14 the authors noted that the inability to speak English had an independent effect, increasing the late initiation of antenatal care among immigrant women [do not speak English and not born in the UK: n = 1060, odds ratio = 1.47 (95% confidence interval 1.23 to 1.76)].14 In another study, immigrant women wanted to attend parent education classes but did not because they were offered in only English.20
Immigrant women with limited English-language proficiency felt both frightened107 and ignored by HCPs.113 Consequently, the women developed the view that they were not being supported properly by HCPs and worried that they would develop complications in their pregnancies.108 Limited language proficiency in some women hindered their involvement and decision-making regarding their care, specifically during delivery.121 Often women gave consent for clinical procedures without fully understanding the explanations provided by the HCPs:20
How are they asking people if they do not even understand, you know? It is the matter of understanding . . . Most . . . don’t even understand the questions they are asking, so how do they expect them to, you know, give their consent for whatever is being done to them?
I was referred to another hospital, they did not advise why. At my third appointment, I had an interpreter. The whole process was rushed, I did not know what to expect. I did not feel involved in any of the decisions – someone else always made them for me.
Limited English-language proficiency also limited the offers the immigrant women would receive for a wide range of available care options. Such women did not receive proper advice on baby care, including on immunisation139 and feeding their babies.110 In one case, the communication barriers between HCPs and a service user resulted in the service user misunderstanding that formula milk was a better option for her baby than breastfeeding.110 Immigrant women who experienced discontinuity in maternity care experienced more difficulties relating to communication.108 However, some women or their partners were found to initiate communications in organising appointments and clarifying procedures in their care.123 Poor communication between the women and HCPs sometimes occurred when the professionals noted a possible challenge in the pregnancy but did not share their concerns with the women.111 Other manifestations of poor communication included the HCPs sometimes being discourteous, compassionless and abrupt.111
The evidence indicates that the women regarded a reassuring and engaging type of communication as more effective.111 Furthermore, women with low levels of English proficiency felt that receiving written information, such as a letter for referral, from the HCP was more helpful than receiving verbal information alone.122 Similarly, careful listening to the concerns of the women and taking time to explain things also improved communication.108
Interventions to reduce communication barriers that impair access and utilisation
The findings from this review identified three types of interventions to address the language and communication challenges, and to improve communication between HCPs and immigrant women: (1) formal interpreting services; (2) informal interpreting by family or friends; and (3) linkworker and advocate services.
Formal interpreting services
The findings highlight that not all women with low proficiencies in spoken English had interpreting support. The availability of interpreting services within maternity services was variable at best. It was often poor or not available when needed.113 For example, participants in one study noted that the interpreters were not provided during their postnatal stay at the wards and postnatal visits:
I asked them [the midwife], ‘[Can] we cancel the meeting until we get an interpreter . . . I didn’t understand you and you didn’t understand me.’ She said, ‘No, it’s OK, we can go on – you understand English’.
In some cases, the women were not aware of the availability of formal interpreting services such as the Commission for Racial Equality service (since replaced by the Equality and Human Rights Commission), or a telephone interpreting service called LanguageLine (LanguageLine Solutions, London, UK).108 The women found the telephone ‘LanguageLine’ service difficult to use and confusing for effective communication, but they were happy with the Commission for Racial Equality interpreters.108 The HCPs also noted that this telephone interpreting service was complicated to use.113
Given the increasing diversity of language needs, it was challenging for the HCPs to organise formal interpreters to facilitate appropriate examinations of the immigrant women. Often the HCPs were not able to identify interpreters for languages not spoken widely or were unable to book interpreters in time. Sometimes interpreters were unable to attend appointments or were not able to understand complex medical terminologies. In some instances, male interpreters were available, but the religious norms for immigrant women of the Muslim faith made male interpreters unacceptable. Often, husbands would interpret for their wives instead.121
Informal interpreting by family or friends
Informal interpreting is a second type of intervention. Immigrant women often had no option other than to arrange their own interpreters from among their family or friends, including their own children or even male associates. However, these women were unhappy about the quality of the informal interpreting, and women who could not arrange their own interpreters missed appointments in antenatal care111 and hospital settings.108 The HCPs also viewed informal interpreters as being unable to properly understand and translate complex medical information.20
Immigrant women in this review noted that getting interpreting support from family members and friends can result in communication challenges for users as well as HCPs.138 For example, using the husband or partner as an interpreter and not having direct communication with the women can result in a patriarchal and controlling relationship.20 In cases of domestic violence in which the perpetrator is the husband or partner, the conveyance of correct information between the HCPs and the women is not guaranteed.121 When using their children as interpreters, the women felt embarrassed sharing their sensitive and private maternity concerns:121
It is awful always having to depend upon someone else, always having to call them up when you know that they are busy, and it makes their lives difficult.
He was a man and was not my brother or my husband, and when they were checking me, I asked him to go out, but I really needed to understand.
Informal interpreting support was provided not only by family and friends of service users but also by HCPs and other workers, including porters, nurses, midwives and doctors.128 Owing to language barriers and the challenges involved in organising formal and informal interpreting support, one analysis identified that the time of day was important in determining the quality of maternity care obtained by non-English-speaking immigrant women.121
Linkworker and advocate services
The recruitment of linkworkers and advocates from the immigrant population was documented as an intervention used to address language-related issues in maternity care. Although noted by only one study,120 this intervention enabled women with low levels of proficiency in English to utilise maternity care services. This study noted that the linkworkers and advocates enabled the immigrant women to communicate better with HCPs and to feel more confident and reassured while accessing maternity care services. The HCPs also appreciated the role of linkworkers in helping them to provide better maternity care to women with limited English.
Despite the benefits of using linkworkers to help immigrant women in maternity care, these linkworkers appeared to be available in antenatal settings only during standard working hours,128 suggesting that their presence overnight and at weekends was not ensured.120 In addition, the linkworkers were not always properly trained for the role. Many HCPs thought that the linkworkers added their own opinions or comments during interpreting, which could harm the quality of antenatal care.128 The HCPs also viewed the linkworker position as a low-status role.128 The linkworker role was criticised by some representatives of immigrant groups because linkworkers are employees of the NHS, therefore may feel conflicted in respect of challenging institutional racism present in the system.120 To address some of the limitations associated with the linkworker role, the authors128 suggested allocating more resources for training linkworkers and offering linkworker service on a 24-hour shift basis.
According to the immigrant women, constructive communication by HCPs includes having an emphatic and engaging conversational style, being reassuring and enhancing rapport, being open to questions for further clarification, offering time to the women to talk and not giving the impression of being rushed.111
Impacts of language and communication barriers on the provision of maternity care information
Immigrant women with limited proficiency in English are unable to benefit from written and spoken material on maternity care.121 Translated content on maternity care is available only in the languages of established immigrant communities and new immigrants usually find such information inaccessible to them.20 Consequently, many immigrant women with limited English-language proficiency were not knowledgeable about the systems and processes of maternity care services in the UK, the range of treatment options available to them, and their usual rights and entitlements. Therefore, these women were not well prepared for the birth of their babies.121 Moreover, not all immigrant women receive maternity care information from health-care providers. For example, nearly half of the women sampled in one study20 did not receive dietary information. Consequently, immigrant women with limited proficiency in speaking or reading English have access to only those resources that are provided in their native language.133 These women therefore depend on their ethnic peers to seek and provide them with information on maternity care, such as infant and maternal nutrition.
Interventions to reduce communication barriers that impair the provision of information
In the review, we found two types of interventions that have been implemented in the past: (1) provision of information in the appropriate ethnocultural languages and (2) provision of bilingual support workers.
Provision of maternity care information in ethnocultural languages
The findings indicated the benefits of providing immigrant women with maternity care information in ethnocultural languages. For example, translating English information into Polish.140 The immigrant women emphasised that their understanding of maternity care services was highly improved when they were offered information in their first language, resulting in their improved access to and utilisation of maternity services.
Provision of bilingual support workers
Bilingual workers are individuals who can speak English as well as another ethnocultural language. The findings on this intervention were reported by only one small-scale study in which immigrant women favourably commented on offers of breastfeeding advice by a bilingual support worker.135 Furthermore, compared with paper-based communication materials, the women thought that videos on maternity care and breastfeeding were more helpful because not all women could read their ethnic languages.116,135
The review135 also noted instances of poor communication among maternity care professionals. During discharge, one participant felt a lack of communication between the maternity care professionals working in the hospital and those working in the community. One of the women in another study111 experienced a so-called ‘silo culture’ between her primary care professionals and the hospital because they failed to share clinical information with one another, resulting in confusion over the first point of contact in need and frustration for that woman.
Conclusion
This theme has identified that immigrant women with limited English-language skills experience communication barriers in accessing and utilising satisfactory maternity care in the UK. These barriers were persistently highlighted in the decades-long time frame covered in this review (1990–2017). However, very few interventions were found that focused on improving verbal and non-verbal communication between HCPs and the immigrant women accessing maternity care; and most were dated. Moreover, evidence on evaluating the effectiveness of these interventions was considered to be methodologically weak and dated, and these interventions may not be relevant for the super-diverse population currently accessing maternity care in the UK.
Gaps in the evidence
The intrapartum phase is a high-risk and critical time, but studies focusing on communication challenges and interventions in this phase are almost absent. Many of the existing studies in respect of communication were conducted several decades ago. In the current period of ethnocultural superdiversity in the UK, with many new and more diverse groups needing maternity care, more contemporary evidence is required. The system lacks comprehensive strategies, at scale, that consider interventions as part of an integrated system of maternal care.
Theme 4: organisation of maternity care, legal entitlements and their impact on the maternity care experiences of immigrant women
This theme provides evidence of how the organisation of maternity care services and legal entitlements impact the experiences of immigrant women in accessing and using these services. This theme also covers findings relating to baby care and breastfeeding.
Organisation of maternity care services and the experiences of immigrant women
The immigrant women in the studies we reviewed had mixed experiences in relation to the maternity care services they received in the UK.127
Positive experiences
Some immigrant women had the positive experiences of feeling safe in giving birth at a hospital rather than at home,117 being able to register a complaint if poor health care was received,136 reaching a hospital facility in time because of its proximity and not being declined access to a maternity service because of limitations in space or the availability of medical supplies.4
Some studies also reported that the women had good experiences with postnatal care:123,136,139
The midwife comes to see you, to help with breast feeding . . . and everything before they refer you to the next person, the health visitor. It is really good. I’ve had no problem with them.
My blood group is B negative. After miscarriage they give me an anti-D injection . . . The positive thing was that the anti-D was sent to my home and the people who brought it to me made an appointment [for me] with the midwife to come and give me the injection.
No matter whether it was during the day, or at night, they were ready to help . . . Even during Christmas, they like to see a smile on their patients’ faces.
Negative experiences
Other women had negative experiences, resulting from not being able to see the same maternity care providers such as a doctor132 or a midwife3 each time:
Most migrant participants expressed opinions regarding the continuity of carer in the community. Some migrant participants preferred to deal with the same HCP throughout the postnatal period, especially if the baby developed any health problems, as the HCP would be familiar with the case.
I would like to have the same midwife throughout my pregnancy, because she can continue to help me . . . Without, I am starting new every time I see a new midwife.
We identified evidence of limited options of birth place and failure to be offered parent education.133 Lack of integration of primary and secondary care was evident, and specifically poor communication was seen between GPs and antenatal caregivers. Owing to staff shortages in the hospitals, the caseloads of the HCPs were reportedly not adjusted to provide enough time to meet the multiple and complex needs of immigrant women:20
I wanted an epidural. It was on my birthing plan, but the doctor wasn’t available, so I just had to stick to the gas and air. So, it is whatever is available.
Sometimes they just don’t give you a choice . . . They took me to theatre, and they gave me epidural . . . had to actually take it, the placenta, out by hand . . . They didn’t ask me for my consent that they are going to put me to sleep.
The findings identified that there were no policies and procedures in place to address FGM-related care needs during labour and the immigrant women with FGM suffered tears during the perinatal period.112
Furthermore, it was found that antenatal services were organised on the presumption that the immigrant women would be aware of how these services worked in practice.20 This assumption was negated by the evidence, which suggested that immigrant women experienced difficulties in understanding most structural aspects of antenatal care.117 In some cases, the women did not have resources to pay for transport to attend antenatal care.3 Not only was antenatal care inaccessible to the women, but they were also not aware of all the complexities and internal organisation of the NHS in the UK.140 Some immigrant women expressed confusion regarding the NHS appointment system and indicated that they were not proficient in using it.127 All of these challenges created a mismatch between their expectations of care and the maternity care actually received, resulting in consequent disappointment among the service users.139
Evidence from the included studies suggested that study participants were also unhappy regarding the bureaucracy involved in receiving maternity care. They also found dissonance between the maternity care models in the UK and their home countries (e.g. women of Middle Eastern origin), especially around labour, for which the women expected more proactive medicalised obstetric interventions, rather than the UK ‘normality’ model.123 The views of immigrant women differed across the trajectory of models of provision of maternity care. Evidence suggests that immigrant women with expectations of frequent access to and preference for more medicalised maternity care were less satisfied with their midwifery-orientated care.127 Similarly, for the caesarean section births, the biomedical care model of the UK providers was found to be different from emic care models in which the cultural aspects of the women’s care would also be given due consideration:112
They are unemotional and practical here, while we are sentimental by nature. She was telling me that the baby was distress and that we had to deliver it immediately, which was true. I understood what she said, but I could not tell her what I wanted.
Rights and entitlements for maternity care and the experiences of immigrant women
The rights and entitlements of immigrant women for maternity care in the UK had an important bearing on the experiences of women in accessing and utilising maternity care. The immigrant women without entitlement to free maternity care services in the UK were deterred by the charges and confidentiality of their legal status; hence, they did not access timely antenatal care.47 Many women in the undocumented and asylum-seeking immigrant category missed their maternity services appointments, as they did not have recourse to public funds.20
Asylum-seeking women were sometimes dispersed in the final phase of their pregnancy, which resulted in discontinuity in the care process and the loss of their social networks.20 The dispersed women felt that they did not have any control or power over their lives.20 The dispersal process, whether in early or late stages of pregnancy, was a main factor in increasing mental stress for pregnant asylum-seeking women.
Pregnant asylum-seeking women reported having to live in accommodation with other unknown asylum-seeking women. Living with other asylum seekers who had their own problems generated more stress and constituted an unsatisfactory environment for the pregnant asylum-seeking women:
If you live with . . . other women [who] are asylum seeker like us, and everyone have problems like stress . . . One is cleaning, one not. One is like, shouting, one is quiet. One is like . . . the TV loud . . . better to stay like, all by your own.
These negative views from asylum-seeking women were also supported by the views of HCPs in one study.122 Maternity care was delivered to asylum seekers as per their health needs assessments, which gave priority to the views of HCPs rather than being a coproduction with asylum seekers. For example, one of the participants in the study noted the following:
It is not a service that is led by them [asylum seekers] . . . at all, it is a maternity-led service.
The women in spousal migrant categories were also not entitled to public recourse for the first 24 months of their arrival in the UK and retained no right to live in the UK if their marriage was dissolved. Such women were specifically discouraged from reporting their personal health needs, particularly those arising from domestic violence.20
Breastfeeding support from maternity services and the experiences of immigrant women
The findings have identified mixed experiences regarding support the women received from HCPs for breastfeeding their babies.
Positive experiences
Findings in our included studies also report that some women are receiving breastfeeding support from their midwives: they provided good information on breastfeeding and its benefits, including a practical demonstration on positioning the baby for breastfeeding.139 The health visitors also offered practical support on breastfeeding to the women when they were in hospitals and encouraged them to continue breastfeeding after discharge from the hospitals. The HCPs also provided digital versatile discs (DVDs) and booklets on breastfeeding to the immigrant women, which they found helpful.
Evidence suggests that having a named HCP for breastfeeding advice and support, and attending a peer support group, facilitated successful breastfeeding. For women with low levels of English-language fluency, the availability of a bilingual peer support worker was found to be helpful in initiating and maintaining breastfeeding.139 The findings noted that primiparous women were more influenced by their bilingual support worker to breastfeed than multiparous women, because the peer support worker was the main source of information for them. Other aspects of positive breastfeeding support included the effective communication of the bilingual peer support worker, her significant knowledge of breastfeeding and her good accessibility to the immigrant women. The findings noted that some immigrant women held the influences of their family and the cultural traditions of country of origin for initiating and continuing breastfeeding in high regard.116
The breastfeeding support offered to the immigrant women included the provision of specific information and support to women with inverted and sore nipples, as well as demonstrations of how to use a breast pump to ensure a supply of milk for breastfeeding.139
Negative experiences
Immigrant women from European and Middle Eastern countries identified a lack of support from hospital staff as the main reason for not breastfeeding their babies.139 Another group of women identified lack of support from hospital staff as one of the reasons for having difficulties in exclusive breastfeeding.135 A third study focusing on the maternity experiences of immigrant women of Muslim faith noted that some women received poor breastfeeding support in hospital, especially from health-care assistants.121
One study reported that women with low levels of English-language fluency were not satisfied with breastfeeding support both in the hospital and at home.139 First-time mothers were especially unhappy about the support. Women with low English-language fluency also experienced delays in receiving support for breastfeeding. For example, an immigrant woman from the Middle East who birthed her baby in the evening did not receive any breastfeeding support until the following afternoon, because the practitioners required time to organise an interpreter. In the absence of professional support for breastfeeding, the immigrant women desired social support from family members, such as their mothers. However, some immigrant women reported that they lacked social support and their subsequent isolation hindered their ability to breastfeed their babies appropriately.
National health-care guidelines and hospital procedures negatively affected some women who wanted to breastfeed their babies. For example, some immigrant women of the Muslim faith felt that privacy was lacking in the hospitals, which interfered with their ability to breastfeed their babies. This situation was particularly problematic when the hospital staff would not allow a curtain to be drawn around their bed.121 Health-care guidelines in the UK suggest that HIV-positive women should avoid breastfeeding their babies to prevent transmission of HIV infection. Some immigrant women were not happy with this restriction, but they nonetheless opted for formula feeding as suggested by the HCPs.
The findings suggested that some immigrant women were not aware of breastfeeding support programmes and organisations such as the ‘Sure Start’ programme. This result is consistent with earlier findings in which some participants reported that they did not attend breastfeeding classes, because their support worker had not informed them about such classes.
Reducing negative impacts
To address organisational and legal entitlement issues in accessing and utilising maternity care, evidence from earlier studies highlighted the need to establish maternity clinics locally, which reduces hospital travel times and minimises waiting times to see HCPs.132 Evidence from this review suggests that immigrant women want to see their midwives as and when needed, even on the same day, and in some instances they also wished increased frequencies of scans and regular check-ups in the early stages of their pregnancies.127
Many women in the asylum-seeking and refugee categories felt lonely and isolated, and they expressed a need for HCPs who could offer them the opportunity to talk, listen and understand their ideas and concerns.110 They also wanted better opportunities to give feedback on the maternity care services they were offered.136
To address poor care due to staff shortages, the women suggested that the maternity services should have policies and procedures to allow their husbands or partners to stay with them in the hospital so that they could assist with the support of the women after birth.107 At the hospital, the women who had delivered by caesarean section wanted more help after the birth of their babies and wanted practical demonstrations on positioning the baby onto the breast for feeding. The evidence arising from the review indicated that supporting immigrant women with breastfeeding could be accomplished by integrating their health and social care and by involving experienced refugee mothers in the support of new ones. To offer continuity in maternity care, the evidence from the review highlighted the importance of having a named midwife for each immigrant woman.121
Conclusion
The evidence from this review suggested that inflexibilities in the organisation of maternity care services in the UK affected its accessibility to and utilisation by immigrant women.
Gaps in the evidence
Most immigrant women come from countries where breastfeeding is a cultural norm, but it is not in the UK. We need more research on how to maintain existing breastfeeding practices, as the health benefits are substantial and they contribute to the health of the nation.
The impact of the limited legal rights on the health of the mother and infant requires further research.
Theme 5: discrimination, racism, stereotyping, cultural sensitivity, inaction and cultural clash in maternity care for immigrant women
This theme addresses all three phases of maternity care (antenatal, intrapartum and postnatal). Reported findings on this theme arise from 12 of the 40 included studies (see Appendix 6). The findings were related to midwives, GPs, gynaecologists and radiologists, and pertained to a range of immigrant categories (asylum seekers, refugees and economic migrants).
Discrimination in maternity care means withholding care or offering poor maternity care to immigrant women because of their perceived ethnocultural backgrounds.152 Racism ‘in general terms consists of conduct or words or practices which disadvantage or advantage people because of their colour, culture, or ethnic origin’ (© Crown copyright. Contains public sector information licensed under the Open Government Licence v3.0).153 Stereotyping has been defined as having negative attitudes towards certain social groups, such as immigrants.154 Cultural sensitivity in maternal care is the practice of recognising and respecting differences in cultural needs and offering maternity care that meets the cultural needs of service users from different cultural backgrounds.65 Inaction in maternity care is the lack of response to a care need presented by a service user.155 Cultural clash is the dissonance between conflicting ideas or advice, resulting from the superposition of differing ethnocultural backgrounds.156
Discrimination and racism
The findings identified that discriminatory treatment and care was received by some immigrant women from HCPs, during various phases of maternity. Discrimination in maternity care services mitigates the delivery of good-quality maternity care.20 The discrimination was often subtle and difficult to specify, but direct and blatant discrimination was also experienced in some cases.121 Subtle discrimination included the staff responding to women’s questions or requests in rigid and inappropriate manners. Evidence from one study reports that immigrant women were often not welcomed or greeted in a friendly manner and not made to feel safe.3 Some women suffered acute negative feelings when they were seen and treated differently by maternity care staff.118
Direct discrimination included health-care staff uttering stereotypical and racist comments:
I got an infection in my scar . . . I went to the midwife and said I’m feeling cold, and all my body shakes . . . She looked at me like this and said, ‘You are OK’. . . . She said to another midwife, ‘These Africans . . . they come here, they eat nice food, sleep in a nice bed . . . I just cried – she doesn’t know me, who I am in my country. The other midwife said ‘What’s wrong with them’ some of them laughed.
Somali women are not into preventive medicine at all.
Immigrant women from the Muslim faith criticised the assumption held by HCPs that their partners or husbands should collaborate with the women during labour. Study participants also challenged the assumptions of the HCPs around their food practices. Sometimes other immigrant women are accused of overusing maternity services as a result of exaggerating symptoms, an accusation that is called the ‘Asian woman syndrome’:121
They [health professionals] should not make the assumption that they [Muslim men] are going to be present at the birth. My husband was not there, I didn’t want him there. My mother was there.121
Why do they assume that all Muslims want to eat curry? You ask for a halal meal, they will send you a curry. Maybe not everybody likes a curry. There are Chinese Muslims, there are Caucasian Muslims, you know? Muslims from all over.121
Several women talked about staff belittling their worries and concerns, implying they were exaggerating symptoms, wasting time or complaining about ‘minor’ problems in order to get help. The women said staff often referred to this as ‘Asian woman syndrome’.121
I have had doctors who tell me to have a coil put in after I have had the baby . . . and when I say I want to carry on having babies, he said, ‘You want to receive more benefits. That’s why you are having more babies’.121
Similarly, women from an African background reported being stereotyped as having high pain thresholds and long labours; hence, they were not given timely or adequate pain relief.20 Other examples of labelling and assumptions being made based on a woman’s perceived cultural background were also found:
I saw a consultant . . . She was not nice. She was very abrupt. ‘Did you circumcise?’ . . . I didn’t know women can be circumcised! ‘I’m asking you. Are you circumcised?’ I don’t understand.
They do me . . . vaginal scan? To check the baby . . . They ask me again if you want to take out the baby?
Some women felt labelled as an asylum seeker, with staff making assumptions about their needs. In one case, this meant a presumed need to terminate the pregnancy.118
Similarly, a GP is reported in another study to have expressed the view that offering counselling services to asylum-seeking women did not fit with their needs because it was a ‘very Western concept’.122
Immigrant women from a Muslim faith noted increases in discrimination and were viewed as a different and dangerous people.121 However, this evidence was from one small study identified in the grey literature.121
The findings highlighted perceived racism in maternity care when immigrant women from specific countries were advised by HCPs to undertake a specific medical intervention owing to their national origin or race:
They targeted me and my baby as high risk for TB [tuberculosis] and offered the BCG [Bacillus Calmette–Guérin] vaccine . . . a difficult decision to make after giving birth. Singled out because Chinese . . . I am very upset by this and my baby has a huge scar! It was pure racism in my mind.
Disrespect, inaction and lack of attention
Findings from one study suggest that participants perceived that the staff did not treat them as human beings with due respect and full attention.109 Because of this lack of respect from HCPs, the women felt devalued, unsupported and fearful when receiving maternity care. Such findings were reported in antenatal, intrapartum and postnatal care settings:
I feel I am treated like the air.
I am rubbish. I haven’t got anything left. I have no value. I pretend too much to be happy but inside me I am dead.
I couldn’t move or breast feed the baby, but they did not help me . . . only if I asked . . . When they sent me to the postnatal . . . my baby choked started frothing at the mouth. I rang the bell more than once until they came. I said, ‘Look at baby! I can’t move’.
I went to the hospital they let me wait . . . Then they examined me. I was in pain no one came and talked with us. They only said to wait . . . I told my husband. ‘I can’t stand it anymore. Go and talk with them’ . . . They said, ‘Sorry, we are coming’.
Some of the midwives spoke to me very arrogantly. Sometimes I got scared as I don’t know the English language very well. It would be very nice if they gave you a smile now and then. Also, it would be nice if they didn’t give orders.
Culturally sensitive maternity care
The evidence in the review noted a prevalence of anxiety about childbirth among the immigrant women in the UK.123 This was expressed by a participant in the study as follows:
They do not stitch you up after delivery, nor do they perform any cosmetic suturing; I don’t know if this is true or not . . . The second concern is that I heard that they do not give a woman any anaesthetic during delivery, which worries me a lot.
The findings indicate a lack of cultural sensitivity and cultural understanding among HCPs working in maternity care, thus resulting in culturally insensitive care for immigrant women.121 The findings indicated that immigrant women of the Muslim faith did not optimally benefit from antenatal classes because they were delivered by non-Muslim educators who were not knowledgeable about the Islamic faith related to maternity. In addition, the sessions were with men and women and included other ethnic and religious backgrounds:121
They [women in Muslim-only antenatal classes] would be able to ask and people would understand about religion, like needing a female doctor . . .
A participant highlighted the lack of cultural knowledge and cultural sensitivity of the staff during the intrapartum phase:
I had a full circumcision, but basically there was no one who had the experience to deliver the baby, so they had to call someone from another hospital. He was a Sudanese man, so I had to have a male doctor to deliver the baby because there was no one else.
Some immigrant women of Muslim faith felt that the maternity care services were unable to understand and meet their cultural and religious needs on the postnatal wards for breastfeeding:121
I wanted the privacy. The dads are there . . . I just wanted to be able to have privacy to breastfeed without people walking around, because I wear hijab as well. The English women, or the non-Muslim women, are happy to breastfeed openly . . . I didn’t want that.
Similarly, in another case, an immigrant woman (whose faith was not indicated) complained as follows:
. . . [she had] asked for placenta for religious condition to be buried, but it was taken away.
Another cultural condition that the immigrant women felt that the staff lacked understanding about and proper responses to FGM.108
In addition to the staff’s lack of cultural understanding, maternity care services, as a whole, were reported as not meeting the cultural needs of immigrant women:121
I don’t even allow my husband to be in the labour room . . . because I feel uncomfortable with men . . . Even he [my husband] refused to come in.121
The views held by immigrant women about culturally insensitive maternity care was endorsed by maternity HCPs, as noted by a study in the West Midlands:20
I don’t think the system works well at all. It’s terrible and it’s geared up for white middle-class women.
By contrast, the findings also noted that in a few cases the midwives were happy to meet the cultural and religious needs of the immigrant women in antenatal and postnatal settings.121 For example, by acting proactively, a midwife was able to discuss the cultural and religious needs of an immigrant woman. When a Muslim woman asked the midwife to sweeten her new baby’s mouth with a date or honey (an Islamic custom), the midwife happily did:121
The midwives were happy to do that, she said, ‘Whatever you have to do’, so they were quite sensitive. They know what we had to do.121
Cultural clash and conflicting medical advice
The findings identified instances of cultural clash and conflicting advice during pregnancy and maternity care.123 Cultural clash and conflicting medical advice resulted because cultural practices and the established medical and maternity care systems differ in the UK from those in the home countries of the participants:
I came here in October, and in January I was pregnant. During that time, I spoke to my doctor in my own country. I don’t want to be confused between [the advice I was getting from the] two doctors, so I am not following [the doctor’s advice] here.
During this pregnancy, my mother was with me and she always reminded me that I was pregnant . . . In my country there is a list of forbidden things.
On the first visit, the midwife told me, ‘You are not sick, you are pregnant’. In Egypt, they let you feel that you are sick and that this is abnormal, which is why they pay more attention to it.
Conclusion
This theme presented evidence that immigrant women were often the subject of discrimination and stereotyping and were offered poor maternity care in the UK. Some maternity care services and staff lacked cultural sensitivity when delivering care to immigrant women. Discrimination and cultural insensitivity in maternity care services contributed to the generation of inequalities in access, utilisation and outcomes for immigrant women in maternity care.
Gaps in the evidence
No intervention was reported that focused on addressing discrimination, stereotyping, racism or cultural insensitivity to improve maternity care for immigrant women.