Systematic Review of Immigrant Women's Experiences With Perinatal Care in North America

Factors affecting women's access to primary care in the United States since the Affordable Care Act: A mixed-methods systematic review

BACKGROUND

In the United States, the Affordable Care Act (ACA) expanded public and private health coverage, increased health insurance affordability, reduced healthcare costs, and improved healthcare quality for many. Despite ACA provisions, lack of insurance and other factors continue to affect working-age women's access to primary care services.

METHODS

We conducted a mixed-method systematic review to identify factors that affect women's access to primary care services since the ACA. In January 2021, MEDLINE, CINAHL, PsycINFO, and Web of Science were searched from 2010 to 2021 and an updated search was conducted in October 2023. We included 26 quantitative and qualitative studies reporting determinants, barriers and facilitators of women's primary care access for women (18 to 64 years). Studies reporting measures of potential access, such as health insurance, and measures of realized access-healthcare service utilization, were included. The Mixed-Methods Appraisal Tool (2018) was used to rate the quality of studies. Andersen's Behavioral Model of Health Services Use guided the narrative synthesis.

FINDINGS

We found consistent evidence that ACA provisions expanding state Medicaid eligibility led to improved insurance coverage, especially for lower-income groups. We found mixed evidence of associations between individual-level determinants, such as age, education, race/ethnicity, income, and different measures of access. Limited qualitative evidence suggests that insurance coverage, low-cost care, positive patient-provider relationships, social support, and translation services enhance access for immigrants and refugees. Barriers include lack of coverage, high healthcare costs, culturally unresponsive healthcare services, poor patient-provider relationships, and transportation issues.

CONCLUSION

Adoption of ACA's expanded Medicaid eligibility criteria would expand insurance coverage to women living in non-expansion states. Innovative healthcare policies, programs, and interventions at the federal, state, and local levels are needed. Suggested strategies include interventions expanding primary healthcare service availability and patient navigation services, and promotion of health literacy, culturally sensitive services, and provider bias education/training.

Latina Women's Perinatal Experiences and Perspectives Around Discrimination, Anti-immigrant Policies, and Community Violence

OBJECTIVE

To describe experiences of Latina women who were currently pregnant or recently gave birth around discrimination, anti-immigrant policies, and community violence during the early COVID-19 pandemic.

DESIGN

Qualitative secondary analysis.

SETTING

Online or phone interviews.

PARTICIPANTS

Latina women who were currently pregnant or recently gave birth (N = 26).

METHODS

We used reflexive thematic analysis to examine transcribed data from semistructured interviews conducted during the early COVID-19 pandemic with a subgroup of participants enrolled in a larger study related to prenatal care. Participants were English- or Spanish-speaking, Medicaid-eligible, Latina-identifying women who resided in Fresno County, California. We analyzed responses to questions about personal discrimination, the Black Lives Matter movement, and immigration policies using the theoretical frameworks of critical race theory and the political economy of health.

RESULTS

We identified four major themes: Avoidance of Community Engagement, Chronic Fear and Vigilance, The Role of Media, and Everyday Discrimination and Injustice.

CONCLUSION

Participant experiences reflect the pervasiveness of fear and socioeconomic inequity and call attention to the racialized structures that affect health and health care access for Latina women. These exposures during the perinatal period may have intergenerational effects. These findings underscore the need for responsive and race-conscious perinatal nursing care for Latina women, assessment of the effect of the current sociopolitical environment on well-being, and policies that support equitable access to health and social care.

A qualitative study on community-based doulas' roles in providing culturally-responsive care to migrant women in Australia

BACKGROUND

There is limited exploration into how culturally-responsive care may be provided to migrant women through community-based doulas.

AIM

We aim to explore the roles of community-based doulas in providing culturally-responsive care to migrant women in Australian maternity settings, from the perspectives of maternity care providers and doulas.

METHODS

We used an interpretive phenomenological qualitative approach with in-depth interviews with 30 maternity care providers and Birth for Humankind doulas, in Victoria, Australia. All interviews were conducted over video-call and inductive thematic analysis was performed using NVivo software.

FINDINGS

Doulas were seen to support and enhance migrant women's maternity care experiences through numerous ways, strengthening cultural-responsive care provision. There were three domains which described the role of doulas in providing migrant women with culturally-responsive care: 1) enhanced care; 2) respectful care; and 3) supportive relationships with providers. The three domains included seven themes: 1) continuous individualised support; 2) social connectedness; 3) creating safe spaces; 4) cultural facilitator; 5) non-judgemental support; 6) enhancing communication and rapport with providers; and 7) making connections.

DISCUSSION

Doulas appeared to counter negative factors that impact migrant women's maternity care experiences. Doulas with previous professional birth support qualifications and trauma-informed care training were equipped to create safe spaces and increase emotional safety for migrant women. Doulas may also have more responsibilities expected of them by providers when connecting migrant women with additional services in situations that may be missed through hospital care.

CONCLUSION

Birth for Humankind doulas in Victoria play an important role in providing culturally-responsive care to migrant women. Employment models may be the next steps in acknowledging their valuable contribution as a complementary service to maternity settings.

Understanding How Community Health Workers Build Trust with Low-Income Women of Color At-Risk for Maternal Child Health Disparities: A Grounded Theory Study

This article examines how Community Health Workers (CHWs) build trust with low-income women of color who have a historical distrust of the healthcare system, and are at risk for maternal-child health disparities. This qualitative study used a grounded theory methodology guided by Charmaz's inductive social constructivist approach. Data were collected using open-ended semi-structured interviews and focus groups with CHWs who worked in community-based and hospital-based programs in California, Oregon, Illinois, Texas, South Carolina, New York, and Maine. Thirty-two CHWs participated, with 95% of participants being of Latinx and African American ethnicity. They served women from Latinx, African American, and Migrant communities. The CHW communication strategies represent aspects of respect and client-centered care and are applied in the development of a theoretical framework. CHWs were able to build and sustain trust at the initial encounter through these specific strategies: 1) addressing immediate needs related to social determinants of health; 2) embodying mannerisms and dress; 3) speaking appropriately to the client's age, culture, and knowledge; 4) easing client's fears through locus of control, and 5) allowing for time flexibility. These findings have implications for practice through interventions to train healthcare providers to build trust with low-income women of color who have a historical distrust of the healthcare system and who are at risk for maternal-child health disparities. Future research is recommended to explore how the communication trust-building constructs also benefit all other groups at similar risk, including those with mental health disorders and infectious diseases. The findings indicate specific communication strategies through which trust can be built, beginning at the initial encounter with low-income women at risk for maternal-child health disparities and who have a historical distrust of the healthcare system.

Transnational prenatal care among migrant women from low-and-middle-income countries who gave birth in Montreal, Canada

OBJECTIVES

There is little research examining transnational prenatal care (TPC) (i.e., prenatal care in more than one country) among migrant women. Using data from the Migrant-Friendly Maternity Care (MFMC) - Montreal project, we aimed to: (1) Estimate the prevalence of TPC, including TPC-arrived during pregnancy and TPC-arrived pre-pregnancy, among recently-arrived migrant women from low- and middle-income countries (LMICs) who gave birth in Montreal, Canada; (2) Describe and compare the socio-demographic, migration and health profiles and perceptions of care during pregnancy in Canada between these two groups and migrant women who received no TPC (i.e., only received prenatal care in Canada); and (3) Identify predictors of TPC-arrived pre-pregnancy vs. No-TPC.

METHODS

The MFMC study used a cross-sectional design. Data were gathered from recently-arrived (< 8 years) migrant women from LMICs via medical record review and interview-administration of the MFMC questionnaire postpartum during the period of March 2014-January 2015 in three hospitals, and February-June 2015 in one hospital. We conducted a secondary analysis (n = 2595 women); descriptive analyses (objectives 1 & 2) and multivariable logistic regression (objective 3).

RESULTS

Ten percent of women received TPC; 6% arrived during pregnancy and 4% were in Canada pre-pregnancy. The women who received TPC and arrived during pregnancy were disadvantaged compared to women in the other two groups (TPC-arrived pre-pregnancy and No-TPC women), in terms of income level, migration status, French and English language abilities, access barriers to care and healthcare coverage. However, they also had a higher proportion of economic migrants and they were generally healthier compared to No-TPC women. Predictors of TPC-arrived pre-pregnancy included: 'Not living with the father of the baby' (AOR = 4.8, 95%CI 2.4, 9.8), 'having negative perceptions of pregnancy care in Canada (general experiences)' (AOR = 1.2, 95%CI 1.1, 1.3) and younger maternal age (AOR = 1.1, 95%CI 1.0, 1.1).

CONCLUSION

Women with more capacity may self-select to migrate during pregnancy which results in TPC; these women, however, are disadvantaged upon arrival, and may need additional care. Already-migrated women may use TPC due to a need for family and social support and/or because they prefer the healthcare in their home country.

Lived Experiences of Mongolian Immigrant Women Seeking Perinatal Care in the United States

INTRODUCTION

There is inadequate information available about many of the smaller minority groups living in the United States. Mongolian culture has unique traditions that warrant understanding to provide culturally congruent care. The purpose of this study was to explore the lived experiences of Mongolian immigrants seeking perinatal care in the United States.

METHOD

Using a phenomenological approach, 12 Mongolian women were interviewed using semi-structured interviews. The study follows the "consolidated criteria for reporting qualitative studies" guidelines for qualitative studies.

RESULTS

Results focus on successes and failures of the health care system in meeting the needs of these women.

DISCUSSION

Cultural communication barriers, disparate health practice beliefs, and limited cultural awareness among providers reduce quality of care. Study findings support practice interventions that enhance provider sensitivity for immigrant women.

RELEVANCE TO PRACTICE

Improved cultural awareness of Asian cultures increases sensitivity to the needs of Mongolian women and can help providers deliver high-quality care.

Immigrant Asian Indian Mothers' Experiences With Pregnancy, Childbirth, and Infant Care in the United States

INTRODUCTION

The purpose of the study was to explore experiences of immigrant Asian Indian women with pregnancy, childbirth, and infant care in the United States.

METHODOLOGY

This study employed a qualitative descriptive approach using semi-structured interviews and followed COREQ (COnsolidated criteria for REporting Qualitative research) guidelines for reporting qualitative research. Nine immigrant Asian Indian mothers residing in the mid-Atlantic region of the United States participated in the study.

RESULTS

Four themes emerged: experiencing cultural differences during the perinatal period in the United States, choosing the best perinatal practices for maternal and infant care, recognizing family as the main support system, and having positive experiences with health care providers.

DISCUSSION

Findings of this study shed light on the need for culturally appropriate care, including proper assessment of Asian Indian mothers' sociocultural aspects and cultural preferences and provision of support and information needed during the perinatal period.

The relationship between internal migration and the likelihood of high-risk pregnancy: Hukou system and high-risk pregnancies in China

BACKGROUND

China has one of the world's largest internal migrant populations. The Chinese Hukou system is a unique household registration system that limits internal migrants in their access to basic urban public services, such as public health insurance and social assistance of their host city. In the case of female internal migrants, this may lead to high-risk pregnancies. The objective of this study is to assess the relationship between internal migrant status (Hukou) and the likelihood of high-risk pregnancies that occur in one large municipal-level obstetrics hospital in Shanghai, China.

METHODS

Medical records data from the Shanghai First Maternity and Infant Hospital from January 1, 2013, to May 31, 2018, were used to analyze 133,358 live births for Shanghai natives (n = 83,872) and internal migrant women (n = 49,486). A propensity score matching approach was used in conjunction with logistic regression analysis to identify the role of internal migrant status (Hukou) on the likelihood of high-risk pregnancies.

RESULTS

A greater likelihood of high-risk pregnancies were found among internal migrant women who moved from other parts of China to Shanghai. This effect was more obvious for women who gave birth for the first time and internal migrant women who were employed.

CONCLUSION

The results show the effects of internal migrant status (Hukou) and the elevated likelihood of high-risk pregnancies among internal migrant women relative to their urban counterparts in Shanghai even after accounting for self-selection by employing the propensity score matching method. China's unique Hukou household registration system limits access to public services for internal migrant women and accordingly may account for the elevated likelihood of high-risk pregnancies.

The impact of COVID-19 on pregnant womens' experiences and perceptions of antenatal maternity care, social support, and stress-reduction strategies

Background

The COVID-19 pandemic has impacted on maternity care, supports and women’s mental health.

Aim

The aim of this study was to assess pregnant women’s satisfaction with antenatal care and social support and to examine stress-reduction strategies women used during the pandemic.

Methods

An online survey was conducted between June and July 2020. Pregnant women, aged over 18 years were recruited. The survey included closed and open-ended questions to assess women’s perceptions and satisfaction with their antenatal care, social support, and stress-reduction strategies. Descriptive statistics and multivariate analysis were used for quantitative analyses; qualitative content analysis was used for open-ended questions.

Findings

573 pregnant women completed the survey. Women reported low levels of social support which was predicted by women’s mental health and demographic factors and was related to public health and maternity service restrictions. Women reported that restrictions implemented in the maternity services limited their face-to face interactions with healthcare professionals and meant their partners could not attend antenatal appointments or support them in the postpartum period in the maternity setting. The lack of information on COVID-19 and pregnancy meant women had greater uncertainty about pregnancy and birth.

Discussion

Our findings indicate how the lack of access to antenatal care and reduced perceived social support as a result of the restrictions implemented in response to the COVID-19 pandemic, potentially intensifies pregnancy specific stress.

Conclusions

There is a need for the provision of supportive care, both formally and informally, particularly with women who may be more vulnerable during a pandemic.

Intersections of Immigration and Sexual/Reproductive Health: An Umbrella Literature Review with a Focus on Health Equity

Identifying the opportunities and barriers of promoting and fulfilling the sexual health rights of migrants remains a challenge that requires systematic assessment. Such an assessment would include estimating the influence of acculturation processes on sexual and reproductive health, and mapping intersectional inequities that influence migrants’ sexual and reproductive health in comparison with the native population. The aim of this research was to locate, select, and critically assess/summarize scientific evidence regarding the social, cultural, and structural factors influencing migrants’ sexual and reproductive health outcomes in comparison with native population. An umbrella review of systematic reviews and/or meta-analyses, following preferred reporting items for systematic reviews and meta-analysis (PRISMA) standards was undertaken. Medline, Scopus, Web of Science, and the Cochrane Database of Systematic Reviews were searched from their start date until June 2019. The quality of the included articles was determined using the assessment of multiple systematic reviews tool (AMSTAR 2). From the 36 selected studies, only 12 compared migrant with native populations. Overall, the findings indicated that migrants tend to underuse maternal health services and have an increased risk of poor sexual and reproductive health outcomes. Specific intersectional inequities were identified and discussed.

Mexican-Born Women's Experiences of Perinatal Care in the United States

Mexican-born women represent a significant proportion of the obstetric patient population in California and have higher incidence of adverse obstetric outcomes than white women, including maternal postpartum hemorrhage and perinatal depression. Little is known, however, about Mexican-born women's experiences of maternity care in the United States. Qualitative methods were used to conduct a secondary analysis of interview transcripts, field notes, original photographs, and analytic memos from a study of 7 Mexican-born women's birth experiences. Participants reported social isolation influenced their expectations of maternity care. Disconnection, characterized by unmet physical and relational needs, yielded negative experiences of maternity care, while positive experiences were the result of attentive care wherein they felt providers cared about them as individuals.

Perinatal health outcomes and care among asylum seekers and refugees: a systematic review of systematic reviews

BACKGROUND

Global migration is at an all-time high with implications for perinatal health. Migrant women, especially asylum seekers and refugees, represent a particularly vulnerable group. Understanding the impact on the perinatal health of women and offspring is an important prerequisite to improving care and outcomes. The aim of this systematic review was to summarise the current evidence base on perinatal health outcomes and care among women with asylum seeker or refugee status.

METHODS

Twelve electronic database, reference list and citation searches (1 January 2007-July 2017) were carried out between June and July 2017. Quantitative and qualitative systematic reviews, published in the English language, were included if they reported perinatal health outcomes or care and clearly stated that they included asylum seekers or refugees. Screening for eligibility, data extraction, quality appraisal and evidence synthesis were carried out in duplicate. The results were summarised narratively.

RESULTS

Among 3415 records screened, 29 systematic reviews met the inclusion criteria. Only one exclusively focussed on asylum seekers; the remaining reviews grouped asylum seekers and refugees with wider migrant populations. Perinatal outcomes were predominantly worse among migrant women, particularly mental health, maternal mortality, preterm birth and congenital anomalies. Access and use of care was obstructed by structural, organisational, social, personal and cultural barriers. Migrant women's experiences of care included negative communication, discrimination, poor relationships with health professionals, cultural clashes and negative experiences of clinical intervention. Additional data for asylum seekers and refugees demonstrated complex obstetric issues, sexual assault, offspring mortality, unwanted pregnancy, poverty, social isolation and experiences of racism, prejudice and stereotyping within perinatal healthcare.

CONCLUSIONS

This review identified adverse pregnancy outcomes among asylum seeker and refugee women, representing a double burden of inequality for one of the most globally vulnerable groups of women. Improvements in the provision of perinatal healthcare could reduce inequalities in adverse outcomes and improve women's experiences of care. Strategies to overcome barriers to accessing care require immediate attention. The systematic review evidence base is limited by combining heterogeneous migrant, asylum seeker and refugee populations, inconsistent use of definitions and limited data on some perinatal outcomes and risk factors. Future research needs to overcome these limitations to improve data quality and address inequalities.

SYSTEMATIC REGISTRATION

Systematic review registration number: PROSPERO CRD42017073315 .