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

Equity in prenatal healthcare services globally: an umbrella review

BACKGROUND

Timely, appropriate, and equitable access to quality healthcare during pregnancy is proven to contribute to better health outcomes of birthing individuals and infants following birth. Equity is conceptualized as the absence of differences in healthcare access and quality among population groups. Healthcare policies are guides for front-line practices, and despite merits of contemporary policies striving to foster equitable healthcare, inequities persist. The purpose of this umbrella review is to identify prenatal healthcare practices, summarize how equities/inequities are reported in relation to patient experiences or health outcomes when accessing or using services, and collate equity reporting characteristics.

METHODS

For this umbrella review, six electronic databases were searched (Medline, EMBASE, APA PsychInfo, CINAHL, International Bibliography of the Social Sciences, and Cochrane Library). Included studies were extracted for publication and study characteristics, equity reporting, primary outcomes (prenatal care influenced by equity/inequity) and secondary outcomes (infant health influenced by equity/inequity during pregnancy). Data was analyzed deductively using the PROGRESS-Plus equity framework and by summative content analysis for equity reporting characteristics. The included articles were assessed for quality using the Risk of Bias Assessment Tool for Systematic Reviews.

RESULTS

The search identified 8065 articles and 236 underwent full-text screening. Of the 236, 68 systematic reviews were included with first authors representing 20 different countries. The population focus of included studies ranged across prenatal only (n = 14), perinatal (n = 25), maternal (n = 2), maternal and child (n = 19), and a general population (n = 8). Barriers to equity in prenatal care included travel and financial burden, culturally insensitive practices that deterred care engagement and continuity, and discriminatory behaviour that reduced care access and satisfaction. Facilitators to achieve equity included innovations such as community health workers, home visitation programs, conditional cash transfer programs, virtual care, and cross-cultural training, to enhance patient experiences and increase their access to, and use of health services. There was overlap across PROGRESS-Plus factors.

CONCLUSIONS

This umbrella review collated inequities present in prenatal healthcare services, globally. Further, this synthesis contributes to future solution and action-oriented research and practice by assembling evidence-informed opportunities, innovations, and approaches that may foster equitable prenatal health services to all members of diverse communities.

Exploring and prioritising strategies for improving uptake of postnatal care services in Thyolo, Malawi: A qualitative study

Although postnatal care services form a critical component of the cascade of care in maternal, newborn, and child health the uptake of these services has remained low worldwide. This study explored and prioritised the strategies for optimising the uptake of postnatal care (PNC) services in Malawi. A qualitative descriptive study followed by nominal group techniques was conducted at three health facilities in Malawi from July to December 2020 and in October 2021. We conducted focus group discussions among postnatal mothers, fathers, healthcare workers, elderly women, and grandmothers. We conducted in-depth interviews with midwives and key health managers. Nominal group techniques were used to prioritise the main strategies for the provision of PNC. The demand strategies include appointment date reminders, provision of free health passport books, community awareness campaigns, and involvement of men in the services. The supply strategies included training health providers, improving clinic operations: task-shifting and hours of operation, having infrastructure for the services, and linkage to other services. Having services delivered near end-user residences was a crosscutting strategy. Refresher training and improvement in the clinic operations especially on hours of operation, appointment date reminders, and linkage to care were the prioritised strategies. There is a need to use acceptable and contextualised strategies to optimise the uptake and delivery of postnatal care services. Educating the healthcare workers and the community on postnatal services is key to increasing the demand and supply of the services.

"It's all about cultural understanding": A reflexive thematic analysis of women's experiences at a dedicated refugee midwifery group practice service

BACKGROUND

Inequitable maternity care provision in high-income countries contributes to ongoing poor outcomes for women of refugee backgrounds. To address barriers to quality maternity care and improve health equity, a co-designed maternity service incorporating community-based group antenatal care, onsite social worker and interpreters, continuity of midwifery carer through a caseload design with 24/7 phone access was implemented for women of refugee background.

OBJECTIVE

To explore and describe women's experiences and perceptions of care from a dedicated Refugee Midwifery Group Practice service.

DESIGN

Qualitative exploratory descriptive study using focus group discussions and interpreters.

SETTING

The study was conducted at a community-based Refugee Midwifery Group Practice service in a tertiary maternity hospital in Brisbane, Australia.

METHODS

We conducted three focus group discussions (June - December 2020) with 16 women, born in six different countries, in three language groups: Sudanese Arabic, Somali, and English. We used reflexive thematic analysis to interpret women's perspectives and generate informed meanings of experiences of care.

RESULTS

We generated four themes 1) accessibility of care, 2) women feeling accepted, 3) value of relationality, and 4), service expansion and promotion. Results demonstrate positive experiences and acceptability due to easy access, strong woman-midwife relationships, and culturally safe care.

CONCLUSION

The service addressed concerns raised in an early evaluation and provides evidence that redesigning maternity services to meet the needs of women with a refugee background speaking multiple languages from many countries is possible and promotes access, use, and satisfaction with care, contributing to improved health equity and perinatal outcomes.

The prevention of perineal trauma during vaginal birth

Perineal trauma after vaginal birth is common, with approximately 9 of 10 women being affected. Second-degree perineal tears are twice as likely to occur in primiparous births, with a incidence of 40%. The incidence of obstetrical anal sphincter injury is approximately 3%, with a significantly higher rate in primiparous than in multiparous women (6% vs 2%). Obstetrical anal sphincter injury is a significant risk factor for the development of anal incontinence, with approximately 10% of women developing symptoms within a year following vaginal birth. Obstetrical anal sphincter injuries have significant medicolegal implications and contribute greatly to healthcare costs. For example, in 2013 and 2014, the economic burden of obstetrical anal sphincter injuries in the United Kingdom ranged between £3.7 million (with assisted vaginal birth) and £9.8 million (with spontaneous vaginal birth). In the United States, complications associated with trauma to the perineum incurred costs of approximately $83 million between 2007 and 2011. It is therefore crucial to focus on improvements in clinical care to reduce this risk and minimize the development of perineal trauma, particularly obstetrical anal sphincter injuries. Identification of risk factors allows modification of obstetrical practice with the aim of reducing the rate of perineal trauma and its attendant associated morbidity. Risk factors associated with second-degree perineal trauma include increased fetal birthweight, operative vaginal birth, prolonged second stage of labor, maternal birth position, and advanced maternal age. With obstetrical anal sphincter injury, risk factors include induction of labor, augmentation of labor, epidural, increased fetal birthweight, fetal malposition (occiput posterior), midline episiotomy, operative vaginal birth, Asian ethnicity, and primiparity. Obstetrical practice can be modified both antenatally and intrapartum. The evidence suggests that in the antenatal period, perineal massage can be commenced in the third trimester of pregnancy to increase muscle elasticity and allow stretching of the perineum during birth, thereby reducing the risk of tearing or need for episiotomy. With regard to the intrapartum period, there is a growing body of evidence from the United Kingdom, Norway, and Denmark suggesting that the implementation of quality improvement initiatives including the training of clinicians in manual perineal protection and mediolateral episiotomy can reduce the incidence of obstetrical anal sphincter injury. With episiotomy, the International Federation of Gynecology and Obstetrics recommends restrictive rather than routine use of episiotomy. This is particularly the case with unassisted vaginal births. However, there is a role for episiotomy, specifically mediolateral or lateral, with assisted vaginal births. This is specifically the case with nulliparous vacuum and forceps births, given that the use of mediolateral or lateral episiotomy has been shown to significantly reduce the incidence of obstetrical anal sphincter injury in these groups by 43% and 68%, respectively. However, the complications associated with episiotomy including perineal pain, dyspareunia, and sexual dysfunction should be acknowledged. Despite considerable research, interventions for reducing the risk of perineal trauma remain a subject of controversy. In this review article, we present the available data on the prevention of perineal trauma by describing the risk factors associated with perineal trauma and interventions that can be implemented to prevent perineal trauma, in particular obstetrical anal sphincter injury.

Delays in Colorectal Cancer Screening for Latino Patients: The Role of Immigrant Healthcare in Stemming the Rising Global Incidence of Colorectal Cancer

The significant global burden of colorectal cancer accentuates disparities in access to preventive healthcare in most low- and middle-income countries (LMICs) as well as large sections of underserved populations within high-income countries. The barriers to colorectal cancer screening in economically transitioning Latin America are multiple. At the same time, immigration from these countries to the USA continues to increase. This case highlights the delays in diagnosis experienced by a recent immigrant from a country with no established colorectal cancer screening program, to an immigrant population in the USA with similar poor screening coverage. We discuss common challenges faced by Latinos in their home countries and the USA, as well as strategies that could be implemented to improve screening coverage in US immigrant populations.

Satisfaction With Primary Care Among the Foreign-Born and the General Population in Finland: A Survey-Based study

Foreign-born people have been found to be less satisfied with health care than native populations across countries. However, studies on differences in satisfaction with treatment between different foreign-born groups are lacking. This study explores differences in satisfaction with primary health care between the foreign-born population from different regions of origins and the general population of Finland. The study uses survey data on foreign-born population (n = 2708) and general population (n = 6671) living in Finland who report using health services. Satisfaction with experienced respect for privacy during treatment, benefit of treatment and smoothness of treatment are predicted by region of origin using logistic regression. Almost all foreign-born groups were less likely to consider treatment appointments beneficial as compared to the general population. Some foreign-born groups (people from Southeast Asia and South and Central Asia) were more satisfied with smoothness of care compared to general population. People from East Asia were less likely than the general population to consider that their privacy had been respected during the examinations and treatment. While we made the positive finding of high overall satisfaction with treatment, we also found important differences between groups. In particular, appointments were found less useful among the foreign-born population. Perceived unusefulness of treatment might lead to underuse of health care, which might result in accumulation of untreated health problems. The results point toward potential development points in the health care system. Addressing these issues might help decrease health disparities between population groups.

African Immigrant Women's Maternal Health Experiences in Clarkston, Georgia: A Qualitative Study

Introduction

The maternal health experiences of African immigrant women, their utilization of health care services, and the effects on maternal health have received limited attention in research. This research explored the maternal health experiences of African immigrant women residing in Clarkston, Georgia, and their use of health services.

Methods

Fourteen African immigrant women responded to semistructured interviews. An adapted version of the Andersen health care utilization model explained the predisposing factors, enabling factors, and need factors, which influence the use of maternal health care for African immigrant women.

Results

Findings were presented according to the Andersen health care utilization model. Analysis of the interviews resulted in 11 themes. The themes were as follows: (1) Community social structure, (2) community health beliefs, (3) health organization concerning the use of women, infants, and children, (4) social support at the individual level, (5) limited English proficiency, (6) need for better health education, (7) perception of care, (8) health financing, (9) long wait times and lack of transportation, (10) fear of medication and obstetrical interventions, and (11) impact of Female Genital Mutilation/Cutting.

Discussion

Maternal health practices of African immigrant women are impacted by environmental and cultural factors. Public health interventions should be implemented to advance African immigrant women's health care utilization practices through required health education and tailored care, which will translate to positive maternal health experiences.

Maternal multimorbidity - experiences of women seeking asylum during pregnancy and after childbirth: a qualitative study

BACKGROUND

Many women seeking asylum during pregnancy and after childbirth have ill-health but detection and assessment of all physical, psychological, and social health needs (maternal multimorbidity) are often difficult as part of routine maternity care. Healthcare providers are key for the early identification and management of vulnerable pregnant women who have additional physical, psychological, and social health needs. We sought to explore the impact of the asylum-seeking process, understanding of wellbeing, expressed health needs (in terms of maternal multimorbidity), and the experiences of maternity care of women seeking asylum during pregnancy and after childbirth in Liverpool, United Kingdom. Enabling factors and barriers to access woman-centred care were also explored.

METHODS

Key informant interviews (n = 10) and one focus group discussion (n = 4) were conducted with women attending a non-profit charitable pregnancy support group. Transcribed interviews were coded by topic and then grouped into categories. Thematic framework analysis was undertaken to identify emerging themes.

RESULTS

The asylum-seeking process negatively impacted women making them feel anxious and depressed with little control or choice over their future. Women reported feeling stressed regarding poor standard of accommodation, low income, dispersal and the uncertainty of their asylum application outcome. Wellbeing during pregnancy and after childbirth was understood to be multifactorial and women understood that their physical health needs were interlinked and negatively impacted by complex psychological and social factors. Women reported that their expectations of maternity services were often exceeded, but information giving, and the use of language interpreters needed to be improved. Women expressed the need for more psychological and social support throughout pregnancy and after childbirth.

CONCLUSIONS

A multidisciplinary team, with links and effective referral pathways to maternal mental health and social services, are necessary for women seeking asylum, to ensure a more integrated, comprehensive assessment of maternal multimorbidity and to provide maternity care in a way that meets all health needs.

Perspectives of women and partners from migrant and refugee backgrounds accessing the Cross Cultural Worker Service in maternity and early childhood services-a survey study

BACKGROUND

Women from migrant and refugee backgrounds living in high-income countries have increased risk of adverse perinatal outcomes and report lower satisfaction with perinatal healthcare. In Sydney, Australia, a new service known as the Cross Cultural Workers (CCWs) in Maternity and Child and Family Health Service (the CCW Service) was implemented to support such women and families from pregnancy to the early parenting period. This study aimed to ascertain the experiences of women and their partners engaging with the CCW Service.

METHODS

A survey study was undertaken. Women accessing the CCW Service were recruited during pregnancy and were asked to complete surveys at three time points: in the third trimester of pregnancy, at 6 and 12 months postpartum. Their partners were invited to complete a survey at 6 months postpartum. Survey data were analysed to compare satisfaction, usefulness, number of CCW interactions, cultural sensitivity, and service improvement recommendations across all three survey timepoints.

RESULTS

A total of 231 surveys were received: 113 during pregnancy, 50 at 6-months postpartum, 44 at 12-months postpartum, and 24 partner surveys. Participants in all surveys reported the CCW Service to be useful (84-94%), stating that it increased their understanding of pregnancy, birth and parenting (95-100%), and that they would recommend the CCW Service (92-98%). Participants experienced a high level of satisfaction (88-95%) irrespective of the number of CCW interactions (p = 0.42). Thoughts on becoming a mother or parent were more positive after meeting the CCW than before for both women (p = 0.01) and partners (p = 0.12). Suggestions for CCW Service improvement were to 1) increase the provision of information, specifically financial entitlements, postnatal depression, and support services, 2) increase involvement of partners in care, 3) increase the CCW workforce/or number of CCWs.

CONCLUSION

The CCW Service was associated with positive experiences and high rates of satisfaction at all timepoints. This service has the potential to inform the implementation of similar models of care that improve accessibility, the perinatal experience, and respond to the unique needs of women and families from migrant and refugee backgrounds.

What women want: A reflexive thematic analysis of the healthcare experiences of women with female genital mutilation/cutting in South Australia

BACKGROUND

Global migration has seen an increase in female genital mutilation/cutting (FGM/C) cases observed in countries where it is not part of the cultural norm. This shift has led to many healthcare professionals (HCPs) reporting a lack of knowledge and skills necessary to support the needs of women with FGM/C.

AIM

To explore the experiences and needs of women with FGM/C accessing women's health services in South Australia.

METHODS

Women with FGM/C were recruited through purposive and snowball sampling to participate in one-to-one semi-structured interviews. The voice recorded interviews were transcribed verbatim, coded, and analysed using Braun and Clarke's reflexive thematic analysis to determine themes.

FINDINGS

Ten migrant and refugee women living in South Australia, were interviewed. Four themes and 13-subthemes were identified. The main themes were, 1) the healthcare experience, 2) cultural values shape the healthcare experience, 3) speaking up about female genital cutting and 4) working together to improve healthcare experiences.

DISCUSSION

Women's cultural needs, not their health needs, play a fundamental role on how women experienced healthcare services. When women's cultural values and traditions are acknowledged by HCPs, they are more likely to trust and feel confident to engage with services and seek medical support. Areas identified for improvement included access to the right interpreters, having more time during appointments, opportunities for continuity of care and the inclusion of family in care and treatment decisions.

CONCLUSION

Women with FGM/C have specific health and cultural needs that can be met through education and provision of woman-centred care.

An economic evaluation of universal and targeted case-finding strategies for identifying antenatal depression: a model-based analysis comparing common case-finding instruments

Half of women with depression in the perinatal period are not identified in routine care, and missed cases reflect inequalities in other areas of maternity care. Case finding (screening) for depression in pregnant women may be a cost-effective strategy to improve identification, and targeted case finding directs finite resources towards the greatest need. We compared the cost-effectiveness of three case-finding strategies: no case finding, universal (all pregnant women), and targeted (only pregnant women with risk factors for antenatal depression, i.e. history of anxiety/depression, age < 20 years, and adverse life events). A decision tree model was developed to represent case finding (at around 20 weeks gestation) and subsequent treatment for antenatal depression (up to 40 weeks gestation). Costs include case finding and treatment. Health benefits are measured as quality-adjusted life years (QALYs). The sensitivity and specificity of case-finding instruments and prevalence and severity of antenatal depression were estimated from a cohort study of pregnant women. Other model parameters were derived from published literature and expert consultation. The most cost-effective case-finding strategy was a two-stage strategy comprising the Whooley questions followed by the PHQ-9. The mean costs were £52 (universal), £61 (no case finding), and £62 (targeted case finding). Both case-finding strategies improve health compared with no case finding. Universal case finding is cost-saving. Costs associated with targeted case finding are similar to no case finding, with greater health gains, although targeted case finding is not cost-effective compared with universal case finding. Universal case finding for antenatal depression is cost-saving compared to no case finding and more cost-effective than targeted case finding.

Interventions to improve perinatal outcomes among migrant women in high-income countries: a systematic review protocol

INTRODUCTION

Women who are migrants and who are pregnant or postpartum are at high risk of poorer perinatal outcomes compared with host country populations due to experiencing numerous additional stressors including social exclusion and language barriers. High-income countries (HICs) host many migrants, including forced migrants who may face additional challenges in the peripartum period. Although HICs' maternity care systems are often well developed, they are not routinely tailored to the needs of migrant women. The primary objective will be to determine what interventions exist to improve perinatal outcomes for migrant women in HICs. The secondary objective will be to explore the effectiveness of these interventions by exploring the impact on perinatal outcomes. The main outcomes of interest will be rates of preterm birth, birth weight, and number of antenatal or postnatal appointments attended.

METHODS AND ANALYSIS

This protocol follows the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Protocols guidelines. EMBASE, EMCARE, MEDLINE and PsycINFO, CENTRAL, Scopus, CINAHL Plus, and Web of Science, as well as grey literature sources will be searched from inception up to December 2022. We will include randomised controlled trials, quasi-experimental and interventional studies of interventions, which aim to improve perinatal outcomes in any HIC. There will be no language restrictions. We will exclude studies presenting only qualitative outcomes and those including mixed populations of migrant and non-migrant women. Screening and data extraction will be completed by two independent reviewers and risk of bias will be assessed using the Quality Assessment Tool for Quantitative Studies. If a collection of suitably comparable outcomes is retrieved, we will perform meta-analysis applying a random effects model. Presentation of results will comply with guidelines in the Cochrane Handbook of Systematic Reviews of Interventions and the PRISMA statement.

ETHICS AND DISSEMINATION

Ethical approval is not required. Results will be submitted for peer-reviewed publication and presented at national and international conferences. The findings will inform the work of the Lancet Migration European Hub.

PROSPERO REGISTRATION NUMBER

CRD42022380678.

Ethnic minority women's experiences of accessing antenatal care in high income European countries: a systematic review

BACKGROUND

Women from ethnic minority backgrounds are at greater risk of adverse maternal outcomes. Antenatal care plays a crucial role in reducing risks of poor outcomes. The aim of this study was to identify, appraise, and synthesise the recent qualitative evidence on ethnic minority women's experiences of accessing antenatal care in high-income European countries, and to develop a novel conceptual framework for access based on women's perspectives.

METHODS

We conducted a comprehensive search of seven electronic databases in addition to manual searches to identify all qualitative studies published between January 2010 and May 2021. Identified articles were screened in two stages against the inclusion criteria with titles and abstracts screened first followed by full-text screening. Included studies were quality appraised using the Critical Appraisal Skills Programme checklist and extracted data were synthesised using a 'best fit' framework, based on an existing theoretical model of health care access.

RESULTS

A total of 30 studies were included in this review. Women's experiences covered two overarching themes: 'provision of antenatal care' and 'women's uptake of antenatal care'. The 'provision of antenatal care' theme included five sub-themes: promotion of antenatal care importance, making contact and getting to antenatal care, costs of antenatal care, interactions with antenatal care providers and models of antenatal care provision. The 'women's uptake of antenatal care' theme included seven sub-themes: delaying initiation of antenatal care, seeking antenatal care, help from others in accessing antenatal care, engaging with antenatal care, previous experiences of interacting with maternity services, ability to communicate, and immigration status. A novel conceptual model was developed from these themes.

CONCLUSION

The findings demonstrated the multifaceted and cyclical nature of initial and ongoing access to antenatal care for ethnic minority women. Structural and organisational factors played a significant role in women's ability to access antenatal care. Participants in majority of the included studies were women newly arrived in the host country, highlighting the need for research to be conducted across different generations of ethnic minority women taking into account the duration of stay in the host country where they accessed antenatal care.

PROTOCOL AND REGISTRATION

The review protocol was registered on PROSPERO (reference number CRD42021238115).

An economic evaluation of targeted case-finding strategies for identifying postnatal depression: A model-based analysis comparing common case-finding instruments

BACKGROUND

Half of women with postnatal depression (PND) are not identified in routine care. We aimed to estimate the cost-effectiveness of PND case-finding in women with risk factors for PND.

METHODS

A decision tree was developed to represent the one-year costs and health outcomes associated with case-finding and treatment for PND. The sensitivity and specificity of case-finding instruments, and prevalence and severity of PND, for women with ≥1 PND risk factor were estimated from a cohort of postnatal women. Risk factors were history of anxiety/depression, age < 20 years, and adverse life events. Other model parameters were derived from published literature and expert consultation. Case-finding for high-risk women only was compared with no case-finding and universal case-finding.

RESULTS

More than half of the cohort had one or more PND risk factor (57.8 %; 95 % CI 52.7 %-62.7 %). The most cost-effective case-finding strategy was the Edinburgh Postnatal Depression Scale with a cut-off of ≥10 (EPDS-10). Among high-risk women, there is a high probability that EPDS-10 case-finding for PND is cost-effective compared to no case-finding (78.5 % at a threshold of £20,000/QALY), with an ICER of £8146/QALY gained. Universal case-finding is even more cost-effective at £2945/QALY gained (versus no case-finding). There is a greater health improvement with universal rather than targeted case-finding.

LIMITATIONS

The model includes costs and health benefits for mothers in the first year postpartum, the broader (e.g. families, societal) and long-term impacts are also important.

CONCLUSIONS

Universal PND case-finding is more cost-effective than targeted case-finding which itself is more cost-effective than not case-finding.

A systematic review and narrative synthesis of fathers' (including migrant fathers') experiences of pregnancy and childbirth

OBJECTIVE

The purpose of this review was to consider factors that influence the experiences of pregnancy and childbirth by fathers including migrant fathers.

METHOD

A systematic review and narrative synthesis were conducted as per the PRISMA guidelines. The spider tool was used to build a search strategy which was used to conduct literature search in eight identified electronic databases: ASSIA, CINAHL, EMBASE, MEDLINE, PsycINFO, PUBMED, Sage and Scopus. Grey literature was searched through the King's Fund Library database, Ethos, The North Grey Literature Collection, Social Care Online and other charity websites such as the Refugee Council and Joseph Rowntree Foundation. The search was conducted across all the databases in the week commencing January 7, 2019, and restricted to studies published in the English language.

RESULTS

The search across all the eight electronic databases identified 2564 records, 13 records through grey literature databases/websites and an additional 23 records identified through hand-searching/forward citation. The number of records after duplicates were removed was 2229. Record screening based on titles and abstracts identified 69 records for full text screening. Dual screening of these full text records identified 12 full records from 12 separate studies, eight of which were qualitative studies, three of which were quantitative studies and one mixed method study.

FINDINGS

This review has revealed three main themes: influence of society and health professionals; adjustment to a new life of fatherhood; and involvement in maternity care. However, the literature has focused on non-migrant father's experiences of pregnancy and childbirth, with little attention paid to fathers who may be migrants.

KEY CONCLUSION AND IMPLICATIONS FOR PRACTICE

This review has exposed a dearth of research on migrant fathers' experiences of pregnancy and childbirth in an era of increasing globalisation and migration between countries. Midwives and other health professionals should be alert to the needs of any father when providing maternity care. More research is needed which considers experiences of migrants and how choosing to move to a new country or being forced to move could influence migrant father's experiences and therefore their needs.

Project20: maternity care mechanisms that improve access and engagement for women with social risk factors in the UK - a mixed-methods, realist evaluation

OBJECTIVES

To evaluate how women access and engage with different models of maternity care, whether specialist models improve access and engagement for women with social risk factors, and if so, how?

DESIGN

Realist evaluation.

SETTING

Two UK maternity service providers.

PARTICIPANTS

Women accessing maternity services in 2019 (n=1020).

METHODS

Prospective observational cohort with multinomial regression analysis to compare measures of access and engagement between models and place of antenatal care. Realist informed, longitudinal interviews with women accessing specialist models of care were analysed to identify mechanisms.

MAIN OUTCOME MEASURES

Measures of access and engagement, healthcare-seeking experiences.

RESULTS

The number of social risk factors women were experiencing increased with deprivation score, with the most deprived more likely to receive a specialist model that provided continuity of care. Women attending hospital-based antenatal care were more likely to access maternity care late (risk ratio (RR) 2.51, 95% CI 1.33 to 4.70), less likely to have the recommended number of antenatal appointments (RR 0.61, 95% CI 0.38 to 0.99) and more likely to have over 15 appointments (RR 4.90, 95% CI 2.50 to 9.61) compared with community-based care. Women accessing standard care (RR 0.02, 95% CI 0.00 to 0.11) and black women (RR 0.02, 95% CI 0.00 to 0.11) were less likely to have appointments with a known healthcare professional compared with the specialist model. Qualitative data revealed mechanisms for improved access and engagement including self-referral, relational continuity with a small team of midwives, flexibility and situating services within deprived community settings.

CONCLUSION

Inequalities in access and engagement with maternity care appears to have been mitigated by the community-based specialist model that provided continuity of care. The findings enabled the refinement of a realist programme theory to inform those developing maternity services in line with current policy.

Experiences and needs of women from ethnic minorities in maternity healthcare: A qualitative systematic review and meta-aggregation

OBJECTIVES

To consolidate the available evidence around ethnic minority women's experiences and needs when accessing maternity care.

METHODS

A qualitative systematic review and meta-aggregation of qualitative data were conducted. Nine electronic databases were searched for qualitative or mixed-methods studies from the inception of each database until January 2022. Using the Nested-Knowledge software, meta-aggregation was conducted according to the Joanna Briggs Institute (JBI) data synthesis approach to identify all potential intersections between different themes. Methodological quality of included studies was assessed using the JBI Qualitative Assessment and Review Instrument (JBI-QARI) and the mixed-methods appraisal tool (MMAT) checklists for qualitative and mixed-methods studies, respectively.

RESULTS

Twenty-two studies (nineteen qualitative and three mixed-methods) were included. All studies were of good methodological quality. An overarching theme 'the struggles and fears of ethnic minority women' was identified. The negative experiences with maternity care were attributed to barriers including ineffective communication, cultural and religious insensitivity, inattentiveness and disregard for women's needs, and isolation-related impact due to the COVID pandemic.

CONCLUSIONS

Overall, our review highlighted several significant gaps between the care provided and the expected care among ethnic minority women accessing maternity care services. This mismatch between their expectations and care resulted in negative experiences, as the women reported being discriminated against and disrespected. There is an urgent need to develop and implement maternity care policies that are inclusive of needs of the ethnic minority women to optimize their maternity care experience.

Maternity care experience of Pakistani ethnic minority women in Hong Kong

Background

Persistent inequalities in maternity care experience and outcomes exist globally for ethnic minority (EM) and migrant women. Despite the fact that this is an important research area, no prior study has been done in Hong Kong (HK) to examine maternity care experience of EM women.

Objectives

To investigate maternity care experience of Pakistani EM women (both local born and immigrants) during pregnancy, birth and after birth in hospital in HK. An evaluation of their satisfaction and factors predicting satisfaction with care during the three phases of maternity care was included in the study.

Methods

A cross sectional survey was conducted among Pakistani EM women who had given birth in HK in last 3 years, using a structured questionnaire by a bilingual interviewer, from April to May 2020. Counts and percentages were used to describe all categorical variables. Association between predictor variables and overall satisfaction was assessed by bivariate analysis and multiple logistic regression.

Results

One hundred and twenty questionnaires were completed. Almost 60 percent of the women were very satisfied with the overall care. More than half of the women described the care they received as kind, respectful and well communicated. After adjusting for age and parity, HK born Pakistani women expressed relatively less satisfaction with care, especially during pregnancy and labor and birth, as compared with Pakistan born women. Women with conversational or fluent English-speaking ability also felt comparatively less satisfied particularly from intrapartum and postnatal care in hospital. Education level had a negative association with satisfaction with care during pregnancy.

Conclusions

Maternity care providers should take into account the diversity of EM women population in HK. Our findings suggest that effective communication and care that can meet individual needs, expectations, and values is imperative to improve experience and quality of maternity care for EM women in HK.

Minoritised ethnic women's experiences of inequities and discrimination in maternity services in North-West England: a mixed-methods study

BACKGROUND

Minoritised ethnic perinatal women can experience judgemental and stigmatising care due to systemic racism. Discriminatory care contributes to increased risks of poor maternal and infant outcomes, including higher rates of mental ill-health. This study aimed to explore minoritised ethnic women's experiences of maternity services, including maternity care and mental health support, within a North-West England locality. Here we use an equity lens to report the findings that describe if and how women's personal, cultural, and spiritual needs were met, their experiences of discriminatory and prejudicial care, and to identify recommendations for service provision.

METHODS

A mixed-methods study was undertaken comprising an online survey, interviews, and community consultations. Questions explored access to and experiences of antenatal care and education; information, communication, and choice; experiences of (dis)respect and judgement; mental health needs and support; cultural/religious needs and support; and overall experiences of maternity care. Eligibility criteria were: women, 18+ years, from self-reported minoritised ethnic backgrounds, who had given birth in the previous 2 years and received maternity care in the locality. Surveys were available in seven languages and distributed via social media, mother-baby groups, and community locations. English-speaking survey participants were invited to take part in a follow-up interview. Community staff were approached to collect data on behalf of the study team. Quantitative data were analysed descriptively (n, %) and merged with qualitative data into descriptive themes.

RESULTS

Overall, 104 women provided data; most self-identified as Asian (65.0%) or Black (10.7%) and were aged between 30-34 (32.0%) or 25-29 years (23.3%). Four descriptive themes are reported: 'accessing care' details variations and barriers in accessing maternity care; 'communication needs, and resources' describes views on adaptions and resources for specific communication needs; 'meeting religious and cultural needs' outlines how various religious and cultural needs were met by maternity providers; 'discriminatory or stigmatising care' reports on experiences of pejorative and inequitable care.

CONCLUSIONS

An equity lens helped identify areas of discriminatory and inequitable care. Key recommendations include cultural safety training for staff; service-user engagement and co-production of research and resources, and appropriate facilities and recording systems to facilitate individualised, needs-based maternity care.

Addressing social inequity through improving relational care: A social-ecological model based on the experiences of migrant women and midwives in South Wales

BACKGROUND

Migrant and ethnic inequalities in maternal and perinatal mortality persist across high-income countries. Addressing social adversity and inequities across the childbirth trajectory cannot be left to chance and the good intentions of practitioners. Robust, evidence-based tools designed to address inequity by enhancing both the quality of provision and the experience of care are needed.

METHODS

An inductive modelling approach was used to develop a new evidence-based conceptual model of woman-midwife relationships, drawing on data from an ethnographic study of relationships between migrant Pakistani women and midwives, conducted between 2013 and 2016 in South Wales, UK. Key analytic themes from early data were translated into social-ecological concepts, and a model was developed to represent how these key themes interacted to influence the woman-midwife relationship.

RESULTS

Three key concepts influencing the woman-midwife relationship were developed from the three major themes of the underpinning research: (1) Healthcare System; (2) Culture and Religion; and (3) Family Relationships. Two additional weaving concepts appeared to act as a link between these three key concepts: (1) Authoritative Knowledge and (2) Communication of Information. Social and political factors were also considered as contextual factors within the model. A visual representation of this model was developed and presented.

CONCLUSIONS

The model presented in this paper, along with future work to further test and refine it in other contexts, has the potential to impact on inequalities by facilitating future discussion on cultural issues, encouraging collaborative learning and knowledge production and providing a framework for future global midwifery practice, education and research.

PATIENT OR PUBLIC CONTRIBUTION

At the outset of the underpinning research, a project involvement group was created to contribute to study design and conduct. This group consisted of the three authors, an Advocacy Officer at Race Equality First and an NHS Consultant Midwife. This group met regularly throughout the research process, and members were involved in discussions regarding ethical/cultural/social issues, recruitment methods, the creation of participant information materials, interpretation of data and the dissemination strategy. Ideas for the underpinning research were also discussed with members of the Pakistani community during community events and at meetings with staff from minority ethnic and migrant support charities (BAWSO, Race Equality First, The Mentor Ring). Local midwives contributed to study design through conversations during informal observations of antenatal appointments for asylum seekers and refugees.

Disparities in the timing of antenatal care initiation and associated factors in an ethnically dense maternal cohort with high levels of area deprivation

BACKGROUND

Late access to antenatal care is a contributor to excess mortality and morbidity among ethnic minority mothers compared to White British in the UK. While individual ethnicity and socioeconomic disadvantage are linked to late antenatal care initiation, studies have seldom explored patterns of late initiation and associated factors in ethnically dense socially disadvantaged settings. This study investigated disparities in the timing of antenatal care initiation, and associated factors in an ethnically dense socially disadvantaged maternal cohort.

METHODS

A retrospective cross-sectional study using routinely collected anonymous data on all births between April 2007-March 2016 in Luton and Dunstable hospital, UK (N = 46,307). Late initiation was defined as first antenatal appointment attended at > 12 weeks of gestation and further classified into moderately late (13-19 weeks) and extremely late initiation (≥ 20 weeks). We applied logistic and multinomial models to examine associations of late initiation with maternal and sociodemographic factors.

RESULTS

Overall, one fifth of mothers (20.8%) started antenatal care at > 12 weeks of gestation. Prevalence of late initiation varied across ethnic groups, from 16.3% (White British) to 34.2% (Black African). Late initiation was strongly associated with non-White British ethnicity. Compared to White British mothers, the odds of late initiation and relative risk of extremely late initiation were highest for Black African mothers [adjusted OR = 3.37 (3.05, 3.73) for late initiation and RRR = 4.03 (3.51, 4.64) for extremely late initiation]. The odds did not increase with increasing area deprivation, but the relative risk of moderately late initiation increased in the most deprived ([RRR = 1.53 (1.37, 1.72)] and second most deprived areas [RRR = 1.23 (1.10, 1.38)]. Late initiation was associated with younger mothers and to a lesser extent, older mothers aged > 35 years. Mothers who smoked during pregnancy were at higher odds of late initiation compared to mothers who did not smoke.

CONCLUSIONS

There is a need to intensify universal and targeted programmes/services to support mothers in ethnically dense socially disadvantaged areas to start antenatal care on time. Local variations in ethnic diversity and levels of social disadvantage are essential aspects to consider while planning services and programmes to ensure equity in maternity care provision.

Trend and causes of maternal death, stillbirth and neonatal death over seven decades in Hong Kong

BACKGROUND

Reducing maternal and perinatal mortality is a global objective. Hong Kong is a city with low maternal and perinatal mortality but little is known about the trend and causes of these deaths in this high-income city. We analyzed the maternal death, stillbirth and neonatal death since 1946 in Hong Kong.

METHODS

Data were extracted from vital statistics, based on the number of registered deaths and births, provided by the Department of Health, the Government of the HKSAR. The annual change rate of mortality was evaluated by regression analysis. Contextual factors were collected to assess the association with mortality.

FINDINGS

Between 1946 and 2017, the stillbirth rate (per 1,000 total births) reduced from 21·5 to 2·4; early and late neonatal deaths (per 1,000 live births) reduced from 14·1 and 18·1 to 0·7 and 0·4 in 2017, respectively. The maternal mortality ratio (per 100,000 live births) declined from 125 to 1·8.The causes of maternal and perinatal deaths were available since 1981 and 1980 respectively. The leading causes of death were thromboembolism (37·0%) and obstetric haemorrhage (30·4%) for maternal death; congenital problem (30·1%) and prematurity (29·0%) for neonatal death. No data on causes of stillbirth were available. No specific shift of pattern was observed in the causes of maternal and neonatal death with time. There were no cases of maternal death due to sepsis and only 2 cases (2·2%) of maternal deaths due to indirect cause.

INTERPRETATION

The maternal and perinatal death have reduced significantly in Hong Kong and maintained at the lowest level globally. Indirect maternal death and sepsis were unusual causes of maternal deaths. Use of ICD-PM stillbirth classification, setting up a maternal death confidential enquiry and adding pregnancy checkbox could be the next step to identify and categorize hidden burden.

FUNDING

Nil.

Limited English proficiency in the labor and delivery unit

PURPOSE OF REVIEW

Limited English proficiency (LEP) impacts patient access to safe and comprehensive care during the antepartum, intrapartum, and postpartum periods. In this review, we explore disparities in care delivery and outcomes that LEP women experience, and discuss the importance of providing language concordant care and using interpretation services appropriately.

RECENT FINDINGS

The number of individuals with LEP is steadily increasing in the United States. Pregnant women with LEP suffer disparities in obstetric care and are at risk for postpartum depression, breastfeeding difficulties, and substandard newborn care after neonatal ICU discharge because of insufficient education. Addressing these issues requires the implementation of language concordant care and education, along with the utilization of medically trained interpreters. Although further evidence is needed, the authors support these interventions to improve patient satisfaction, decrease medical errors, and curtail misdiagnoses.

SUMMARY

The pregnant woman with limited English proficiency is at risk of receiving suboptimal care and experiencing negative outcomes during the antepartum, intrapartum, and postpartum periods. The use of medically trained interpreters and the provision of language concordant care, through workforce diversification and the creation of forms and educational materials in diverse languages, can improve patient safety, outcomes, and quality of care.

A Systematic Review and Meta-Analysis of the Risk of Stillbirth, Perinatal and Neonatal Mortality in Immigrant Women

Objectives: This study aimed to investigate the risk of stillbirth, perinatal and neonatal mortality in immigrant women compared to native-origin women in host countries.

Methods: A systematic literature review and meta-analysis was conducted. Relevant studies were identified using a thorough literature search and their quality was appraised. The analysis of heterogeneous data was carried out using the random effects model and publication bias was assessed using the Harbord-test. Also, the pooled odds ratio of events was calculated through the DerSimonian and Laird, and inverse variance methods.

Results: In the search process 45 studies were retrieved consisting of 8,419,435 immigrant women and 40,113,869 native-origin women. The risk of stillbirth (Pooled OR = 1.35, 95% CI = 1.22–1.50), perinatal mortality (Pooled OR = 1.50, 95% CI = 1.35–1.68), and neonatal mortality (Pooled OR = 1.09, 95% CI = 1.00–1.19) in the immigrant women were significantly higher than the native-origin women in host countries. According to the sensitivity analyses, all results were highly consistent with the main data analysis results.

Conclusion: The immigrant women compared to the native-origin women had the higher risks of stillbirth, perinatal and neonatal mortality. Healthcare providers and policy makers should improve the provision of maternal and neonatal healthcare for the immigrant population.

Pre-conceptual counselling in cardiology patients: still work to do and still missed opportunities. A comparison between 2015 and 2019 in women with cardiac disease attending combined obstetric cardiology clinics. Should the European Guidelines change anything?

Women with underlying cardiac conditions have an increased risk of adverse pregnancy outcomes. Counselling reproductive age women with heart disease is important to assist them in deciding whether to pursue pregnancy, to ensure their best cardiovascular status prior to pregnancy, and that they understand the risks of pregnancy for them and baby. This also provides an opportunity to explore management strategies to reduce risks. For this growing cohort of women, there is a great need for pre-conceptual counselling.This retrospective comparative audit assessed new referrals and pre-conceptual counselling of women attending a joint obstetric-cardiology clinic at a tertiary maternity centre in a 12-month period of 2015-2016 compared with 2018-2019. This reflected the timing of the introduction of a multidisciplinary meeting prior to clinics and assessed the impact on referrals with the introduction of the European Society of Cardiology guidelines.Data were reviewed from 56 and 67 patients in respective audit periods. Patient's risk was stratified using modified World Health Organization classification.Less than 50% of women with pre-existing cardiac conditions had received pre-conceptual counselling, although half of them had risks clearly documented. The majority of patients had a recent electrocardiograph and echocardiogram performed prior to counselling, and there was a modest improvement in the number of appropriate functional tests performed between time points. One-third of patients in both cohorts were taking cardiac medications during pregnancy.There was a significant increase in the number of pregnant women with cardiac disease and in complexity according to modified World Health Organization risk classification. While there have been improvements, it is clear that further work to improve availability and documentation of pre-pregnancy counselling is needed.

Project20: interpreter services for pregnant women with social risk factors in England: what works, for whom, in what circumstances, and how?

BACKGROUND

Black and minority ethnic women and those with social risk factors such as deprivation, refugee and asylum seeker status, homelessness, mental health issues and domestic violence are at a disproportionate risk of poor birth outcomes. Language barriers further exacerbate this risk, with women struggling to access, engage with maternity services and communicate concerns to healthcare professionals. To address the language barrier, many UK maternity services offer telephone interpreter services. This study explores whether or not women with social risk factors find these interpreter services acceptable, accessible and safe, and to suggest solutions to address challenges.

METHODS

Realist methodology was used to refine previously constructed programme theories about how women with language barriers access and experience interpreter services during their maternity care. Twenty-one longitudinal interviews were undertaken during pregnancy and the postnatal period with eight non-English speaking women and their family members. Interviews were analysed using thematic framework analysis to confirm, refute or refine the programme theories and identify specific contexts, mechanisms and outcomes relating to interpreter services.

RESULTS

Women with language barriers described difficulties accessing maternity services, a lack of choice of interpreter, suspicion around the level of confidentiality interpreter services provide, and questioned how well professional interpreters were able to interpret what they were trying to relay to the healthcare professional during appointments. This resulted in many women preferring to use a known and trusted family member or friend to interpret for them where possible. Their insights provide detailed insight into how poor-quality interpreter services impact on their ability to disclose risk factors and communicate concerns effectively with their healthcare providers. A refined programme theory puts forward mechanisms to improve their experiences and safety such as regulated, high-quality interpreter services throughout their maternity care, in which women have choice, trust and confidence.

CONCLUSIONS

The findings of this study contribute to concerns highlighted in previous literature around interpreter services in the wider healthcare arena, particularly around the lack of regulation and access to high-quality interpretation. This is thought to have a significant effect on pregnant women who are living socially complex lives as they are not able to communicate their concerns and access support. This not only impacts on their safety and pregnancy outcomes, but also their wider holistic needs. The refined program theory developed in this study offers insights into the mechanisms of equitable access to appropriate interpreter services for pregnant women with language barriers.

Midwives' insights in relation to the common barriers in providing effective perinatal care to women from ethnic minority groups with 'high risk' pregnancies: A qualitative study

PROBLEM

Childbearing women from ethnic minority groups in the United Kingdom (UK) have significantly poorer perinatal outcomes overall.

BACKGROUND

Childbearing women from ethnic minority groups report having poorer experiences and outcomes in perinatal care, and health professionals report having difficulty in providing effective care to them. Yet barriers in relation to providing such care remain underreported.

AIM

The aim of this study was to elicit midwives' insights in relation to the common barriers in providing effective perinatal care to women from ethnic minority groups with 'high risk' pregnancies and how to overcome these barriers.

METHODS

A qualitative study was undertaken in a single obstetric led unit in London, UK. A thematic analysis was undertaken to identify themes from the data.

FINDINGS

A total of 20 midwives participated. They self-identified as White British (n=7), Black African (n=7), Black Caribbean (n=3) and Asian (n=3). Most (n=12) had more than 10 years' experience practising as a registered midwife (range 2 - 35 years). Four themes were identified: 1) Communication, 2) Continuity of carer, 3) Policy and 4) Social determinants. Racism and unconscious bias underpin many of the findings presented.

DISCUSSION

Co-created community hubs may improve access to more effective care for childbearing women from ethnic minority groups. A focus on robust anti-racism interventions, continuity of carer, staff wellbeing and education along with the provision of orientation and bespoke translation services are also suggested for the reduction of poorer outcomes and experiences.

CONCLUSION

Along with policies designed to promote equality and irradicate racism, there is a need for co-created community hubs and continuity of carer in perinatal services. Further research is also required to develop and evaluate culturally safe, and evidence-based interventions designed to address the current disparities apparent.

An exploration of migrant women's perceptions of public health messages to reduce stillbirth in the UK: a qualitative study

BACKGROUND

Stillbirth is a global public health priority. Within the United Kingdom, perinatal mortality disproportionately impacts Black, Asian and minority ethnic women, and in particular migrant women. Although the explanation for this remains unclear, it is thought to be multidimensional. Improving perinatal mortality is reliant upon raising awareness of stillbirth and its associated risk factors, as well as improving maternity services. The aim of this study was to explore migrant women's awareness of health messages to reduce stillbirth risk, and how key public health messages can be made more accessible.

METHOD

Two semi-structured focus groups and 13 one to one interviews were completed with a purposive sample of 30 migrant women from 18 countries and across 4 NHS Trusts.

RESULTS

Participants provided an account of their general awareness of stillbirth and recollection of the advice they had been given to reduce the risk of stillbirth both before and during pregnancy. They also suggested approaches to how key messages might be more effectively communicated to migrant women.

CONCLUSIONS

Our study highlights the complexity of discussing stillbirth during pregnancy. The women in this study were found to receive a wide range of advice from family and friends as well as health professionals about how to keep their baby safe in pregnancy, they recommended the development of a range of resources to provide clear and consistent messages. Health professionals, in particular midwives who have developed a trusting relationship with the women will be key to ensuring that public health messages relating to stillbirth reduction are accessible to culturally and linguistically diverse communities.

Involving service users in the Birth Timing project, a data linkage study analysing the timing of births and their outcomes

INTRODUCTION

We report on service user participation in a population-based data linkage study designed to analyse the daily, weekly and yearly cycles of births in England and Wales, the outcomes for women and babies, and their implications for the NHS. Public Involvement and Engagement (PI&E) has a long history in maternity services, though PI&E in maternity data linkage studies is new in the United Kingdom. We have used the GRIPP2 short form, a tool designed for reporting public involvement in research.

OBJECTIVES

We aimed to involve and engage a wide range of maternity service users and their representatives to ensure that our use of patient-identifiable routinely collected maternity and birth records was acceptable and that our research analyses using linked data were relevant to their expressed safety and quality of care needs.

METHODS

A three-tiered approach to PI&E was used. Having both PI&E co-investigators and PI&E members of the Study Advisory Group ensured service user involvement was part of the strategic development of the project. A larger constituency of maternity service users from England and Wales was engaged through four regional workshops.

RESULTS

Two co-investigators with experience of PI&E in maternity research were involved as service user researchers from design stage to dissemination. Four PI&E study advisors contributed service user perspectives. Engagement workshops attracted around 100 attendees, recruited largely from Maternity Services Liaison Committees in England and Wales, and a community engagement group. They supported the use of patient-identifiable data, believing the study had potential to improve safety and quality of maternity services. They contributed their experiences and concerns which will assist with interpretation of the analyses.

CONCLUSION

Use of PI&E 'knowledge intermediaries' successfully bridged the gap between data intensive research and lived experience, but more inclusivity in involvement and engagement is required. Respecting the concerns and questions of service users provides social legitimacy and a relevance framework for researchers carrying out analyses.

Access to and interventions to improve maternity care services for immigrant women: a narrative synthesis systematic review

Background

In 2016, over one-quarter of births in the UK (28.2%) were to foreign-born women. Maternal and perinatal mortality are disproportionately higher among some immigrants depending on country of origin, indicating the presence of deficits in their care pathways and birth outcomes.

Objectives

Our objective was to undertake a systematic review and narrative synthesis of empirical research that focused on access and interventions to improve maternity care for immigrant women, including qualitative, quantitative and mixed-methods studies.

Review methods

An information scientist designed the literature database search strategies (limited to retrieve literature published from 1990 to 2018). All retrieved citations (45,954) were independently screened by two or more team members using a screening tool. We searched grey literature reported in related databases and websites. We contacted stakeholders with subject expertise. In this review we define an immigrant as a person who relocates to the destination country for a minimum of 1 year, with the goal of permanent residence.

Results

We identified 40 studies for inclusion. Immigrant women tended to book and access antenatal care later than the recommended first 10 weeks of pregnancy. Primary factors included limited English-language skills, lack of awareness of availability of the services, lack of understanding of the purpose of antenatal appointments, immigration status and income barriers. Immigrant women had mixed perceptions regarding how health-care professionals (HCPs) had delivered maternity care services. Those with positive perceptions felt that HCPs were caring, confidential and openly communicative. Those with negative views perceived HCPs as rude, discriminatory or insensitive to their cultural and social needs; these women therefore avoided accessing maternity care. We found very few interventions that had focused on improving maternity care for these women and the effectiveness of these interventions has not been rigorously evaluated.

Limitations

Our review findings are limited by the available research evidence related to our review questions. There may be many aspects of immigrant women’s experiences that we have not addressed. For example, few studies exist for perinatal mental health in immigrant women from Eastern European countries (in the review period). Many studies included both immigrant and non-immigrant women.

Conclusions

Available evidence suggests that the experiences of immigrant women in accessing and using maternity care services in the UK are mixed; however, women largely had poor experiences. Contributing factors included a lack of language support, cultural insensitivity, discrimination and poor relationships between immigrant women and HCPs. Furthermore, a lack of knowledge of legal entitlements and guidelines on the provision of welfare support and maternity care to immigrants compounds this.

Future work

Studies are required on the development of interventions and rigorous scientific evaluation of these interventions. Development and evaluation of online antenatal education resources in multiple languages. Development and appraisal of education packages for HCPs focused on the provision of culturally safe practice for the UK’s diverse population. The NHS in the UK has a hugely diverse workforce with a vast untapped linguistic resource; strategies could be developed to harness this resource.

Study registration

This study is registered as PROSPERO CRD42015023605.

Funding

This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 8, No. 14. See the NIHR Journals Library website for further project information.