Caring for pregnant refugee women in a turbulent policy landscape: perspectives of health care professionals in Calgary, Alberta

Understanding Refugees Health Experiences in Host Countries: Three Theoretical Perspectives

Healthcare providers working with forcefully displaced populations often have limited knowledge and skills regarding the care of this population. The reasons are twofold. First, most of the research on refugee health does not consider refugees' adaptive skills, diversity of experiences, and daily life context. Second, healthcare providers' knowledge of how the sociopolitical environment shapes health research and practice in the context of refugee care is often limited. This work aims to specify gaps in refugee healthcare and research by applying a relational approach to three theoretical frameworks. The relational approach supports a pragmatic, in-depth understanding of healthcare practices by shifting the focus of the inquiry from description of social structures toward exploration of processes and relations that propagate and sustain such structures. The focus is on the threefold interaction between refugees, healthcare providers, and healthcare institutions. The three theoretical frameworks are as follows: First, using concepts from the Theory of Practice by Bourdieu, we examine how gaps in care can result from a mismatch between the dispositions and skills that refugees develop through life experience and the cultural-professional practices of healthcare providers in host countries. Second, the Cultural Determinants of Help Seeking by Saint Arnault is applied to posit that gaps in care can result from differences in the meanings that healthcare providers and refugees assign to their interactions. Finally, we use the concept of Othering as described in nursing by Canales to explain how power dynamics inherent in the interaction between refugees and healthcare systems can affect refugee healthcare and research. This relational approach helps to elucidate some of the culture-bound mechanisms of health maintenance and help-seeking and brings attention to the sociopolitical context that shapes the way we care to refugees.

Structural Origins of Poor Health Outcomes in Documented Temporary Foreign Workers and Refugees in High-Income Countries: A Review

Despite growing evidence of racial and institutional discrimination on minoritized communities and its negative effect on health, there are still gaps in the current literature identifying health disparities among minoritized communities. This review aims to identify health barriers faced by relatively less studied migrant subgroups including documented temporary foreign workers and refugees residing in high-income Organisation for Economic Co-operation and Development (OECD) countries focusing on the structural origins of differential health outcomes. We searched Medline, CINAHL, and Embase databases for papers describing health barriers for these groups published in English between 1 January 2011 and 30 July 2021. Two independent reviewers conducted a title, abstract, and full text screening with any discrepancies resolved by consensus or a third reviewer. Extracted data were analyzed using an inductive thematic analysis. Of the 381 articles that underwent full-text review, 27 articles were included in this review. We identified housing conditions, immigration policies, structural discrimination, and exploitative labour practices as the four major emerging themes that impacted the health and the access to healthcare services of our study populations. Our findings highlight the multidimensional nature of health inequities among migrant populations and a need to examine how the broader context of these factors influence their daily experiences.

Single-Centre Retrospective Cohort Study of Demographic Characteristics and Perinatal Outcomes in Pregnant Refugee Patients in Toronto, Canada

Pregnant refugee patients are especially vulnerable to adverse perinatal outcomes. Detailed characterization of this heterogenous population will identify risk factors and thus guide contextualized initiatives for improved patient care. A retrospective cohort study of obstetrical refugee patients at a tertiary-care hospital in Toronto, Ontario. Of 196 pregnant refugees, 48% were fluent English speaking, 57% had poor social support, and 42% lived in a shelter. Eighty-seven percent started prenatal care after the first trimester, which was associated with delivery of a large-for-gestational-age infant (p = 0.043). Sixteen percent experienced family violence, which was associated with poor fetal aggregate outcomes (p = 0.03). There were significantly higher rates of pre-eclampsia and Cesarean sections in refugee versus non-refugee patients (p < 0.05). Pregnant refugees are at risk for psychosocial challenges and experience significantly worse obstetrical outcomes compared with non-refugees. Quality improvement initiatives should focus on access to early prenatal care, stable housing, and support for victims of family violence.

System-level factors influencing refugee women's access and utilization of sexual and reproductive health services: A qualitative study of providers' perspectives

Refugee women have poor outcomes and low utilization of sexual and reproductive health (SRH) services, which may be driven by access to and quality of SRH services at their resettled destinations. While healthcare providers offer valuable insights into these topics, little research has explored United States (U.S.) providers' experiences. To fill this literature gap, we investigate U.S. providers' perspectives of healthcare system-related factors influencing refugee women's access and utilization of SRH services. Between July and December 2019, we conducted in-depth, semi-structured interviews with 17 providers serving refugee women in metropolitan Atlanta in the state of Georgia (United States). We used convenience and snowball sampling for recruitment. We inquired about system-related resources, facilitators, and barriers influencing SRH services access and utilization. Two coders analyzed the data using a qualitative thematic approach. We found that transportation availability was crucial to refugee women's SRH services access. Providers noted a tension between refugee women's preferred usage of informal interpretation assistance (e.g., family and friends) and healthcare providers' desire for more formal interpretation services. Providers reported a lack of funding and human resources to offer comprehensive SRH services as well as several challenges with using a referral system for women to get SRH care in other systems. Culturally and linguistically-concordant patient navigators were successful at helping refugee women navigate the healthcare system and addressing language barriers. We discussed implications for future research and practice to improve refugee women's SRH care access and utilization. In particular, our findings underscore multilevel constraints of clinics providing SRH care to refugee women and highlight the importance of transportation services and acceptable interpretation services. While understudied, the use of patient navigators holds potential for increasing refugee women's SRH care access and utilization. Patient navigation can both effectively address language-related challenges for refugee women and help them navigate the healthcare system for SRH. Future research should explore organizational and external factors that can facilitate or hinder the implementation of patient navigators for refugee women's SRH care.

Experiences of nurses caring for involuntary migrant maternal women: a qualitative systematic review

OBJECTIVE

The objective of this review was to identify, critically appraise, and synthesize qualitative evidence on the experiences of nurses providing care within various health care delivery environments to involuntary migrant women who are experiencing pregnancy, birth, or post-birth.

INTRODUCTION

Nurses are central to providing care to populations experiencing inequities. These populations include forcibly displaced pregnant and/or mothering women who have migrated involuntarily. Most of these women are ethnically diverse and often experience poverty and low literacy. This review is focused on the experiences of nurses providing care to these women.

INCLUSION CRITERIA

This review considered qualitative, peer-reviewed studies published in academic journals. Studies and study abstracts that examined nurses' experiences of providing care to involuntary migrant maternal women were included. Women could be pregnant and/or mothering. All settings in which nurses practice were considered.

METHODS

Information sources that were systematically searched for this review included CINAHL (EBSCO), PsycINFO (EBSCO), MEDLINE (EBSCO), PubMed (NLM), Web of Science, and Google Scholar. A gray literature search in Google was also developed. Studies published in English from 2000 onward were considered. Final searches were conducted in January 2021 using language within database thesauruses, such as CINAHL headings and MeSH terms, as well as keywords related to qualitative inquires on experiences of nurses caring for involuntary migrant maternal women. An intersectionality lens was applied within all review methods. Study selection was conducted by two reviewers who screened titles and abstracts that aligned with the inclusion criteria. The review followed the JBI approach for critical appraisal, data extraction, and data synthesis.

RESULTS

Twenty-three qualitative studies were included in this review. Qualitative methodologies within these studies included case study, ethnography, interpretive descriptive, and grounded theory. Nine studies considered the sex of participating nurses, and three studies considered participant history of migration. A total of 115 findings were pooled into four categories and aggregated into the following two synthesized findings: i) Nurses integrate cultural and linguistic diversity within practice; and ii) Nurses assess for inequities resulting from forced migration on maternal women. Study quality was rated as moderate on ConQual scoring, with dependability rated as moderate and credibility rated as high.

CONCLUSIONS

Key implications are made within nursing education programming, nursing practice, and policy analysis. In the realm of nursing education, integration of migrant status as a health determinant will enhance nurses' skills in assessing migrant status and understanding how varying statuses contribute to barriers among involuntary migrant women accessing health services. Providing ongoing education to nurses centered on trauma and violence-informed practice is recommended. With regard to nursing practice, review findings revealed the need for creative solutions to overcome language barriers. Innovative approaches for nurses working across language barriers in acute and community health contexts when interpreter services are not available need further exploration and protocol integration. Examination of clinical care pathways is needed for inclusion of involuntary migrant women, and exploring assessment strategies targeting how migrant status contributes to limited health service accessibility. For policy, organizations need to build policies that promote examination of migrant status and its health impacts among involuntary migrant maternal women exposed to migration-related trauma and violence to support nurses in their care provision.

SYSTEMATIC REVIEW REGISTRATION NUMBER

PROSPERO CRD42019137922.

Factors influencing quality of life among syrian refugees pregnant women in Jordan: A cross-sectional study

Background

Pregnancy is a critical period of transition incorporating important normal physical, emotional, hormonal, and physiological status changes. These changes might affect the quality of life (QOL) of pregnant woman. This study aimed to examine the levels of quality of life and perceived social support of Syrian refugees' pregnant women in Al-Zaatari Refugee Camp in Jordan.

Methods

A cross-sectional survey design was used. A sample of 319 pregnant women was recruited from two maternal health clinics at Al-Zaatari Refugee Camp. Data were collected from June to August 2020 using the Arabic version of World Health Organization Quality of Life (WHOQOL-BREF), the Multidimensional Perceived Social Support (MSPSS) questionnaires, and two sheets were used to assess sociodemographic and obstetric variables.

Results

The study reveals that Syrian refugees' pregnant women had good satisfaction with their overall QOL and health status and social support. A significant relationship was found between the socioeconomic index and QOL. Also, age, being in the third trimester, and parity correlated negatively with QOL. In contrast, those who stayed in Jordan as a refugee for a longer period reported better QOL.

Conclusion

Syrian women in Jordan, in general, have a good QOL and high level of social support. However, women were least satisfied with their physical health domain. Several factors affected QOL including income, employment status, age, number of children, and pregnancy trimester. Social support is an important factor in improving the QOL among Syrian refugees' pregnant women.

Provision of antenatal care in Europe-A scientific study commissioned by European Board and College of Obstetrics and Gynaecology (EBCOG)

Differences in the way health care delivery across countries may have important impacts on health outcomes and can result in inequalities. A questionnaire survey of members of national societies through EBCOG and EAPM was carried out in 2021. A total of 53 responses were received from 26 countries. Most countries reported that routine antenatal care is primarily delivered by medical staff, involving obstetric specialists or family doctors mostly in government-run facilities. Women from minority groups are able to access antenatal care easily in most countries. Less than 10% of women did not attend antenatal care throughout the pregnancy. Most booking for antenatal care takes place in the first trimester and the number of visits range from 6 to 10 depending on parity. Most countries provide routine ultrasound with 2-3 reported scans performed by specifically trained health care professionals. Facilities for prenatal screening/diagnosis of malformations in both low- and high-risk cases varied across Europe. While antenatal care is relatively standardized throughout Europe, important differences still exist in care delivery and accessibility to care. Antenatal preventive strategies appear to be variably available throughout Europe.

Determinants and Inequities in Sexual and Reproductive Health (SRH) Care Access Among Im/Migrant Women in Canada: Findings of a Comprehensive Review (2008-2018)

Given growing concerns of im/migrant women's access to sexual and reproductive health (SRH) services, we aimed to (1) describe inequities and determinants of their engagement with SRH services in Canada; and (2) understand their lived experiences of barriers and facilitators to healthcare. Using a comprehensive review methodology, we searched the quantitative and qualitative peer-reviewed literature of im/migrant women's access to SRH care in Canada from 2008 to 2018. Of 782 studies, 38 met inclusion criteria. Ontario (n = 18), British Columbia (n = 6), and Alberta (n = 6) were primary settings represented. Studies focused primarily on maternity care (n = 20) and sexual health screenings (n = 12). Determinants included health system navigation and service information; experiences with health personnel; culturally safe and language-specific care; social isolation and support; immigration-specific factors; discrimination and racialization; and gender and power relations. There is a need for research that compares experiences across diverse groups of racialized im/migrants and a broader range of SRH services to inform responsive, equity-focused programs and policies.

Maternal mortality in Lebanon: Increased vulnerability among Syrian refugees

OBJECTIVE

To compare the burden and causes of maternal deaths between Syrian and Lebanese women for the period of 2010-2018.

METHODS

A retrospective analysis was conducted of maternal deaths from the national notification system at the Ministry of Public Health in Lebanon during the period of 2010-2018. Maternal deaths among Syrian refugees and Lebanese citizens were compared based on cause of death, age of the woman, and nationality. Causes of maternal deaths were categorized as direct and indirect following WHO definitions.

RESULTS

The maternal mortality ratio among the Syrian refugee women in Lebanon was higher than that of Lebanese women in the period 2010-2018, with its highest rate of 55.1 in 2017. Hemorrhage and indirect causes of maternal deaths are more common among Syrian refugee women whereas embolism and hypertension have higher proportions among Lebanese women. Maternal deaths within 48 h after birth are more common among Syrian than Lebanese women.

CONCLUSION

Syrian refugee women carry an increased risk for maternal mortality in Lebanon. Improving timely access and equitable provision of appropriate care should be a priority for the health system in Lebanon.

Cultural competence and experiences of maternity health care providers on care for migrant women: A qualitative meta-synthesis

BACKGROUND

The United Nations Sustainable Development Goals 2030 aim to reduce health care inequity and maternal and infant mortality rates amongst marginalized populations. To provide adequate and culturally relevant maternity care for minority ethnic groups, it is imperative to examine health care providers' views on care for migrant women. We reviewed published accounts of views and experiences of maternity health care providers providing maternity care for migrant women as a way of exploring their cultural competency.

METHOD

A qualitative meta-synthesis was conducted. Systematic searches were conducted in five electronic databases from inception dates through February 2021. Qualitative data were analyzed using a framework thematic analysis based on Campinha-Bacote's five-component cultural competency model.

FINDINGS

Eleven studies were included. Findings were presented according to Campinha-Bacote's model: cultural awareness, cultural knowledge (personal responsibility, familial role and cultural influence, the influence of social and system factors, conflicting maternity care expectations), cultural encounter (language and communication), and cultural desire (establishing trust and going the extra mile, resources to boost culturally competent care).

DISCUSSION

Our findings can inform the design of high-quality behavioral change, health care management, sociological, and other relevant studies, along with reviews of what matters to service users about cultural responsiveness. Our data also suggest that health system constraints can exacerbate the lack of cultural competency. Improving the quality of care for migrant communities will necessitate a joint effort between health care organizations, health care providers, policymakers, and researchers in developing and implementing more culturally relevant maternity care policies and management interventions.

Maternal health care for refugee women - A qualitative review

OBJECTIVE

The number of forced migrants increased worldwide, while pregnant refugee women are considered a vulnerable group, concerning their physical and mental health. How do maternal health care professionals manage their maternal health care? The aim is to review the current evidence regarding the interaction between migrant refugee women and professionals in maternal health care provision after resettlement and in high-income host countries.

DESIGN

We conducted a systematic qualitative review and searched the databases PubMed (MEDLINE); CINAHL; PSYNDEX, PsycINFO and Cochrane Library. Studies were judged for eligibility: a study had to address maternal health care provision for asylum seeking refugee (and migrant) women.

FINDINGS

16 primary studies were included. Heterogeneity of the included studies exists regarding e.g. origin of the women, reasons for migration and receiving country. Nevertheless, synthesis provides valuable information on challenges and chances within interactions in maternal health care for asylum seeking refugee (and migrant) women: Finding one's way in the unknown health care system is a barrier for women, which professionals meet by informing the women and coordinating their care. The perceived diversity of women may lead to conflicts in care. While some studies recommend "cultural recipes", others emphasize the individuality of women and prefer holistic care approaches.

KEY CONCLUSIONS

Maternal health care professionals face different barriers when providing maternal health care to refugee (and migrant) women such as communication barriers, coordinating care and handling women's diversity.

IMPLICATIONS FOR PRACTICE

Initiating and enhancing public health activities such as training courses for professionals that convey general principles such as woman-centered care or communication techniques are valuable opportunities to improve asylum seeking refugee (and migrant) women's maternal health care.

The childbirth experiences of Syrian refugee mothers living in Turkey: a qualitative study

Objective:The study aims to examine the childbirth experiences of Syrian refugee mothers living in Turkey.Methods: This qualitative study was conducted with 12 mothers who had a vaginal birth and were assisted by midwives. The data were collected using an in-depth interview form and analyzed with the thematic analysis technique.Results: The childbirth experiences of the mothers were grouped under two main headings as negative and positive experiences. "Negative childbirth experiences" were divided into 4 main themes as "negative emotions experienced during childbirth, lack of effective communication due to the language barrier, difficulties experienced related to hospital policies and dissatisfaction with midwives". "Positive birth experiences", were categorized under three main themes as "satisfaction with the midwife, finding the country safe to give birth, and mother' s positive attitude towards birth process". The mothers were satisfied with "the attitudes and behaviors of the midwives and their professional practices", and the positive attitude of mothers towards birth in religious and cultural terms contributed to the positive birth perception.Conclusion: Refugee mothers were found to have both positive and negative childbirth experiences. Individualized, empathic communication-based, culturally sensitive and evidence-based care may contribute to the positive childbirth experiences of refugee women.

Antenatal Care Utilization and Obstetric and Newborn Outcomes Among Pregnant Refugees Attending a Specialized Refugee Clinic

The objective of the study is to characterize the antenatal care utilization and obstetric and newborn outcomes among refugee women at a specialized refugee clinic and determine whether these outcomes varied between refugees (government-assisted or privately-sponsored) and asylum seekers. This retrospective cohort study included women receiving antenatal care at a specialized refugee clinic between 2011 and 2016. Time from arrival to first clinic visit, Adequacy of Prenatal Care Utilization Index, and obstetric and newborn outcomes were examined, stratified by refugee category. Amongst 179 women, median time from arrival to first clinic visit was longer for asylum seekers (2.8 months, IQR 12.9) compared to government-assisted and privately-sponsored refugees (0.4 months, IQR 0.7, and 1.6 months, IQR 3.2, respectively; p < 0.01). A larger proportion of asylum seeking women received inadequate antenatal care. No difference was found in obstetric and newborn outcomes. Differences in antenatal care utilization between refugee categories suggest that barriers may remain for asylum seekers; however, obstetric and newborn outcomes were comparable amongst refugee categories.

"It's a life you're playing with": A qualitative study on experiences of NHS maternity services among undocumented migrant women in England

BACKGROUND

Undocumented migrant women experience complex barriers to maternity services, are less likely to receive the recommended level of maternity care, and have poorer obstetric outcomes than non-migrant women. There are concerns increasing restrictions on entitlement to health services have a detrimental impact on access to services and obstetric outcomes, particularly among undocumented migrant women. The study aimed to investigate the experiences of undocumented migrant women who have been pregnant in England, and factors affecting access to care and health outcomes.

METHODS

We conducted in-depth semi-structured interviews June-December 2017 with a purposive sample of migrant women born outside the UK (aged>18) who had experiences of pregnancy and undocumented status (without permission to reside) in the UK, recruited through Doctors of the World (DOTW) UK. Interpreting services were used on request. Interviews were recorded, transcribed, and analysed using thematic analysis. Ethical approval: Imperial College London Research Ethics Committee (ICREC reference: 17IC3924).

RESULTS

Semi-structured interviews were conducted with 20 participants, 10 of whom had their first antenatal appointment after the national target of 13 weeks, and nine of whom reported complications. Themes defining women's experiences of pregnancy included: restricted agency, intersecting stressors, and an ongoing cycle of precarity, defined by legal status, social isolation, and economic status.

CONCLUSIONS

This study provides new evidence of women's experiences of pregnancy in the UK in the context of increasingly restrictive health policies including charging and data sharing. Six recommendations are made to ensure the UK and other migrant receiving countries work towards reducing inequalities and achieving national and global targets for maternal and child health and universal health coverage.

Exploring the State of Gender-Centered Health Research in the Context of Refugee Resettlement in Canada: A Scoping Review

Interdisciplinary health research that investigates gender as a relational process is necessary to facilitate a safe and healthy resettlement process for refugees in Canada. This scoping review explores the range, nature, and extent of published research examining gender in relation to refugee health during resettlement in Canada. An initial search of six databases yielded 7325 articles published before June 2019. A total of 34 articles published between 1988 and 2019 were included for in-depth review. Articles meeting inclusion criteria primarily focused on refugee women. Categories of focus included maternal health, social and emotional health, health impacts of sexual and gender-based violence and torture, access to health and social services, decision-making and health-seeking behavior, mental health, and sexual and reproductive health. Our thematic analysis identified connections between gender roles, expectations, ideals, and health through interactions and lived experiences within the family, community, and healthcare system. Review findings suggest that many refugee women are influenced by pervasive gender roles and expectations as well as exposed to gendered health systems and practices that may pose risks to health, particularly mental health and access to services. Further efforts should be made to understand processes and experiences of resilience and community building in countering negative impacts of gendered beliefs and practices on health during resettlement.

Barriers and facilitators of patient centered care for immigrant and refugee women: a scoping review

BACKGROUND

Migrants experience disparities in healthcare quality, in particular women migrants. Despite international calls to improve healthcare quality for migrants, little research has addressed this problem. Patient-centred care (PCC) is a proven approach for improving patient experiences and outcomes. This study reviewed published research on PCC for migrants.

METHODS

We conducted a scoping review by searching MEDLINE, CINAHL, SCOPUS, EMBASE and the Cochrane Library for English-language qualitative or quantitative studies published from 2010 to June 2019 for studies that assessed PCC for adult immigrants or refugees. We tabulated study characteristics and findings, and mapped findings to a 6-domain PCC framework.

RESULTS

We identified 581 unique studies, excluded 538 titles/abstracts, and included 16 of 43 full-text articles reviewed. Most (87.5%) studies were qualitative involving a median of 22 participants (range 10-60). Eight (50.0%) studies involved clinicians only, 6 (37.5%) patients only, and 2 (12.5%) both patients and clinicians. Studies pertained to migrants from 19 countries of origin. No studies evaluated strategies or interventions aimed at either migrants or clinicians to improve PCC. Eleven (68.8%) studies reported barriers of PCC at the patient (i.e. language), clinician (i.e. lack of training) and organization/system level (i.e. lack of interpreters). Ten (62.5%) studies reported facilitators, largely at the clinician level (i.e. establish rapport, take extra time to communicate). Five (31.3%) studies focused on women, thus we identified few barriers (i.e. clinicians dismissed their concerns) and facilitators (i.e. women clinicians) specific to PCC for migrant women. Mapping of facilitators to the PCC framework revealed that most pertained to 2 domains: fostering a healing relationship and exchanging information. Few facilitators mapped to the remaining 4 domains: address emotions/concerns, manage uncertainty, make decisions, and enable self-management.

CONCLUSIONS

While few studies were included, they revealed numerous barriers of PCC at the patient, clinician and organization/system level for immigrants and refugees from a wide range of countries of origin. The few facilitators identified pertained largely to 2 PCC domains, thereby identifying gaps in knowledge of how to achieve PCC in 4 domains, and an overall paucity of knowledge on how to achieve PCC for migrant women.

Pregnancy Related Health Care Needs in Refugees-A Current Three Center Experience in Europe

Background: Immigration into Europe has reached an all-time high. Provision of coordinated healthcare, especially to refugee women that are at increased risk for adverse pregnancy outcomes, is a challenge for receiving health care systems. Methods: We assessed pregnancy rates and associated primary healthcare needs in three refugee cohorts in Northern Germany during the current crisis. Results: Out of n = 2911 refugees, 18.0% were women of reproductive age, and 9.1% of these were pregnant. Pregnancy was associated with a significant, 3.7-fold increase in primary health care utilization. Language barrier and cultural customs impeded healthcare to some refugee pregnant women. The most common complaints were demand for pregnancy checkup without specific symptoms (48.6%), followed by abdominal pain or urinary tract infections (in 11.4% of cases each). In 4.2% of pregnancies, severe complications such as syphilis or suicide attempts occurred. Discussion: We present data on pregnancy rates and pregnancy associated medical need in three current refugee cohorts upon arrival in Germany. Healthcare providers should be particularly aware of the requirements of pregnant migrants and should adapt primary caretaking strategies accordingly.