The results of this study provide valuable insights into perinatal healthcare services in Australia and how they affect the wellbeing of refugee women from African backgrounds. In particular, the results highlighted how system-level factors and a sense of autonomy throughout care, all affect wellbeing outcomes amongst refugee women from African backgrounds post-resettlement. These results corroborate many of the findings of past literature, whilst also adding novel contributions to the evidence base in the Australian context, and key recommendations for improved perinatal healthcare for this population.
Overview of findings in relation to previous literature
A key finding of this study was that perinatal healthcare system-level factors, particularly continuity of care, affected participants’ psychological wellbeing, an important finding with significant practice implications. Participants stated that how they were treated by medical staff was impactful, reflecting previous research [
26,
27]. Equally, negative care experiences have been reported to cause notably poor wellbeing outcomes including apprehension amongst patients to disclose their feelings, wishes and needs; thereby placing women in a position of vulnerability [
26].
Overall, continuity of care was perceived as best-practice perinatal care by both groups of participants. Previous research also notes the importance of continuity of care for relationship-building, detecting mental health and other issues such as family violence, improving wellbeing outcomes, increasing maternal health literacy, and providing reassurance for women in an unfamiliar healthcare system [
26,
28,
29]. However, few participants in this study experienced care continuity. Participants who previously gave birth in Australia also discussed at-home postpartum follow-up care as important for refugee women who may otherwise be isolated, reflecting recommendations from previous research among other populations [
29].
The need for improved culturally safe care [
30] was also strongly emphasized, and was seen in some examples provided by participants such as cases where women were able to engage in cultural practices such as bonding with babies for extended periods immediately after birth. On the other hand, participants described encounters with medical staff who had limited awareness of how culture shapes pregnancy-related experiences and preferences. This was perceived by some participants to fuel negative assumptions about them and their fitness to parent. Misinterpretations amongst healthcare practitioners in relation to culturally diverse childbirth beliefs are not uncommon [
31] and can lead to negative outcomes, including distress, as was experienced by participants in this study. Culturally unsafe care was seen particularly in relation to a lack of respect for participants’ privacy, including concerning culturally relevant topics such as FGM; also documented in other Australian and international studies [
16,
18,
21,
26]. Participants’ experiences of perinatal care which failed to be culturally safe contributed to a belief that they would receive disadvantaged care as a consequence of their cultural background; and indeed, previous Australian studies have shown that culturally diverse women were less likely than Australian born women to have their maternity and post-natal care needs met [
21,
32].
Importantly, discussions of culturally safe care also point to the need for trauma-informed practice. The tenets of trauma-informed practice as they are commonly understood—including ensuring patients’ safety, building trust and rapport, and empowering patients—are directly aligned with ensuring cultural safety more generally and thus working to embed trauma-informed practice in maternity care will enhance efforts at cultural safety, and vice versa. More generally, trauma-informed care can be seen to cut across all themes found in this study, including in relation to empowering women as equal decision-makers in their care and consideration of the ongoing impacts of perinatal care experiences. As such, trauma-informed practice is a key practice recommendation to stem from this study.
While some of the above suggestions could be applied to all culturally diverse women—particularly those from African backgrounds in the case of FGM especially—the findings of this study also pointed to the need for refugee-sensitive perinatal care which acknowledges the psychosocial challenges and implications of refugee status, including previous experiences of trauma. This supports other research [
29,
33] and indicates that it is crucial for perinatal practitioners to understand the particular needs of refugee background women. There are very few refugee-specific perinatal services in Australia. Such services could include the provision of psycho-social support from trained bi-cultural mental health staff, as well as peer support groups of women from African backgrounds who are all at similar pre- or post-natal stages and therefore may be experiencing similar challenges and requiring similar support [
21]. In these instances, facilitators or staff could be trained in the provision of culturally safe, trauma-informed care as discussed above, to ensure that refugee background women receive care that is targeted and helpful. Beyond refugee-specific services, refugee-sensitive care may also include elements that are easier to implement, such as training in issues that refugee women may have experienced to a greater degree than other women, such as the impact of sexual assault or FGM. In fact, the findings from this research project have fed directly into a partnership program between a key South Australian African Women’s organisation and a local hospital. This partnership seeks to bring together African women and hospital staff to facilitate such training and knowledge transfer. Notably, since some of the experiences identified in the research are not unique to refugee women, it is likely that such training will greatly benefit all women accessing perinatal services. Overall, greater knowledge and sensitivity amongst perinatal practitioners to ensure refugee-responsive care is essential for ensuring positive wellbeing outcomes in the perinatal period and beyond.
Another key finding from this study was participants’ wishes to be recognised as equal decision-makers with a degree of control. Some participants (many of whom had given birth previously) felt that they were provided with insufficient support, mirroring another Australian study with African-background women [
27]. Other participants felt that they were not treated as knowledgeable or autonomous in their perinatal care and were not listened to by hospital staff. For some women this may be especially important as pregnancy and childbirth can incite feelings of empowerment and control [
30]. There is a known relationship between feeling in control during the perinatal period and positive wellbeing outcomes; where validating women as experts and elevating their strength as mothers can also contribute to achieving positive postpartum health goals more generally [
34,
35]. However, many participants in this study felt powerless, which was contributed to by inadequate consent processes regarding involvement of student midwives in particular. Little research has investigated this specific issue, though some research has explored similar issues regarding medical students more generally [
36]. Overall, supporting women to feel valued and recognised as key decision-makers throughout their perinatal care is essential for promoting positive wellbeing outcomes, and for ensuring continued service use.
Finally, participants’ discussions of the long-lasting mental health impacts of perinatal healthcare experiences highlighted the significant implications for psychological wellbeing. Multiple participants were deeply negatively affected emotionally by their experiences of perinatal care, with feelings of regret and anger, and sometimes suicidal ideation. Suicide is a leading cause of maternal death in developed countries, making it essential that women receive quality perinatal healthcare [
37]. For many participants, the psychological turmoil following their perinatal care experiences instilled apprehension towards seeking support in future; a result also found by Mannaya, et al. [
4]. It is crucial that women are supported to seek perinatal care given the existing relationship between low service use and mental health challenges in pregnant women [
37]. In this study, participants described a community consensus that good quality perinatal healthcare was ‘lucky’ to find for African background women, likely reducing service engagement and fueling already pervasive health inequalities amongst refugees in the post-resettlement context [
26].
Study limitations and future research
While the study made an important contribution to knowledge in this area, it is not without its limitations. In particular, it is important to acknowledge the potential limitations of the coverage of experiences of participants involved in this research. Although every effort was made to include the refugee women experiencing the greatest vulnerability, some may not have had access or means to participate, meaning the participants may represent those with particular resources or interests. It is also worth noting that the later stages of recruitment and interviewing intersected with COVID-19 restrictions, creating challenges for recruitment (e.g. due to social distancing policies, fear, or lack of resources) and participation (e.g. the technical and rapport-building challenges of interviewing via telephone).
Additionally, the scope of this study – focusing specifically on the experiences of women with refugee status – addresses limitations of the current evidence base where those with refugee and migrant status are often combined under a singular definition. Exploring deeper insights into the perspectives of women of refugee backgrounds specifically offers recognition of the uniqueness of their experiences and contributes to specific recommendations for improving psychological wellbeing outcomes in the perinatal context. The findings of this study lay the foundations for future research, including deeper exploration of cultural differences amongst women from different African countries and cultures. Further research with participants of asylum seeker backgrounds would also be valuable, as those with asylum seeking status are generally less supported by healthcare systems in resettlement countries, and therefore may face additionally unique challenges in the perinatal healthcare context.
Finally, as noted in the methodology above, we reiterate that the composition of the research team disproportionately included non-migrant women and academics. We tried to account for this, and the associated power differentials, in the design, conduct, analysis, and reporting of this project, and it is worth noting that the project involved extension collaboration and co-authorship with women of African background who had refugee experiences. Nevertheless, these power differentials should be considered in relation to the research findings.
Conclusion and recommendations
With a dearth of literature on this topic and few refugee-focused perinatal services currently operating in Australia, nor comprehensive guidelines for best-practice perinatal care for refugee women, this study addresses a crucial literature gap regarding how experiences with mainstream perinatal healthcare services affects the wellbeing of African-background women with refugee backgrounds. In particular, change is required at the system level to promote the successful implementation of practice recommendations, highlighted by the findings in this study. Firstly, employment of a continuity of care model is recommended to ensure a high standard of individualised perinatal care, which also recognises the role of patients in informed decision-making. Secondly, it is crucial that practitioners are educated and competent in providing culturally- and refugee-competent perinatal care to patients that empowers women to be active agents in their care. Finally, Australian perinatal healthcare services must be equipped to provide refugee women from the African continent with tailored and trauma-informed support. This support must recognise the potential psychological impacts (and the extent of those impacts) of perinatal healthcare service experiences on women’s wellbeing. Providing optimal care to women from refugee backgrounds at this critical time of life is crucial for improving wellbeing outcomes for this group of women.