The discussion that follows is organised into three sections following the objectives listed above, namely: identifying a conceptual framework; designing a methodological approach; and establishing an operational structure. Within each section we summarise the key observations from the preliminary studies undertaken, highlighting (i) insights gained from the comparative approach and (ii) challenges raised by exploring the issues cross-nationally.
Terms, categories and labels
We found instances of: the same term being used to mean different things both within and across the country settings; certain terms carrying pejorative connotations in one or more of the countries while being acceptable in the others; and certain terms being commonly used in one setting with no conceptual equivalent existing in the other two countries.
For instance, there was confusion over the terms 'migrant' and 'immigrant'. Researchers in Canada pointed out that whereas 'migrant' tends to carry the connotation of temporary or seasonal movement, 'immigrant', in their context, refers to someone who has moved to the country with the intention of settling permanently and 'landed immigrant' is the official term for someone who has been granted the right to live in Canada permanently. In Germany, the distinction between permanent and temporary migrants to the country is emphasised through the use of the terms
Gastarbeiter (guest worker) and
Ausländer (foreigner) or
Aussiedler (resettler), reflecting different legal statuses and entitlements. In contrast, the UK researchers felt that the terms 'migrant' and 'immigrant' were used fairly interchangeably -perhaps reflecting a less rigid categorisation of people entering the country and the possibility of those on fixed-term work permits deciding to settle permanently and gain citizenship. However, the UK researchers also alerted the team to the negative connotations that the term 'immigrant' can carry, and noted that though the term 'migrant' is sometimes used in public health and epidemiological work to encompass all those born outside the UK, neither 'migrant' nor 'immigrant' would tend to be used for the children or grandchildren of people who had migrated to Britain. Similarly, though the terms 'foreign born' and 'foreign origin' have been used in the UK, they have carried distasteful associations and are uncommon. In contrast, the German team noted that German scholars do not reject the term 'migrant' for the second generation, and cited Schönwälder [
18] who argues that the use of this term
(Einwanderer) is not perceived as othering or excluding in the German context. Nevertheless, some scholars have opted to use the phrase 'individuals with a migration background', in recognition of the problematic nature of the label 'migrant'.
Germany was unique in its use of specific terms to distinguish between migrants of German ethnic background, termed
Aussiedler (resettler) and migrants of ethnic background other than German, termed
Ausländer (foreigner). It was also noted that the latter are constructed in policy discourse and the popular media as much more problematic than the former. Despite no conceptual equivalent, research team members in both Canada and the UK did identify collective terms that served to distinguish 'types' of migrant or minority and which could be seen to contribute to the racialisation of particular groups. So, for instance, the term 'visible minority' is used in Canada and the collective 'Black and minority ethnic' or 'BME' is used in the UK, both of which place emphasis on skin colour, and by implication a degree of cultural distance from the majority White population, as well as group together people with very diverse backgrounds and circumstances. Contrary to the UK and Canada, the German team reported that the terms 'race' and 'ethnicity' are rarely used and the concept of ethnic minorities is uncommon in Germany [
18]. The German situation is, of course, similar to much of Europe where past abuses have given rise to strong concerns regarding the identification of ethnic identity in official data.
Differences were also evident in the standard practices and specific categories and labels employed by statutory authorities and researchers to identify and enumerate migrant or ethnic 'groups'. So, for instance, in Germany population registers exist and the Federal Institute for Statistics provides regular updates on the 'foreign population' by legal status and the population size by country of citizenship, while ethnicity and language are rarely monitored. In Canada and the UK, population level data on migrants/minorities come primarily from the censuses, though the concepts, questions and categories employed diverge importantly. Aspinall [
19] has noted the inclusion in Canadian state data collection of ethnic origin/ancestry (originally defined through the paternal ancestor) as well as 'population group'. Indeed, in the most recent Canadian census in 2006 a range of questions were included relating to migration and ethnicity (for 20% of people who received the long form), asking about 'ethnic or cultural origins of ancestors' as well as country of birth of both parents, citizenship, languages spoken and a question that categorises people into one of the following categories by simply asking 'Is this person...?': White, Chinese, South Asian, Black, Filipino, Latin American, Southeast Asian, Arab, West Asian, Korean, Japanese, Other-specify. In the UK, data on migrant status and ethnic group are collected at census, the latter since 1991, but not ancestral origins. In recent years, use of the 2001 Census ethnic categories has been required in statutory agencies including the health sector, and, though data are far from complete, it is common to find information on service use and outcome by ethnic group. Many large-scale national surveys also gather data on ethnic group. The 2001 census in England asked respondents, 'What is your ethnic group?' and provided five major response options each with sub-categories: White - (British; Irish; Other); Mixed - (White and Black Caribbean; White and Black African; White and Asian; Other); Asian or Asian-British - (Indian; Pakistani; Bangladeshi; Other); Black or Black British (Caribbean; African; Other); Other ethnic group - (Chinese; Other). Clearly, the ethnic categories in use in Canada and the UK differ greatly, with some categories carrying different meanings in the two contexts and some having saliency only in one setting. Furthermore, there has been change over time in both question wording and in response options in both countries.
It is beyond the scope of the current paper to describe comprehensively the diversity of terms and their meanings in use across the three countries. Instead, our objective here was to highlight how our cross-national comparative work vividly illustrated the way in which the concepts and terms relating to migrant/minority populations are neither natural nor neutral entities, but rather are the product and producer of particular forms of social relations. These observations highlighted the importance of: (i) clearly articulating our understandings of the key terms to be used in the research in ways that acknowledged their socio-historical foundations; and (ii) carefully considering the utility and limits of any ethnic or migrant categories employed - aspects that would not ordinarily come under scrutiny in single country work.
In addition, a more challenging issue was raised -
Is it possible or desirable to develop a set of concepts, terms and categories that are relevant across all three countries? This is a contentious issue. While some researchers advocate working towards standardized instruments and categories for use across diverse settings [
13,
15], others argue that processes of 'ethnogenesis' are so historically and geographically specific that such harmonization is impossible and unwise [
14]. This tension relates to the fundamental epistemological question of how comparative research should steer a course between identifying the similarities across, and the differences between, the settings under investigation [
20,
21]. Our preference was to follow the lead of researchers who have tried to adopt frameworks that encompass both national-level contextual specificity and universal patterns or trends [
16,
22]. We therefore adopted an approach that did not seek to impose standard concepts or measures (something we felt was neither conceptually nor operationally feasible) but rather to work with the national peculiarities of our three countries. This meant that our theoretical approach incorporated explicit attention to understanding
processes of identification and categorisation rather than working with fixed categories as taken-for-granted. At the same time, however, this approach did not preclude from our framework the consideration of over-arching processes that shape the maternity experiences and outcomes of migrant/minority women across the three settings. Such an approach seems particularly appropriate to research on migration, ethnicity and health for at least two reasons. First, there is a danger that the adoption of standardized terminology and simplistic comparisons of fixed migrant/minority categories risks the reification of concepts and essentialisation (whether in genetic or culturalist terms) of migrant/minority populations. Second, this area of work, perhaps more than any, demands that our theoretical frameworks reflect the 'social realities of the postmodern world' [14, p58]; realities in which international migration, ethnic diasporas and transnational identities are juxtaposed with the contextual specificities of particular settings. Our approach therefore sought to work both with and against the established discourses in the three countries to understand the social locations of migrant/minority groups and the implications for maternal health. Such an approach, we felt, offered the potential for important new insights. At the same time, it was recognized that moving beyond accepted concepts and terms may create problems at a country-level. We were conscious of the need to engage with local stakeholders and to generate research products that were meaningful and applicable to these actors; suggesting the importance of employing familiar concepts and terminology. Even the phrase 'migrant/minority women', which we adopted within the project as a shorthand for women who trace a significant part of their family heritage outside their country of residence, would require explanation at the country level. Clearly, the more creative and flexible approach, while potentially fruitful, would undoubtedly necessitate additional effort.
We also recognise that our proposed approach is by no means the norm in health focused research. Indeed, there are a growing number of quantitative 'variable' analyses that compare the health experiences and outcomes of groups of people similarly labelled and categorised across countries [
23‐
26]. While careful attention to the comparability of the outcome measures across national settings is a hallmark of these studies, we suggest that such work would benefit from similar scrutiny of the utility and meaning of the migrant/minority categories employed, particularly if the ambition is to move beyond simple description, to explanation of differences and/or prescriptions for policy and practice.
Understanding migrant/minority healthcare experiences and outcomes in wider socio-political context
The diversity of concepts and labels in use highlighted above indicated a need for the whole research team to have an appreciation of the historical and present-day patterns of immigration and the policy and societal discourses relating to migration and ethnicity across the three countries. Our preliminary work therefore included the preparation of briefing papers that described these aspects for each country and allowed comparison across the settings. The key issues identified across the three countries showed both similarities and divergence, as summarised below in Table
1:
Migration patterns
| Post WW2 arrival of displaced/forced migrants from eastern Europe, followed by large numbers of guest workers in 1950s-1970s, followed by asylum seekers and migrants from disintegrating socialist countries in 1990s. | Between 1950s and 1980s immigration predominantly from Europe (UK, Italy) and the US. From 1980s onwards, increasing numbers of arrivals from Asian countries. In the 1990s, immigration rates were at their highest and three quarters of new arrivals were 'visible minorities'. | Significant post WW2 immigration from ex-colonies in South Asia and the Caribbean as well as from Poland and Ukraine, fluctuating over time with changing immigration rules. Fluctuating numbers of asylum seekers since 1990s. Significant European migration since EU expansion, notably from Poland, but often temporary. |
Population diversity*
| A large and long-established population of migrant background (20% of total population). Numerically, people of Turkish citizenship are by far the largest migrant group. Migrants from non-European countries are gaining increased attention in recent years. | Around 20% of the total population was born outside Canada. The 'Chinese' are identified as the most populous 'visible minority' (25% of whom are Canadian-born). | Latest estimates show 16% of the population belongs to an ethnic group other than 'White British', and 11% were born outside UK. Largest enumerated ethnic groups are 'Indian' and 'Pakistani'. India is most common country of birth outside UK, followed by Poland. |
Policy orientation
| Reluctance to embrace an ethnically diverse identity at policy and societal level [ 27]. A history of firmly anti-immigration policy orientation. Citizenship based until 2000 on parental heritage rather than country of birth. Persistent resistance to dual citizenship [ 28]. Recent years, significant tensions and divergent political agendas [ 29]. | Immigrant ancestry and multiculturalism are hallmarks of Canadian identity [ 30, 31]. Successive governments across the political spectrum have encouraged immigration and high levels of naturalisation [ 32, 33]. Points based system for accepting migrants since 1967. More recent policy interpretations of multiculturalism emphasise the importance of attachment to Canada and active citizenship, as opposed to maintenance of cultural distinctiveness [ 28]. | Long recognised itself as an immigrant-receiving and multi-ethnic country [ 34, 35]. Self-perception of a strong legal and policy race relations framework. Critics argue that race equality legislation and policy conflict with that relating to immigration control, citizenship, cohesion, as well as foreign policy [ 36, 37]. Significant backlash against multiculturalism in past decade, though consistent policy concern with diversity and equality (despite limited evidence of progress towards a fairer society) [ 38]. |
Migrant/minority rights and welfare
| Persistent discriminatory treatment of migrants categorised as not ethnic German by state institutions as well as within housing and employment sectors [ 39]. Low rates of naturalization [ 28]. Poor socioeconomic indicators among most immigrant groups, particularly Turkish [ 28]. Some significant recent intervention to recognise and address needs of immigrants [ 40]. | Generally acknowledged success in accommodating diversity [ 28]. Extensive programmes and resources directed towards 'integration' initiatives [ 28]. But, veneer of tolerance and celebration of diversity masks structural barriers to economic and social wellbeing of non-European migrant groups who have higher levels of unemployment and lower income than other groups [ 31]. | Introduction of additional requirements for citizenship in 2000s. Relatively low naturalisation rates. Recently characterised as having a 'weak' integration policy [ 41]. Persistent socioeconomic disadvantage among migrant and minority groups, particularly those categorised as Bangladeshi and Pakistani [ 42]. Evidence of continued high levels of racial discrimination at institutional and inter-personal levels [ 28]. |
Societal discourses
| Public fears of threat to identity and economic welfare. Significant public suspicion of Muslims [ 43]. Mass media stereotyping and pathologising of migrants, particularly Muslims [ 44]. | Harsh criticism is levelled at government approaches to multiculturalism that are seen to ignore the hierarchies of power and opportunity that perpetuate poor welfare outcomes for racialised groups [ 45‐ 47]. Significant concerns about cohesion and Canadian identity expressed by some sections of the general public, particularly among Québécois, though broadly positive public opinion towards immigration [ 48]. Surveys suggest high levels of racial discrimination in society, particularly among some groups [ 49]; Racism is increasingly recognised as a critical issue by policy makers [ 50]. | Widespread public concern that immigration levels are too high posing threats to identity and economic opportunities [ 28]. Media contributing to misinformation and negative stereotyping of migrant/minority communities. Islamophobia a particular problem [ 51‐ 53]. |
In addition to identifying areas of divergence and commonality that would provide the backdrop for our subsequent investigations, the process of looking across the three national contexts served to highlight a number of more fundamental themes that deserved a greater focus within the conceptual framework for our study.
First, multiple strands of policy and legislation were seen to have relevance to the ways in which migrant/minority groups - their characteristics, needs and entitlements - are constructed and responded to by the state and other actors; strands which may conflict and undermine, or alternatively support and reinforce. It would therefore be important for us to look beyond the health sector to understand how wider state intervention shapes the healthcare experiences and outcomes of migrant/minority people, including how this varies across 'types' of migrant/minority as categorised by state institutions. Second, the language of policy discourse is frequently imprecise and open to multiple interpretations, so that how policy is forged in the practice of health organisations and professionals - what Lipsky has termed 'street level bureaucracy' [
54] - requires careful scrutiny. Our conceptual framework therefore needed to incorporate attention to these processes of policy interpretation and translation. Third, the significant inter-play between public opinion, the media and government action must be appreciated. Wider societal discourses, frequently (mis)informed and fuelled by the media, impact importantly upon the wellbeing of migrant/minority groups via: (i) the daily stress of living with a racialised identity (which often involves direct experience of discriminatory behaviour), (ii) the influence they have on government responses in the form of policy and services, and (iii) the attitudes and behaviours of health professionals who operate within this wider societal context. Our review work suggested that, even where there are very positive strands within government policy, migrant/minority experiences are frequently characterised by social and economic barriers to achieving wellbeing. These observations suggested that rather than adopting the tendency to classify our countries according to some explicit or implicit hierarchy related to how well they served the maternity needs of migrant/minority women, it would be more fruitful to explore the qualitative variation across the countries. Looking for what is positive and negative in the different settings and understanding why this is so might then enable us to synthesise elements of good practice and to translate lessons across contexts [
15].
The significance of migration histories and local factors
A more specific insight that emerged prominently during our cross-national comparative work was the particular significance of migration histories for both individuals and collectives. The migration experiences of particular immigrant groups at particular points in time are shaped by both historical antecedents and prevailing social and economic circumstances, with important implications for their subsequent entitlements and opportunities within the receiving country. For instance, Staniewicz [
55] highlighted the way in which the reluctant reception of Polish immigrants to the UK in recent years has contrasted sharply with their more positive post-war experiences. While a focus on migrant status and its implications for health experiences and outcomes has been quite prominent in past research in Germany and Canada [
56‐
58], this is less apparent in UK health research [
59]. Indeed, the cross-national comparative work alerted the UK research team to the evident gulf between health research that foregrounds migration (and which tends to focus on recent immigrants, refugees and asylum seekers) and that which foregrounds ethnicity (which tends to focus on established post-colonial communities) and the potential benefits of integrating these strands of work. Closely related to this insight, was the observation that there can be significant within-country variation in patterns of migration and the associated experiences of migrant groups, shaped by local economic, social and historical specificities, as well as the particular responses of local and regional state institutions and other actors. Again, the importance of considering diversity within the nation-state was immediately apparent to the researchers in Canada and Germany, where federal political systems result in very obvious policy divergence between regions. These observations encouraged the UK researchers to reflect on patterns and causes of internal diversity in migrant/minority identifications, experiences and outcomes, and how these might be considered within the research design. Furthermore, the comparative approach raises the more fundamental question of whether the nation-state is the most useful and meaningful unit of analysis [
15,
20]. A focus on migrant/minority groups suggests the importance of exploring flows and networks rather than constructing imaginary communities that are geographically bounded and stable. Nonetheless, there is clearly a need to recognise the nation-state as a meaningful policy and legal environment as well as to balance the demand for country-relevant research findings with broader knowledge that can contribute to our understanding of global issues.
Identifying meaningful research questions
There were significant differences across our three countries in terms of both the volume of existing research in the field of migrant/minority maternal health and the prevailing policy and practice context of maternity services. This presented challenges in terms of identifying a set of research questions which, if answered, would be meaningful for each of the country contexts, as well as provide opportunities for broader comparative analysis. We were aware of past criticisms that much comparative research fails to go beyond descriptive accounts of the individual countries included to produce deeper interpretations and genuine integration of scholarship [
15,
17,
20]. In addition, however, we were concerned that our findings should be pertinent to national policy-makers and practitioners, lending themselves to translational activities, rather than being of purely theoretical or academic interest.
Our cross-country preliminary work identified common issues facing migrant/minority women and maternity services across the three countries despite their divergence in social, policy and service constellation, including, among others: ineffective cross-language and cross-cultural communication; discrimination, stereotyping and insensitivity at provider and program levels; and a failure to recognize and respond to the complex issues within some migrant women's lives (such as trauma, isolation, mobility, poverty). Such transcending issues were therefore taken as the starting point to develop a broad set of research questions that had general applicability. At the same time, however, the contrasting knowledge bases and service contexts demanded that we also generate country-specific research questions to guide data generation and analysis.
In addition, the review of existing evidence across the settings forced the research team to reflect on (i) the nature, source and implications of biases in the existing data sources and evidence base, and (ii) our responsibilities as researchers to consider not just the rigour of the present study, but our contribution to the wider evidence base and the extent to which it serves the needs of all sections of the population.
Integrating data analysis and interpretation across the country settings
The approach to research design described above meant that we could ensure the viability and relevance of analyses in all three countries. It did, however, raise the issue of how to avoid the project developing into three parallel studies operating independently rather than an integrated whole yielding more than the sum of its parts. As discussed above, our conceptual work clearly indicated a comparative approach intended to generate insights that extended beyond the country-level contexts to more over-arching processes. The issue of how data should be integrated across divergent settings in cross-national work is widely acknowledged to be challenging [
20,
22], but there is little in the way of coherent guidance on how to go about this process in practice. As described above, we were faced with the possibility of generating data from highly divergent socio-political settings using different methodological tools. How then should we design and justify our comparative analytical method?
Here it was helpful to consider how existing models of (i) integrating data in mixed methods studies, and (ii) approaches to cross-national comparison within social science, might inform our approach. In relation to mixed methods work, Mason's [
62] notion of 'Constructing multi-dimensional explanations' is useful. In contrast to 'triangulation', where the aim of employing different methods is to achieve more accurate measurement and consequently a more valid representation of the phenomenon under investigation, the multi-dimensional approach views different data collection methods as offering alternative perspectives on the social phenomenon of interest. Taking this approach, the complexity, uncertainty and potential contradictions of our cross-national comparative data can be seen positively, offering the possibility of asking distinctive but inter-related questions about migrant/minority maternity experiences. The aim of such an approach would not be integration of the data into one coherent whole, but rather an understanding of the migrant/minority experience as multidimensional. Similarly, Wrede et al.'s [
16] notion of 'decentred comparative research', in which there is a conscious effort to ensure both reflexivity and local sensitivity in analysis is helpful. As discussed above, research into migration, ethnicity and health, we believe, demands an in-depth understanding of the socio-cultural, economic and political context. Both these orientations to data analysis and integration view the complexity and 'messiness' of the data generated through such a holistic approach as beneficial rather than problematic.
Nevertheless, a whole host of practical and procedural issues arise in terms of how an international team should actually work with the datasets generated to conduct analyses and generate findings. Furthermore, this type of integration is challenging both for the researchers who may struggle to extract meaning from large volumes of 'untamed' data and for research users for whom the nuance, complexity and uncertainty of resulting research products may be difficult to incorporate into decision-making.
Service user involvement and participatory research
The involvement of service users and members of the public in health research is a well-established element of research design in the UK. While not without critics (and consisting of a variety of approaches in practice), researchers are expected to adopt strategies that facilitate the involvement of users within the research process and these are commonly subject to scrutiny within research funding and ethical approval processes. User participation in health research is supported by large numbers of third sector organisations as well as a network of state-funded organisations - so-called LINks - set up to promote and support the involvement of local people in the commissioning of health and social care services, and the national-level body, INVOLVE, that has an explicit remit to promote the empowerment of the public to become involved in research [
70]. The importance of such involvement is particularly emphasised within the field of migration, ethnicity and health research, with many researchers and consumer organisations arguing that user participation is a fundamental principle of good research in this area [
71,
72]. In Canada too, there is widespread expectation of service user involvement in healthcare and a well-established research tradition of user involvement with state funding encouraging so-called 'collaborative or engaged scholarship' through the provision of grants for community-university partnerships [
73,
74]. As in the UK, such approaches have been used widely with community groups representing marginalised populations, particularly indigenous populations [
75].
As such, our Canadian and UK researchers had the advantage of well-established networks and past experience of engaging service users and community members in their research; a significant contrast to the German situation where such involvement is much less well developed and few structures exist to support inclusive or participatory research designs. These divergent research contexts were evident in the differential make-up of participants to the three in-country workshops held as part of the project. In the UK and Canada representatives of service user organisations as well as migrant/minority women who had recently experienced maternity services were recruited to the workshops and Project Advisory Groups relatively easily. However in Germany, the lack of pre-existing structures and short time frame made it difficult to identify migrant/minority women willing to engage with the study in this way and other strategies were adopted, including a series of individual interviews, to gain insights from these important stakeholders.
While the differential research contexts prompted debate and offered the potential for learning across the teams, it also added complexity. While the UK and Canadian work would be importantly shaped by the perspectives and priorities of migrant/minority women themselves, such engagement would be much less in Germany. There was no easy solution to this problem, but it did suggest the need for careful and ongoing reflection and documentation of the ways in which such user involvement shaped the generation, interpretation and presentation of data. Furthermore, it raised the question of whether and how migrant/minority service users participating in the UK and Canadian parts of the study should or could be involved in the generation of knowledge relating to Germany and the broader integration of data across the countries alongside members of the research team.
Clearly, the extent to which these aspects of operational structure are considered problematic relates fundamentally to one's epistemological and political stance. For those researchers who argue in favour of user involvement and diversity of research teams both in terms of (i) generating more authentic and useful findings, and (ii) the democratisation of the research process, a cross-national design that cannot ensure these elements, is cause for concern. Indeed, some researchers suggest we should be wary of research accounts that have not been adequately informed by the experiential knowledge of those who are the subject of the research [
76].