Background
Methods
Search strategy
Inclusion and exclusion criteria
Approach to analysis
Results and discussion
The countries and the included studies
Australia
Canada
Sweden
United Kingdom
USA
What do non-immigrant women want from their maternity care?
AUSTRALIA
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n=790, including 92 immigrant women from non-English speaking (NES) countries | ||
Postal survey, one week of births. | ||
Overall: 88% rated antenatal care as very good/good, 67% said care in labour and birth was managed as they liked. | ||
NES-immigrant women: 72% rated antenatal care as very good/good | ||
n=1336; including 142 immigrant women from non-English speaking (NES) countries. | ||
Postal survey, two weeks of births. | ||
Overall: 63% rated antenatal care as very good, 71% for care in labour and birth, and 52% for postnatal hospital care. | ||
NES-immigrant women: 45% rated antenatal care as very good, 42% for care in labour and birth, and 40% for postnatal hospital care | ||
n=1616; including 164 immigrant women from non-English speaking (NES) countries | ||
Postal survey, two weeks of births. | ||
Overall: 67% rated antenatal care as very good, 72% for care in labour and birth, and 51% for postnatal hospital care. | ||
NES-immigrant women: 49% rated antenatal care as very good, 55% for care in labour and birth, and 40% for postnatal hospital care | ||
Overall findings about what women want: all three surveys
|
Key findings for immigrant women: all three surveys
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Conclusions and key recommendations: all three surveys
|
Adequate information and explanations, concerns addressed | Immigrant women were under-represented in all three surveys, nevertheless: | Access to information, good relationships with caregivers and involvement in decision making were critical to enhancing women’s positive ratings of their care |
Active say in decisions about care | ||
Caregivers being helpful, not rushed, sensitive, kind and understanding | What immigrant women wanted was very similar to the overall findings, including: good explanations, an active say in decisions, helpful, kind caregivers and support with infant care after birth | Recommendations include: |
Knowing caregivers (eg knowing midwife before labour, birth centres, own doctor; knowing midwives on postnatal ward) | Women born overseas in non-English speaking countries were less positive about their maternity care than women born in Australia or than women born overseas in English speaking countries | Greater focus on continuity of care provision, improving staff communication and listening skills and more woman-centred, individualised care |
Receiving helpful, consistent and supportive advice about infant feeding and care | ||
CANADA
| ||
n=6421; including 470 recent immigrants. | ||
Computer Assisted Telephone Interviews (CATIs) in French, English and 13 community languages. Sample drawn from Canadian Census. | ||
Overall: 54% rated their overall experience of labour and birth as “very positive”; | ||
79% felt they were shown respect; and 73% were happy with their participation in decision-making. | ||
Overall findings about what women want
|
Key findings for immigrant women
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Conclusions and key recommendations
|
Little data about factors contributing to satisfaction with care and what women wanted and valued. | Despite interviews conducted in English, French and 13 community languages, women reporting a first language other than English or French, were under-represented. | Recommendations not specifically focused on potential improvements to care based on women’s experiences. Rather recommendations focused on the need for more education for caregivers and women about evidence-based care practices (eg need to reduce the extent of routine use of electronic fetal monitoring and episiotomy, and supine position for birth). |
Women with a midwife as the primary birth attendant and those with no interventions in labour were more satisfied with care. | 17% of recent immigrant women reported not receiving care in a language they could understand. | |
Half the women thought having the same care provider for pregnancy, labour and birth was important. | No differences reported between groups (i.e., recent immigrants, non-recent immigrants, and Canadian-born women) in their satisfaction with the compassion, competence, privacy, or respect demonstrated by their health care provider or their own involvement in decision-making during the entire pregnancy, labour and birth, and immediate postpartum period [9]. | For immigrant women, recommendations focused on the need for education about improving health behaviors such as pre-conception use of folic acid, screening for postpartum depression, improving access to health care providers in the postpartum period, and removing language barriers to seeking care. |
SWEDEN
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n=2746; 266 immigrant women | ||
Postal survey | ||
Overall: 53% very positive about intrapartum care and 35% about postpartum care | ||
Overall findings about what women want
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Key findings for immigrant women
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Conclusions and key recommendations
|
Caregivers who provide adequate support and information, with enough time to answer questions and give help; and who are friendly, non-judgemental and respectful | Non-Swedish speaking women were excluded, nevertheless: women born outside Sweden were somewhat less happy with their care than Swedish-born women: | Authors recommend midwives support patients in a professional and caring manner, asking women about their needs for information and offering individualised care. |
Continuity of care: small numbers of care providers preferred Attention paid to partners’ needs | Acknowledgement that non-Swedish speaking women were excluded, thus those foreign-born women recruited were likely to be more integrated into Swedish society. | |
Pre-birth visits to labour ward | ||
UNITED KINGDOM
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First class delivery: A national survey of women’s views of maternity care 1995[16] | ||
n=2406; numbers of immigrant women not reported | ||
Postal survey | ||
n=2966; 229 black and ethnic minority women born outside UK | ||
Postal survey | ||
Overall: 48% very satisfied with antenatal care; 56% with care for labor and birth; and 39% with postnatal care | ||
Towards Better Births: a survey of recent mothers 2007[18] | ||
n=26,325; numbers of immigrant women not reported | ||
Postal survey, sample drawn from NHS Trusts in England | ||
Overall: 68% rated antenatal care as excellent or very good; 75% for care in labor and birth; and 69% for postnatal care | ||
Delivered with care: a national survey of women’s experiences of maternity care 2012[19] | ||
n=5,333; 1,152 immigrant women | ||
Postal or online survey:4,945 postal respondents; 407 online respondents | ||
Overall: 88% very satisfied or satisfied with antenatal care; 87% with care for labor and birth; 76% with postnatal care | ||
Overall findings about what women want: all four surveys
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Key findings for immigrant women: two surveys
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Conclusions and key recommendations: all four surveys
|
Being treated as an individual, with personalised care | Analyses for women born outside the UK are only available for the 2006 and 2010 surveys, for black and minority ethnic (BME) groups: | Recommendations focused on the need for: |
Caregivers who are supportive, kind, sensitive, and not rushed | Individualised care for a diverse childbearing population | |
Care from a small number of staff; knowing the midwives involved in care | Women in these groups were - | Women to be given more choice about place of birth and care provider |
Feeling involved in decisions about care and having choices about care options | Less likely to feel spoken to with respect and understanding, and in a way they could understand | More information and opportunity for discussion about care and more involvement for women in decision-making. |
Not being left alone in labour | Less likely to feel they had options in care or adequate information | |
Being listened to, and spoken to in a way that is understandable | Less likely to describe care providers positively (eg as kind, informative, supportive, sensitive, considerate) | |
Being given information and explanations when needed | Less likely to be satisfied with care | |
USA
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n=1583 (1447 online surveys; 136 telephone interviews); numbers of immigrant women not reported | ||
Overall: For labour and birth, 85-90% reported doctors/midwives and nurses as supportive, understanding and informative, BUT 25% found doctors/midwives rushed and >25% gave less than the highest rating for: information given in a way they could understand; | ||
n=1573 (1373 online surveys; 200 telephone interviews); numbers of immigrant women not reported | ||
Care for labour and birth from doctors rated as ‘excellent’ by 71% of women; from midwives and nursing staff by 68% | ||
35% rated the maternity care system as ‘excellent’; 47% as ‘good’; 16% as ‘fair’ or ‘poor’ | ||
‘Listening to Mothers III’: Third national US survey of women’s childbearing experiences[24] | ||
n=2400; 167 immigrant women | ||
Online survey | ||
Overall: 80% of women reported their care providers to be ‘completely’ or ‘very trustworthy’ in relation to information about pregnancy and birth | ||
30% of women said they didn’t ask a question at least once because their care provider seemed rushed | ||
15% reported that their care provider had used words they did not understand ‘always’ or ‘usually’ | ||
36% rated the maternity care system as ‘excellent’; 47% as ‘good’; 17% as ‘fair’ or ‘poor’ | ||
Overall findings about what women want: all three surveys
|
Key findings for immigrant women
|
Conclusions and key recommendations: all three surveys
|
Being treated with kindness and understanding | No findings have been reported in any of the surveys to date specifically comparing immigrant and non-immigrant women | Key recommendations for care improvements include: |
Supportive, unrushed care | Better access for women to effective, safe and appropriate maternity care | |
Feeling comfortable to ask questions | Improved education of women about their rights to truly informed choice, with full and clear explanations about all aspects of care | |
Receiving information they needed | Active involvement of women in decision-making | |
Full and clear explanations understanding what was done and why | ||
Involvement in decision-making about care | ||
Non–discriminatory care | ||
Intervention (only) when needed |
Pregnancy care
Intrapartum care
Postpartum care
Summary of what non-immigrant women want
What do immigrant women want from their maternity care?
Findings in the population-based studies
Findings in the studies specific to immigrant women
Country and study | Problems with care as reported by immigrant women | Key findings about what immigrant women want | Author conclusions and key recommendations |
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AUSTRALIA
| |||
Inadequate information about care | Attention to individual needs | Thai women have diverse needs, perceptions and experiences. Women did not receive adequate information about care. An environment needs to be created that acknowledges diversity and meets the needs of individual women. | |
1998, 1999
| Difficulties communicating, though some believed care was better in Australia than in Thailand | Support and kindness | |
30 Thai women | |||
In-depth interviews about antenatal, intrapartum and postnatal care | Women felt they were unable to follow traditional customs in hospital. | ||
Communication difficulties | Respectful, understanding caregivers | Vietnamese, Turkish and Filipino women reported similar wants and needs from maternity care as Australian-born women in the companion Survey of Recent Mothers 1994, however these three groups of immigrant women were less likely to experience care that met their needs. | |
1998(2), 1999, 2002
| |||
Being left alone in labour | Attention to individual needs, not cultural stereotypes | Recommendations included: more attention to the quality of care immigrant women receive and particularly to strategies for overcoming language barriers to effective communication; and better information provision. | |
Mothers in a New Country’ (MINC) study
| Not feeling welcomed when came to hospital in labour | ||
107 Vietnamese women | Experience of discrimination by some staff | Active say in decisions about care | |
108 Turkish women | Not enough support about own and infant care postnatally | Information and explanations from staff | |
104 Filipino women | Rushed caregivers | Supportive care | |
Semi-structured interviews about antenatal, intrapartum and postnatal care | Long waits at antenatal appointments | Recognition of the need to rest and recover post-birth | |
Staff experienced sometimes as unkind or rude and care experienced as culturally stereotyped | |||
Communication difficulties | Caregivers who show warmth and humanity, and are caring and supportive | Suggestions for care improvement included provision of sufficient information and culturally sensitive services. Health care providers need to attend to individual preferences and circumstances and avoid discrimination. | |
2002
| |||
15 Muslim women from Lebanon, Turkey, Jordan, Egypt, Kuwait, Malaysia, Singapore, Morocco and Pakistan | Perceived stereotyping by caregivers | Female caregivers wherever possible | |
In-depth interviews about prenatal testing and antenatal care | Lack of familiarity with services | Good information and explanations, especially about how care is provided and available services | |
Problems with male caregivers | Caregivers sensitive to cultural differences, but able to provide care that responds to individual (not stereotyped) needs | ||
Care experienced as discriminatory | |||
Difficulties communicating with caregivers | Choice about care options | Authors recommended focus on improvement of service delivery and equity; improving access to interpreter services and bilingual staff; and integrating the biomedical model for maternity services with health beliefs of the diverse cultures. | |
2001
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160 Vietnamese women Focus group discussions, in-depth interviews and survey about care among Vietnamese women who opted for early discharge | Women reported feeling anxious and being fearful when approaching staff for assistance and experiencing discriminition | Adequate advice about self care | |
Disempowerment in culturally unfamiliar hospital surroundings. | Involvement in making decisions about care | ||
Supportive caregivers, with enough time to discuss concerns | |||
Adequate support and advice about baby care | |||
Communication difficulties | Adequate information about options for care | Improving communication and access to information identified as essential to ensure women understand all the options available to them. | |
2002 and 2006
| |||
67 Cambodian, Lao and Vietnamese women with experience of childbirth in Australia | Lack of familiarity with care options | Good communication and involvement in decision-making | |
In-depth interviews about prenatal testing, and experiences of caesarean birth | Women of ethnic minorities do not have the same access to information and do not understand the implications of services offered to them. | Appropriate help with communication via interpreters and/or support people | |
Chu[37] | Language difficulties | Caregivers who are friendly and understanding | Authors recommend a focus on empowerment for women and cooperation with community organisations, and service providers to improve cross-cultural communication. |
2005
| Long waiting times | ||
30 women from Hong Kong, Taiwan and China about childbirth beliefs and care experiences | Insufficient information and advice | Quality in service provision: shorter waiting times | |
Semi-structured interviews | Bilingual staff and/or interpreters | ||
Supportive after birth care so mother can rest; helpful advice about infant care | |||
Adequate information about care options | |||
Despite care often being seen as better than in Afghanistan, problems identified included: | Unrushed care | Recommendations for care that is more consistently supportive, respectful and caring; strategies to reduce waiting times for antenatal visits, sufficient time for women to ask questions and receive adequate information and explanations, particularly when unfamiliar with how care is provided and when in need of assistance with communication. | |
2012
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Time and encouragement to ask questions | |||
40 Afghan women | Long waiting times for antenatal care, rushed staff | Kindness and respect | |
Structured telephone interviews about maternity care received when giving birth, with follow-up in-depth face-to-face interviews with 10 women | Problems with communication, lack of interpreting support | ||
Insufficient time for adequate information and explanations | Preference for female caregivers | ||
At times, unkind, rude staff | |||
For some, having male caregivers | |||
Problems with hospital food (non-Halal) | |||
Communication difficulties due to lack of English | Supportive care | Authors noted the important role of family and community as in supporting migrant women through their maternity care. Better provision of interpreter services recommended; better social support for women; and reducing cultural barriers through cross-cultural training for health care providers to improve maternity services. | |
2009
| Insufficient information offered in other languages | Information and explanations | |
10 women from Asia (Vietnam, China, Japan, Korea, Philippines) living in rural Tasmania | Reluctance to express preferences, and make wishes known | Acknowledgment of need for rest and care of mother post-birth | |
Semi-structured interviews about care experiences | |||
CANADA
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Chalmers & Hashi[40] | Insensitivity of staff to women’s experiences of pain in labour | Involvement in decision-making | Authors highlight need to enhance awareness of cross-cultural practices; address women’s perceptions and needs; use fewer interventions; and provide more respectful treatment. Need also to educate caregivers about traditional female genital cutting. |
2000
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432 Somali women Structured interviews about experiences of maternity care in Canada in the context of female circumcision | Inappropriate responses to traditional female circumcision (surprise, disgust) | Respectful and sensitive care | |
Felt concerns not listened to | |||
Language difficulties | Family-centred care | Changes in care needed to ensure culturally safe care for immigrant Punjabi women. | |
2008
| Lack of familiarity with services and care | Acknowledgement of individual differences in beliefs and preferences | |
15 women from Punjab, India In-depth interviews about their perinatal experiences in Canada | Preferences and concerns not acknowledged | Good information about how care is provided and childbirth classes | |
Support for maternal rest after birth | |||
Reitmanova & Gustafson[42] | Inadequate support and inattentive care in labour and postpartum | Adequate information, especially about pain and labour management in labour | Mainstream information and practices designed for Canadian-born women lacks flexibility to meet the needs of immigrant Muslim women. Recommendations included cultural and linguistically appropriate maternity and health information and establishing partnerships with immigrant communities. |
2008
| |||
Not enough respect for rest and privacy after birth | |||
In-depth semi-structured interviews with 6 Muslim women from five countries (not specified) about their experiences of care | Experience of discrimination | Care sensitive to individual needs and beliefs | |
Insensitivity and lack of knowledge on the part of staff about their cultural/religious practices | Appropriate language support and information in community languages | ||
Language barriers | Multilingual staff and information/education in community languages, especially about available services and care | Recommendations of authors include the need for multilingual staff and provision of educational materials in a variety of formats. | |
2009
| |||
Unfamiliarity with care provided | Supportive care and adequate help with infant care | ||
Structured interviews with 30 south Asian and 30 Canadian-born women about maternity care and perceived barriers | Lack of explanations for tests and procedures | Women caregivers | |
Lack of assistance with baby care after birth | |||
SWEDEN
| |||
Lack of knowledge among staff for handling traditional female circumcision | Good monitoring of health of mother and checks during pregnancy, and of infant after birth | Authors conclude that health providers need to improve their knowledge about female circumcision and also provide culturally sensitive perinatal surveillance in order to address women’s concerns and any cultural misconceptions about pregnancy and birth. | |
2000
| |||
15 Somali women | Not enough emotional support | Kind, attentive care; sensitivity to individual needs, especially care for female circumcision | |
In-depth interviews about childbirth and experiences of care in Sweden | Fear of caesarean section | ||
Although pleased with high standard of clinical care, made to feel ashamed of their traditional female circumcision by some staff | Sensitive and understanding care | Authors recommend culturally adjusted care and providing systematic education about female circumcision. | |
2006
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21 women from Somalia, Eritrea and Sudan | Requests not dealt with sensitively | Good communication | |
Exploratory interviews about maternity care in the context of traditional female circumcision | Language difficulties | Attention to individual needs | |
Felt unable to follow certain cultural beliefs/traditions | |||
UNITED KINGDOM
| |||
Communication difficulties | Sensitive, respectful care attentive to individual needs and concerns | Authors discuss issues and implications of differences between women and services in what is considered ‘normal’ maternal behaviour and the need to improve the quality of care to immigrant women, especially to attend to individual and cultural diversity. | |
1990
| |||
Long waiting times | Careful monitoring of health of mother, and fetus/infant | ||
32 women, 19 of whom were immigrants (countries not specified: India, Pakistan and Bangladesh??). | Staff rushed, no time for discussion | Good explanations and information about care and tests; careful physical checks | |
Women spoke Hindi, Punjabi and Urdu and/or English Semi-structured interviews | Lack of support from staff, especially postnatally when women most of all wanted to rest | Good support for rest and care of infant in hospital after birth | |
McCourt & Pierce[48] | Communication/language difficulties | Good communication and information about options for care | Authors note that minority ethnic women in fact shared similar values and had expectations of services similar to the wider population, but that conventional services did not provide minority ethnic women with high quality of maternity care. The authors suggest this is related to the institutional organisation of care which needs to become more focused on addressing all women’s individual needs. |
2000
| |||
Inadequate information about care options | Friendly, kind staff | ||
20 ‘minority ethnic’ women interviewed, including 6 Somali women about experiences with maternity care (half caseload and half standard care) | Staff rude or off-hand (standard care) | Good access to interpreting services when needed | |
Qualitative interviews | Concerns not listened to | Attention to individual concerns | |
Not enough support for rest after birth | Primary care provider who gets to know each woman and her needs | ||
Acknowledgement of need for rest and support after birth | |||
Davies & Bath[49] | Poor communication with staff | Good care and adequate information about options for care | Key underlying problem considered to be poor communication between non-English speaking Somali women and health workers. This needs to be addressed with better use of interpreters and more individualised care. |
2001
| Limited use of interpreters | ||
13 Somali women: | Prejudiced attitudes of staff | Attention to specific individual needs | |
Focus group and structured interviews about ‘maternity information concerns’. | Lack of information | Supportive care and rest after birth | |
Harper Bulman & McCourt[50] | Poor communication and inadequate provision of interpreting services led to needs not being met | Kind and attentive staff | Need for better integrated and more appropriately used interpreting services that enable greater continuity for women. Advocacy or link-worker schemes may also be appropriate. |
2002
| |||
12 Somali women: | Not enough information and discussions about important topics, such as managing pain | Better interpreting services | |
Six Individual in-depth interviews and two focus groups | Stereotyping and racism from staff | Staff who understand when interpreters are needed | |
Lack of understanding of cultural differences | |||
Language difficulties (but assisted when interpreters available) | Good use of interpreters to assist communication and provision of information | Considerations need to be made for social and economic circumstances of migrant families. | |
2005
| |||
Reduced care options when English lacking | |||
9 Bangladeshi women (8 immigrants) | |||
Semi-structured interviews about childbirth experiences and needs | |||
USA
| |||
Experiences of discrimination in interactions with nurses believed to be due to skin colour and/or lack of English | Supportive, non-discriminatory care with a known care provider | Need culturally appropriate health education materials on labour and delivery for the Somali refugee community. Health care teams need to receive training on Somali culture, traditions and values and Somali women’s expectations. | |
2004
| |||
14 Somali women | Inadequate information about pain relief and side effects | Full explanations | |
Two focus groups with 20-item interview guide, facilitated by Somali-speaking group moderator | Poor explanations (eg for caesarean birth, which women feared) | Hospital tour with language support | |
Communication problems and concern about the competence of interpreters. | Education for partners to familiarise them with women’s needs for pregnancy and birth | ||
Information about services in accessible language & format (eg videos) | |||
Jambunathan and Stewart[53] | Communication problems with health care providers | Preference for minimal intervention in pregnancy and birth | Health care providers need to better understand Hmong women, eg when touching and communicating with women and informing them about hospitalisation and medical procedures. |
1995
| |||
Miscarriage feared if touched by doctors and nurses which resulted in delayed prenatal visits | Understanding from care providers about women’s own experiences and concerns | ||
52 Hmong women | |||
Semi-structured interviews conducted 4-6 months after birth | Wary about interventions and procedures for labour and birth | ||
Lazarus and Phillipson[54] | Long clinic waits | Reduced waiting times | Few differences reported: Puerto Rican and ‘white’ women wanted the same things from care. |
1990
| Insufficient time at appointments | More time at appointments | |
27 Puerto Rican women (17 immigrant, 10 born in the US) and 26 indigent ‘white’ women; and 150 observations of clinical interactions | Poor communication and explanations | Known care providers | |
Many different physicians for prenatal care: contradictory advice, lack of familiarity with woman’s concerns and circumstances | Sound information and explanations that can be understood | ||
Qualitative interviews about prenatal care conducted prospectively from early pregnancy, combined with anthropological observations of prenatal care interactions | Better communication about care (not just because of language problems) | ||
Shaffer[55] | Problems with communication due to language barriers | Being able to communicate with health care providers in own language | Authors recommend culturally appropriate health care to meet Hispanic migrant women’s needs. |
2002
| |||
46 Hispanic migrant women Qualitative interviews during pregnancy exploring factors influencing access to prenatal care | Culturally appropriate health care |