Immigrant women’s experiences of maternity-care services in Canada: a systematic review using a narrative synthesis

Theory development did not play a large role in this synthesis, because we aimed to explore the experiences of immigrant women rather than to implement any intervention with measurable endpoints and outcome measures. However, a preliminary framework of the maternity-care experiences and outcomes of immigrant women was used to interpret and understand our synthesis. Developing this framework was an iterative process involving multiple revisions as we worked through elements 2–4.

The preliminary synthesis provided an initial description and a map of the results of all the included research studies. This initial synthesis was further evaluated by the entire team to identify contextual and methodological factors that may have influenced the published results. Interrogation of the preliminary synthesis facilitated the construction of explanations as to how and why maternity services may have been implemented or may have affected immigrant women of childbearing age in a particular manner. We carefully organised the results, compared these results with other literature and noted the preliminary patterns that emerged regarding both the women’s experiences of maternity services and the development and implementation of health services and healthcare interventions. The results were then documented in the form of textual descriptions that included descriptive paragraphs under the subject headings of ‘Setting,’ ‘Participants,’ ‘Aim,’ ‘Sampling and recruitment,’ ‘Method,’ ‘Analysis,’ ‘Results’ and ‘Thick’ or ‘Thin’ study.

The assessment of publications as ‘thick’ or ‘thin’ as described by Roen et al. [50] had been previously been adapted by our team. This assessment method, which itself drew on the work of Denzin et al. [51], may be applied to both quantitative and qualitative narrative findings because the emphasis is on textual analysis of the narrative findings. We suggest that ‘thick’ papers (a) offer greater explanatory insights into the outcome of interest; (b) provide a clear account of the process by which the findings were produced—including the sample, its selection and its size, with any limitations or bias noted—along with clear methods of analysis and adjustments for confounding in statistical studies; and (c) present a developed and plausible interpretation of the analysis based on the data presented. In contrast, thin papers (a) offer only limited insights; (b) lack a clear account of the process by which the findings were produced; and (c) present an underdeveloped and weak interpretation of the analysis based on the data presented. Table 1 contains textual descriptions of the selected articles.

Patterns emerging from the textual descriptions and cross-literature comparisons allowed us to identify the factors that affect maternity interventions and the implementation of maternity services. These factors were synthesised into five main themes regarding barriers and enablers that shape maternity services for immigrant women (described in the ‘Conceptual or thematic analysis’ section below). Throughout the synthesis process, careful attention was paid to the heterogeneity of research methods, methodological approaches and population characteristics encompassed in the literature.

In addition to tabulation, the findings were grouped and clustered using ATLAS.ti data analysis (see Figures 1 and 2) software (ATLAS.ti Scientific Software Development GmbH, Berlin, Germany) .The lead author has expertise in this software and consults as a trainer through an affiliation with the North American ATLAS.ti Training Center. Publications were uploaded as PDF files (Adobe Systems Inc., San Jose, CA, USA) and coded in accordance with the summary data requirements. The review team collectively decided on data variables (for example, study design and sample population), bearing in mind the categories that would be most informative for textual descriptions within the narrative synthesis. One reviewer extracted the data, and then one or more team members reviewed the data for accuracy and completeness. The publications selected for the non-empirical literature review were generally not research studies; hence, narrative descriptions of the key messages of those publications were constructed. Additional file 2 contains further information regarding data extraction.

As mentioned earlier, the research studies appraised using the Joanna Briggs Institute [45], Critical Skills Appraisal Programme [46] and Crombie tools for survey [47]. We used a previously established weighting system—high, medium and low [48]. The quantitative studies were largely appraised as medium as high whereas the qualitative studies were largely medium and low quality in our appraisals. In team meetings, we discussed and documented potential sources of bias within the synthesis process, resolved discrepancies and built a consensus regarding the robustness of the synthesis. Our review of non-empirical literature provided additional understanding of the experiences that immigrant women have had with maternity-care services in Canada. This literature review was essential in part because some non-empirical reports (such as correspondence pieces published in peer-reviewed journals) can highlight unique aspects of the topic that are not empirically studied. In addition, some audiences (such as policymakers and foundations) use grey literature as a primary source of their information [43]. The literature review also identified concepts or themes reflecting the barriers and enablers that shape maternity services for immigrant women. Quantitative papers mainly addressed the issues and assessment of adequate or inadequate utilisation of perinatal care; satisfaction of prenatal care provided to the immigrant women; valuation of prenatal classes; assessment of postpartum depression Edinburgh Postnatal Depression Scale (EPDS) and breastfeeding and childcare issues. Qualitative papers largely described immigrant women’s experiences and concerns about their maternity care that includes education classes, breastfeeding difficulties, depressive symptoms, social isolation and lack of adequate support from the care services. The detailed description is narrated in the next section.

Research studies included in this systematic review generally reported that immigrant women were far less likely to have knowledge about or attend prenatal classes. Research findings from eight quantitative studies [52‐59] and three qualitative studies [18, 24, 60] suggested that pregnant immigrant women receive less adequate perinatal care than pregnant non-immigrant women [24, 54‐60]. Several studies reported that the two groups had similar rates and timings of seeking prenatal care by physicians, but found that immigrant women were far less likely to have knowledge about or attend prenatal classes [56, 57, 60]. A survey of South Asian immigrants in Calgary showed that 53% of respondents were unaware of prenatal classes [52]. Another study in same city but with a diverse sample reported high awareness (75%) of prenatal classes (but unknown utilisation levels) [59]. Several studies reported that the reasons for not attending prenatal classes were lack of transportation, language barriers [18, 57, 59] and negative perceptions about the type of information provided [18, 55]. Nonetheless, some immigrant women believed that prenatal classes and prenatal care were helpful because they had been fearful of the childbirth experience, particularly in the absence of any other support at home. In general, the studies recommended that prenatal education and classes should be offered in the language of the immigrants, with particular attention being given to the cultural and ethnic context [52, 54, 60]. The classes should also be offered in convenient locations and address topics of importance to the immigrant population [59].

Only a few studies reported on the breastfeeding information that immigrant women received from hospital staff [24, 54, 61]. Two studies showed that a lack of knowledge and information was a major barrier that prevented immigrant mothers from initiating breastfeeding [18, 61]. Some immigrant women reported that they were unable to start breastfeeding because they lacked peer support and knowledge about how to handle their babies [62]. Other immigrant women believed in the benefits and convenience of breastfeeding and had peer support to facilitate its use [24]. Data available from a Canadian census showed that more immigrant women than Canadian women received help to start breastfeeding in the hospital [55]. In another study, immigrant mothers reported being satisfied with the support for breastfeeding, but more immigrant mothers had their babies receive supplemental water or formula, received formula samples upon discharge and had staff show them how to express milk if needed [56]. However, studies have reported the intense level of difficulties faced by immigrant women after discharge without documentation of resolution of these issues [63]. It was also documented that recent immigrant women in Quebec were 2.2 times more likely to breastfeed [35]. These studies suggest that providing culturally relevant explanations about breastfeeding and other prenatal preparations are important and should be included in programs for pregnant immigrant women in Canada.

Although some immigrant mothers reported satisfaction with the adequacy of perinatal care they received, satisfaction was not consistent across the country. For clarity, we have subdivided this theme into three categories: (a) prenatal care [18, 24, 52, 54, 59, 60, 64]; (b) delivery and in-hospital care [18, 24, 52‐57, 63, 65‐67]; and (c) postpartum care [18, 24, 29, 30, 35, 55‐57, 60‐64, 68‐71].

Some immigrant mothers reported inadequate utilisation of prenatal care because they lacked health insurance coverage; for example, the majority of uninsured women in Montreal were categorised as having inadequate prenatal care utilisation [54]. Some reports showed that immigrant mothers were sometimes not informed about the availability of prenatal classes, their purpose or the support offered to attend them. Reitmanova and Gustafson [24] qualitatively explored the maternity healthcare needs and the barriers to accessing maternity health services that existed for immigrant Muslim women living in St. John’s, NL, Canada. This study reported that some immigrant women were not told about these classes or did not understand their purpose; some did not attend the classes because the no-care arrangements were offered for their other children; and some refused to participate in these classes because they were not designed exclusively for women. Attending these classes together with men would have caused observant Muslims great discomfort because it would have contravened their religious beliefs [24]. In addition, immigrant women who exhibit symptoms of stress and anxiety in the prenatal period may have a high risk of postpartum depression. These women reported that their stressors included migration issues, language difficulties, marital conflict, conflict with family members and in-laws and physical health problems [59, 64].

Studies reporting on the adequacy of delivery and in-hospital care showed mixed perceptions among immigrant mothers. Some studies reported satisfaction for the care the mothers received in the hospital [54‐56]. These studies provided positive accounts of the immigrant pregnant women receiving support for the promotion of breastfeeding during hospitalisation. Loiselle et al. [56] reported that immigrant mothers perceived that they were more likely to receive health professional support for breastfeeding than were Canadian-born mothers. Similarly, Wallace et al. [59] found that 90% of the pregnant immigrant women in their study thought that hospital staff were sensitive to their cultural and religious beliefs [59]. However, other studies reported some dissatisfaction. Muslim women in one study (n = 6) experienced remarks that were insulting, insensitive, stereotypical and embarrassing [24]. Somali women had several issues with their care, often related to their female genital circumcisions: (a) less than 1% had wanted a caesarean but 50% had received one; (b) some complained of having little discussion or say about procedures related to their birth and pain management; (c) 87.5% reported that hurtful comments had been made by their caregivers related to their circumcisions; and (d) many thought the nurses regarded them as being lazy (83.6%) or reluctant to cooperate (79.6%) [53]. Indo-Canadian immigrant women learned fewer baby care and self-care procedures than non-immigrant women [57]. Several Punjabi women reported experiencing difficulty during their hospital stay because they were not served hot food; hospital staff instead provided cold food such as sandwiches, Jell-O, and salads [18]. In addition, nurses are compelled to encourage women to begin walking and washing as soon as possible following delivery to enable their early discharge, which may conflict with cultural prescriptions of strict bed rest or the avoidance of showers [63]. Various studies reported incidents of poor treatment received from the hospital staff with respect to cultural sensitivity, delivery options, pain management and communication with immigrant mothers [52‐56, 59, 63‐67].

The adequacy of postpartum care experienced by immigrant mothers also varied greatly. Those in Ontario were reported to have good postpartum access to an obstetrician or public health nurse [69], but immigrant mothers in other parts of the country were not routinely contacted by a healthcare provider after discharge to address issues such maternal depression and social isolation [55, 63]. Kingston et al. [55] compared the maternity experiences of recent immigrants (5 years or less in Canada) and non-recent immigrants (more than 5 years) with those of Canadian-born women; after discharge, fewer recent immigrants than Canadian-born women were contacted by a healthcare provider (84% versus 95%) or saw one (70% versus 79%) other than in routine visits [55]. Similarly, in 12 of 20 immigrant mother-infant pairs, Katz and Gagnon [63] found no charted evidence either of contact within 48 h of discharge or of interventions to address maternal depression and social isolation.

The satisfaction that immigrant mothers feel with the perinatal care they receive from nurses, physicians and the healthcare system is evidently related to multiple factors. Consideration of these factors will be important in tailoring context-based programs to ensure the delivery of adequate maternity care to immigrant women.

Almost all the selected studies identified barriers in the delivery of maternity care to immigrant women in Canada, primarily involving access problems or negative experiences. These barriers include lack of knowledge among immigrant mothers, especially of knowledge and programs related to breastfeeding and postpartum depression [60, 70]; language barriers [60]; transportation problems, difficulties in making appointments, absence of partners, absence of child care, cold weather, perceptions of inappropriate referrals and differences in cultural practices [29]; wait times for appointments [64]; the presence of men in prenatal classes (in contravention of the religious beliefs of the women) [24]; lack of health insurance [24, 54]; concerns about the ability of the family to manage potential complications [66]; and time and money constraints [24, 52, 60].

Immigrant mothers in Montreal (speaking English or French) agreed more strongly than Canadian-born mothers that hospital staff helped them to feel confident in breastfeeding; Canadian-born women felt that they had received contradictory information from hospital staff [56]. In general, however, a lack of accurate information about breastfeeding was considered a major problem [60, 63]. Immigrant women reported that they found no community support related to breastfeeding and postpartum depression [60, 63, 64]. Immigrant women also said that they did not discuss their feelings of depression with their doctors or other healthcare professionals in their pre- or post-delivery check-ups because they felt too rushed or were not asked about possible emotional disturbances [70]. Lack of access to appropriate information and education related to family planning and immunisation were also reported as barriers to adequate maternity care [52, 55, 56, 63, 69].

Most studies highlighted issues related to the use of English in providing maternity care to immigrant women. For example, some immigrant women stated that language difficulties were the only barrier that would prevent them from using maternity services [70]. However, some immigrant women living in Vancouver (a large multi-ethnic urban centre) were fortunate to have access to healthcare professionals and resources in one of their preferred languages [56]. Studies have also discussed the attitudes of healthcare professionals towards immigrant women during and after hospitalisation. Several women reported being discouraged by staff who did not seem genuinely interested in overcoming the language barrier to help them or to provide appropriate information [63, 64, 70].

Cultural differences also caused difficulties for immigrant women in comprehending information, and some complained that maternity care is not always culturally and linguistically appropriate for them [24]. If these women failed to follow instructions because of their cultural preferences, healthcare staff often labelled the women as lazy or noncompliant [65]. Few immigrant women perceived that healthcare providers were insensitive to their pain or failed to provide them with special care when they were in need [65, 70]. Nonetheless, Katz and Gagnon [63] stated that 87.5% of women reported that hurtful comments were made by healthcare professionals at some stage of their maternity care.

The studies we reviewed indicated that immigrant mothers generally did not receive appropriate information regarding maternal and child health before and during their pregnancy [55] or after delivery of their babies [69]. In some instances, interpreter services were not available (as in Montreal), thus preventing some immigrant mothers from expressing their concerns or understanding the classes and information that were provided to them [71]. Mothers with postpartum depression who accessed psychological support received the information about this support primarily from friends or advertisements [70].

Immigrant parents identified social support as a key factor that helped them in accessing maternal services in Canada. However, immigrant women were more likely than Canadian-born women to perceive that they received less social support during their pregnancy or the postpartum period. Immigrant women appreciated and valued the limited social support they received from community services; but this support was not enough to overcome their problems and most of the time, they felt isolated and secluded [55, 69]. Immigrant parents with babies in neonatal intensive care units reported their appreciation of the social support they received (sometimes via long-distance telephone) from family, friends, staff, a spouse or partner, other children and their religious community [67]. However, immigrant women in other studies reported receiving only weak support during their pregnancy [24, 64, 69]. The women often expressed the wish to have someone from their community with previous maternity experience to spend some time with them, but this was not always possible [24]. Some immigrant women said that they did not know where to get maternity information, they felt isolated and they perceived that no one was available to help them and their babies [64, 63, 69, 71]. Sword et al. [69] reported that particularly after the birth of the newborn, immigrant women were less likely than Canadian-born women to get household help, reassurance and support or financial assistance; the main reason cited was a lack of information about the social support services available for the immigrants. Immigrant women also contrasted their experiences of social isolation with the situation in their countries of origin, which often placed high importance on family members and friends providing social support immediately after the birth of a child [65].

The types of community services available and the roles played by community health nurses were identified as crucial to the support received by immigrant mothers [64]. For new mothers of South Asian and Chinese origin who had postpartum depression and who described outside support as helpful, community health nurses typically played key roles [60]. Unfortunately, immigrant women generally received low social support at home even when psychosocial concerns were identified and documented [66, 69]. These mothers reported lack of knowledge with regard to the availability of support services in the community related to issues such as breastfeeding and postpartum depression, often leading to feelings of social isolation [60, 71]. Lack of social support and feelings of isolation have led to physiological problems documented in the hospital records of many immigrant women. For example, about 45% of the immigrant women had psychosocial concerns (largely anxiety and social isolation) identified in their hospital or community clinic charts [63]. Overall, lack of adequate social support and feelings of isolation were described in a variety of ways in three quantitative [55, 63, 69] and four qualitative [24, 67, 70, 71] studies.

Many of the selected studies described various outcomes of pregnancies, including birth outcomes [54, 67], postpartum mental health [30, 55, 58, 64, 69‐71], and breastfeeding and childcare issues [35, 53, 60, 63, 65]. Many immigrant mothers mentioned that the low quality of maternal services available for them in their home countries, including unsanitary conditions and the requirement to pay, resulted in poor birth outcomes there [67]. However, some immigrant women had similar birth outcomes in their new country: uninsured immigrant women who received inadequate prenatal care were reported to suffer from poor outcomes with respect to gestational or foetal age, birth weight, number of vaginal deliveries, number of induced deliveries, the use of epidural analgesia and attendance at the postpartum visit [54].

The access to and use of postpartum mental health services by immigrant mothers were explored in several studies. One study showed that newcomer women with less prenatal care (beginning later in the pregnancy or limited in amount) were two times more likely to have an Edinburgh Postnatal Depression Scale score of greater than or equal to 10 (P = 0.03) [58]. In another study in Montreal of 50 refugee mothers who received a home visit at 4 months postpartum, 26 were found to have symptoms of postpartum depression and 16 reported skipping meals because of a lack of resources [71]. Almost none of the women with postpartum depression had sought out referrals to psychological support services via nurses: they had accessed the information through friends or advertisements instead [70]. Many immigrant women also reported that their interactions with healthcare practitioners were not supportive, but few described these encounters as critically important; the studies recommended that support for these women move beyond the medical management of depression [64, 65]. Several studies concluded that immigrant women require a range of postpartum supports that take into account social, cultural and other contextual factors [64, 68, 71].

Fewer immigrant women than Canadian-born women were reported to have accessed prenatal classes on breastfeeding and childcare; for example, in a study of 20 immigrant mothers via reviews of hospital and community clinic charts, eight were found to have breastfeeding difficulties. Resolution was recorded in two of these, referral was documented in one, six had been unable to resolve their problems in hospital, five still had problems on follow-up with a community nurse and one had already switched to bottle-feeding [63]. Despite fewer newcomers attending prenatal classes, breastfeeding initiation rates were found to be similar for immigrant and Canadian-born women, and immigrant mothers were 1.7 times more likely to be breastfeeding at 3 months [55].