Background
-
Asylum seekers are individuals who have sought international protection and whose claims for refugee status have not yet been determined, irrespective of when they may have been lodged. An asylum seeker has applied for asylum on the grounds of persecution in their home country relating to their race, religion, nationality, political belief or membership of a particular social group. This population remains classified as asylum seeker for as long as the application is pending.
-
Refugees have been forced to leave their country in order to escape war, persecution or natural disaster. The 1951 Convention relating to the Status of Refugees describes a refugee as “a person who owing to a well-founded fear of being persecuted for reasons of race, religion, nationality, membership of a particular social group, or political opinion, is outside the country of this nationality and is unable to or, owing to such fear, is unwilling to avail himself of the protection of that country”. A refugee is an asylum seeker whose application has been successful.
-
Migrants include those who move, either temporarily or permanently from one place, area or country of residence to another for reasons such as work or seeking a better life (i.e. economic migrants), for family reasons or to study. People also migrate to flee conflict or persecution, which is where the definition converges with the terms refugee and asylum seeker.
Methods
Identification of studies
-
Systematic reviews with a quantitative, qualitative or mixed methods evidence synthesis
-
Published in the English language
-
Included any perinatal health outcomes (e.g. postnatal depression, low birth weight) or perinatal care (e.g. access to maternity services, experiences of care) during the preconception, antenatal and postnatal periods
-
Clearly stated that women with asylum seeker or refugee status were populations within the included studies. This included reviews of migrant women where asylum seekers and refugees were part of the included population
-
Scoping reviews which aimed to identify the extent and nature of the evidence base without a formal evidence synthesis
-
Published abstracts without full texts and protocols of systematic reviews. We searched for any subsequent full text publications of these works
-
Reviews that focussed on refugees living in camps
Quality assessment
Data extraction
Evidence synthesis
Results
Included systematic reviews
Author, year | Aim of the systematic review | Methods | Population included | Search strategy (years, databases and supplementary searches) |
---|---|---|---|---|
Alhasanat and Fry-McComish 2015 [16] | To identify the prevalence and risk factors for postnatal depression amongst immigrant women in industrialised countries and compare it with prevalence and risk factors amongst Arab women in their home countries | Quantitative with narrative | Migrant including asylum seekers and/or refugees | 1990–2013 Four databases searched No supplementary searches |
Anderson et al. 2017 [5] | To evaluate the prevalence and risk factors of mental disorders in the perinatal period amongst migrant women | Quantitative with meta-analysis | Migrant including asylum seekers and/or refugees | From inception of database to Oct 2015 Six databases searched No supplementary searches |
Aubrey et al. 2017 [9] | To broadly explore and synthesise current evidence surrounding women’s preference for female physicians in obstetrics and gynaecology | Mixed methods | Migrant including asylum seekers and/or refugees | From inception of database Five databases searched Supplementary searches: reference list, citations |
Balaam et al. 2013 [30] | To explore migrant women’s perceptions of their needs and experiences related to pregnancy and childbirth | Qualitative | Migrant including asylum seekers and/or refugees | 1996–2010 Seven databases searched No supplementary searches |
Bollini et al. 2009 [26] | To explore whether differences in pregnancy outcomes observed across receiving countries in Europe are associated with varying degrees of implementation of integration policies | Quantitative with meta-analysis | Migrant including asylum seekers and/or refugees | 1966–2004 One database searched No supplementary searches |
Collins et al. 2011 [18] | To review the rates and risk factors associated with postnatal depression in refugees, asylum seekers and migrant women | Quantitative with narrative | Migrant including asylum seekers and/or refugees | 1990–2009 Ten databases searched No supplementary searches |
De Maio 2010 [19] | This review investigates the health of immigrants to Canada by critically examining differences in health status between immigrants and the native-born population and by tracing how the health of immigrants changes after settling in the country | Quantitative with narrative | Migrant including asylum seekers and/or refugees | 1990–2010 Four databases searched Supplementary searches: reference list |
Downe et al. 2009 [31] | To locate and synthesise qualitative accounts of barriers to antenatal care as reported by high-risk, marginalised, pregnant women in the UK | Qualitative | Marginalised populations including asylum seekers and/or refugees | 1980–2007 Seven databases searched Supplementary searches: reference list |
Falah-Hassani et al. 2015 [17] | Estimate the prevalence of postpartum depressive systems in immigrant women. Compare this prevalence to non-immigrant women. Determine risk factors for postpartum depressive systems in immigrant women | Quantitative with meta-analysis | Migrant including asylum seekers and/or refugees | 1950–2014 Seven databases searched Supplementary searches: reference list |
Fellmeth et al. 2017 [6] | Summarise and synthesise evidence on prevalence, associated factors and effectiveness of interventions for any perinatal mental disorder in migrant women | Quantitative with meta-analysis | Migrant including asylum seekers and/or refugees | No specific start date until January 2015 Eight databases searched Supplementary searches: hand searching journals, reference list |
Gagnon et al. 2009 [25] | To assess whether migrants in western industrialised countries have consistently poorer perinatal health than receiving-country women | Quantitative with meta-analysis | Migrant including asylum seekers and/or refugees | 1995–2008 Four databases searched Supplementary searches: reference list, citations |
Gissler et al. 2009 [27] | To determine if migrants in western industrialised countries have consistently higher risks of stillbirth, neonatal mortality or infant mortality; if there are migrant sub-groups at potentially higher risk; and what might be the explanations for any risk differences found | Quantitative with meta-analysis | Migrant including asylum seekers and/or refugees | 1995–2006 Four databases searched Supplementary searches: reference list |
Hadgkiss and Renzaho 2014 [14] | To document physical health problems that asylum seekers experience on settlement in the community and to assess their utilisation of healthcare services and barriers to care, in an international context | Mixed methods | Asylum seekers | 2002–2012 Four databases searched Supplementary searches: reference list |
Heaman et al. 2013 [35] | Do migrant women in Western industrialised countries have higher odds of inadequate prenatal care compared to receiving-country women, and what factors are associated with inadequate prenatal care amongst migrant women in Western industrialised countries? | Quantitative with narrative | Migrant including asylum seekers and/or refugees | 1995–2010 Three databases searched Supplementary searches: reference list |
Higginbottom et al. 2015 [36] | What are the experiences of immigrant women in Canada in accessing and navigating maternity and healthcare services from conception to 6 months postpartum? | Mixed methods | Migrant including asylum seekers and/or refugees | Inception to 2013 Ten databases searched Supplementary searches: hand searches within journal websites |
Higginbottom et al. 2014 [32] | To synthesise qualitative literature to describe how immigrant women experience maternity services in Canada | Qualitative | Migrant including asylum seekers and/or refugees | Inception to March 2012 Eight databases searched Supplementary searches: contacting authors, reference list |
Higginbottom et al. 2012 [23] | To identify and descriptively synthesise current empirical literature on immigrants’ experiences of maternity healthcare services in Canada, to outline practice implications and/or to offer recommendations for future research | Mixed methods | Migrant including asylum seekers and/or refugees | 2000–2010 Five databases searched Supplementary searches: reference list, citations |
Mengesha et al. 2016 [10] | To identify studies that focussed on the views and experiences of culturally and linguistically diverse women in accessing sexual and reproductive health care in Australia | Mixed methods | Migrant including asylum seekers and/or refugees | April 1990–May 2015 Seven databases searched Supplementary searches: reference list |
Merry et al. 2013 [28] | To determine if migrants in Western industrialised countries consistently have different rates of caesarean than receiving-country-born women and to identify the reasons that explain these differences | Quantitative with meta-analysis | Migrant including asylum seekers and/or refugees | Inception to Jan 2012 Eleven databases searched Supplementary searches: reference list |
Merry et al. 2016 [7] | To provide a synthesis to what is known regarding caesarean births amongst migrants living in high-income countries | Quantitative with narrative | Migrant including asylum seekers and/or refugees | 2012–2015 Thirteen databases searched No supplementary searches |
Nilaweera et al. 2014 [22] | To summarise the available evidence about the prevalence, nature and determinants of postpartum mental health problems amongst women born in South Asian countries who had migrated to high-income countries, and identify barriers and enablers to seeking health care for these difficulties | Mixed methods | Migrant including asylum seekers and/or refugees | Inception to February 2013 Four databases searched No supplementary searches |
Pedersen et al. 2014 [24] | A meta-analysis of all published observational studies from Western European countries comparing the risk of maternal mortality between the receiving-country women and a defined migrant population | Quantitative with meta-analysis | Migrant including asylum seekers and/or refugees | 1970–2013 Four databases searched Supplementary searches: reference list |
Schmied et al. 2017 [8] | To report the findings of a meta-ethnographic study of the experiences, meanings and ways of ‘dealing with’ symptoms or a diagnosis of postnatal depression amongst migrant women living in high-income countries with a view to informing culturally appropriate health service design and delivery | Qualitative | Migrant including asylum seekers and/or refugees | 1999–2016 Five databases searched Supplementary searches: reference list, citations |
Small et al. 2014 [33] | There were two review questions: 1. What do immigrant and non-immigrant women want from their maternity care? 2. How do immigrant and non-immigrant women’s experiences and ratings of care compare, both within and across included countries? | Qualitative | Migrant including asylum seekers and/or refugees | 1989–2011 Five databases searched No supplementary searches |
Tobin et al. 2017 [20] | To synthesise qualitative research on refugee and immigrant women’s experiences of postpartum depression to gain insight into the unique needs of this group of women | Qualitative | Migrant including asylum seekers and/or refugees | 2004–2014 Five databases searched Supplementary searches: reference list |
Villalonga-Olives et al. 2016 [29] | To discuss differences between the USA and Europe regarding reproductive health outcomes of immigrants and to elucidate why these differences occur | Quantitative with narrative | Migrant including asylum seekers and/or refugees | Dates not clear Two databases searched No supplementary searches |
Wikberg and Bondas 2010 [34] | To explore and describe a patient perspective in research on intercultural caring in maternity care | Qualitative | Migrant including asylum seekers and/or refugees | 1995–2009 Twelve databases searched Supplementary searches: reference list |
Winn et al. 2017 [11] | To understand the experiences of pregnant immigrant women accessing perinatal care in North America | Qualitative | Migrant including asylum seekers and/or refugees | Inception to July 2016 Five databases searched Supplementary searches: reference list |
Wittkowski et al. 2017 [21] | To appraise and assimilate qualitative findings of postnatal depression in immigrant mothers | Qualitative | Migrant including asylum seekers and/or refugees | 1990–2014 Six databases searched Supplementary searches: reference list |
Quality of evidence
Perinatal health outcomes amongst women who are migrants (including asylum seekers and refugees)
Author, year | Number of studies | Publication date range | Sample size1 | Topic area of results | Summary of author conclusions |
---|---|---|---|---|---|
Alhasanat and Fry-McComish 2015 [16] | 26 | 1998–2013 (date range of migrant studies) | 9089 | Perinatal health outcomes (mental health); access, utilisation and experience of perinatal healthcare | Some similarities in the risk factors for postnatal depression amongst migrant women and Arabic women in their country of birth: lack of social support, stressful life events, lack of emotional support from the partner, history of antenatal depression and marital dissatisfaction. Immigration stress and lack of access to health care services were found amongst migrant women. Lack of social support was more predominant in studies on migrant women |
Anderson et al. 2017 [5] | 53 | 1986–2015 | 119,076 (for the 52 studies which reported sample size) | Perinatal health outcomes (mental health) | Depression is common amongst pregnant and postpartum migrant women, although there is no evidence for an overall increased risk of depression amongst migrant women when compared to non-migrant women |
Aubrey et al. 2017 [9] | 54 | 2002–2016 (data for only 10 included studies reported) | Not reported | Access to and utilisation of perinatal healthcare | A key finding of both qualitative and quantitative studies was a preference for female providers because of religious reasons and comfort with a female provider. Provider competence was prioritised over gender |
Balaam et al. 2013 [30] | 16 | 2000–2010 | 393 (excluding men and health professionals) | Access, utilisation and experience of perinatal healthcare | Migrant women’s vulnerable situation when pregnant and giving birth must be improved |
Bollini et al. 2009 [26] | 65 | 1966–2004 | 18,322,978 women including 1,632,401 migrant women | Perinatal health outcomes (neonatal intensive care, offspring mortality, preterm birth, low birth weight, congenital anomalies, postpartum haemorrhage) | Risk ratios for low birth weight, preterm delivery, perinatal mortality and congenital anomalies between immigrant and native-born women were more similar in countries with strong integration policies. There was a migrant penalty for those European countries with weak integration policies |
Collins et al. 2011 [18] | 8 | 1998–2008 | 4574 (for the 7 studies which reported sample size) | Perinatal health outcomes (mental health) | Nearly all studies found rates of probable postnatal depression were higher in migrant women than native-born women |
De Maio 2010 [19] | 51 | 2006–2010 | Not reported | Perinatal health outcomes (mental health, low birth weight, preterm birth, placental dysfunction); access to and utilisation of perinatal healthcare | Mental health issues are less prevalent amongst migrants than the Canadian-born population. However, this advantage diminishes as length of residence in Canada increases. Living in areas with a high density of migrants may help immigrants to retain this advantage |
Downe et al. 2009 [31] | 8 | 1998–2006 | 569 (excluding men and health professionals) | Perinatal healthcare access and experiences | A non-threatening, non-judgemental antenatal service run by culturally sensitive staff may increase access to antenatal care for marginalised women. Multiagency initiatives aimed at raising awareness of, and providing access to, antenatal care may also increase uptake |
Falah-Hassani et al. 2015 [17] | 24 | 1995–2013 | 63,926 | Perinatal health outcomes (mental health) | The prevalence of depressive symptoms is 1.5–2.0 higher in migrant women compared with non-migrant women. Migrant women were more likely to develop depressive symptoms if they had shorter residency in the destination country, lower levels of social support, poorer marital adjustment and insufficient household income |
Fellmeth et al. 2017 [6] | 45 | 1986–2013 | 19,439 (including 7985 migrant) | Perinatal health outcomes (mental health) | Higher prevalence of postnatal depression in migrant women. Local language ability, length of residency and adhering to traditional birth practices were protective factors |
Gagnon et al. 2009 [25] | 133 | 1968–2005 | 20,152,134 | Perinatal health outcomes (maternal and offspring mortality, mode of delivery, low birth weight, preterm birth, maternal health, congenital anomalies, maternal and infant infections, infant morbidities); access to and utilisation of perinatal healthcare | Of 9 outcome categories, 2 appear to be better amongst migrant women (health-promoting behaviour and birth weight), 6 appear worse (infection, congenital anomalies and infant morbidity, prenatal care, maternal health, feto-infant mortality and mode of delivery) and 1 did not differ in most studies (preterm birth) |
Gissler et al. 2009 [27] | 34 | 1980–2002 | Not reported | Perinatal health outcomes (offspring mortality) | In the European studies, all non-refugee migrants had higher crude stillbirth rates, perinatal mortality rates, neonatal mortality rates and infant mortality rates |
Hadgkiss and Renzaho 2014 [14] | 32 | 2002–2012 | Not reported | Perinatal health outcomes (offspring mortality, mode of delivery, birth weight, preterm birth, complex obstetric issues) | This study highlights the health inequities faced by asylum seekers residing in the communities of host countries, internationally |
Heaman et al. 2013 [35] | 29 | 1996–2007 | 24,362,611 | Access to and utilisation of perinatal healthcare | Migrant women were more likely to receive inadequate prenatal care than receiving-country women. Inadequate prenatal care varied widely by country of birth, indicating that this is not a homogeneous group |
Higginbottom, et al. 2012 [23] | 30 | Not reported | Not reported | Perinatal health outcomes (mental health); access to and utilisation of perinatal healthcare | New migrants are ten times more likely than Canadian-born women to experience personal barriers when accessing healthcare. Language is a particular problem, and current interpreting services are either underutilised or unavailable |
Higginbottom et al. 2014 [32] | 22 | 1990–2011 | 510 (for 21 studies that reported data, excluding 2 studies exclusively with health professionals) | Access, utilisation and experience of perinatal healthcare | Experiences in maternity healthcare for migrant women are deeply embedded in the social position of the women which influences the availability of social supports, communication possibilities with health professionals and socio-economic status, all of which relate to the organisational environment. Furthermore, migrants and healthcare staff have different beliefs and values which form their perceptions on how maternity healthcare should be provided. Cultural knowledge, beliefs, religious and traditional customs were most relevant for migrants, whereas healthcare staff emphasise biomedical needs |
Higginbottom et al. 2015 [36] | 24 | 1995–2011 | 10,339 | Access, utilisation and experience of perinatal healthcare | Analysis of these 24 studies led to the development of five interrelated themes: utilisation of prenatal care and educational classes; adequacy of perinatal care; barriers to maternity care in the pre- and postnatal periods; isolation and limited social support; and outcomes related to the access to and the use of services |
Mengesha et al. 2016 [10] | 22 | 1998–2014 | 1943 | Access, utilisation and experience of perinatal healthcare | Although culturally and linguistically diverse women in Australia have the opportunity to obtain necessary health services, they experience numerous barriers in accessing and utilising sexual and reproductive healthcare |
Merry et al. 2013 [28] | 76 | 1956–2010 | 1,029,454 | Perinatal health outcomes (mode of delivery) | Sub-Saharan African, Somali and South Asian migrants consistently have higher caesarean rates while Eastern-European and Vietnamese migrants have lower overall caesarean rates compared to receiving-country-born women. North African, West Asian and Latin American migrant women have higher emergency caesarean rates |
Merry et al. 2016 [7] | 33 | 2012–2015 | Not reported | Perinatal health outcomes (mode of delivery) | Women from sub-Saharan Africa and South Asia consistently show overall higher rates of caesarean compared with non-migrant women. Women from Latin America, North Africa and Middle East consistently show higher rates of emergency caesarean. Higher rates are more common with emergency caesareans than with planned caesareans |
Nilaweera et al. 2014 [22] | 15 | 2003–2012 | 102,427 (quantitative studies), 84 (qualitative studies) | Perinatal health outcomes (mental health); access, utilisation and experience of perinatal healthcare | The prevalence of clinically significant symptoms of postnatal depression and diagnosed postnatal depression for South Asian women who migrate to high-income countries is between 5 and 20%. This rate is likely to be under-reported because of a lack of specific sub-group analyses and studies on South Asian countries. Barriers to accessing healthcare need to be addressed including proficiency in English language, unfamiliarity with local services and lack of attention to mental health by healthcare providers |
Pedersen et al. 2014 [24] | 13 | 1969–2008 | 42,290,654 women including 6,102,663 migrant | Perinatal health outcomes (maternal mortality) | Migrant women in Western European countries have a doubled risk of dying during or after pregnancy when compared with indigenous-born women. A higher risk of death from direct causes suggests sub-standard obstetric care may be responsible for the majority of the excess deaths amongst migrant women |
Schmied et al. 2017 [8] | 15 | 1999–2015 | 256 | Perinatal health outcomes (mental health); access, utilisation and experience of perinatal healthcare | Women who are migrants report higher levels of depressive symptoms, which can severely compromise mother-baby interaction and subsequent attachment relationships |
Small et al. 2014 [33] | 22 | 1990–2012 | Sample sizes ranged from 6 to 432, with a total of 2498 migrant women | Access, utilisation and experience of perinatal healthcare | What migrant and non-migrant women want from maternity care is similar: safe, high-quality, attentive and individualised care, with adequate information and support. Migrant women were less positive about their care than non-migrant women. Communication problems and lack of familiarity with care systems negatively affected migrant women’s experiences, as did perceptions of discrimination and care which was not kind or respectful |
Tobin et al. 2017 [20] | 13 | 2004–2013 | 139 | Perinatal health outcomes (mental health); access, utilisation and experience of perinatal healthcare | Migrant women with postnatal depression may lack understanding of their condition, are often isolated, alone, fear stigmatisation and risk being considered an unfit mother. Raising awareness with healthcare providers of the meaning of postnatal depression for migrant women is key to the provision of effective care |
Villalonga-Olives et al. 2016 [29] | 68 | 1994–2013 | 80,572,311 (6 studies no data reported) | Perinatal health outcomes (low birth weight) | The prevalence of low birth weight amongst migrants varies by the host country characteristics as well as the composition of migrants to different regions. The primary driver of migrant health is the migrant ’regime’ in different countries at specific periods of time. The ’healthy migrant effect’ in the USA is largely missing from Europe |
Wikberg and Bondas 2010 [34] | 40 | 1988–2008 | More than 1160 women from more than 50 cultures | Experience of perinatal healthcare | Alice in Wonderland emerged as an overarching metaphor to describe intercultural caring in maternity care. There are specific cultural and maternity care features in intercultural caring: an inner core of caring consisting of respect, presence and listening, as well as external factors such as economy and organisation that affect intercultural caring. Legal status, power relationships and racism influence intercultural caring |
Winn et al. 2017 [11] | 19 | 1995–2015 | Not reported | Access, utilisation and experience of perinatal healthcare | Three main meta-themes were developed: (1) Expectations Of Pregnancy As Derived From Home, (2) Reality Of Pregnancy In The Host Health Care System. These two themes were connected by our third meta-theme: Support |
Wittkowski et al. 2017 [21] | 16 | 1996–2011 | 337 | Perinatal health outcomes (mental health); access, utilisation and experience of perinatal healthcare | Migrant mothers living in Western countries are subject to multifaceted and multifactorial stressors following the birth of their child, possibly making them more susceptible to developing postnatal depression and influencing their subsequent healthcare behaviour. These stressors are related to migration or being a migrant in a Western society as well as cultural influences which are harder to comply with as a migrant living in a different country, removed from their socio-cultural context. Social support appears to play an integral and mediating role for migrant mothers living in Western countries |
Perinatal mental health
-
Stress and support. This was the most frequently and consistently reported risk factor for the development of mental health disorders amongst migrant women. Examples provided included emotional stress, a history of violence or abuse, having witnessed or experienced stressful life events and their premigration experience such as having migrated for political reasons or problems with the police or army in their home country [5, 6, 16‐18]. Lack of social support and lack of family support were also reported to be important risk factors. There was a consistent pattern of low social support increasing the risk and good social support being protective against perinatal mental health disorders [5, 6, 17‐19, 22]. Having no relatives or friends, a lack of emotional support from their spouse, being unmarried, having no partner, having migrated for marriage, marital adjustment problems and a lack of domestic decision-making power in relation to the child were all risk factors for perinatal mental health disorders amongst migrant women, whereas having a close relationship with their partner was reported to be protective [5, 6, 16, 17, 22].
-
Adjustment to host country. The most commonly reported risk factors for perinatal mental health disorders were difficulties with the host country language [5, 6, 17, 19, 22] and being unfamiliar with local life [19]. Anderson et al. [5] reported inconsistent evidence in their included studies relating to the length of time resident in the host country, whereas other reviews reported that shorter duration of residence was a risk factor for perinatal mental health disorders [6, 17]. Fellmeth et al. [6] reported that adherence to traditional postpartum practices was protective against postnatal depression in migrant populations.
-
Pregnancy care and infant feeding. Experience of perinatal healthcare including operative caesarean and instrumental delivery and poor satisfaction with support [6, 18] and also infant feeding experience including formula feeding and feeding problems [6, 17, 22] were risk factors for the development of perinatal mental health disorders reported by four systematic reviews [7, 17, 18, 22].
-
Health status and history. The risk of perinatal mental health disorders was increased when migrant women perceived their overall health to be low [17, 19] or had a history of mental health disorders [6, 22]. Fellmeth et al. [6] reported ORs for postnatal depression to be between 24.9 and 29.7 when there was a personal or family history of depression.
-
Socio-demographics. Risk factors included low income or socio-economic status, unemployment [5, 16, 17], low education [17], having a visible minority status [19] and primiparity [6]. Fellmeth et al. [6] also reported that maternal age > 30 years and < 25 years were risk factors for increased postnatal depression.