Immigrant and non-immigrant women’s experiences of maternity care: a systematic and comparative review of studies in five countries

Background Understanding immigrant women’s experiences of maternity care is critical if receiving country care systems are to respond appropriately to increasing global migration. This systematic review aimed to compare what we know about immigrant and non-immigrant women’s experiences of maternity care. Methods Medline, CINAHL, Health Star, Embase and PsychInfo were searched for the period 1989–2012. First, we retrieved population-based studies of women’s experiences of maternity care (n = 12). For countries with identified population studies, studies focused specifically on immigrant women’s experiences of care were also retrieved (n = 22). For all included studies, we extracted available data on experiences of care and undertook a descriptive comparison. Results What immigrant and non-immigrant women want from maternity care proved similar: safe, high quality, attentive and individualised care, with adequate information and support. Immigrant women were less positive about their care than non-immigrant women. Communication problems and lack of familiarity with care systems impacted negatively on immigrant women’s experiences, as did perceptions of discrimination and care which was not kind or respectful. Conclusion Few differences were found in what immigrant and non-immigrant women want from maternity care. The challenge for health systems is to address the barriers immigrant women face by improving communication, increasing women’s understanding of care provision and reducing discrimination.


Background
Increasing global migration has implications both for health care provision in receiving countries and for the health care experiences of immigrant populations. This is nowhere more apparent than in the experience of women giving birth post-migration. A systematic review of immigrant women's perinatal outcomes published in 2010 [1] identified very few studies over a ten-year period which described any aspect of immigrant women's maternity care experiences in comparison with nonimmigrant women. Some population-based studies of women's experiences of maternity care conducted in a few countries do include limited data on immigrant and refugee women's experiences of care for comparison with non-immigrant women, but immigrant women are commonly under-represented in these studies because of the formidable challenges of undertaking inclusive cross-cultural research that is population-based and large scale [2,3]. These challenges include: sampling and recruitment issues, difficulties in translation and in assessment of validity with the use of standard research instruments, and increased research costs. Other studies have specifically investigated the experiences of individual groups of immigrant and refugee women, and to date these are mostly small and qualitative. Given the dearth of adequatelysized and appropriately conducted studies directly comparing representative immigrant and non-immigrant experiences of maternity care, a systematic review drawing on data in general population studies and in specific immigrant studies in the same countries, would seem to offer the best opportunity for drawing together and comparing what is known about immigrant and nonimmigrant experiences, and what women wantand getfrom their maternity care.
Our purpose in selecting studies for this review was thus twofold. First, we aimed to identify and review all published population-based studies of women's experiences of maternity care to determine what they say about what women want from care, including any data, if available, about immigrant women. Second, having identified the countries where such studies have been conducted, we aimed to investigate further what is known about the experiences of immigrant women in each of these countries, by identifying and reviewing studies focused specifically on immigrant women's experiences of their maternity care. For the purposes of this review, we define immigrant women as those women not themselves born in the country in which they are giving birth.
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?

Search strategy
Ovid was used to search the electronic databases Medline, CINAHL, Health Star, Embase and PsychInfo for the period 1989-2011. The search strategy was developed by MR with the assistance of the Health Sciences Librarian at La Trobe University in February 2010 and further searches were conducted to update the literature to December 2012. 1989 was chosen as the start year because the first population-based study of women's experiences of maternity care was known to have been conducted in that year [4]. Terms combined in the search included: emigration/ emigrant, immigration/immigrant, migrant, ethnic group, ethnic minority, population groups, refugees, non-English speaking, women, view, opinion, attitude, experience, maternal health services, maternity care, perinatal care, prenatal/antenatal care, intrapartum care, postnatal care, delivery, obstetrics, midwifery. For an example of the search strategies used, see Additional file 1.

Inclusion and exclusion criteria
Population-based studies of women's experiences of care, defined as those with national or regional samples with representativeness assessed, were identified, retrieved and reviewed. Studies with a hospital-based or convenience sample or where representativeness could not be assessed were excluded. With these criteria, 12 studies from five countries were included . One national study was identified from Scotland, [25] but subsequently excluded, as its overall population representativeness could not be assessed. Studies focusing specifically on immigrant women's experiences of maternity care from these same five countries were then also identified, retrieved and reviewed. Studies of ethnic minorities who were not themselves immigrants or refugees were excluded, as were retrieved studies which on review, were found to focus only on cultural beliefs and practices around childbirth without investigating immigrant women's actual experiences of the maternity care they received. For the immigrant studies, all retrieved studies were included (i.e. no quality criteria were applied), for two reasons. First, our purpose was to include as much data as possible about a diverse range of immigrant women's experiences for comparison with data on nonimmigrant women from the population-based studies. Second, the immigrant studies were relatively few across the included countries; and most were small and qualitative. Twenty-two studies of immigrant women's experiences of care were identified, retrieved and reviewed across the five included countries .

Approach to analysis
Papers were read and the findings summarised, noting (where available) overall ratings of care and key conclusions about what women wanted from care (RS, MR and TS). The country, year of study, sample size and study type (e.g., population-based postal survey, qualitative interview study) were also noted. For the populationbased studies, the main findings were recorded separately for non-immigrant and immigrant women, except when the data did not distinguish these groups of interest (the three US studies and two of the UK studies). Study findings were tabulated for ease of discussion and interpretation (MR and RS) and a descriptive thematic analysis of the extracted data was undertaken [56]. Two authors independently developed codes for describing the data (MR and RS) and a third author (TS) reviewed these. The resulting interpretation of the data was then reviewed and revised by all authors.
What do non-immigrant women want from their maternity care?
The key findings from the population-based studies about what non-immigrant women appreciate and want from their maternity care proved remarkably similar across the included countries, as can be seen in the study summaries provided in Table 1. Most of these population-based studies assessed women's overall ratings of care for each of the three phases of care: during pregnancy, during labour and birth and during the postpartum hospital stay. The exceptions to this were: the Canadian survey, in which    [4,5] 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 Survey of Recent Mothers in Victoria 1994 [6,7] 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. 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 Maternity Experiences Survey (MES) 2006 [11,12] 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.  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. Caregivers who provide adequate support and information, with enough time to answer questions and give help; and who are friendly, non-judgemental and respectful

SWEDEN
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
First class delivery: A national survey of women's views of maternity care 1995 [16] n=2406; numbers of immigrant women not reported women were asked to rate their satisfaction with six aspects of their interaction with health care providers during the entire pregnancy, labour and birth, and immediate postpartum period, [11] and the US surveys, where women were not asked to give overall ratings of their care except in response to a question in the 2005 and 2013 surveys asking women their view about the maternity care system overall, with 35% and 36% rating it as excellent, 47% and 47% as good, and 16% and 17% as poor, respectively [22,24].

Pregnancy care
Women commonly reported problems in pregnancy care with long waiting times, staff not taking time to attend to individual concerns and provide enough information, staff seeming rushed, and lack of continuity of care [3,6,9,12,13,17]. Seeing fewer caregivers during antenatal visits was associated with more positive experiences of care, or was seen as important by women in most studies [6,8,[11][12][13]17]. The need for adequate and consistent information, being treated as an individual, and having effective interaction with caregivers were also commonly reported to be important in shaping positive experiences about pregnancy care [3,8,13,[16][17][18].

Intrapartum care
Dissatisfaction with intrapartum care in the population based studies was consistently associated with lack of sufficient information during labour, the perception that caregivers were not kind and understanding, caregivers being unhelpful, and not having an active say in making decisions [4,5,7,15,17,19,21,22,24]. The nature of women's interactions with caregivers appears to be a critical factor for women's experiences at all stages of care. The earliest Australian survey conducted in 1989 revealed a four to sixfold increase in dissatisfaction if women had not received sufficient information from caregivers [5]. Likewise, women who described their caregivers as not being very kind and understanding were four to five times more likely to be dissatisfied with their care; and caregivers regarded as being unhelpful was associated with significant dissatisfaction with intrapartum care [5]. The 2008 national survey in England reported that women were more satisfied with intrapartum care when they received individualised care, enough information and explanations, and were cared for by kind and understanding staff [18]. Involvement in decisions about care and having an 'active say' also seem to be consistently important factors associated with more positive experiences of care in labour and birth [5,15,18,19,21,23,24].

Postpartum care
Women were less positive about their postpartum care compared with the care they received in pregnancy, or during labour and birth in all three Australian surveys [8][9][10], in the four UK surveys [16][17][18][19] and also in the Swedish study [14].
The factors that seem to be important in women's experiences of their postpartum care are focused on the attitudes and behaviour of staff: caregivers being sensitive and understanding, providing support and advice, and the helpfulness of that advice and support [10,[14][15][16][17][18][19]. Factors associated with women's negative experiences of postnatal care included: when their concerns and anxieties were not taken seriously, staff being rushed and too busy to spend time with them, staff not being sensitive and understanding, and not providing enough advice and support about baby care. Another important factor was receiving enough support and advice about women's own health and recovery [10,15]. In the national Swedish study, content analysis of responses to open-ended questions regarding women's negative experiences of postpartum hospital care two months and one year after the birth showed that the aspects of care women were most dissatisfied with were: shortages of staff and staff being rushed, staff behaviour, lack of attention to women's concerns, inadequate support and advice, and lack of sufficient information and explanation regarding baby care and women's own physical and emotional health after birth [14].

Summary of what non-immigrant women want
Drawing on the common themes emerging across the population-based studies from these five countries, we propose the 'QUICK' summary, where 'QUICK' is a mnemonic that captures the essence of what women want from their maternity care: Q = Quality care that promotes wellbeing for mothers and babies with a focus on individual needs. U = Unrushed caregivers with enough time to give information, explanations and support. I = Involvement in decision-making about care and procedures. C = Continuity of care with caregivers who get to know and understand women's individual needs and who communicate effectively. K = Kindness and respect.
When one or more of these aspects of care was lacking, women were likely to be less happy with their care.
What do immigrant women want from their maternity care?

Findings in the population-based studies
Where data were available for immigrant women in the population-based studies, the key findings have also been included in Table 1. The immigrant women born in countries where English was not the principal language spoken who responded to the three Australian surveysalthough unlikely to be representative of all immigrant women, given English language requirements for participationwere less happy with their care than non-immigrant women and more likely to have difficulties with getting the information and support they required [4][5][6][7][8][9][10]. In the Canadian [11,12] and Swedish [13,15] studies, similar levels of satisfaction with care were found for immigrant and non-immigrant women, although language issues are acknowledged to have excluded many immigrant women from participation in the Swedish study, and almost one in five immigrant participants in the Canadian study reported not receiving care in a language they could understand [11,12]. Only two of the UK studies [17,19] provided data on immigrant women, with comparisons made for black and minority women without reference to country of birth in the others. Immigrant women of black and minority ethnicity were less likely to feel spoken to with respect and understanding, and in a way they could understand; to feel they had options in care or adequate information; and were less likely to describe care providers positively [17,19]. Findings for immigrant mothers were not reported in the US surveys [20][21][22][23][24] the third survey did give the numbers of immigrant women participating, but did not report their experiences separately [24].

Findings in the studies specific to immigrant women
The findings about what immigrant women value in their maternity care from studies conducted to investigate specific groups of immigrant women's experiences are summarised in Table 2, and are organised by each receiving country. Table 2 shows that the findings from these studies are not only quite consistent across immigrant groups originating from very different cultures and countries, but also that the 'QUICK' summary elements found in the population studies, appear also to be central in the accounts of immigrant women from these immigrant-specific studies, again regardless of women's country or culture of origin, or of the country to which they had migrated.
Despite evidence that immigrant women want to be involved in decisions about their care, [28][29][30][31][39][40][41] some studies found that immigrant women were at times reluctant to make their wishes known [39,41]. Experiences of discrimination, and/or cultural stereotyping were also commonly reported in the immigrant studies from all five countries [28][29][30][31][32]40,42,44,45,48,50,52]. Studies of Somali immigrants in Canada, Sweden and the UK also found that women felt staff were insensitive to their experiences of pain in labour and responded inappropriately to traditional female genital cutting, demonstrating a lack of knowledge about this issue [40,44,45,50].
Some studies noted particular cultural issues that immigrant women felt were not well understood during their maternity care and about which they desired more understanding from their caregivers. One US study of Hmong women described women's fears of being touched by doctors and nurses because of beliefs about the causes of miscarriage [53]. Some studies reported women's preference for female caregivers, [28][29][30][31][32]43] with Muslim women in particular expressing this preference. It is worth noting however that this question is rarely asked in studies of non-immigrant, or non-minority women, so whether immigrant women are more likely to prefer female caregivers than non-immigrant women is not readily known. Several Australian studies found that women sometimes found it difficult to follow traditional cultural practices in hospital (for example food preferences, not showering after birth), and women reported that they were rarely asked by caregivers about their postnatal practice preferences [26,27,31,37,39].
Interestingly though, lack of attention to cultural issues or restrictions on traditional cultural practices by caregivers were not the principal focus of women's descriptions of negative aspects of the maternity care they received post migration. Communication problems and discriminatory or negative caregiver attitudes appear to be the more critical areas of concern reported by women in the studies reviewed here, just as immigrant women's positive experiences of care centred around appreciation of being treated with kindness and respect and having their individual concerns addressed competently and sympathetically.
Two published systematic reviews of studies of immigrant women's experiences of childbirth and maternity care broadly support the findings about immigrant women's experiences from our five included countries [57,58]. The first is a recent systematic review which included 16 qualitative studies from six European countries (Greece, Ireland, Norway, Sweden, Switzerland and the     UK). It aimed to investigate immigrant women's needs and experiences of pregnancy and childbirth and found as we did, that good communication and information, an understanding of how care operates in their new homeland, caregivers who are respectful, non-discriminatory and kind, and achieving a safe pregnancy and birth are key aspects of what immigrant women wanted from their maternity care [57]. The second review [58] included 40 qualitative studies from Australia, Canada, Denmark, Ireland, Israel, Japan, Norway, South Africa, Sweden, and the USA. Aiming to explore aspects of intercultural caring from immigrant women's perspectives of their maternity care, the review concludes that addressing communication problems, providing continuity of care, addressing racism and discrimination and providing flexibility in care to accommodate individual and cultural diversity are likely to enhance immigrant women's experiences of maternity care. What the current review additionally offers is a comparison with non-immigrant women, previously missing in the literature.

Strengths and limitations
This review has drawn together the available populationbased studies of women's experiences of maternity care in order to assess what is known about immigrant compared with non-immigrant women's experiences. As immigrant women have often been under-represented in population-based research, we supplemented our review of these studies with the findings from studies focused on specific groups of immigrant women in each of the countries where population-based studies were identified. This is both a strength, and a limitation. It could be said that we are not comparing like with like, and that is true. Most of the specific immigrant studies are small and qualitative in design and the representativeness of the immigrant participants cannot be ascertained. On the other hand, synthesising the evidence from a range of study types for immigrant women, in an area where assembling representative samples is particularly difficult, has proved informative, particularly given the consistency that has emerged in the findings from both the population-based and the qualitative studies. Examining studies drawn from the same receiving countries is also a strength of this review. Had factors associated with different maternity care systems been important in shaping women's experiences of care, then this should have become apparent in comparisons of women's experiences in the different countries. It is significant that at least in relation to care in Australia, Canada, Sweden, the UK and the United States of America, women identify the same problems with care and articulate very similar wishes in relation to what they want from care when giving birth. We are not aware of other reviews that have as yet attempted to directly compare immigrant and non-immigrant women's experiences of care within and across countries, as we have done here.
Finally, this review is limited by the studies that have been conducted to date. Globally, relatively few countries have undertaken population-based studies of women's experiences of their maternity care. Of these, only the Canadian study has used a multi-language strategy in an attempt to address the under-representativeness of immigrant women in population studies, and the Australian research involved a companion study of three immigrant groups [28][29][30][31] in tandem with one of the three population surveys [4][5][6][7][8] undertaken there. It is also worth noting that the recent waves of migration between countries in the European Union and of refugee and asylum-seeking arrivals are not yet well represented in studies of women's experiences of maternity care.

Summary of the key findings
This review has found that immigrant and non-immigrant women appear to have very similar ideas about what they want from their maternity care, notwithstanding the diversity of countries and cultures of origin of the women represented in the reviewed studies. In regard to women's overall ratings of their maternity care however, immigrant women commonly gave poorer ratings of the care they received compared with non-immigrant women, and a range of additional challenges they faced tended to have negative impacts on their experiences of care. These chiefly included: communication difficulties due to language problems, lack of familiarity with how care was provided and experiences of discrimination.
Authors of the studies of immigrant women often recommended the need for more culturally sensitive care, with cultural competency training for maternity services staff seen as a means to this end. While in some studies immigrant women did comment on staff not understanding their cultural beliefs and practices, a careful examination of what women most commonly wantedas shown in Table 2 demonstrates that women themselves were focused more on the need for respectful care that was attentive to their individual needs, on assistance with communication difficulties and on receiving better information about how care is provided in their new country. Women in more than one study commented that staff cannot possibly 'know' every culture. Moreover, cultural beliefs and practices are not static phenomena, with considerable diversity among women from within any one culture with regard to adherence to particular traditions or beliefs, so that encouraging staff to ask all women about their childbirth preferences and beliefs is likely both to be more achievable, and also to result in more responsive care for all women, immigrant and nonimmigrant alike.
Notably in this review, women from a range of immigrant backgrounds in studies from all five receiving countries, reported problems with discrimination or prejudice in their experiences of care. If services are to take seriously what immigrant women say they want, then perhaps what is most needed to improve care is an enhanced focus on promoting equity and non-discriminatory attitudes in care provision, along with strategies aimed at improving communication (including training in working effectively with interpreters), and better recognition of the need to familiarise immigrant women with how maternity care is provided, so that they can more actively participate in decisions about their care and feel less anxious and disempowered about giving birth in their new country.

Conclusion
What this review has revealed is that improvements in immigrant women's often poorer ratings of care will only come if more attention is paid to addressing the additional challenges they face due to language difficulties, lack of familiarity with care systems and at times, exposure to discriminatory attitudes and poorer quality care. Proper recognition of these extra challenges is required in the provision of care. In addition, maternity staff need to be supportedwith time, resources and trainingto enable them to provide appropriate and non-discriminatory care to immigrant women, in accord with published declarations and standards of quality care for immigrant populations [59,60]. More inclusive approaches to enable the involvement of immigrant women in future populationbased studies of women's experiences of maternity care would also ensure that care improvements for immigrant women can be appropriately evaluated over time.

Additional file
Additional file 1: PRISMA checklist, including example search strategy.