Hora Soltani, Frankie J Fair, Liselotte Raben, Helen Watson, Maria van den Muijsenbergh, Maria Papadakakis, Tasos Mastrogiannakis, Mervi Jokinen, Eleanor Shaw, Eirini Sioti, Diederik Aarendonk, Diana Castro Sandoval, Artemis Markatou, Victoria Vivilaki
Due to political and economic hardship, migration to Europe is growing progressively (World Health Organization, 2018) impacting on population development and cultural diversity with its increased demand on health and social care in the host countries. A considerable proportion of migrants are childbearing women and families. Migration coupled with pregnancy could expose women to a vulnerable situation particularly with a lack of supportive family network, traumatic experiences through migration journey and a lack of familiarity with social care and health systems. Depending on their origin and experiences, migrant women may be at a higher risk of poorer pregnancy outcomes (Almeida & Caldas, 2013; Arcaya et al., 2015; Esscher et al., 2013; Hadgkiss & Renzaho, 2014; Hanegem et al., 2011; Hayes et al., 2011; Malin & Gissler, 2009; Nielsen & Krasnik, 2010; Pedersen et al., 2014; Rechel et al., 2013; Urquia et al., 2015; van den Akker & van Roosmalen, 2016; Van Oostrum et al., 2011; World Health Organization, 2018; Zwart et al., 2008). It is therefore important to provide appropriate perinatal services which are equitable, trauma aware and sensitive to the needs of a diverse range of communities (WHO Regional Committee for Europe, 2016). Through a project called “Operational Refugee and Migrant Mothers Approach (ORAMMA)” which was a three-site multidisciplinary research project funded by the European Union, we focussed on developing an integrated maternity care model for migrant women with the core elements of midwife-led continuity of care and peer supporters and tested the feasibility of its implementation in three different settings within Europe (Greece, The Netherlands and UK). This project has involved several overlapping approaches; first, systematically exploring the evidence about migrant women’s needs, their experiences of maternity care and current guidelines relevant to their care to develop a best-practice model of care, second, undertaking community engagement and recruiting maternity peer supporters (MPS), developing training materials for health care professionals and MPSs and finally implementing this model of care for migrant women during pregnancy, birth and the postpartum period. In this series, we are presenting a summary of a systematic review which explored perinatal care experiences of migrant mothers within European countries (Fair et al., 2020).
Using a systematic approach we assessed the state of literature on migrant women’s experiences of pregnancy, childbirth and maternity care in their destination European country (Fair et al., 2020). The following databases were searched for peer-reviewed articles published between 2007-2017: CINAHL, MEDLINE, PUBMED, PSYCHINFO and SCOPUS. Qualitative and mixed-methods studies with a relevant qualitative component were considered for inclusion if they explored any aspect of migrant women’s experiences of maternity care in Europe. A thematic synthesis was used to analyse the data.
Forty seven studies were included which were conducted in 14 European countries namely UK (Babatunde & Moreno-Leguizamon, 2012; Binder, Borne, et al., 2012; Binder, Johnsdotter, et al., 2012; Briscoe & Lavender, 2009; Choudhry & Wallace, 2012; Essén et al., 2011; R. Feldman, 2013; Gardner et al., 2014; Gaudion & Allotey, 2009; Hanley, 2007; Hufton & Raven, 2016; Lephard & Haith-Cooper, 2016; Leung, 2017; Phillimore, 2015; Straus et al., 2009; Treisman et al., 2014; Yeasmin & Regmi, 2013), Sweden (Byrskog et al., 2016; Hjelm et al., 2007; Lundberg & Gerezgiher, 2008; Ny et al., 2007; Ranji et al., 2012; Robertson, 2015), Norway (Garnweidner et al., 2013; Garnweidner-Holme et al., 2017; Glavin & Sæteren, 2016; Viken et al., 2015; Wandel et al., 2016), Portugal (Almeida et al., 2014; Almeida & Caldas, 2013; Coutinho et al., 2014; Topa et al., 2017), Netherlands (Gitsels-van der Wal et al., 2015; Jonkers et al., 2011; Schoevers et al., 2010), Ireland (Dempsey & Peeren, 2016; Szafranska & Gallagher, 2016; Tobin et al., 2014), Finland (Degni et al., 2014; Wikberg et al., 2012), Czech Republic (Velemínskỳ et al., 2014), France (Sauvegrain et al., 2017), Germany (Petruschke et al., 2016), Greece (Iliadi, 2008), Italy (Baken et al., 2007), Spain (Barona-Vilar et al., 2013) and Switzerland (Bollini et al., 2007). These were all focused on the experiences of women who were described as refugees, asylum seekers or migrants. The sample size in these studies varied from four to 193 participants and included a total of 1330 migrant women.
Four overarching analytical themes emerged from the literature which are discussed below.
1) Access to services and finding the way
Before accessing maternity care women considered the value of care. They weighed up the consequences of accessing care, particularly when they lacked trust in healthcare providers or were fearful that their visibility in maternity services could result in deportation. For some migrant women who wanted to access care, there were difficulties in finding the way into an unfamiliar system that was different to that of their country of origin and where the women were often unaware of their rights and entitlement to care as well as a lack of information about the services that were available to them. Previous experiences also meant some women did not perceive a need for frequent antenatal care. Other issues included cost of transportation, concerns over having to pay for care and lack of flexibility in timing or location of appointments. There were also barriers such as the rigid use of telephone appointment booking systems which women found too challenging to navigate in a new language.
2) Communication issues and Lack of cultural understanding
Language barriers were significant problems which sometimes hindered accurate information sharing and led to a lack of understanding of procedures for which women were asked to provide consent. Providing appropriate interpreters seemed to be a challenge, raising the debate about the use of relatives as interpreters. Women should be given an opportunity to choose between relatives or professional interpreters before each consultation to ensure suitable information sharing. Any professional interpreter should have appropriate training to understand related medical terms, as well as the importance of data protection and confidentiality. Professional interpreters are particularly important for sensitive matters such as undertaking universal screening for domestic violence.
Women identified a lack of information around pregnancy, childbirth or the postpartum period, especially in an accessible language or formal. Professional advice sometimes conflicted with cultural and family advice and this left women feeling unsure about which actions to take. Women’s cultural backgrounds influenced some of their preferences and beliefs about care. Experiences in their country of origin also influenced their expectation of the need for medical surveillance and interventions during pregnancy and childbirth and meant procedures which were familiar to practitioners were not always familiar to women.
3) Quality of care
Healthcare providers’ attitude was an important factor in how migrant women perceived the quality of care. Some women found providers to be unfriendly and disrespectful, failing to respond to their concerns in a caring manner, ignoring them and not taking their complaints seriously. When encountering the healthcare system, some migrant women expressed a sense of being seen and treated differently. Prejudice and stereotyping by healthcare providers led to assumptions based on women’s perceived cultural backgrounds and left them feeling that their needs were overlooked. In contrast some providers overly focussed on cultural and psychosocial factors when assessing patient’s symptoms, and therefore overlook potentially serious medical conditions.
Women valued healthcare providers who were encouraging and reassuring, supportive, respectful, good listeners and good information-providers. Women also appreciated providers who demonstrated cultural sensitivity, although this did not necessarily require an in-depth knowledge of individual customs and traditions. Overall, some migrant women described exemplary care, receiving treatment that was empathetic, caring, culturally sensitive and compassionate, while other migrants reported discrimination. Continuity of care was also seen as an important factor in establishing trusting relationships. Individualised care, with friendly, unhurried healthcare providers encouraged women to attend for maternity care and positively influenced their sense of well-being.
4) My needs go beyond clinical care
Many migrant women presented with needs outside the ordinary remit of maternity healthcare provision. Preoccupation with financial difficulties and poor living conditions often impacted on their ability to focus on the pregnancy. Financial pressures such as difficulties covering basic living costs, transport to appointments and costs of essential care, as well as concerns about being allowed to work or employment insecurity in the host country, negatively influenced the experiences of these women. Living condition were significant factors contributing to undesirable health experiences. Concerns included living in temporary or shared accommodation, poor housing conditions and the impact of dispersal, whereby women were moved by migration authorities to new, unknown areas within the host country.
Above all limited social support and the absence of family and friends’ network left many migrant childbearing women feeling lonely, isolated, hopeless and distressed. More importantly for some migrant women the burden of traumatic experiences prior to or during migration or experiences of discrimination led to a sense of losing identity and stresses; these often became evident as pain and illness in their body.
A wide range of psychosocial issues have been identified as significant contributing factors impacting on migrant women’s experiences of perinatal care within Europe, which are aligned with the well-known wider determinants of health (Farley et al., 2006; P. J. Feldman et al., 2000; Kruger et al., 2011; Marmot et al., 2019; Parker et al., 1994; Stillerman et al., 2008). Therefore to meet the unique needs of migrant women, care is required which goes beyond traditional models; addressing social and mental wellbeing alongside physical wellbeing of mothers and their infants (Graham et al., 2016). This requires closer cross-agency working with effective collaboration between healthcare, social care, the voluntary sector and communities (World Health Organization, 2018). To address the social determinants of health and avoid discrimination it calls for person-centred, high-quality, continuity of care that incorporates aspects of cultural competency and trauma aware care . Maternity services should develop trauma-informed care through staff training, by reviewing policies and procedures through a compassionate lens, and developing pathways of support to meet the needs of these vulnerable women (Sperlich et al., 2017).
Implications for practice and research
Migrant women need culturally-competent healthcare providers who provide equitable, high quality and trauma-informed maternity care, undergirded by interdisciplinary and cross-agency team-working and continuity of care. New models of maternity care are needed which go beyond clinical care and address migrant women’s unique socioeconomic and psychosocial needs. In light of this review and expert input an eLearning package was developed for health care professionals available from https://oramma.eu/e-course/
Funding was received from the Consumers, Health, Agriculture and Food Executive Agency (CHAFEA) of the European Commission Grant Number 738148. The content of this article represents the views of the authors only and is their sole responsibility, it cannot be considered to reflect the views of the European Commission and/or the Consumers, Health, Agriculture and Food Executive Agency or any other body of the European Union. The European Commission and the Agency do not accept any responsibility for use that may be made of the information it contains.
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