Pregnant Single and Far From Home Migrant Women in Nineteenth-century Paris Review Article

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Open Access

Peer-reviewed

Enquiry Article

Migrant women's experiences of pregnancy, childbirth and motherhood care in European countries: A systematic review

• Frankie Off-white,
• Liselotte Raben,
• Helen Watson,
• Victoria Vivilaki,
• Maria van den Muijsenbergh,
• Hora Soltani,
• the ORAMMA team

ten

• Published: Feb xi, 2020
• https://doi.org/10.1371/journal.pone.0228378

Figures

Abstruse

Background

Across Europe in that location are increasing numbers of migrant women who are of childbearing age. Migrant women are at chance of poorer pregnancy outcomes. Models of maternity intendance demand to be designed to run across the needs of all women in club to ensure equitable access to services and to accost health inequalities.

Objective

To provide up-to-engagement systematic prove on migrant women's experiences of pregnancy, childbirth and maternity intendance in their destination European country.

Search strategy

CINAHL, MEDLINE, PubMed, PsycINFO and Scopus were searched for peer-reviewed articles published between 2007 and 2017.

Selection criteria

Qualitative and mixed-methods studies with a relevant qualitative component were considered for inclusion if they explored any attribute of migrant women's experiences of maternity care in Europe.

Information drove and analysis

Qualitative information were extracted and analysed using thematic synthesis.

Results

The search identified 7472 articles, of which 51 were eligible and included. Studies were conducted in 14 European countries and focused on women described as migrants, refugees or asylum seekers. Iv overarching themes emerged: 'Finding the fashion—the experience of navigating the system in a new place', 'We don't understand each other', 'The way you lot care for me matters', and 'My needs become beyond being pregnant'.

Conclusions

Migrant women need culturally-competent healthcare providers who provide equitable, high quality and trauma-informed maternity intendance, undergirded by interdisciplinary and cross-agency team-working and continuity of intendance. New models of maternity care are needed which go beyond clinical care and address migrant women's unique socioeconomic and psychosocial needs.

Commendation: Fair F, Raben L, Watson H, Vivilaki V, van den Muijsenbergh M, Soltani H, et al. (2020) Migrant women'south experiences of pregnancy, childbirth and motherhood care in European countries: A systematic review. PLoS ONE xv(2): e0228378. https://doi.org/10.1371/journal.pone.0228378

Editor: Nihaya Daoud, Ben-Gurion University of the Negev Faculty of Health Sciences, ISRAEL

Received: May 17, 2019; Accustomed: January 14, 2020; Published: February xi, 2020

Copyright: © 2020 Off-white et al. This is an open access commodity distributed under the terms of the Artistic Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original writer and source are credited.

Information Availability: All relevant data are within the paper and its Supporting Information files.

Funding: MM,HS & VV - grant received from the Consumers, Health, Agriculture and Food Executive Agency (CHAFEA) of the European Committee Grant Number 738148. http://ec.europa.eu/chafea/index_en.htm The funders had no role in report pattern, data drove and analysis, determination to publish, or preparation of the manuscript.

Competing interests: The authors have declared that no competing interests exist.

Introduction

International migration continues to grow quickly [one]. Betwixt 2000 and 2017, the migrant population increased by 85 million, from 173 to 258 million [1]. In 2017, more than 90 million international migrants were residing in the World Health System (WHO) European region and more half of these migrants were women, many of childbearing age [2]. There are no universally accustomed definitions for a migrant at an international level [2] and this heterogeneous group includes individuals who vary by length of stay in a country, documentation and residency status, movement existence voluntary or forced, and reasons for migration [2,3]. Health needs and outcomes in this heterogeneous group is a circuitous topic, as these are influenced by the interaction of the process of migration and exposure to risks and access to the determinants of health in the country of origin, during transit and in the destination land [ii].

On average the fertility rate in the migration population is college than the native population [4]. Among women living in the United Kingdom, birth data from 2015 show a total fertility rate (the average number of children a adult female has in her lifetime) of 2.06 for non-UK built-in women versus 1.75 for Uk born women [5]. Pregnancy is a period of increased vulnerability for migrant women [6,7]. There is a consequent trend for poorer pregnancy outcomes amidst migrant women [two] who are at greater hazard of maternal and neonatal morbidity and bloodshed when compared to native born women [2,8–17]. This is a result of the circuitous interplay of multiple factors including substandard healthcare in the land of origin [2] and issues around accessing care and the quality of care in the new state [2,14,18]. Moreover, migration itself can have significant negative consequences for people's physical and mental health and their wellbeing due to migration-related social bug, similar poor socio-economical status, bigotry and social exclusion, multiple losses, and the chronic stress caused by these [19–21]. It is often observed that migrants leaving their country of origin are healthier than comparable native populations. This phenomenon has been chosen the "healthy migrant effect" and is normally explained through the positive self-selection of immigrants and the positive option, screening and discrimination applied by host countries [22]. But, although often healthy when arriving in the state, the health of migrants deteriorates over fourth dimension, and in general, they charge per unit themselves to accept poorer health compared to the native population of their host countries [twenty].

Across the WHO European region there is consensus and commitment to ensure the availability, accessibility, affordability and quality of essential health services for migrants in transit and host environments [23]. Hence European countries have a common responsibility to tackle inequalities and provide high quality healthcare that meets the needs of childbearing migrant women. However across European Union (EU) member states, the services provided for migrants and how they are administered, financed and delivered differs between countries; with some providing care free of charge, some requiring health insurance and some available to those making national insurance contributions through a place of piece of work [24].

A previous qualitative evidence synthesis [25] has explored both migrant women'south care experiences and their perceived care needs for data published prior to June 2010. Still, an updated review was deemed important with the acknowledgement that changing global, political and economic climates take led to increased migration into Europe [2,26]. This includes recent political unrest and conflict in many Heart Eastern and Sub-Saharan countries [26], the updated rights of costless movement of citizens and their families within the European Economic Area laid downward in a Directive in 2004 [27] and an increased recognition of the need to integrate the health needs of migrants and refugees into national health strategies [2]. This review therefore aimed to provide upwards-to-date systematic evidence on migrant women's experiences of pregnancy, childbirth and maternity care in their destination country within Europe.

Methods

A systematic search of five databases was undertaken to identify articles pertaining to migrant women's experiences of pregnancy and maternity intendance in their destination state. The following databases were searched; CINAHL, MEDLINE, PUBMED, PSYCHINFO and SCOPUS. Databases were searched from 2007 until the final search on 22/05/2017. The indicate of commencement was taken equally 2007 due to the changing political landscape within the Eu at that indicate, with the health of migrants existence a focus of the European union president in 2007 [28]. The search strategy comprised of three facets, with terms relating to (i) migrant (ii) maternity and (iii) feel. The Boolean operators AND and OR were used alongside truncation operators and phrase-searching, and the search syntax was adjusted for each database. The full search strategy, as applied in MEDLINE (EBSCO interface) is provided in S1 File. In addition to the electronic database search, the reference lists of eligible studies were examined to identify any other relevant studies and citation tracking was undertaken.

Study selection and data extraction

Screening of the titles and abstracts against the inclusion and exclusion criteria in Table 1 was carried out by two researchers independently. This was followed by double-screening the total-text of potentially relevant sources. Whatever disagreements concerning eligibility were resolved through discussion between team members. Study characteristics and all qualitative data that related to women's experiences of any attribute of maternity care within the host country were extracted using a standardised class.

Disquisitional appraisement

Included articles were quality appraised using the qualitative National Institute for Health and Care Excellence (Dainty) critique tool [29] (run across S2 File) and 10% were appraised by a second reviewer to ensure consistency. A low-quality score (-) was assigned if either near criteria were not met, or it was judged that in that location were significant flaws in the study pattern. The commodity was classified equally moderate quality (+) if virtually criteria were met and information technology was identified that there may be some flaws in the study resulting in a lack of rigor. A loftier-quality score (++) required that the majority of the appraisal criteria were met and the study was judged to be trustworthy and reliable and there was meaning prove of author reflexivity.

Bear witness synthesis

A thematic synthesis was undertaken involving 3 carve up steps; i) line by line coding calculation new codes to the 'banking concern' of codes as required, two) organising codes into descriptive themes according to their similarities or differences and using new codes to capture the grouping of original codes, iii) generating analytical themes [xxx]. Coding was undertaken using NVivo and Atlas.ti packages. A total of 28% of the articles were double-coded, and development of the last analytic themes involved discussion with the whole research team to achieve consensus.

Confidence in the findings

The confidence in the findings of this review was assessed independently by two reviewers using the Confidence in the Evidence from Reviews of Qualitative Research (CERQual) approach [31,32]. This assesses conviction in the evidence base in 4 components: (i) methodological limitations which evaluates any methodological concerns in the chief studies contributing to the review finding, (2) relevance to the review question evaluates the applicability of primary study data to the context specified in the review question, (iii) coherence which evaluates the fit betwixt the master study's information and the review finding information technology contributes to and (iv) adequacy of the data which evaluates the richness and quantity of primary study data for each review finding [33]. An overall judgement for conviction in each review finding of 'high', 'moderate' or 'low' was determined based on evaluation of the four components.

Results

A flow diagram of the study selection process tin can be seen in Fig ane. A total of 7472 citations were initially identified out of which 51 articles (47 studies) were included.

Description of included studies

The characteristics of the included studies can be seen in Table two and the reasons for exclusion at abstract and full text can be found in S3 File. Of the 47 included studies, 43 exclusively used qualitative methodology and four adopted a mixed methods approach and reported relevant qualitative information [34–37]. Individual interviews were exclusively undertaken in 27 of the studies [8,38–63] and focus groups in five studies [64–68]. Multiple methods of information collection were used in fourteen studies [34–36,69–79] including eight which conducted both interviews and focus groups with different groups of women [69,71–75,77,79]. One study used a questionnaire which included relevant qualitative data [37]. Studies were undertaken in 14 European countries, ranged in size from four [70] to 193 [37] participants and included a total of 1330 migrant women, although one report did not specify the number of participants and could non be included in this number [34]. The majority of studies (n = 34) were published from 2012 onwards. A full of seven studies were rated as loftier quality [35,40,60,64,67,71,74], 22 were of moderate quality [38,39,41,43,45,46,48,53,55–57,61–63,65,70,73,75–79] and xviii of low quality [8,34,36,37,42,44,47,49–52,54,58,59,66,68,69,72].

Information synthesis

4 overarching analytic themes emerged from the literature.

Finding the way—navigating the system in a new place.

Weighing it up. Before accessing maternity care women considered the value [35,51,52,60,81,82], and necessity [65] of care. They also weighed up the financial costs of accessing care [37,49,61], and the consequences of accessing care, particularly when they had a lack of trust in healthcare providers (HCPs) [39,75], previous poor experiences with HCPs [38], or were fearful that their visibility in motherhood services could result in deportation [35,36,66,82].

"I had my first daughter when I was illegal, information technology has been a terrible experience fifty-fifty though my sister helped me, I was always fearing that someone would knock at the door and would send us back to Portugal… Fifty-fifty when I had contractions I was afraid to go to the hospital fearing to be sent back to Portugal." (Bollini et al 2007, pp.82) [66]

Finding the way in and through the system. For some migrant women who wanted to access care, at that place were difficulties in finding the mode into the system. The system was unfamiliar and different to that of their country of origin and the women were often unaware of their rights and entitlement to care [34,36,42,53,61,65,72,78,82,83]. There was a lack of information about the services that were available and if the services were gratis [36,53,61,82]. Some women faced difficulties in being accepted for registration for primary healthcare services [36,53,82], were refused entry to healthcare facilities [75], and struggled to provide the required documentation or insurance that were prerequisites for care [66,80]. Having friends and relatives who had already settled in the new state and could speak the local language helped migrant women observe the way into the system, along with NGOs who provided information about entitlement and available services [36,51]. Women being held in detention centres were isolated from these sources of assist and reported that the mode into the arrangement was blocked past detention centre staff who refused or delayed their access to intendance [35,53].

"The Domicile Office put me in detention eye so I could non attend my appointments. There were no maternity services there for me for the ii months I was in that location. I was offered appointments merely they were cancelled at short discover without anyone telling me why." (Phillimore 2015, pp.576) [35]

Costs related to transportation and payment for care were identified every bit factors influencing ongoing access to care [34,44,53,61,83]. Those who received free care identified that this enabled them to access care, which was frequently in contrast to the situation in their state of origin [37,49,67,81]. Flexibility in the system in relation to the timing and location of appointments influenced access [61,65,70]. Inflexibility in the system, such as the rigid use of telephone booking systems for appointments were an ongoing bulwark that women faced when trying to navigate the system in a new linguistic communication [34,75,82].

"I get so nervous to communicate through the telephone, is so difficult … instead I go there to get an engagement but they tell me I take to phone …Why?" (Robertson 2015, pp.62) [75]

We don't empathise each other.

Women highlighted that information, advice and the opportunity to talk over their health and the health of their unborn child with a HCP was extremely important to them [63,74,78]. However, they identified a range of issues related to advice and understanding which are discussed in the sub-themes; Overcoming linguistic communication barriers, Unmet information needs and Different expectations of intendance.

Overcoming language barriers. Women faced significant language barriers in the new country and felt that their language difficulties made them problem patients [69], that impacted on their relationship with their HCPs [37,53,66,78]. Fifty-fifty when women could proficiently manage everyday situations, they nevertheless often lacked the vocabulary to cope with medical terminology [53,58,70,75].

"I asked them, "[Can] nosotros cancel the meeting until we get an interpreter… I didn't sympathise you and yous didn't understand me." She said, "No, it'southward OK, nosotros can go on—you sympathise English."' (Lephard & Haith-Cooper 2016, pp. 134) [53]

Failure to use professional interpreters was a bulwark to receiving satisfactory care [38,44,58,60,69,83], hindered accurate data sharing and led to frequent misinterpretation [52,70,81] and a lack of understanding of procedures women were asked to give consent for [35,52,threescore].

"They [midwives] communicated by sign language and I was never sure I had understood properly." (Briscoe & Lavender 2009, pp.twenty) [707]

However, the utilise of professional interpreters was met with caution when discussing intimate or difficult matters [47,69,74,82] or when women had come from areas of persecution leaving them suspicious of anybody [75]. When women's partners were asked to interpret during intendance encounters some women felt vulnerable [35,82,83] and embarrassed [51,74] and felt that their partners were reluctant to reveal their own poor understanding [52,70,74].

"If I could have someone who is not my husband it could make a big deviation because throughout my pregnancy I did not say annihilation about my needs or problems. My husband was saying everything." (Phillimore 2015 pp.576) [35]

Unmet information needs. Women identified a lack of information around pregnancy, childbirth or the postpartum menstruum, and a lack of data that was bachelor in an accessible language or format [8,35,37,46–50,52,58,64,66,seventy–72,75–79,81–83]. Professional advice often conflicted with cultural and family advice [41,46,49,54,63,77–79] and this left women feeling insecure about which actions to take [46,63,77].

"I did not give water, and I was criticized by my family and relatives. They told me: He is a man being, he gets thirsty and that milk does non quench thirst… while the wellness clinic said: no, he does not need h2o" (Wandal et al 2016, pp.4) [77]

Women too identified that their care and safety were adversely affected when they did not disclose of import data to HCPs, as did non want to be a nuisance or failed to sympathise the importance of their health history or potential seriousness of their electric current or previous symptoms [52,76].

"I thought: it is a holiday, I do not want to exist a trouble for someone. I will try to go Monday or Tuesday after the holidays. But I retrieve at present: why did I wait ? Why didn't I phone immediately ?" (Jonkers et al 2011, pp.149) [52]

Different expectations of intendance. Some women reported being fearful of being treated poorly in the new country when their expectation of maternity care was based on poor experiences in their country of origin [60,61].

"I was so scared of them (the midwives)… I thought they would crush me…if I scream or if I cry. So in labour I don't speak, then that I don't upset them." (Tobin et al 2014, pp.836) [sixty]

Procedures which were familiar to practitioners were not always familiar to women coming from other care systems [eight,seventy], and this caused women to feel fearful [60,82] and to lack trust in the information provided by HCPs [39].

"They were putting all those funny cords around me which were so tight, so irritating, I didn't know what those were, I never had seen them earlier. It's like going to another planet and yous are seeing all these things which are happening to you and y'all can't ask annihilation." (Tobin et al 2014, pp.836) [60]

Women's cultural backgrounds influenced some of their preferences [39,56,60,71] and beliefs virtually procedures [49,55,67,70,71,81] and the mode they wanted to discuss these [56,74]. Experiences in their country of origin influenced their expectation of the need for medical surveillance and interventions during pregnancy and childbirth [8,42,43,63,80,81].

"According to our religion, we Somali women, we don't think that giving birth by caesarean department is a good affair and that a woman should give birth by vagina and not past opening her stomach to accept the baby out. Somali women'south general belief is that caesarean birth is not a real way of a adult female to give nativity. And how many times doctors will cut her breadbasket if she has to deliver many times in her life?" (Degni et al 2014, pp.357) [67]

"I constitute it extremely friendly but very low in real medicine? It'south all midwife based, no exams, which is very strange for me". (Dempsey & Peeren 2016, pp.377) [43]

The way you care for me matters.

Impact of poor care. The HCPs attitude was an important factor in how migrant women perceived the quality of intendance. Some women found HCPs to be unfriendly [67,74] and disrespectful [63,81], declining to respond to their concerns in a caring matter, ignoring them [74,75] and non taking their complaints seriously [49,52,66,74,75]. This fabricated women dubiousness their own capabilities [75]. Unsatisfactory interactions with HCPs often led to a lack of connexion and poor relationships with HCPs which resulted in women feeling isolated and fearful of existence mistreated [sixty].

"Actually they should accept asked in a friendly manner if we needed help…information technology was a very unpleasant experience, I felt like an idiot, equally totally incompetent." (Robertson, 2015, pp.63) [75]

When encountering the healthcare arrangement, migrant women expressed a sense of existence seen and treated differently [37,l,53,75,76]. Many women felt that their customs and civilisation were not understood by those caring for them [35,37,45,54,55,64,67,76,78,83]. Prejudice and stereotyping by HCPs [eight,35,37,57,58,66,75,77,78] led to assumptions based on women'south perceived cultural backgrounds and left them feeling that their needs were disregarded [35,52,53]. In contrast some HCPs were noted to overly focus on cultural and psychosocial factors when assessing patient's symptoms, and therefore overlook potentially serious medical weather condition [l,67].

"I recollect that people that work in the wellness care settings … the doctors, the nurses, the midwives and even cleaners need pedagogy in unlike cultures. They need to understand that patients from different cultures and race are not inferiors and non …monsters." (Degni et al 2014, pp.360) [67]

Migrant women highlighted several other factors which resulted in inadequate and ineffective care including; long waiting times for appointments [61,lxxx], the perceived busyness of HCPs which prevented women sharing their anxieties and concerns [70,81,82], inadequate noesis of legislation by administrative staff [80], not beingness involved in controlling [80], and limited access to specialist intendance [lxxx].

Importance of good care. Women stressed the importance of good quality intendance and reported several examples from their experiences. They valued HCPs who were encouraging and reassuring [50,60,77], supportive [43,46,50,70,75] good listeners [50,71] and good information-providers [50,57,74]. Moreover, they wanted to exist cared for by HCPs who had a respectful mental attitude [43,48,62,74], made them feel emotionally safe [43] and would take their concerns seriously [75]. Women as well appreciated HCPs who demonstrated cultural sensitivity, although this did not necessarily require an in-depth knowledge of individual community and traditions [48,78].

'You lot know when I talk most myself I experience proficient nigh it because I know in that location's someone who's listening and understanding which makes me feel better.' (Briscoe & Lavander 2009, pp.twenty) [70]

Good care encompassed a trusting relationship betwixt women and HCPs, which empowered women to feel confident and prepared for childbirth [63,75,78], even overcoming a lack of social networks or back up [75].

"When one feels well-treated and cared for, ane never forgets it…peculiarly when you experience alone and vulnerable with a lot of need of support…information technology is worth and then much." (Robertson 2015, pp.63) [75]

Continuity of care was seen as an important factor in establishing these trusting relationships [51,58,63,75,78,81]. Individualised intendance, with friendly, unhurried HCPs encouraged women to attend for motherhood care and positively influenced their sense of well-being [37,74,81]. Fragmented care given past different midwives negatively influenced the effectiveness of intendance and the women's conviction to attend appointments [82].

"For example, when I was struck by panic again, I went to the delivery ward, and there was the same midwife, and (she) immediately knew me. Yes, she remembered the name and that it was the kickoff pregnancy, it was nice.. .. Information technology felt like she was a relative." (Wikberg et al 2012, pp.644) [78]

Women likewise identified that skillful care required facilities that were hygienic [37,74] and promoted privacy [81] and informed pick [74,78].

My needs go beyond being meaning.

Many migrant women presented to their HCPs and to the researchers in the primary studies with needs that were outside the ordinary remit of maternity healthcare provision and across the issue of their pregnancy. Preoccupation with these other needs impacted on their time and power to focus on the pregnancy [35,36,62].

"I was and so busy to survive, to detect nutrient, and shelter. I merely did not recollect of antenatal checks at all." (Schoevers et al 2010, pp.260) [36]

Financial difficulties and poor living weather. Fiscal pressures were identified past many migrant women which led to difficulties covering basic living costs [35,82,83], ship to appointments [35,53,72,82,83] and costs of essential care [51]. This was exacerbated by non being allowed to piece of work in the host country [35,66,70,82] or difficultly securing a job [49,63,74,75]. Although some women encountered actual or feared employment insecurity [35,61,65,66,82] and exploitation [66], others appreciated the protection of national employment laws [81].

"worst aspect I recall during pregnancy he want to dismiss me […] but could not, could non because I had my rights, […] just he fired me presently after the birth of my daughter" (Topa et al 2017 pp.115) [61]

Concerns over living atmospheric condition were likewise mutual [44,52,53,62,66,70,73,83] and included; living in temporary [seventy] or shared accommodation [44,53], poor housing conditions [44,lxx] and the impact of dispersal [35,44,53,lxx,73,82], whereby women were moved by migration government to new, unknown areas within the host land. This increased women's feelings of stress [44] and powerlessness [70].

"They give me a [hotel] room… [It was] very small, information technology was smelling of cigarettes. The duvet was very dingy. The bed… the walls… everything was very muddied." (Lephard & Haith-Cooper 2016, pp.132) [53]

"They were maxim they're taking me to Birmingham. I had no one in Birmingham. I don't know anyone at all in Birmingham. I was similar Oh God, where are they taking me?" (Briscoe & Lavendar 2009, pp.21) [70]

The brunt of traumatic experiences. Many childbearing women had experienced trauma or persecution prior to or during migration [45,52,60–63,75], and the resulting stress oftentimes became evident as pain and illness in their trunk [75]. These experiences left women with a lost or negative sense of identity [45,58,70] and existence unwilling to trust their interpretations of their bodily symptoms [75].

''People were killed; I survived, because they idea I was dead, you tin can see the scars on my confront, where the bullets entered my face … They did what they wanted with u.s.a., beating u.s., having rape parties" (Treisman et al 2014, pp.150) [62]

Social support and relationship issues. Childbearing women who had family present in their destination country appreciated their assistance with domestic tasks [49,68,79] and their guidance [49,74,79,81], and support [56,59,71]. However, many migrant childbearing women lacked this social back up and this left them feeling lonely [45,51,53,sixty,63,64,73,78,83], isolated [35,44,45,47,49,58,60,70,74,78,79], hopeless [51] and deeply distressed [37,60,lxx,74]. Women were particularly aware of the lack of support from their own mothers [45,53,lx,74,78,81] and highlighted that beingness able to contact family members was important [63]. Without family back up women were worried almost having no i to ask for advice [74,78,81], found raising children more hard [74,77,81] and felt that the changes in societal roles [61,75] and lack of other social support [40] caused tension in the relationship with their partners [75].

"This was my first infant, I was afraid and besides I don't have family here… and was crying all the fourth dimension and very lonely." (Babatunde & Moreno-Leguizamon 2012, pp.5) [64]

Women who experienced domestic violence were restricted from talking about this as information technology was often non acceptable within their civilisation [47] and they were not always aware that violence was forbidden in the destination land [47]. Where the woman experiencing abuse was also dependent upon the partners' family for communication with HCPs it left her unable to talk openly about her circumstances or to study pregnancy problems [35]. Although the midwife was seen equally a resource to signpost to domestic violence support services by some [40], others were unsure if a midwife could help them [40,47].

"…I don't believe a Somali woman would get and tell her (the midwife) if she is having bug or anything like that…if it has gone far plenty that a adult female has decided to report the human, and then she knows she can call the police force, or that she tin can get help from friends instead". (Byrskog et al 2016, pp. 12) [40]

CERQual assessment

The summary scores from the CERQual cess of confidence in the findings can be seen in Table 3 and full details are shown in S4 File. A total of 16 findings were assessed, with twelve scoring high conviction and iii scoring moderate confidence and one scoring low confidence.

Discussion

Main findings

Migrant women's struggles with communication and linguistic communication barriers are recurrent themes within this and previous reviews. Migrant women study a poor agreement of medical terminology [25] and still there is inadequate employ of interpreters within the healthcare system [25,84]. Poor advice and the provision of insufficient information impact on women'due south ability to cull appropriate care options and provide informed consent [25,84–87]. An inability to converse in the local language also means women discover information technology difficult to establish a relationship with their care provider and this impacts upon women accessing care [25,84,88,89]. HCPs can help women to overcome linguistic communication barriers by providing appropriate information, engaging professional person interpreters more frequently and ensuring they give women the opportunity to inquire the questions that they take [90–99].

In line with other studies [25,85–87,89,100,101], a lack of agreement betwixt migrants and HCPs in terms of their traditional customs and their expectations of maternity care was plant to impact upon their access of services. The bug conspicuously signal to a need for HCPs to receive education and training in culturally competent care to better place women'due south expectations of intendance and how to sympathise and appropriately respond to women'due south needs related to their cultural groundwork, to ensure constructive maternity care and reduce barriers to accessing care [22].

Women'southward fear of deportation impacting upon use of services identified within this review is in line with previous literature [88] as is lack of awareness of entitlements to maternity care [86]. The United nations, to which all European countries vest, has adult the Convention on the Elimination of all Forms of Discrimination Confronting Women [102] which states that all maternity services, including routine antenatal treatment, must exist treated as existence immediately necessary; 'No woman must ever be denied, or have delayed, motherhood services due to charging issues' (Department of Health and Social Care (2018) p. 67) [103]. Healthcare providers demand to ensure the provision of adequate back up and timely advice for migrant mothers on their entitlements to intendance to allay fears and improve admission to intendance, with the ultimate aim of reducing pregnancy complications.

While the good for you migrant miracle may mean that some migrants are healthier than the native population [22]; a theme which emerged particularly strongly within this review is that to meet the unique needs of many migrant women there is a necessity for care which goes beyond traditional models. Other academic studies and reports accept highlighted migrant women'south unstable or inappropriate living conditions, their financial struggles [25,89,104,105] and the enormous burden of loneliness and the lack of a family network effectually them [25,85,100,104–106]. As the wider determinants of health are well recognised [107], including intimate partner violence [108], depression health literacy [109–111], express social support [112]; addressing social and mental wellbeing alongside physical wellbeing is seen equally important for the overall health of mothers and their infants [113]. Addressing the wider determinants of wellness which impact on migrant women requires closer cross-agency working with constructive collaboration between healthcare, social care, the voluntary sector and communities [2]. This current review too highlighted that many migrant women accept experienced trauma prior to and during migration, which is widely recognised to impact on mental wellness and wellbeing in the destination state [114]. Maternity services should develop trauma-informed care [115] to promote a culture of safety and avoid re-traumatisation through staff training and reviewing policies and procedures through a trauma lens and developing pathways of support to meet the needs of these vulnerable women [115].

Some migrant women described exemplary intendance, receiving handling that was compassionate, caring, culturally sensitive and compassionate. However other migrants reported discrimination prevalent in the HCPs that they encountered. Care is seen to be impacted where women do not feel well treated or where they feel discriminated confronting [84,85], while unrushed, kind, empathetic HCPs are appreciated [25,84,85]. Our findings suggest that continuity of care increases migrant women's satisfaction with maternity care. This is in line with the Cochrane review into continuity of midwife intendance models which has establish increased satisfaction reported by women receiving continuity by a known midwife, too as reduced rates of preterm birth and perinatal death [116]. To address the social determinants of wellness and avoid discriminating against migrant women, it calls for person-centred, high-quality, continuity of intendance that incorporates aspects of cultural competency and trauma aware intendance. The evidence within this review, alongside other show, led to the development of the ORAMMA integrated perinatal care model [117]. This model has been feasibility tested and volition be reported in farther articles currently under development. Other known integrated healthcare models include Customs Orientated Primary Care [118,119], besides as the integrated approach adult within the European Refugees-Human Move and Informational Network (EUR-Man) project [120].

Strengths and limitations

This review provides up-to-date, systematic evidence located using a comprehensive search undertaken past a multidisciplinary team. Assessing confidence in the evidence using the CERQual arroyo is a further strength of this review. The review is strengthened past the inclusion of a large number of eligible studies set in xiv dissimilar European countries which included migrant women from a wide range of countries of origin. However, some papers did not provide a articulate or consistent definition for the term 'migrant' or provide details virtually how recently the women within their study had arrived in the host country, the specific country of origin or the reason for migration. Hence, some issues that may be more pertinent to particular migrants may not exist visible within this synthesis. This review focussed exclusively on migrant women'southward experiences of maternity care within European host countries. It is recognised that many experiences may overlap with migrant experiences beyond other world regions for example social isolation, language and cultural barriers. Notwithstanding, to ensure local applicability further in-depth investigation would be required on country or community specific factors influencing migrant experiences.

Conclusion

There are several implications for do and research from this review.

• It is important that migrant women feel understood. Professional interpreters should be provided at each engagement/care encounter to enable HCPs to heed to women and build a friendly, trusting relationship with women.
• HCPs should avoid stereotyping and respect and adapt traditional or cultural practices that are relevant in the perinatal menses.
• Migrant women'south needs go across their pregnancy and include psychosocial-emotional and economic challenges. To address these needs cantankerous-agency working is needed alongside culturally competent and trauma-informed models of maternity intendance that incorporates continuity.
• Hereafter research should focus on providing robust evidence on clinical perinatal outcomes for migrant mothers and explore the needs of different migrant populations to facilitate development of tailored interventions.

Supporting information

Acknowledgments

ORAMMA team members are:

M Papadakaki Department of Social Piece of work, School of Health Sciences, Hellenic Mediterranean University, Heraklion, Greece; M Jokinen Exercise and Standards Professional Counselor, The Royal College of Midwives, London, UK; President of European Midwives Association (EMA) and Vice Chair European Forum for National Nurses and Midwives Associations (EFNNMA); E Shaw Heart for the History of Science, Technology and Medicine at the University of Manchester, Manchester, Uk; Eastward Sioti Department of Midwifery, Kinesthesia of Health and Caring Sciences, University of West Attica, Athens, Hellenic republic; T. Mastrogiannakis CMT Prooptiki, Athens, Hellenic republic; A Markatou CMT Prooptiki, Athens, Hellenic republic; D Aarendonk European Forum for Primary Care, Utrecht, Netherlands; and D Castro Sandoval European Forum for Primary Care, Utrecht, Netherlands.

Co-ordinator for the ORAMMA consortium is Victoria Vivilaki, email: v_vivilaki@yahoo.co.uk

The content of this article represents the views of the authors but 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 take any responsibility for employ that may be made of the information it contains.

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