Table 2.

Studies specific to immigrant women’s experiences of maternity care

Country and study	Problems with care as reported by immigrant women	Key findings about what immigrant women want	Author conclusions and key recommendations
AUSTRALIA
Rice & Naksook[26,27]	Inadequate information about care	Attention to individual needs	Thai women have diverse needs, perceptions and experiences. Women did not receive adequate information about care. An environment needs to be created that acknowledges diversity and meets the needs of individual women.
1998, 1999	Difficulties communicating, though some believed care was better in Australia than in Thailand	Support and kindness
30 Thai women
In-depth interviews about antenatal, intrapartum and postnatal care	Women felt they were unable to follow traditional customs in hospital.
Small et al. [28-31]	Communication difficulties	Respectful, understanding caregivers	Vietnamese, Turkish and Filipino women reported similar wants and needs from maternity care as Australian-born women in the companion Survey of Recent Mothers 1994, however these three groups of immigrant women were less likely to experience care that met their needs.
1998(2), 1999, 2002
	Being left alone in labour	Attention to individual needs, not cultural stereotypes	Recommendations included: more attention to the quality of care immigrant women receive and particularly to strategies for overcoming language barriers to effective communication; and better information provision.
Mothers in a New Country’ (MINC) study	Not feeling welcomed when came to hospital in labour
107 Vietnamese women	Experience of discrimination by some staff	Active say in decisions about care
108 Turkish women	Not enough support about own and infant care postnatally	Information and explanations from staff
104 Filipino women	Rushed caregivers	Supportive care
Semi-structured interviews about antenatal, intrapartum and postnatal care	Long waits at antenatal appointments	Recognition of the need to rest and recover post-birth
	Staff experienced sometimes as unkind or rude and care experienced as culturally stereotyped
Tsianakas & Liamputtong[32,33]	Communication difficulties	Caregivers who show warmth and humanity, and are caring and supportive	Suggestions for care improvement included provision of sufficient information and culturally sensitive services. Health care providers need to attend to individual preferences and circumstances and avoid discrimination.
2002
15 Muslim women from Lebanon, Turkey, Jordan, Egypt, Kuwait, Malaysia, Singapore, Morocco and Pakistan	Perceived stereotyping by caregivers	Female caregivers wherever possible
In-depth interviews about prenatal testing and antenatal care	Lack of familiarity with services	Good information and explanations, especially about how care is provided and available services
	Problems with male caregivers	Caregivers sensitive to cultural differences, but able to provide care that responds to individual (not stereotyped) needs
	Care experienced as discriminatory
Tran et al. [34]	Difficulties communicating with caregivers	Choice about care options	Authors recommended focus on improvement of service delivery and equity; improving access to interpreter services and bilingual staff; and integrating the biomedical model for maternity services with health beliefs of the diverse cultures.
2001
160 Vietnamese women Focus group discussions, in-depth interviews and survey about care among Vietnamese women who opted for early discharge	Women reported feeling anxious and being fearful when approaching staff for assistance and experiencing discriminition	Adequate advice about self care
	Disempowerment in culturally unfamiliar hospital surroundings.	Involvement in making decisions about care
		Supportive caregivers, with enough time to discuss concerns
		Adequate support and advice about baby care
Liamputtong & Watson[35,36]	Communication difficulties	Adequate information about options for care	Improving communication and access to information identified as essential to ensure women understand all the options available to them.
2002 and 2006
67 Cambodian, Lao and Vietnamese women with experience of childbirth in Australia	Lack of familiarity with care options	Good communication and involvement in decision-making
In-depth interviews about prenatal testing, and experiences of caesarean birth	Women of ethnic minorities do not have the same access to information and do not understand the implications of services offered to them.	Appropriate help with communication via interpreters and/or support people
Chu[37]	Language difficulties	Caregivers who are friendly and understanding	Authors recommend a focus on empowerment for women and cooperation with community organisations, and service providers to improve cross-cultural communication.
2005	Long waiting times
30 women from Hong Kong, Taiwan and China about childbirth beliefs and care experiences	Insufficient information and advice	Quality in service provision: shorter waiting times
Semi-structured interviews		Bilingual staff and/or interpreters
		Supportive after birth care so mother can rest; helpful advice about infant care
		Adequate information about care options
Shafiei et al. [38]	Despite care often being seen as better than in Afghanistan, problems identified included:	Unrushed care	Recommendations for care that is more consistently supportive, respectful and caring; strategies to reduce waiting times for antenatal visits, sufficient time for women to ask questions and receive adequate information and explanations, particularly when unfamiliar with how care is provided and when in need of assistance with communication.
2012
		Time and encouragement to ask questions
40 Afghan women	Long waiting times for antenatal care, rushed staff	Kindness and respect
Structured telephone interviews about maternity care received when giving birth, with follow-up in-depth face-to-face interviews with 10 women	Problems with communication, lack of interpreting support
	Insufficient time for adequate information and explanations	Preference for female caregivers
	At times, unkind, rude staff
	For some, having male caregivers
	Problems with hospital food (non-Halal)
Hoang et al. [39]	Communication difficulties due to lack of English	Supportive care	Authors noted the important role of family and community as in supporting migrant women through their maternity care. Better provision of interpreter services recommended; better social support for women; and reducing cultural barriers through cross-cultural training for health care providers to improve maternity services.
2009	Insufficient information offered in other languages	Information and explanations
10 women from Asia (Vietnam, China, Japan, Korea, Philippines) living in rural Tasmania	Reluctance to express preferences, and make wishes known	Acknowledgment of need for rest and care of mother post-birth
Semi-structured interviews about care experiences
CANADA
Chalmers & Hashi[40]	Insensitivity of staff to women’s experiences of pain in labour	Involvement in decision-making	Authors highlight need to enhance awareness of cross-cultural practices; address women’s perceptions and needs; use fewer interventions; and provide more respectful treatment. Need also to educate caregivers about traditional female genital cutting.
2000
432 Somali women Structured interviews about experiences of maternity care in Canada in the context of female circumcision	Inappropriate responses to traditional female circumcision (surprise, disgust)	Respectful and sensitive care
	Felt concerns not listened to
Grewal et al. [41]	Language difficulties	Family-centred care	Changes in care needed to ensure culturally safe care for immigrant Punjabi women.
2008	Lack of familiarity with services and care	Acknowledgement of individual differences in beliefs and preferences
15 women from Punjab, India In-depth interviews about their perinatal experiences in Canada	Preferences and concerns not acknowledged	Good information about how care is provided and childbirth classes
		Support for maternal rest after birth
Reitmanova & Gustafson[42]	Inadequate support and inattentive care in labour and postpartum	Adequate information, especially about pain and labour management in labour	Mainstream information and practices designed for Canadian-born women lacks flexibility to meet the needs of immigrant Muslim women. Recommendations included cultural and linguistically appropriate maternity and health information and establishing partnerships with immigrant communities.
2008
	Not enough respect for rest and privacy after birth
In-depth semi-structured interviews with 6 Muslim women from five countries (not specified) about their experiences of care	Experience of discrimination	Care sensitive to individual needs and beliefs
	Insensitivity and lack of knowledge on the part of staff about their cultural/religious practices	Appropriate language support and information in community languages
Brar et al. [43]	Language barriers	Multilingual staff and information/education in community languages, especially about available services and care	Recommendations of authors include the need for multilingual staff and provision of educational materials in a variety of formats.
2009
	Unfamiliarity with care provided	Supportive care and adequate help with infant care
Structured interviews with 30 south Asian and 30 Canadian-born women about maternity care and perceived barriers	Lack of explanations for tests and procedures	Women caregivers
	Lack of assistance with baby care after birth
SWEDEN
Essen et al. [44]	Lack of knowledge among staff for handling traditional female circumcision	Good monitoring of health of mother and checks during pregnancy, and of infant after birth	Authors conclude that health providers need to improve their knowledge about female circumcision and also provide culturally sensitive perinatal surveillance in order to address women’s concerns and any cultural misconceptions about pregnancy and birth.
2000
15 Somali women	Not enough emotional support	Kind, attentive care; sensitivity to individual needs, especially care for female circumcision
In-depth interviews about childbirth and experiences of care in Sweden	Fear of caesarean section
Berggren et al. [45]	Although pleased with high standard of clinical care, made to feel ashamed of their traditional female circumcision by some staff	Sensitive and understanding care	Authors recommend culturally adjusted care and providing systematic education about female circumcision.
2006
21 women from Somalia, Eritrea and Sudan	Requests not dealt with sensitively	Good communication
Exploratory interviews about maternity care in the context of traditional female circumcision	Language difficulties	Attention to individual needs
	Felt unable to follow certain cultural beliefs/traditions
UNITED KINGDOM
Woollett & Dosanjh-Matwala[46,47]	Communication difficulties	Sensitive, respectful care attentive to individual needs and concerns	Authors discuss issues and implications of differences between women and services in what is considered ‘normal’ maternal behaviour and the need to improve the quality of care to immigrant women, especially to attend to individual and cultural diversity.
1990
	Long waiting times	Careful monitoring of health of mother, and fetus/infant
32 women, 19 of whom were immigrants (countries not specified: India, Pakistan and Bangladesh??).	Staff rushed, no time for discussion	Good explanations and information about care and tests; careful physical checks
Women spoke Hindi, Punjabi and Urdu and/or English Semi-structured interviews	Lack of support from staff, especially postnatally when women most of all wanted to rest	Good support for rest and care of infant in hospital after birth
McCourt & Pierce[48]	Communication/language difficulties	Good communication and information about options for care	Authors note that minority ethnic women in fact shared similar values and had expectations of services similar to the wider population, but that conventional services did not provide minority ethnic women with high quality of maternity care. The authors suggest this is related to the institutional organisation of care which needs to become more focused on addressing all women’s individual needs.
2000
	Inadequate information about care options	Friendly, kind staff
20 ‘minority ethnic’ women interviewed, including 6 Somali women about experiences with maternity care (half caseload and half standard care)	Staff rude or off-hand (standard care)	Good access to interpreting services when needed
Qualitative interviews	Concerns not listened to	Attention to individual concerns
	Not enough support for rest after birth	Primary care provider who gets to know each woman and her needs
		Acknowledgement of need for rest and support after birth
Davies & Bath[49]	Poor communication with staff	Good care and adequate information about options for care	Key underlying problem considered to be poor communication between non-English speaking Somali women and health workers. This needs to be addressed with better use of interpreters and more individualised care.
2001	Limited use of interpreters
13 Somali women:	Prejudiced attitudes of staff	Attention to specific individual needs
Focus group and structured interviews about ‘maternity information concerns’.	Lack of information	Supportive care and rest after birth
Harper Bulman & McCourt[50]	Poor communication and inadequate provision of interpreting services led to needs not being met	Kind and attentive staff	Need for better integrated and more appropriately used interpreting services that enable greater continuity for women. Advocacy or link-worker schemes may also be appropriate.
2002
12 Somali women:	Not enough information and discussions about important topics, such as managing pain	Better interpreting services
Six Individual in-depth interviews and two focus groups	Stereotyping and racism from staff	Staff who understand when interpreters are needed
	Lack of understanding of cultural differences
Jayaweera et al. [51]	Language difficulties (but assisted when interpreters available)	Good use of interpreters to assist communication and provision of information	Considerations need to be made for social and economic circumstances of migrant families.
2005
	Reduced care options when English lacking
9 Bangladeshi women (8 immigrants)
Semi-structured interviews about childbirth experiences and needs
USA
Herrel et al. [52]	Experiences of discrimination in interactions with nurses believed to be due to skin colour and/or lack of English	Supportive, non-discriminatory care with a known care provider	Need culturally appropriate health education materials on labour and delivery for the Somali refugee community. Health care teams need to receive training on Somali culture, traditions and values and Somali women’s expectations.
2004
14 Somali women	Inadequate information about pain relief and side effects	Full explanations
Two focus groups with 20-item interview guide, facilitated by Somali-speaking group moderator	Poor explanations (eg for caesarean birth, which women feared)	Hospital tour with language support
	Communication problems and concern about the competence of interpreters.	Education for partners to familiarise them with women’s needs for pregnancy and birth
		Information about services in accessible language & format (eg videos)
Jambunathan and Stewart[53]	Communication problems with health care providers	Preference for minimal intervention in pregnancy and birth	Health care providers need to better understand Hmong women, eg when touching and communicating with women and informing them about hospitalisation and medical procedures.
1995
	Miscarriage feared if touched by doctors and nurses which resulted in delayed prenatal visits	Understanding from care providers about women’s own experiences and concerns
52 Hmong women
Semi-structured interviews conducted 4-6 months after birth	Wary about interventions and procedures for labour and birth
Lazarus and Phillipson[54]	Long clinic waits	Reduced waiting times	Few differences reported: Puerto Rican and ‘white’ women wanted the same things from care.
1990	Insufficient time at appointments	More time at appointments
27 Puerto Rican women (17 immigrant, 10 born in the US) and 26 indigent ‘white’ women; and 150 observations of clinical interactions	Poor communication and explanations	Known care providers
	Many different physicians for prenatal care: contradictory advice, lack of familiarity with woman’s concerns and circumstances	Sound information and explanations that can be understood
Qualitative interviews about prenatal care conducted prospectively from early pregnancy, combined with anthropological observations of prenatal care interactions		Better communication about care (not just because of language problems)
Shaffer[55]	Problems with communication due to language barriers	Being able to communicate with health care providers in own language	Authors recommend culturally appropriate health care to meet Hispanic migrant women’s needs.
2002
46 Hispanic migrant women Qualitative interviews during pregnancy exploring factors influencing access to prenatal care		Culturally appropriate health care