Table 2. Characteristics of included studies.
| Qualitative studies | ||||||||||||
| * studies marked with an asterix are taken as the primary report for that study | ||||||||||||
| First author (year) | Study design | Setting (country research undertaken in) | Participants | Aim | Data collection | Data analysis | Outcomes | Comments | Quality score | |||
| sample size | country of origin | age | parity | |||||||||
| Almeida & Caldas (2013) [8] | Qualitative | Portugal | 14 | Brazil (n = 7) and Portugal (n = 7) | Not reported | Not reported | To investigate native Portuguese and immigrant women’s perceptions of maternity care. | Semi-structured interviews | Qualitative content analysis. | Brazilian women were dissatisfied with the quality of information provided by the health professionals, the communications skills of these professionals, and reported reduced access to medical specialties, especially in primary care | Only results from migrant women were used | - |
| *Almeida, Caldas et al (2014) Almeida, Casanova et al (2014) [38,80] |
Qualitative | Portugal | 31 | African countries (11), Eastern European countries; (7), Brazil (7) and 6 Portugal | 20–45 years |
Not reported | To investigate native and immigrant women’s perceptions about quality and appropriateness of maternity care | Semi-structured interviews | Qualitative content | Misinformation about legal rights and inadequate clarification during medical appointments frequently interacted with social determinants, such as low social-economic status, unemployment, and poor living conditions, to result in lower perceived quality of healthcare. | Only results from migrants were extracted | + |
| Babatunde & Moreno-Leguizamon (2012) [64] | Qualitative | UK | 17 | Nigeria (11), Ghana (2), Kenya (1), Somalia (1), Sierra Leone (2) | 16–45 years | Not reported | To establish cultural elements related to postnatal depression through women’s narratives. | Focus groups | Thematic analysis | Women who experienced postnatal depression did not perceive the signs as related to illness but as something else in their daily lives. Depression was not identified by health visitors, despite prolonged contact with the women. | ++ | |
| Barona-Vilar et al (2013) [65] | Qualitative descriptive and exploratory study | Spain | 26 immigrant women and 24 midwifes | Bolivia and Ecuador | 20–35 years | 1- >2 children | To explore the perceptions, attitudes and experiences of Ecuadorian and Bolivian women with regard to motherhood, pregnancy and their experiences of the health-care system. | Focus groups | Content analysis | Women reported that it was not necessary to go as soon and as frequently for health examinations during pregnancy as the midwives suggested. The main barriers identified to health-care services were linked to insecure or illegal employment status, inflexible appointment timetables for prenatal checkups and sometimes to ignorance about how public services worked | Only results from migrant women were used | + |
| Binder, Johnsdotter et al (2012) [39] | Qualitative. Hermeneutic | UK | 54 immigrant women and 62 NHS maternal care providers | Sub-Saharan regions in Africa (Somalia, Ghana, Nigeria, Senegal, Eritrea). |
18–48 years | 1–10 children | To explore the influence of pre-migration socio-cultural factors on post-migration maternal care-seeking, and barriers between immigrant women and maternal care providers during the care encounter. | Semi-structured interviews | Constant comparison and triangulation with framework | Broken trust between women and maternal care providers may result in delays at the facility level, expressed as women’s choice for late-booking, non-adherence, or inappropriate decision-making, and as provider frustration resulting from the inability to impart optimal treatment. | + | |
| Binder, Borné et al (2012) [69] | Qualitative | UK | 50 immigrant women, 10 white British women and 62 obstetric care providers | Somalia (39) and Ghana (11) and UK (10) |
18–48 years | 1–10 children | To explore immigrant women's experiences of communication and conceptions of maternity care. | In depth- individual interviews and focus groups | Qualitative techniques using a framework of naturalistic enquiry. | Women encountered difficulties in health communication. Professionalism and competence were more important than meeting providers from one's own ethnic group. Interpreter use was limited by issues of quality, trust, and accessibility and has potential for improvement | Only results from migrant women were used | - |
| Bollini et al (2007) [66] | Qualitative | Switzerland | 31 immigrant women and 9 native Swiss women | Turkey (14), Portugal (17) | Between <30 and >50 (not specified) | Between 1 and >2 children | To explore the issues of pregnancy and delivery in migrant women in their interaction with the Swiss healthcare system |
Focus groups | Coding and the construction of themes | Migrant women face stressful situations, which may differ according to nationality and length of stay in the country. Main factors negatively affecting pregnancy were stress due to precarious living conditions, heavy work during pregnancy, inadequate communication with healthcare providers, and feelings of racism and discrimination in society | Only results from migrant women were used | - |
| Briscoe & Lavender (2009) [70] | Qualitative. Longitudinal exploratory multiple case study | UK | 4 |
Afghanistan, Congo, Rwanda, Somalia. |
19–36 years | 1–3 | To explore and synthesize female asylum seekers' and refugees' experience of maternity care | In-depth interviews. Photographs taken by the women. Field notes and observation. | Construction of themes | The women perceived ‘self’ as a response to social interaction. At times, ‘taken for granted’ communication in practice created a barrier to understanding for the women. Social policy related to seeking asylum, dispersal, housing and health affected the lives and maternity experiences of women | + | |
| Byrskog et al (2016) [40] | An explorative, qualitative approach | Sweden |
17 | Somalia | 18–45 years | Between 0 and >7 children | To explore how Somali-born women understand and relate to violence and wellbeing during their migration transition and their views on being questioned about violence in Swedish antenatal care | Individual semi-structured interviews | Thematic analysis. | A balancing act between keeping private life private and the new welfare system was identified, where the midwife’s questions about violence were met with hesitance. The midwife was, however, considered a resource for access to support services in the new society. A focus on pragmatic strategies to move on in life, rather than dwelling on potential experiences of violence and related traumas, was prominent. Social networks, spiritual faith and motherhood were crucial for regaining coherence in the aftermath of war. Dialogue and mutual adjustments were identified as strategies used to overcome power tensions in intimate relationships undergoing transition | ++ | |
| Choudhry & Wallace (2012) [41] | Descriptive qualitative study | UK | 20 | South Asia. 11 born in UK, 9 outside UK. | Not reported | 9 para 1, 9 para 2, 2 expecting first baby | To explore the influence of acculturation on breastfeeding practices of South Asian women. | Semi-structured interviews | Thematic analysis | 5 themes - ‘Maa Kaa Dood’ (The mother’s milk); The most convenient method for me; Formula feeding as a way of fulfilling the baby’s demands; Breast isn’t always best – women’s experience of information and role conflict; Learning by observation – the formula feeding culture | Only results from migrant women were used | + |
| Coutinho et al (2014) [42] | Qualitative, exploratory, descriptive study | Portugal | 82 (60 immigrant women and 22 native Portuguese women) | Brazil, Ukraine, China, Moldova, Russia, France, Span, India, Portugal and others | Not reported | Not reported | To identify the unmet expectations of the health system by Portuguese and immigrant women, during pregnancy, childbirth and postpartum. |
Semi-structured interviews. Guidelines were used. Recorded. | Content analysis | Major emerging categories of unmet expectations referred to the accessibility, human resources, incentives to maternity care, physical and environmental conditions, and organization of the health system. | Only results from migrant women were used | - |
| Degni et al (2014) [67] | Qualitative | Finland | 70 | Somali women from Kenya (18), Mogadishu (32) and Hargeysa (20) | 18–50 years | 2–10 children | To explore immigrant Somali women’s experiences of reproductive and maternity health care services and their perceptions about the service providers | Focus groups. | Themes constructed | Participants were satisfied with the care they received in Finland. Despite their satisfaction, the health care providers’ social attitudes towards them were perceived as unfriendly, and communication as poor | ++ | |
| Dempsey & Peeren (2016) [43] | Qualitative—grounded theory | Ireland | 12 | Eastern Europe | 20–40 years | Varied, numbers not reported. | To explore migrant Eastern European women’s experience of pregnancy in Ireland | Semi-structured interviews | Construction of themes | Migrant women who experience pregnancy in their host country face multiple, multi-faceted challenges. Migrant Eastern European women may have particular struggles with transitioning to a less medicalised maternity healthcare system. |
+ | |
| Essén et al (2011) [71] | Qualitative | UK | 101 (39 Somali women and 62 obstetric care providers) | Somalia | 18–48 years (Somali women) | 1–10 children | To explore the attitudes of Somali women and their western obstetric care providers towards Caesarean section | In-depth semi-structured interviews and focus groups |
Framework of naturalistic inquiry using the emic/etic model. | Somali women expressed fear and anxiety throughout the pregnancy and identified strategies to avoid caesarean section Avoiding or refusing caesarean was based on a rational choice to avoid death and coping with adverse outcome relied on fatalistic attitudes | Only results from migrant women were used | ++ |
| Feldman (2014) [44] | Qualitative | UK | 20 women | 14 different countries | Not reported | Not reported | To investigate the experiences of women who had been dispersed during pregnancy and of midwives involved in caring for these women | Individual interviews, face-to-face or telephone | Not specified | Dispersal interrupted women's access to maternity care. Women experienced practical barriers to accessing care and communication problems. Women experienced the postnatal period as emotional and stressful and had concerns about their living conditions. | - | |
| Gardner et al (2014) [45] | Qualitative | UK | 6 | Nigeria and Ghana | 22–26 | 1–3 | To explore the lived experience of postnatal depression in West African mothers living in the UK. | Semi-structured interviews | Interpretive Phenomenological Analysis | West African mothers living in the UK experienced isolation and a lack of practical, emotional and professional support in the postnatal period. | + | |
| Garnweidner et al (2013) [46] | Qualitative | Norway | 17 (5 ethnic Norwegian and 12 immigrants) |
Algeria, Albania, Pakistan, Thailand, Turkey, Russia, Sri Lanka, Somalia. | On average 28 years old | Not reported | To explore experiences with nutrition-related information during routine antenatal care among women of different ethnical backgrounds | Individual interviews | Interpretative phenomenological analysis | Participants reported that they were provided with little nutrition-related information. The information was perceived as presented in very general terms and focused on food safety. Weight management and the long-term prevention of diet-related chronic diseases had hardly been discussed. Women were confused about information given by the midwife which was incongruent with their original food culture. The participants were actively seeking for nutrition-related information | Only results from migrant women were used | + |
| Garnweidner et al (2017) [47] | An explorative qualitative approach | Norway | 8 (5 immigrants and 3 ethnic Norwegian |
Iraq, Turkey, Pakistan, Poland, Spain and Norway | Not reported | 1–3 children | To investigate pregnant women's experiences of domestic violence and how this is addressed in antenatal care | Individual semi-structured interviews | Thematic analysis according to | Even though none of the participants were asked about domestic violence in antenatal care, they offered different suggestions on how and when midwives should talk about it. | Only results from migrant women were used | - |
| Gaudion & Allotey (2009) [72] | Qualitative | UK | 43 | Afghanistan, China, Eritrea, Ethiopia, Iraq, Iran, Sri Lanka, Somalia, Central and West Africa, Uganda, Zimbabwe and Russia | Many were teenagers who entered UK as unaccompanied asylum seeking children (otherwise NR) | Not reported | To describe refugee and asylum seeking women's experiences of pregnancy, childbirth and maternity services | Interviews and focus groups | Thematic analysis. |
Women reported over stretched services, language and communication problems, issues around access and engagement, and the importance of cultural issues. | Teenagers were also included | - |
| Gitsels-van der Wal et al (2015) [48] | Qualitative | Netherlands | 12 | Morocco | 20–36 years | 0–3 children | To explore the preferences of pregnant Moroccan women regarding content of and approach to antenatal counselling for anomaly screening. | Interviews | Thematic analysis. | Women underlined the importance of accurate and detailed information about the tests procedures and the anomalies that could be detected and preferred counsellors to initiate discussions about moral topics and its relationship with the women's religious beliefs and values to facilitate an informed choice about whether or not to participate in the screening tests. Women preferred a counsellor who respects and treats them as an individual who has an Islamic background. | + | |
| Glavin & Sæteren (2016) [49] | Qualitative | Norway | 10 | Somali | 25–34 | 1–4 children |
To explore Somali new mothers’ experiences of the Norwegian maternity health care system. | Semi-structured interviews | Content analysis | Findings highlighted inadequate integration into Norwegian society, the need for and fear of a caesarean delivery, issues of family support around the postpartum period and support from health services | Norway public health services cover all women and children | - |
| Hanley (2007) [68] | Qualitative | UK | 10 | Bangladeshi | 16–24 | 1–4 | To explore Bangladeshi mothers' interpretations of postnatal depression and its effect on the wellbeing on the mother, family and community. | Focus groups | Thematic analysis | When mothers experienced emotional issues they sought the support of their family, friends and religious leaders, and, although familiar with some primary care services, they were not always their first point of contact | - | |
| Hjelm et al (2007) [50] | Qualitative | Sweden | 27 | Middle East (14) Sweden (13) | Mean age = 35 | 2 nulliparous 12 parous | To explore patients’ evaluation of a specialised gestational diabetes clinic | Semi-structured individual interviews | Content analysis | The healthcare model was perceived as functioning well. Women from the Middle East felt cared for, had been given the necessary information and claimed to follow advice. Adequate information reduced respondents’ anxiety and increased their control over the situation | Only results from migrant women were used | - |
| Hufton & Raven (2016) [73] | Qualitative | UK | 35 (30 immigrant mothers and 5 maternal HCPs) |
From 19 countries | Not reported | 0–8 children |
To explore infant feeding practices of immigrant mothers. | Semi-structured interviews and focus groups | Framework approach | Overall mothers were dissatisfied with their infant feeding outcomes. Mothers who were positive to human immunodeficiency virus followed the UK guidelines but struggled with guilt of not being able to breastfeed. All mothers unable to exclusively breastfeed experienced a sense of loss. Lack of wider support services coupled with complex lifestyles appeared to create challenges in providing infant feeding support | Only results from migrant women were used | + |
| Iliadi (2008) [51] | Qualitative | Greece | 26 | Iraq, Iran, Sudan, Lebanon, Syria, Afghanistan, Armenia, Turkey, Albania, Serbia, Zaire | Not reported | Primigravid (11), Multparous (15) | To examine whether refugee women, receive antenatal care and to explore possible factors that may influence their attitude towards maternity care | Semi-structured interviews | Latent content analysis | Analysis showed that refugee women enter antenatal care in the first trimester of their pregnancies, but they may miss from one to many appointments due to the language and financial barrier, the unfamiliarity with the national health system, and the women’s view of pregnancy as a natural event | - | |
| Jonkers et al (2011) [52] | Qualitative—grounded theory | Netherlands | 40 immigrant women (and 10 Dutch women) with severe maternal morbidity | Morocco Turkey, Suriname’ Dutch Caribbean Eastern Europe Middle East, Asian and sub- Saharan Africa | Not reported | Not reported | To investigate ethnicity-related factors contributing to sub-maternity care and the effects on severe maternal morbidity among immigrant women Netherlands | In-depth interviews |
Thematic analysis | Women unaware of potential pregnancy complications and felt that HCP paid insufficient attention to pregnancy complications. | Only results from migrant women were used. It was not possible in this study to separate 1st/2nd generation migrants | - |
| Lephard & Haith-Cooper (2016) [53] | Qualitative interpretive, in line with hermeneutic phenomenology | UK | 6 | Sub-Sahara Africa (4), Eastern Europe (2) | Over 18 otherwise not recorded | 5 primigravid, 1 had 1 previous child | To understand the experiences of women seeking asylum while accessing local maternity services | Semi-structure interviews. | Thematic analysis | Women experienced pre-booking challenges, inappropriate accommodation, dispersal, being alone and not being listened to | + | |
| Leung (2017) [54] | Qualitative | UK | 10 | China | Average age 36 | 8 primigravid, 2 mulitiparous | To explore how cultural beliefs influence postpartum dietary choices and infant feeding practices. |
Semi-structured interviews | Not reported | Women felt midwives were unaware of their cultural practices when offering postnatal dietary advice | - | |
| Lundberg & Gerezgiher (2008) [55] | Qualitative—ethnography. | Sweden | 15 | Eritrea |
31–45 years | 3 to 5 children | To explore Eritrean immigrant women’s experiences of female genital mutilation during pregnancy, birth and postpartum. | Semi-structured interviews | Thematic analysis |
Women reported fear and anxiety, extreme pain and long-term complications and health-care professionals’ knowledge of circumcision | + | |
| Ny et al (2007) [74] | Qualitative | Sweden | 13 | Turkey, Syria, Iraq and Lebanon | 23–41 | 1–6 children | To describe Middle Eastern mothers' experiences of the maternal health care services in Sweden and the involvement of their male partner. | Focus group discussions and individual interviews. | Content analysis | Women developed trust in the midwife based on the knowledge and the empathy the midwife imparted, and did not feel that the midwife's understanding of their native language or culture was vital to develop a good relationship | ++ | |
| Petruschke et al (2016) [56] | Qualitative exploratory | Germany | 19 Turkish origin (11 German origin) | Turkey | 21–41 years | 42% nulliparous | To identify possible differences in the Turkish and German women’s attitudes towards epidural analgesia. | Semi-structured interviews | Content analysis | Turkish women ascribe meaning to labour pain and reject epidural for fear of long-term complications and because they don’t view epidural delivery as natural | + | |
| Ranji et al (2012) [57] | Exploratory, qualitative | Sweden |
9 | Iran (5), Afghanistan (4) |
21–39 years | 2 nulliparous, 7 had one child. | To describe immigrant parents’ experiences of ultrasound examination in the second trimester of pregnancy | In depth interviews | Content analysis | Parents were impressed by the quality of their communication with the care-givers, found the process to be well organised and did not experience discrimination on the basis of being an immigrant | + | |
| Robertson (2015) [75] | Intersectional approach | Sweden | 25 | 17 countries | 21–50+ | Not reported | To analyse women’s reflections on how their migration and resettlement influenced their health and healthcare needs during childbearing. | Focus groups and semi-structured individual interviews | Content analysis | The hardships of migration, resettlement, and constraints in the daily life made women feel tense and disembodied. Being treated as a stranger and rejected in healthcare encounters was devaluing and discriminating. Women felt stronger and had fewer complications during pregnancy and labour when they had a confident, caring relationship with caregivers/midwives. | Interviews were a long time post delivery for some participants | + |
| Sauvegrain et al (2017) [76] | Qualitative | France | 33 | Sub Saharan Africa (16) France (17) |
21–44 | P1 = 12 P2 = 13 P3 = 3 P4 = 3 P6 = 2 |
To analyse whether the prenatal care trajectories among women with hypertensive disorders during pregnancy differed between immigrant and native women | Semi-structured interviews | Identification of themes | Some evidence of differential care. | Only results from migrant women were used | + |
| Strauss et al (2009) [58] | Ethnography | UK | 8 | Somalia | 23–57 | Not specified | To examine cultural and social aspects of childbirth and how they intersect with the needs and experiences of Somali women in the UK. | In-depth narrative interviews | Thematic analysis | Concerns raised around: the mismanagement of care for women who have been circumcised, aspects of communication, continuity of care and attitudes of health professionals | - | |
| Szafranska & Gallagher (2013) [59] | Descriptive qualitative approach | Ireland | 6 | Poland, | Not reported | Not reported | To explore the factors that influence Polish women's decisions to initiate and continue breastfeeding in Ireland | Unstructured face-to face interviews. | Identification of themes | Professional and family support are key to successful BF | - | |
| Tobin et al (2014) [60] | Qualitative Dramatisitic pentad |
Ireland | 22 | 9 different countries | 18–40 | 9 primiparous, 13 multiparous | To gain insight into women's experiences of childbirth in Ireland while seeking asylum | In depth unstructured interviews | Narrative analysis | Women experienced a lack of connection, communication and culturally competent care | ++ | |
| Topa et al (2017) [61] | Qualitative—critical feminist exploratory design with hermeneutic approach. | Portugal | 10 | Ukraine | 28–49 | 6 x para 1, 4 x para 2 | To investigate migrant women’s perceptions of the quality and appropriateness of maternity care received in public health services | Semi-structured interviews | Thematic analysis. | Women feel misinformed about their legal rights and free access to maternal health services. They were dissatisfied with the quality of information provided by HCP and their communication skills. They felt that their access to medical specialties was limited. | + | |
| Treisman et al (2014) [62] | Qualitative | UK | 12 | Africa | 23–41 years | Not reported | To investigate how UK-based African women perceive, make sense of, and manage a diagnosis of HIV during pregnancy, and after delivery | Semi-structured interview | Interpretive phenomenological analysis (IPA). | Receiving an HIV diagnosis challenged the normalcy and joy of becoming a mother. Women experienced stigma and breaches of confidentiality from HCP. Women found their inability to breastfeed most distressing as this was central to their cultural identity as mothers. | + | |
| Viken et al (2015) [63] | Qualitative exploratory, descriptive design with hermeneutic approach | Norway | 17 | South America, Europe, Middle East, Africa, Asia | 20–38 | 1–8 children | To explore the maternal health coping strategies of migrant women in Norway | Semi-structured interviews | Qualitative content analysis. | There were both good and bad experiences of care from HCPs during pregnancy and childbirth. Culture influenced the women's views of health and disease. | + | |
| Wandal et al (2016) [77] | Qualitative | Norway | 38 (16 | Somalia | 21–40 years | Majority multiparous | To explore infant feeding practices among Somali-born mothers in Norway, and the ways in which they navigate among different information sources | Semi-structured interviews and focus groups. | Development of categories | The mothers experienced challenges of dealing with conflicting recommendations and expectations regarding infant feeding. They navigated among different sources of information, taking into consideration traditional values, experiences and habits from living in Norway, and research-based knowledge. | + | |
| *Wikberg et al (2012) Wikberg et al (2014) [78,81] |
Ethnography | Finland | 17 | Australia(1), Bosnia (3), Burma (1), Colombia(1) Estonia (3), Hungary (1) India (1), Iraq (2) Russia (1), Thailand(1), Uganda (1), and Vietnam (1) | 19–36 years | 9x para 1, 4x para 2, 3x para 3, 1x para 4 | To explore immigrant mothers' experiences of maternity care | Interviews, observations and field notes. | Focussed ethnographic analysis. | There were differences between the women's expectations and their maternity care experience. Caring was related to the changing culture. Finnish maternity care traditions were sometimes imposed on the immigrant new mothers. Female nurse was seen as a professional friend, and the conflicts encountered were resolved. | + | |
| Yeasmin & Regmi (2013) [79] | Qualitative | UK | 26 | Bangladesh | 20–44 years old | Most had more than 1 baby | To examine the food habits and beliefs of pregnant British Bangladeshi women | Focus groups and in depth semi-structured interviews | Identification of themes | Culture influence women's perceptions of 'good' and 'bad' food and their food habits during pregnancy. | + | |
(green) ++ article judged to be of high quality as majority of NICE appraisal tool [29] criteria met. Study judged to be reliable and trustworthy, with evidence of author reflexivity
(yellow) + article judged to be of moderate quality as most criteria met in NICE appraisal tool, Study however deemed to lack rigor due to some flaws in study design
(red) - article judged to be of low quality as most criteria within the NICE critical appraisal tool not met