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

Background Across Europe there are increasing numbers of migrant women who are of childbearing age. Migrant women are at risk of poorer pregnancy outcomes. Models of maternity care need to be designed to meet the needs of all women in society to ensure equitable access to services and to address health inequalities. Objective To provide up-to-date systematic evidence on migrant women’s experiences of pregnancy, childbirth and maternity care 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 aspect of migrant women's experiences of maternity care in Europe. Data collection and analysis Qualitative data 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. Four overarching themes emerged: ‘Finding the way—the experience of navigating the system in a new place’, ‘We don't understand each other’, ‘The way you treat me matters’, and ‘My needs go beyond being pregnant’. Conclusions 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.


Introduction
International migration continues to grow rapidly [1]. Between 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 Organization (WHO) European region and more than half of these migrants were women, many of childbearing age [2]. There are no universally accepted 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 being voluntary or forced, and reasons for migration [2,3]. Health needs and outcomes in this heterogeneous group is a complex 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 country [2].
On average the fertility rate in the migration population is higher 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 woman has in her lifetime) of 2.06 for non-UK born women versus 1.75 for UK born women [5]. Pregnancy is a period of increased vulnerability for migrant women [6,7]. There is a consistent trend for poorer pregnancy outcomes amongst migrant women [2] who are at greater risk of maternal and neonatal morbidity and mortality when compared to native born women [2,[8][9][10][11][12][13][14][15][16][17]. This is a result of the complex interplay of multiple factors including substandard healthcare in the country of origin [2] and issues around accessing care and the quality of care in the new country [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 problems, like poor socio-economic status, discrimination and social exclusion, multiple losses, and the chronic stress caused by these [19][20][21]. It is often observed that migrants leaving their country of origin are healthier than comparable native populations. This phenomenon has been called the "healthy migrant effect" and is usually explained through the positive self-selection of immigrants and the positive selection, screening and discrimination applied by host countries [22]. But, although often healthy when arriving in the country, the health of migrants deteriorates over time, and in general, they rate themselves to have poorer health compared to the native population of their host countries [20].
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 work [24].
A previous qualitative evidence synthesis [25] has explored both migrant women's care experiences and their perceived care needs for data published prior to June 2010. However, an updated review was deemed important with the acknowledgement that changing global, political and economic climates have led to increased migration into Europe [2,26]. This includes recent political unrest and conflict in many Middle Eastern and Sub-Saharan countries [26], the updated rights of free movement of citizens and their families within the European Economic Area laid down 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 up-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 care in their destination country. The following databases were searched; CINAHL, MEDLINE, PUBMED, PSYCHINFO and SCO-PUS. Databases were searched from 2007 until the final search on 22/05/2017. The point of commencement was taken as 2007 due to the changing political landscape within the EU at that point, with the health of migrants being a focus of the EU president in 2007 [28]. The search strategy comprised of three facets, with terms relating to (i) migrant (ii) maternity and (iii) experience. The Boolean operators AND and OR were used alongside truncation operators and phrase-searching, and the search syntax was adapted 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 fulltext of potentially relevant sources. Any disagreements concerning eligibility were resolved through discussion between team members. Study characteristics and all qualitative data that related to women's experiences of any aspect of maternity care within the host country were extracted using a standardised form.

Critical appraisal
Included articles were quality appraised using the qualitative National Institute for Health and Care Excellence (NICE) critique tool [29] (see S2 File) and 10% were appraised by a second reviewer to ensure consistency. A low-quality score (-) was assigned if either most criteria were not met, or it was judged that there were significant flaws in the study design. The article was classified as moderate quality (+) if most criteria were met and it was identified that there may be some flaws in the study resulting in a lack of rigor. A high-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 significant evidence of author reflexivity.

Evidence synthesis
A thematic synthesis was undertaken involving 3 separate steps; i) line by line coding adding new codes to the 'bank' of codes as required, ii) organising codes into descriptive themes according to their similarities or differences and using new codes to capture the group of original codes, iii) generating analytical themes [30]. Coding was undertaken using NVivo and Atlas.ti packages. A total of 28% of the articles were double-coded, and development of the final 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 confidence in the evidence base in four components: (i) methodological limitations which evaluates any methodological concerns in the primary studies contributing to the review finding, (ii) 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 between the primary study's data and the review finding it 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 confidence 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 can be seen in Fig 1. 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 2 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 data [34][35][36][37]. Individual interviews were exclusively undertaken in 27 of the studies [8, and focus groups in five studies [64][65][66][67][68]. Multiple methods of data collection were Finding the way in and through the system. For some migrant women who wanted to access care, there were difficulties in finding the way 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 free [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 country and could speak the local language helped migrant women find 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 help and reported that the way into the system was blocked by detention centre staff who refused or delayed their access to care [35,53].
"The Home Office put me in detention centre so I could not attend my appointments. There were no maternity services there for me for the 2 months I was there. I was offered appointments but they were cancelled at short notice without anyone telling me why." (Phillimore 2015, pp.576) [35] Costs related to transportation and payment for care were identified as 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 often in contrast to the situation in their country 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 barrier that women faced when trying to navigate the system in a new language [34, 75,82].
"I get so nervous to communicate through the telephone, is so difficult . . . instead I go there to get an appointment but they tell me I have to phone . . .Why?" (Robertson 2015, pp.62) [75] We don't understand each other. Women highlighted that information, advice and the opportunity to discuss 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 communication and understanding which are discussed in the sub-themes; Overcoming language barriers, Unmet information needs and Different expectations of care.
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]. Even when women could proficiently manage everyday situations, they still often lacked the vocabulary to cope with medical terminology [53,58,70,75]. However, the use 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 everyone [75]. When women's partners were asked to interpret during care 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]. Unmet information needs. Women identified a lack of information around pregnancy, childbirth or the postpartum period, and a lack of information that was available in an accessible language or format [8,35,37,[46][47][48][49][50]52,58,64,66,[70][71][72][75][76][77][78][79][81][82][83] Women also identified that their care and safety were adversely affected when they did not disclose important information to HCPs, as did not want to be a nuisance or failed to understand the importance of their health history or potential seriousness of their current or previous symptoms [52,76].

"I thought: it is a holiday, I do not want to be a problem for someone. I will try to go Monday or Tuesday after the holidays. But I think now: why did I wait ? Why didn't I phone immediately ?" (Jonkers et al 2011, pp.149) [52]
Different expectations of care. 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 beat me. . .if I scream or if I cry. So in labour I don't speak, so that I don't upset them." (Tobin et al 2014, pp.836) [60] Procedures which were familiar to practitioners were not always familiar to women coming from other care systems [8,70], 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 before. It's like going to another planet and you are seeing all these things which are happening to you and you can't ask anything." (Tobin et al 2014, pp.836) [60] Women's cultural backgrounds influenced some of their preferences [39,56,60,71] and beliefs about procedures [49, 55,67,70,71,81] and the way 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 section is a good thing and that a woman should give birth by vagina and not by opening her stomach to take the baby out. Somali women's general belief is that caesarean birth is not a real way of a woman to give birth. And how many times doctors will cut her stomach if she has to deliver many times in her life?" (Degni et  The way you treat me matters. Impact of poor care. The HCPs attitude was an important factor in how migrant women perceived the quality of care. Some women found HCPs to be unfriendly [67,74] and disrespectful [63,81], failing to respond to their concerns in a caring matter, ignoring them [74,75] and not taking their complaints seriously [49,52,66,74,75]. This made women doubt their own capabilities [75]. Unsatisfactory interactions with HCPs often led to a lack of connection and poor relationships with HCPs which resulted in women feeling isolated and fearful of being mistreated [60]. "Really they should have asked in a friendly way if we needed help. . .it was a very unpleasant experience, I felt like an idiot, as totally incompetent." (Robertson, 2015, pp.63) [75] When encountering the healthcare system, migrant women expressed a sense of being seen and treated differently [37,50,53,75,76]. Many women felt that their customs and culture were not understood by those caring for them [35,37,45,54,55,64,67,76,78,83]. Prejudice and stereotyping by HCPs [8,35,37,57,58,66,75,77,78] led to assumptions based on women's perceived cultural backgrounds and left them feeling that their needs were overlooked [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 conditions [50,67].
"I think that people that work in the health care settings . . . the doctors, the nurses, the midwives and even cleaners need education in different cultures. They need to understand that patients from different cultures and race are not inferiors and not . . .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 [61,80], the perceived busyness of HCPs which prevented women sharing their anxieties and concerns [70,81,82], inadequate knowledge of legislation by administrative staff [80], not being involved in decision-making [80], and limited access to specialist care [80].
Importance  [75]. Women also appreciated HCPs who demonstrated cultural sensitivity, although this did not necessarily require an in-depth knowledge of individual customs and traditions [48,78]. (Briscoe & Lavender 2009, pp.20) [70] Good care encompassed a trusting relationship between women and HCPs, which empowered women to feel confident and prepared for childbirth [63,75,78], even overcoming a lack of social networks or support [75].

'You know when I talk about myself I feel good about it because I know there's someone who's listening and understanding which makes me feel better.'
"When one feels well-treated and cared for, one never forgets it. . .especially when you feel lonely and vulnerable with a lot of need of support. . .it is worth so 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 care, with friendly, unhurried HCPs encouraged women to attend for maternity care and positively influenced their sense of well-being [37, 74,81]. Fragmented care given by different midwives negatively influenced the effectiveness of care and the women's confidence 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 first pregnancy, it was nice.. .. It felt like she was a relative." (Wikberg et al 2012, pp.644) [78] Women also identified that good care required facilities that were hygienic [37,74] and promoted privacy [81] and informed choice [74,78].

My needs go beyond being pregnant.
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 beyond the issue of their pregnancy. Preoccupation with these other needs impacted on their time and ability to focus on the pregnancy [35,36,62].
"I was so busy to survive, to find food, and shelter. I simply did not think of antenatal checks at all." (Schoevers et al 2010, [66], others appreciated the protection of national employment laws [81].  [53] "They were saying they're taking me to Birmingham. I had no one in Birmingham. I don't know anyone at all in Birmingham. I was like Oh God, where are they taking me?" (Briscoe & Lavendar 2009, pp.21) [70] The burden of traumatic experiences. Many childbearing women had experienced trauma or persecution prior to or during migration [45,52,[60][61][62][63]75], and the resulting stress often became evident as pain and illness in their body [75]. These experiences left women with a lost or negative sense of identity [45, 58,70] and being unwilling to trust their interpretations of their bodily symptoms [75]. 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 support and this left them feeling lonely [45,51,53,60,63,64,73,78,83], isolated [35,44,45,47,49,58,60,70,74,78,79], hopeless [51] and deeply distressed [37,60,70,74]. Women were particularly aware of the lack of support from their own mothers [45,53,60,74,78,81] and highlighted that being able to contact family members was important [63]. Without family support women were worried about having no one to ask for advice [74,78,81], found raising children more difficult [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 baby, I was afraid and also I don't have family here. . . and was crying all the time and very lonely." (Babatunde & Moreno-Leguizamon 2012, pp.5) [64] Women who experienced domestic violence were restricted from talking about this as it was often not acceptable within their culture [47] and they were not always aware that violence was forbidden in the destination country [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 report pregnancy problems [35]. Although the midwife was seen as a resource to signpost to domestic violence support services by some [

CERQual assessment
The summary scores from the CERQual assessment 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 confidence and three scoring moderate confidence and one scoring low confidence.

Main findings
Migrant women's struggles with communication and language barriers are recurrent themes within this and previous reviews. Migrant women report a poor understanding of medical terminology [25] and yet there is inadequate use of interpreters within the healthcare system [25,84]. Poor communication and the provision of insufficient information impact on women's ability to choose appropriate care options and provide informed consent [25, [84][85][86][87]. An inability to converse in the local language also means women find it 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 language barriers by providing appropriate information, engaging professional interpreters more frequently and ensuring they give women the opportunity to ask the questions that they have [90][91][92][93][94][95][96][97][98][99].
In line with other studies [25, [85][86][87]89,100,101], a lack of understanding between migrants and HCPs in terms of their traditional customs and their expectations of maternity care was found to impact upon their access of services. The issues clearly point to a need for HCPs to receive education and training in culturally competent care to better identify women's expectations of care and how to understand and appropriately respond to women's needs related to their cultural background, to ensure effective maternity care and reduce barriers to accessing care [22].
Women's 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 belong, has developed the Convention on the Elimination of all Forms of Discrimination Against Women [102] which states that all maternity services, including routine antenatal treatment, must be treated as being immediately necessary; 'No woman must ever be denied, or have delayed, maternity services due to charging issues' (Department of Health and Social Care (2018) p. 67) [103]. Healthcare providers need to ensure the provision of adequate support and timely advice for migrant mothers on their entitlements to care to allay fears and improve access to care, with the ultimate aim of reducing pregnancy complications.
While the healthy migrant phenomenon 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 have highlighted migrant women's 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 around them [25,85,100,[104][105][106]. As the wider determinants of health are well recognised [107], including intimate partner violence [108], low health literacy [109][110][111], limited social support [112]; Table 3. CERQual summary scores.

Analytic theme Review finding CERQual assessment of confidence in the evidence
Finding the way-Navigating the system in a new place Migrant women weigh up the value of maternity care and the costs and consequences of accessing care.

HIGH
Some migrant women are unaware of their rights and entitlements to maternity care.

HIGH
Migrant women face difficulties in finding the way into the maternity care system.

HIGH
Ongoing access to maternity care is influenced by financial factors

HIGH
Ongoing access to maternity care is influenced by flexibility in the system addressing social and mental wellbeing alongside physical wellbeing is seen as important for the overall health of mothers and their infants [113]. Addressing the wider determinants of health which impact on migrant women requires closer cross-agency working with effective collaboration between healthcare, social care, the voluntary sector and communities [2]. This current review also highlighted that many migrant women have experienced trauma prior to and during migration, which is widely recognised to impact on mental health and wellbeing in the destination country [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 care, receiving treatment that was empathetic, 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 against [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 care models which has found increased satisfaction reported by women receiving continuity by a known midwife, as well as reduced rates of preterm birth and perinatal death [116]. To address the social determinants of health and avoid discriminating against migrant women, it calls for person-centred, high-quality, continuity of care that incorporates aspects of cultural competency and trauma aware care. The evidence within this review, alongside other evidence, led to the development of the ORAMMA integrated perinatal care model [117]. This model has been feasibility tested and will be reported in further articles currently under development. Other known integrated healthcare models include Community Orientated Primary Care [118,119], as well as the integrated approach developed within the European Refugees-Human Movement and Advisory Network (EUR-Human) project [120].

Strengths and limitations
This review provides up-to-date, systematic evidence located using a comprehensive search undertaken by a multidisciplinary team. Assessing confidence in the evidence using the CERQual approach is a further strength of this review. The review is strengthened by the inclusion of a large number of eligible studies set in 14 different European countries which included migrant women from a wide range of countries of origin. However, some papers did not provide a clear or consistent definition for the term 'migrant' or provide details about 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 be visible within this synthesis. This review focussed exclusively on migrant women's experiences of maternity care within European host countries. It is recognised that many experiences may overlap with migrant experiences across other world regions for example social isolation, language and cultural barriers. However, 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 practice and research from this review.
• It is important that migrant women feel understood. Professional interpreters should be provided at each appointment/care encounter to enable HCPs to listen to women and build a friendly, trusting relationship with women.
• HCPs should avoid stereotyping and respect and accommodate traditional or cultural practices that are relevant in the perinatal period.
• Migrant women's needs go beyond their pregnancy and include psychosocial-emotional and economic challenges. To address these needs cross-agency working is needed alongside culturally competent and trauma-informed models of maternity care that incorporates continuity.
• Future 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. Co-ordinator for the ORAMMA consortium is Victoria Vivilaki, email: v_vivilaki@yahoo. co.uk

Supporting information
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.