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.
To provide up-to-date systematic evidence on migrant women’s experiences of pregnancy, childbirth and maternity care in their destination European country.
CINAHL, MEDLINE, PubMed, PsycINFO and Scopus were searched for peer-reviewed articles published between 2007 and 2017.
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.
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’.
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.
Citation: Fair F, Raben L, Watson H, Vivilaki V, van den Muijsenbergh M, Soltani H, et al. (2020) Migrant women’s experiences of pregnancy, childbirth and maternity care in European countries: A systematic review. PLoS ONE 15(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; Accepted: January 14, 2020; Published: February 11, 2020
Copyright: © 2020 Fair et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Data 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 Commission Grant Number 738148. http://ec.europa.eu/chafea/index_en.htm The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
Competing interests: The authors have declared that no competing interests exist.
International migration continues to grow rapidly . Between 2000 and 2017, the migrant population increased by 85 million, from 173 to 258 million . 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 . There are no universally accepted definitions for a migrant at an international level  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 .
On average the fertility rate in the migration population is higher than the native population . 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 . Pregnancy is a period of increased vulnerability for migrant women [6,7]. There is a consistent trend for poorer pregnancy outcomes amongst migrant women  who are at greater risk of maternal and neonatal morbidity and mortality when compared to native born women [2,8–17]. This is a result of the complex interplay of multiple factors including substandard healthcare in the country of origin  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 [19–21]. 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 . 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 .
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 . 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 .
A previous qualitative evidence synthesis  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 , the updated rights of free movement of citizens and their families within the European Economic Area laid down in a Directive in 2004  and an increased recognition of the need to integrate the health needs of migrants and refugees into national health strategies . 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.
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 SCOPUS. 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 . 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 full-text 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.
Included articles were quality appraised using the qualitative National Institute for Health and Care Excellence (NICE) critique tool  (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.
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 . 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 . An overall judgement for confidence in each review finding of 'high', 'moderate' or 'low' was determined based on evaluation of the four components.
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 [34–37]. Individual interviews were exclusively undertaken in 27 of the studies [8,38–63] and focus groups in five studies [64–68]. Multiple methods of data 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 . Studies were undertaken in 14 European countries, ranged in size from four  to 193  participants and included a total of 1330 migrant women, although one study did not specify the number of participants and could not be included in this number . The majority of studies (n = 34) were published from 2012 onwards. A total of seven studies were rated as high 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 18 of low quality [8,34,36,37,42,44,47,49–52,54,58,59,66,68,69,72].
Four 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  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 , or were fearful that their visibility in maternity services could result in deportation [35,36,66,82].
“I had my first daughter when I was illegal, it has been a terrible experience even though my sister helped me, I was always fearing that someone would knock at the door and would send us back to Portugal… Even 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) 
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 , 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) 
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) 
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 , 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].
"I asked them, “[Can] we cancel the meeting until we get an interpreter… I didn’t understand you and you didn’t understand me.” She said, “No, it’s OK, we can go on—you understand English.”’ (Lephard & Haith-Cooper 2016, pp. 134) 
Failure to use professional interpreters was a barrier to receiving satisfactory care [38,44,58,60,69,83], hindered accurate information sharing and led to frequent misinterpretation [52,70,81] and a lack of understanding of procedures women were asked to give consent for [35,52,60].
“They [midwives] communicated by sign language and I was never sure I had understood properly.” (Briscoe & Lavender 2009, pp.20) 
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 . 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].
“If I could have someone who is not my husband it could make a big difference because throughout my pregnancy I did not say anything about my needs or problems. My husband was saying everything.” (Phillimore 2015 pp.576) 
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 [8,35,37,46–50,52,58,64,66,70–72,75–79,81–83]. 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 human being, he gets thirsty and that milk does not quench thirst… while the health clinic said: no, he does not need water" (Wandal et al 2016, pp.4) 
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) 
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) 
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 .
“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) 
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 al 2014, pp.357) 
“I found it extremely friendly but very low in real medicine? It’s all midwife based, no exams, which is very strange for me”. (Dempsey & Peeren 2016, pp.377) 
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 . 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 .
"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) 
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) 
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 , not being involved in decision-making , and limited access to specialist care .
Importance of good care. Women stressed the importance of good quality care 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 be cared for by HCPs who had a respectful attitude [43,48,62,74], made them feel emotionally safe  and would take their concerns seriously . 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].
‘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.’ (Briscoe & Lavender 2009, pp.20) 
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 .
“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) 
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 .
"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) 
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, pp.260) 
Financial difficulties and poor living conditions. Financial pressures were identified by many migrant women which led to difficulties covering basic living costs [35,82,83], transport to appointments [35,53,72,82,83] and costs of essential care . This was exacerbated by not being allowed to 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 , others appreciated the protection of national employment laws .
“worst aspect I think during pregnancy he want to dismiss me […] but could not, could not because I had my rights, […] but he fired me soon after the birth of my daughter” (Topa et al 2017 pp.115) 
Concerns over living conditions were also common [44,52,53,62,66,70,73,83] and included; living in temporary  or shared accommodation [44,53], poor housing conditions [44,70] and the impact of dispersal [35,44,53,70,73,82], whereby women were moved by migration authorities to new, unknown areas within the host country. This increased women’s feelings of stress  and powerlessness .
“They give me a [hotel] room… [It was] very small, it was smelling of cigarettes. The duvet was very dirty. The bed… the walls… everything was very dirty.” (Lephard & Haith-Cooper 2016, pp.132) 
“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) 
The burden 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 often became evident as pain and illness in their body . 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 .
‘‘People were killed; I survived, because they thought I was dead, you can see the scars on my face, where the bullets entered my face … They did what they wanted with us, beating us, having rape parties" (Treisman et al 2014, pp.150) 
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  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 . 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  caused tension in the relationship with their partners .
“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) 
Women who experienced domestic violence were restricted from talking about this as it was often not acceptable within their culture  and they were not always aware that violence was forbidden in the destination country . 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 . Although the midwife was seen as a resource to signpost to domestic violence support services by some , others were unsure if a midwife could help them [40,47].
“…I don't believe a Somali woman would go and tell her (the midwife) if she is having problems or anything like that…if it has gone far enough that a woman has decided to report the man, then she knows she can call the police, or that she can get help from friends instead”. (Byrskog et al 2016, pp. 12) 
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.
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  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 [25,84–87]. 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 [90–99].
In line with other studies [25,85–87,89,100,101], 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 .
Women’s fear of deportation impacting upon use of services identified within this review is in line with previous literature  as is lack of awareness of entitlements to maternity care . The United Nations, to which all European countries belong, has developed the Convention on the Elimination of all Forms of Discrimination Against Women  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) . 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 ; 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 [25,85,100,104–106]. As the wider determinants of health are well recognised , including intimate partner violence , low health literacy [109–111], limited social support ; addressing social and mental wellbeing alongside physical wellbeing is seen as important for the overall health of mothers and their infants . 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 . 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 . Maternity services should develop trauma-informed care  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 .
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 . 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 . 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 .
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.
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.
S4 File. Full CERQual assessment scoring table.
ORAMMA team members are:
M Papadakaki Department of Social Work, School of Health Sciences, Hellenic Mediterranean University, Heraklion, Greece; M Jokinen Practice and Standards Professional Advisor, 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 Centre for the History of Science, Technology and Medicine at the University of Manchester, Manchester, UK; E Sioti Department of Midwifery, Faculty of Health and Caring Sciences, University of West Attica, Athens, Greece; T. Mastrogiannakis CMT Prooptiki, Athens, Greece; A Markatou CMT Prooptiki, Athens, Greece; 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: firstname.lastname@example.org
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.
- 1. International Organization for Migration. World Migration Report 2018. 2017. International Organization for Migration Publications; Geneva.
- 2. World Health Organization. Report on the health of refugees and migrants in the WHO European Region: No public health without refugee and migrant health. 2018. World Health Organization: Copenhagen.
- 3. De Grande H, Vandenheede H, Gadeyne S, Deboosere P. Health status and mortality rates of adolescents and young adults in the Brussels-Capital Region: differences according to region of origin and migration history. Ethnicity and Health 2014;19(2):122–143. pmid:23438237
- 4. Kulu H, Hannemann T, Pailhé A, Neels K, Krapf S, González-Ferrer A, et al. Fertility by birth order among the descendants of immigrants in selected European countries. Population and Development Review 2017;43(1):31–60.
- 5. Office for National Statistics. Total Fertility Rates (TFR) for UK and non UK born women in the UK, 2004 to 2015. 2016; Available from: https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/conceptionandfertilityrates/adhocs/006295totalfertilityratestfrforukandnonukbornwomenintheuk2004to2015. Accessed May 2, 2019.
- 6. Bunevicius R, Kusminskas L, Bunevicius A, Nadisauskiene R, Jureniene K, Pop V. Psychosocial risk factors for depression during pregnancy. Acta Obstetricia et Gynecologica 2009;88(5):599–605.
- 7. Schetter CD. Psychological science on pregnancy: Stress processes, biopsychosocial models, and emerging research issue. Annual Review of Psychology 2011;62:531–558. pmid:21126184
- 8. Almeida LM, Caldas JP. Migration and maternal health: Experiences of Brazilian women in Portugal. Revista Brasileira de Saúde Materno Infantil 2013;13(4):309–316.
- 9. Esscher A, Högberg U, Haglund B, Essën B. Maternal mortality in Sweden 1988–2007: more deaths than officially reported. Acta Obstetricia et Gynecologica Scandinavica 2013;92(1):40–46. pmid:23157437
- 10. Hayes I, Enohumah K, McCaul C. Care of the migrant obstetric population. International Journal of Obstetric Anesthesia 2011;20(4):321–329. pmid:21840201
- 11. Malin M, Gissler M. Maternal care and birth outcomes among ethnic minority women in Finland. BMC Public Health 2009;9:84. pmid:19298682
- 12. Pedersen GS, Grøntved A, Mortensen LH, Andersen A-N, Rich-Edwards J. Maternal mortality among migrants in western Europe: a meta-analysis. Maternal & Child Health Journal 2014;18(7):1628–1638.
- 13. Urquia ML, Glazier RH, Mortensen L, Nybo-Andersen AM, Small R, Davey MA, et al. Severe maternal morbidity associated with maternal birthplace in three high-immigration settings. European Journal of Public Health 2015;25(4):620–625. pmid:25587005
- 14. van den Akker T, van Roosmalen J. Maternal mortality and severe morbidity in a migration perspective. Best Practice & Research: Clinical Obstetrics & Gynaecology 2016;32:26–38.
- 15. Van Hanegem N, Miltenburg AS, Zwart JJ, Bloemenkamp KW, Van Roosmalen J. Severe acute maternal morbidity in asylum seekers: a two-year nationwide cohort study in the Netherlands. Acta Obstetricia et Gynecologica Scandinavica 2011;90(9):1010–1016. pmid:21446931
- 16. Van Oostrum IE, Goosen S, Uitenbroek D, Koppenaal H, Stronks K. Mortality and causes of death among asylum seekers in the Netherlands. Journal of Epidemiology & Community Health 2011;65(4):376–383.
- 17. Zwart JJ, Richters JM, Ory F, de Vries JI, Bloemenkamp KW, van Roosmalen J. Severe maternal morbidity during pregnancy, delivery and puerperium in the Netherlands: a nationwide population-based study of 371,000 pregnancies. BJOG: an international journal of obstetrics and gynaecology. 2008;115(7):842–850.
- 18. Arcaya MC, Arcaya AL, Subramanian SV. Inequalities in health: definitions, concepts, and theories. Global Health Action 2015;8(1):27106.
- 19. Hadgkiss EJ, Renzaho AM. The physical health status, service utilisation and barriers to accessing care for asylum seekers residing in the community: a systematic review of the literature. Australia Health Review 2014;38(2):142–159.
- 20. Nielsen SS, Krasnik A. Poorer self-perceived health among migrants and ethnic minorities versus the majority population in Europe: a systematic review. International Journal of Public Health 2010;55(5):357–371. pmid:20437193
- 21. Rechel B, Mladovsky P, Ingleby D, Mackenbach JP, McKee M. Migration and health in an increasingly diverse Europe. Lancet 2013;381(9873):1235–1245. pmid:23541058
- 22. Matlin SA, Depoux A, Schütte S, Flahault A, Saso L. Migrants’ and refugees’ health: towards an agenda of solutions. Public Health Reviews 2018;39:27.
- 23. Regional Committee for Europe. Strategy and action plan for refugee and migrant health in the WHO European Region. 2016. World Health Organization: Copenhagen.
- 24. European Commission. Migrant access to social security and healthcare: policies and practice. European Migration Network Study 2014. Available from: https://ec.europa.eu/home-affairs/sites/homeaffairs/files/what-we-do/networks/european_migration_network/reports/docs/emn-studies/emn_synthesis_report_migrant_access_to_social_security_2014_en.pdf. Accessed December 17, 2019.
- 25. Balaam M, Akerjordet K, Lyberg A, Kaiser B, Schoening E, Fredriksen A, et al. A qualitative review of migrant women's perceptions of their needs and experiences related to pregnancy and childbirth. Journal of Advanced Nursing 2013;69(9):1919–1930. pmid:23560897
- 26. Lionis C, Petelos E, Mechili E-, Sifaki-Pistolla D, Chatzea V-, Angelaki A, et al. Assessing refugee healthcare needs in Europe and implementing educational interventions in primary care: a focus on methods. BMC International Health and Human Rights 2018;18:11. pmid:29422090
- 27. Directive of the European Parliament and of the Council of the European Union. Directive 2004/38/EC The right of citizens of the Union and their family members to move and reside freely within the territory of the Member States amending Regulation (EEC) No 1612/68 and repealing Directives 64/221/EEC, 68/360/EEC, 72/194/EEC, 73/148/EEC, 75/34/EEC, 75/35/EEC, 90/364/EEC, 90/365/EEC and 93/96/EEC. Available form: https://eur-lex.europa.eu/LexUriServ/LexUriServ.do?uri=OJ:L:2004:158:0077:0123:en:PDF Accessed December 17, 2019.
- 28. Peiro MJ, Benedict R. Migration health policy. The Portuguese and Spanish EU Presidencies. Eurohealth 2010;16(1):1–4.
- 29. National Institute for Health and Care Excellence. Methods for the development of NICE public health guidance: Process and methods. 2012;Third Edition. NICE (National Institute for Health and Care Excellence): London.
- 30. Thomas J, Harden A. Methods for the thematic synthesis of qualitative research in systematic reviews. BMC Medical Research Methodology 2008;8:45. pmid:18616818
- 31. Lewin S, Glenton C, Munthe-Kass H, Colvin C, Gulmezoglu M, Noyes J. Using qualitative evidence in decision making for health and social interventions: an approach to assess confidence in findings from qualitative evidence syntheses (GRADE-CERQual). PLoS Medicine 2015;12(10).
- 32. Lewin S, Booth A, Glenton C, Munthe-Kaas H, Rashidian A, Wainwright M, et al. Applying GRADE-CERQual to qualitative evidence synthesis findings: introduction to the series. Implementation Science 2018;13(Suppl 1):2. pmid:29384079
- 33. Lewin S, Bohren M, Rashidian A, Munthe-Kaas H, Glenton C, Colvin CJ, et al. Applying GRADE-CERQual to qualitative evidence synthesis findings—paper 2: how to make an overall CERQual assessment of confidence and create a summary of qualitative findings table. Implementation Science 2018;13(Supp 1):10.
- 34. Baken E, Bazzocchi A, Bertozzi N, Celeste C, Chattat R, D’Augello V, et al. La salute materno-infantile degli stranieri e l’accesso ai servizi. Analisi qualiquantitativa nel territorio cesenate. (Italian) [Maternal and child health of migrants and access to services. Qualitative quantitative analysis in the Cesena area]. Quaderni acp 2007;14(2):56–60.
- 35. Phillimore J. Delivering maternity services in an era of superdiversity: The challenges of novelty and newness. Ethnic and Racial Studies 2015;38(4):568–582.
- 36. Schoevers MA, van den Muijsenbergh METC, Lagro-Janssen ALM. Illegal female immigrants in the Netherlands have unmet needs in sexual and reproductive health. Journal of Psychosomatic Obstetrics & Gynecology 2010;31(4):256–264.
- 37. Velemínský M Jr, Průchova D, Vránová V, Samková J, Samek J, Porche S, et al. Medical and salutogenic approaches and their integration in taking prenatal and postnatal care of immigrants. Neuroendocrinology Letters 2014;35(Suppl 1):67–79.
- 38. Almeida L, Caldas JP, Ayres-de-Campos D, Dias S. Assessing maternal healthcare inequities among migrants: a qualitative study. Cadernos de Saúde Pública 2014;30(2):333–340. pmid:24627061
- 39. Binder P, Johnsdotter S, Essén B. Conceptualising the prevention of adverse obstetric outcomes among immigrants using the 'three delays' framework in a high-income context. Social Science & Medicine 2012;75(11):2028–2036.
- 40. Byrskog U, Essén B, Olsson P, Klingberg-Allvin M. 'Moving on' Violence, wellbeing and questions about violence in antenatal care encounters. A qualitative study with Somali-born refugees in Sweden. Midwifery 2016;40:10–17. pmid:27428093
- 41. Choudhry K, Wallace LM. 'Breast is not always best': South Asian women's experiences of infant feeding in the UK within an acculturation framework. Maternal and Child Nutrition 2012;8(1):72–87. pmid:22136221
- 42. Coutinho E, Rocha A, Pereira C, Silva A, Duarte J, Parreira V. Experiences of motherhood: Unmet expectations of immigrant and native mothers, about the Portuguese health system. Atencion Primaria 2014;46(Suppl 5):140–144.
- 43. Dempsey M, Peeren S. Keeping things under control: exploring migrant Eastern European womens' experiences of pregnancy in Ireland. Journal of Reproductive & Infant Psychology 2016;34(4):370–382.
- 44. Feldman R. When maternity doesn't matter: Dispersing pregnant women seeking asylum. British Journal of Midwifery 2014;22(1):23–28.
- 45. Gardner PL, Bunton P, Edge D, Wittkowski A. The experience of postnatal depression in West African mothers living in the United Kingdom: a qualitative study. Midwifery 2014;30(6):756–763. pmid:24016554
- 46. Garnweidner LM, Sverre Pettersen K, Mosdøl A. Experiences with nutrition-related information during antenatal care of pregnant women of different ethnic backgrounds residing in the area of Oslo, Norway. Midwifery 2013;29(12):e130–7. pmid:23481338
- 47. Garnweidner-Holme L, Lukasse M, Solheim M, Henriksen L. Talking about intimate partner violence in multi-cultural antenatal care: a qualitative study of pregnant women's advice for better communication in South-East Norway. BMC Pregnancy Childbirth 2017;17:123. pmid:28420328
- 48. Gitsels-van dW, Martin L, Manniën J, Verhoeven P, Hutton EK, Reinders HS. Antenatal counselling for congenital anomaly tests: Pregnant Muslim Moroccan women's preferences. Midwifery 2015;31(3):e50–7. pmid:25637462
- 49. Glavin K, Sæteren B. Cultural Diversity in Perinatal Care: Somali New Mothers' Experiences with Health Care in Norway. Health Science Journal 2016;10(4):1–9.
- 50. Hjelm K, Bard K, Nyberg P, Apelqvist J. Management of gestational diabetes from the patient's perspective—a comparison of Swedish and Middle-Eastern born women. Journal of Clinical Nursing 2007;16(1):168–178. pmid:17181679
- 51. Iliadi P. Refugee women in Greece:- a qualitative study of their attitudes and experience in antenatal care. Health Science Journal 2008;2(3):173–180.
- 52. Jonkers M, Richters A, Zwart J, Öry F, van Roosmalen J. Severe maternal morbidity among immigrant women in the Netherlands: patients' perspectives. Reproductive Health Matters 2011;19(37):144–153. pmid:21555095
- 53. Lephard E, Haith-Cooper M. Pregnant and seeking asylum: Exploring women's experiences 'from booking to baby'. British Journal of Midwifery 2016;24(2):130–136.
- 54. Leung G. Cultural considerations in postnatal dietary and infant feeding practices among Chinese mothers in London. British Journal of Midwifery 2017;25(1):18–24.
- 55. Lundberg PC, Gerezgiher A. Experiences from pregnancy and childbirth related to female genital mutilation among Eritrean immigrant women in Sweden. Midwifery 2008;24(2):214–225. pmid:17316934
- 56. Petruschke I, Ramsauer B, Borde T, David M. Differences in the Frequency of Use of Epidural Analgesia between Immigrant Women of Turkish Origin and Non-Immigrant Women in Germany—Explanatory Approaches and Conclusions of a Qualitative Study. Geburtshilfe Frauenheilkd 2016;76(9):972–977. pmid:27681522
- 57. Ranji A, Dykes A, Ny P. Routine ultrasound investigations in the second trimester of pregnancy: the experiences of immigrant parents in Sweden. Journal of Reproductive & Infant Psychology 2012;30(3):312–325.
- 58. Straus L, McEwen A, Hussein FM. Somali women's experience of childbirth in the UK: perspectives from Somali health workers. Midwifery 2009;25(2):181–186. pmid:17600598
- 59. Szafranska M, Gallagher L. Polish women's experiences of breastfeeding in Ireland. Practising Midwife 2016;19(1):30–32. pmid:26975131
- 60. Tobin C, Murphy-Lawless J, Tatano Beck C. Childbirth in exile: Asylum seeking women's experience of childbirth in Ireland. Midwifery 2014;30(7):831–838. pmid:24071035
- 61. Topa JB, Nogueira CO, Neves SA. Maternal health services: an equal or framed territory? International Journal of Human Rights in Healthcare 2017;10(2):110–122.
- 62. Treisman K, Jones FW, Shaw E. The experiences and coping strategies of United Kingdom-based African women following an HIV diagnosis during pregnancy. The Journal Of The Association Of Nurses In AIDS Care: JANAC 2014;25(2):145–157. pmid:23523367
- 63. Viken B, Lyberg A, Severinsson E. Maternal health coping strategies of migrant women in Norway. Nursing Research and Practice 2015;878040: pmid:25866676
- 64. Babatunde T, Moreno-Leguizamon C. Daily and cultural issues of postnatal depression in African women immigrants in South East London: tips for health professionals. Nursing Research And Practice 2012;181640: pmid:23056936
- 65. Barona-Vilar C, Más-Pons R, Fullana-Montoro A, Giner-Monfort J, Grau-Muñoz A, Bisbal-Sanz J. Perceptions and experiences of parenthood and maternal health care among Latin American women living in Spain: A qualitative study. Midwifery 2013;29(4):332–337. pmid:22398026
- 66. Bollini P, Stotzer U, Wanner P. Pregnancy outcomes and migration in Switzerland: results from a focus group study. International Journal of Public Health 2007;52(2):78–86. pmid:18704286
- 67. Degni F, Suominen SB, El Ansari W, Vehviläinen-Julkunen K, Essen B. Reproductive and maternity health care services in Finland: perceptions and experiences of Somali-born immigrant women. Ethnicity & Health 2014;19(3):348–366.
- 68. Hanley J. The emotional wellbeing of Bangladeshi mothers during the postnatal period. Community Practitioner 2007;80(5):34–37. pmid:17536469
- 69. Binder P, Borné Y, Johnsdotter S, Essén B. Shared language is essential: communication in a multiethnic obstetric care setting. Journal of Health Communication 2012;17(10):1171–1186. pmid:22703624
- 70. Briscoe L, Lavender T. Exploring maternity care for asylum seekers and refugees. British Journal of Midwifery 2009;17(1):17–24.
- 71. Essén B, Binder P, Johnsdotter S. An anthropological analysis of the perspectives of Somali women in the West and their obstetric care providers on caesarean birth. Journal of Psychosomatic Obstetrics & Gynecology 2011;32(1):10–18.
- 72. Gaudion A, Allotey P. In the bag: meeting the needs of pregnant women and new parents in exile. Practising Midwife 2009;12(5):20–23. pmid:19517965
- 73. Hufton E, Raven J. Exploring the infant feeding practices of immigrant women in the North West of England: a case study of asylum seekers and refugees in Liverpool and Manchester. Maternal & Child Nutrition 2016;12(2):299–313.
- 74. Ny P, Plantin L, Karlsson D,Elisabeth , Dykes A. Middle Eastern mothers in Sweden, their experiences of the maternal health service and their partner's involvement. Reproductive Health 2007;4:9. pmid:17958884
- 75. Robertson EK. "To be taken seriously": women's reflections on how migration and resettlement experiences influence their healthcare needs during childbearing in Sweden. Sexual & Reproductive HealthCare 2015;6(2):59–65.
- 76. Sauvegrain P, Azria E, Chiesa-Dubruille C, Deneux-Tharaux C. Exploring the hypothesis of differential care for African immigrant and native women in France with hypertensive disorders during pregnancy: a qualitative study. BJOG: an international journal of obstetrics and gynaecology 2017;124(12):1858–1865.
- 77. Wandel M, Terragni L, Nguyen C, Lyngstad J, Amundsen M, de Paoli M. Breastfeeding among Somali mothers living in Norway: Attitudes, practices and challenges. Women & Birth 2016;29(6):487–493.
- 78. Wikberg A, Eriksson K, Bondas T. Intercultural Caring From the Perspectives of Immigrant New Mothers. JOGNN: Journal of Obstetric, Gynecologic & Neonatal Nursing 2012;41(5):638–649.
- 79. Yeasmin SF, Regmi K. A Qualitative Study on the Food Habits and Related Beliefs of Pregnant British Bangladeshis. Health Care for Women International 2013;34(5):395–415. pmid:23550950
- 80. Almeida L, Casanova C, Caldas J, Ayres-de-Campos D, Dias S. Migrant Women's Perceptions of Healthcare During Pregnancy and Early Motherhood: Addressing the Social Determinants of Health. Journal of Immigrant & Minority Health 2014;16(4):719–723.
- 81. Wikberg A, Eriksson K, Bondas T. Immigrant New Mothers in Finnish Maternity Care: An Ethnographic Study of Caring. International Journal of Childbirth 2014;4(2):86–102.
- 82. Phillimore J. Migrant maternity in an era of superdiversity: New migrants' access to, and experience of, antenatal care in the West Midlands, UK. Social Science & Medicine 2016;148:152–159.
- 83. Newall D, Phillimore J, Sharpe H. Migration and maternity in the age of superdiversity. Practising Midwife 2012;15(1):20–22. pmid:22324128
- 84. Small R, Roth C, Raval M, Shafiei T, Korfker D, Heaman M, et al. Immigrant and non-immigrant women's experiences of maternity care: a systematic and comparative review of studies in five countries. BMC Pregnancy and Childbirth 2014;14:152. pmid:24773762
- 85. Wikberg A, Bondas T. A patient perspective in research on intercultural caring in maternity care: A meta-ethnography. International Journal of Qualitative Studies on Health & Well-Being 2010;5(1):1–15.
- 86. Sudbury H, Robinson A. Barriers to sexual and reproductive health care for refugee and asylum-seeking women. British Journal of Midwifery 2016;24(4):275–281.
- 87. Santiago M, Figueiredo M. Immigrant Women's Perspective on Prenatal and Postpartum Care: Systematic Review. Journal of Immigrant & Minority Health 2015;17(1):276–284.
- 88. Ostrach B. ' Yo No Sabía …'-Immigrant Women's Use of National Health Systems for Reproductive and Abortion Care. Journal of Immigrant & Minority Health 2013;15(2):262–272.
- 89. Boerleider AW, Wiegers TA, Manniën J, Francke AL, Devillé WLJM. Factors affecting the use of prenatal care by non-western women in industrialized western countries: A systematic review. BMC Pregnancy Childbirth 2013;13:81. pmid:23537172
- 90. Cohen AL, Rivara F, Marcuse EK, McPhillips H, Davis R. Are language barriers associated with serious medical events in hospitalized pediatric patients? Pediatrics 2005;116(3):575–579. pmid:16140695
- 91. Divi C, Koss RG, Schmaltz SP, Loeb JM. Patients with limited English experience more serious errors. International Journal for Quality in Health Care 2007;19(2):60–67. pmid:17277013
- 92. Karliner LS, Jacobs EA, Chen AH, Mutha S. Do professional interpreters improve clinical care for patients with limited English proficiency? A systematic review of the literature. Health Services Research 2007;42(2):727–754. pmid:17362215
- 93. Flores G. The impact of medical interpreter services on the quality of health care: a systematic review. Medical Care Research & Review 2005;62(3):255–299.
- 94. Jacobs EA, Shepard DS, Suaya JA, Stone E-L. Overcoming language barriers in health care: costs and benefits of interpreter services. American Journal of Public Health 2004;94(5):866–869. pmid:15117713
- 95. Jacobs EA, Sadowski LS, Rathouz PJ. The impact of an enhanced interpreter service intervention on hospital costs and patients satisfaction. Journal of General Internal Medicine 2005;22(Supplement 2):306–311.
- 96. Meeuwesen L. Language barriers in migrant health: a blind spot. Patient Education and Counseling 2012;86(2):135–136. pmid:22284163
- 97. Ku L, Flores G. Pay now or pay later: Providing interpreters services in health care. Health Affairs 2005;24(2):435–444. pmid:15757928
- 98. Gany F, Kapelusznik L, Prakash K, Gonzalez J, Orta LY, Tseng C-. The impact of medical interpretation method on time and errors. Journal of General Internal Medicine 2007;22(Supplement 2):319–323.
- 99. Ramirez D, Engel KG, Tang TS. Language interpreter utilization in the emergency department setting: a clinical review. Journal of Health Care for the Poor and Underserved 2008;19(2):352–362. pmid:18469408
- 100. Benza S, Liamputtong P. Pregnancy, childbirth and motherhood: A meta-synthesis of the lived experiences of immigrant women. Midwifery 2014;30(6):575–584. pmid:24690130
- 101. Nilaweera I, Doran F, Fisher J. Prevalence, nature and determinants of postpartum mental health problems among women who have migrated from South Asian to high-income countries: a systematic review of the evidence. Journal of Affective Disorders 2014;166:213–226. pmid:25012434
- 102. General Assembly. Convention on the Elimination of All Forms of Discrimination against Women. General Assembly Resolution 34/180. 1979. UN General Assembly.
- 103. Department of Health and Social Care. Guidance on implementing the overseas visitor charging regulations. 2018. Department of Health and Social Care: Leeds
- 104. Schmied V, Black E, Naidoo N, Dahlen HG, Liamputtong P. Migrant women's experiences, meanings and ways of dealing with postnatal depression: A meta-ethnographic study. PLoS One 2017;12(3):e0172385. pmid:28296887
- 105. Wittkowski A, Patel S, Fox JR. The Experience of Postnatal Depression in Immigrant Mothers Living in Western Countries: A Meta-Synthesis. Clinical Psychology & Psychotherapy 2017;24(2):411–427.
- 106. Higginbottom G, Reime B, Bharj K, Chowbey P, Ertan K, Foster-Boucher C, et al. Migration and Maternity: Insights of Context, Health Policy, and Research Evidence on Experiences and Outcomes From a Three Country Preliminary Study Across Germany, Canada, and the United Kingdom. Health Care for Women International 2013;34(11):936–965. pmid:23631670
- 107. Marmot M. Fair Society, Healthy Lives: The Marmot Review: Strategic Review of Health Inequalities in England post-2010. 2010. Department of International Development: London.
- 108. Parker B, McFarlane J, Soeken K. Abuse during pregnancy: effects on maternal complications and birth weight in adult and teenage women. Obstetrics and Gynecology 1994;84(3):323–328. pmid:8058224
- 109. Farley TA, Mason K, Rice J, Habel JD, Scribner R, Cohen DA. The relationship between the neighbourhood environment and adverse birth outcomes. Paediatric & Perinatal Epidemiology 2006;20(3):188–200.
- 110. Stillerman KP, Mattison DR, Guidice LC, Woodruff TJ. Environmental exposures and adverse pregnancy outcomes: a review of the science. Reproductive Sciences 2008;15(7):631–650. pmid:18836129
- 111. Kruger DJ, Munsell MA, French-Turner T. Using a life history framework to understand the relationship between neighborhood structural deterioration and adverse birth outcomes. Journal of Social, Evolutionary, and Cultural Psychology 2011;5(4):260–274.
- 112. Feldman PJ, Dunkel-Schetter C, Sandman CA, Wadhwa PD. Maternal social support predicts birth weight and fetal growth in human pregnancy. Psychosomatic Medicine 2000;62(5):715–725. pmid:11020102
- 113. Graham W, Woodd S, Byass P, Filippi V, Gon G, Virgo S, et al. Diversity and divergence: the dynamic burden of poor maternal health. Lancet 2016;388(10056):2164–2175. pmid:27642022
- 114. Sangalang CC, Becerra D, Mitchell FM, Lechuga-Peña S, Lopez K, Kim I. Trauma, Post-Migration Stress, and Mental Health: A Comparative Analysis of Refugees and Immigrants in the United States. Journal of Immigrant and Minority Health 2018: https://doi.org/10.1007/s10903-018-0826-2.
- 115. Sperlich M, Seng JS, Yang Li Y, Taylor J, Bradbury-Jones C. Integrating Trauma-Informed Care into Maternity Care Practice: Conceptual and Practical Issues. Journal of Midwifery and Women’s Health 2017;62(6):661–672. pmid:29193613
- 116. Sandall J, Soltani H, Gates S, Shennan A, Devane D. Midwife-led continuity models versus other models of care for childbearing women. Cochrane Database of Systematic Reviews 2016(Issue 4). Art. No.: CD004667.
- 117. Vivilaki V, Soltani H, van den Muijsenbergh M et al. Approach to Integrated Perinatal Healthcare for Migrant and Refugee Women. 2017. Available from: http://oramma.eu/wp-content/uploads/2018/12/ORAMMA-D4.2-Approach_reviewed.pdf. Accessed November 15, 2019.
- 118. Mullen F, Epstein L. Community-Oriented Primary Care: New Relevance in a Changing World. American Journal of Public Health (AJPH) 2002;92(11):1748–1755.
- 119. Mash B, Ray S, Essuman A, Burgueño E. Community-orientated primary care: a scoping review of different models, and their effectiveness and feasibility in sub-Saharan Africa. BMJ Global Health. 2019;4:e001489. pmid:31478027
- 120. Mechili EA, Angelaki A, Petelos E, Sifaki-Pistolla D, Chatzea VE, Dowrick C, et al. Compassionate care provision: an immense need during the refugee crisis: lessons learned from a European capacity-building project. Journal of Compassionate Health Care 2018;5:2 https://doi.org/10.1186/s40639-018-0045-7. Accessed December 17, 2019.