Experiences and needs of women from ethnic minorities in maternity healthcare: A qualitative systematic review and meta-aggregation

ObjectivesTo consolidate the available evidence around ethnic minority women’s experiences and needs when accessing maternity care.MethodsA qualitative systematic review and meta-aggregation of qualitative data were conducted. Nine electronic databases were searched for qualitative or mixed-methods studies from the inception of each database until January 2022. Using the Nested-Knowledge software, meta-aggregation was conducted according to the Joanna Briggs Institute (JBI) data synthesis approach to identify all potential intersections between different themes. Methodological quality of included studies was assessed using the JBI Qualitative Assessment and Review Instrument (JBI-QARI) and the mixed-methods appraisal tool (MMAT) checklists for qualitative and mixed-methods studies, respectively.ResultsTwenty-two studies (nineteen qualitative and three mixed-methods) were included. All studies were of good methodological quality. An overarching theme ‘the struggles and fears of ethnic minority women’ was identified. The negative experiences with maternity care were attributed to barriers including ineffective communication, cultural and religious insensitivity, inattentiveness and disregard for women’s needs, and isolation-related impact due to the COVID pandemic.ConclusionsOverall, our review highlighted several significant gaps between the care provided and the expected care among ethnic minority women accessing maternity care services. This mismatch between their expectations and care resulted in negative experiences, as the women reported being discriminated against and disrespected. There is an urgent need to develop and implement maternity care policies that are inclusive of needs of the ethnic minority women to optimize their maternity care experience.     

Factors influencing Aboriginal and Torres Strait Islander women’s breastfeeding practice: A scoping narrative review

BackgroundThe nutritional and health benefits of breastfeeding for infants and young children are well-established however rates of breastfeeding initiation and duration for Aboriginal and Torres Strait Islander children are lower than non-Indigenous children.AimTo describe factors influencing breastfeeding practice amongst Aboriginal and Torres Strait Islander women.MethodsA scoping narrative review was conducted using the Joanna Briggs Institute framework. A search was conducted in four online databases (PubMed, Scopus, ANU SuperSearch, and Science Direct). Findings were analysed using [30] narrative synthesis.FindingsThis review included 9 journal articles, a conference summary and a book. This review identified four factors influencing women’s breastfeeding practice; sources of support, culturally appropriate care, intention to breastfeed and social determinants.ConclusionMultiple social determinants resulting from colonization have interrupted traditional infant feeding practices and women’s sources of support. Although Aboriginal and Torres Strait Islander women have strong intention to breastfeed, their breastfeeding outcomes are impacted by lack of pro-breastfeeding support when encountering breastfeeding challenges as well as norms surrounding the use of infant formula milk. Culturally appropriate care is essential for identifying women’s needs and avoiding stereotyping. Further research is needed to investigate the effectiveness of breastfeeding interventions for this group of women.     

The maternity experiences of women seeking asylum in high-income countries: a meta-ethnography

ProblemThe maternity care experiences and perinatal outcomes of women seeking asylum in high-income countries (HICs) are poorer than the general population of pregnant women in that HIC. There is a paucity of literature on the maternity experiences of women seeking asylum in HICs.BackgroundThere is an increasing number of women seeking asylum in HICs due to escalating violence and human rights abuses. Asylum-seeking women are a distinct group whom are likely to have different needs to refugees or migrants as a result of their undocumented status.AimThis literature review aimed to explore the emotional, physical and health information needs of women seeking asylum in the perinatal period in HICs, to provide insights to better address their maternity needs.MethodA meta-ethnography described by Noblit and Hare, was applied to analyse the studies, to reflect the voices of women seeking asylum, hosted in HICs in their perinatal period.FindingsEight studies were included in the review. The overarching theme was ‘just having to survive.’ Four sub-themes were revealed which highlighted the vulnerability of asylum-seeking women. They included: ‘I was never sure if I had understood’, ‘feeling ignored and alone’, ‘ongoing dislocation and recurrent relocation’ and ‘knowing there’s someone who cares for you’.DiscussionImproved maternity care for women seeking asylum requires culturally appropriate respectful maternity care and supportive strategies such as consistent access to language services.ConclusionIt is recommended that future research is targeted to explore the maternity experience of women seeking asylum in HICs, such as Australia.     

Midwives’ insights in relation to the common barriers in providing effective perinatal care to women from ethnic minority groups with ‘high risk’ pregnancies: A qualitative study

ProblemChildbearing women from ethnic minority groups in the United Kingdom (UK) have significantly poorer perinatal outcomes overall.BackgroundChildbearing women from ethnic minority groups report having poorer experiences and outcomes in perinatal care, and health professionals report having difficulty in providing effective care to them. Yet barriers in relation to providing such care remain underreported.AimThe aim of this study was to elicit midwives' insights in relation to the common barriers in providing effective perinatal care to women from ethnic minority groups with 'high risk' pregnancies and how to overcome these barriers.MethodsA qualitative study was undertaken in a single obstetric led unit in London, UK. A thematic analysis was undertaken to identify themes from the data.FindingsA total of 20 midwives participated. They self-identified as White British (n = 7), Black African (n = 7), Black Caribbean (n = 3) and Asian (n = 3). Most (n = 12) had more than 10 years’ experience practising as a registered midwife (range 2 – 35 years). Four themes were identified: 1) Communication, 2) Continuity of carer, 3) Policy and 4) Social determinants. Racism and unconscious bias underpin many of the findings presented.DiscussionCo-created community hubs may improve access to more effective care for childbearing women from ethnic minority groups. A focus on robust anti-racism interventions, continuity of carer, staff wellbeing and education along with the provision of orientation and bespoke translation services are also suggested for the reduction of poorer outcomes and experiences.ConclusionAlong with policies designed to promote equality and irradicate racism, there is a need for co-created community hubs and continuity of carer in perinatal services. Further research is also required to develop and evaluate culturally safe, and evidence-based interventions designed to address the current disparities apparent.     

Trust,privacy, community,and culture: Important elements of maternity care for Aboriginal and Torres Strait Islander women giving birth in Victoria.

BackgroundThe Australian maternity system must enhance its capacity to meet the needs of Aboriginal and Torres Strait Islander (First Nations) mothers and babies, however evidence regarding what is important to women is limited.AimsThe aim of this study was to explore what women having a First Nations baby rate as important for their maternity care as well as what life stressors they may be experiencing.MethodsWomen having a First Nations baby who booked for care at one of three urban Victorian maternity services were invited to complete a questionnaire.Results343 women from 76 different language groups across Australia. Almost one third of women reported high levels of psychological distress, mental illness and/or were dealing with serious illness or death of relatives or friends. Almost one quarter reported three or more coinciding life stressors. Factors rated as most important were privacy and confidentiality (98 %), feeling that staff were trustworthy (97 %), unrestricted access to support people during pregnancy appointments, (87 %) birth (66 %) and postnatally (75 %), midwife home visits (78 %), female carers (66 %), culturally appropriate artwork, brochures (68 %) and access to Elders (65 %).ConclusionsThis study provides important information about what matters to women who are having a First Nations baby in Victoria, Australia, bringing to the forefront social and cultural complexities experienced by many women that need to be considered in programme planning. It is paramount that maternity services partner with First Nations communities to implement culturally secure programmes that respond to the needs of local communities.     

Community perspectives on delivering trauma-aware and culturally safe perinatal care for Aboriginal and Torres Strait Islander parents

BackgroundSince colonisation, Aboriginal and Torres Strait Islander peoples have experienced violence, loss of land, ongoing discrimination and increased exposure to traumatic events. These include adverse childhood experiences which can lead to complex trauma, and are associated with increased incidence of high-risk pregnancies, birth complications and emergence of post-traumatic symptoms during the perinatal period, potentially impacting parenting and leading to intergenerational trauma. The perinatal period offers unique opportunities for processing experiences of trauma and healing yet can also be a time when parents experience complex trauma-related distress. Therefore, it is essential that trauma-aware culturally safe perinatal care is accessible to Aboriginal and Torres Strait Islander parents.AimThis study aimed to understand community perspectives of what ‘trauma-aware culturally safe perinatal care’ would look like for Aboriginal and Torres Strait Islander parents.MethodsData were collected during a workshop held with predominantly Aboriginal and Torres Strait Islander key stakeholders to co-design strategies to foster trauma-aware culturally safe perinatal care. Data were thematically analysed.FindingsFour overarching themes represent proposed goals for trauma-aware culturally safe care: Authentic partnerships that are nurtured and invested in to provide the foundations of care; a skilled workforce educated in trauma awareness; empowering and compassionate care for building trust; and safe and accessible environments to facilitate parent engagement.ConclusionsProvision of trauma-aware culturally safe care achieving these goals is likely to enable parents experiencing complex trauma to access appropriate support and care to foster healing in the critical perinatal period.     

An interpretive review of women's experiences of gestational diabetes mellitus: Proposing a framework to enhance midwifery assessment

BackgroundGestational diabetes mellitus (GDM) affects almost 5% of pregnancies in Australia, and within 15 years, 25% of affected women will go on to develop Type 2 Diabetes Mellitus (T2DM). The adoption of preventive health behaviours may be influenced by women's experiences of GDM.QuestionThis review sought to understand women's beliefs, values, perceptions and experiences following diagnosis of GDM.MethodsPeer reviewed and professional journals were searched for primary research, published between January 1991 and December 2011 that explored the beliefs, values, perceptions and experiences of peripartum or postpartum women with a diagnosis or history of GDM.FindingsNineteen studies met the inclusion criteria and the majority of these studies were qualitative (n = 15). Each study was reviewed and synthesis revealed three emergent themes and core concepts related to each theme: Responses (initial reaction to GDM diagnosis, negative thoughts following diagnosis, struggle to manage GDM, feelings of ‘loss of control’, changes to identity and adapting to change), Focus of Concern (concern for baby's health, mother's concern for her own health, perceived seriousness of GDM, perceived fear of T2DM) and Influencing Factors (cultural roles and beliefs, social stigmas, social support, professional support, adequate and appropriate information, social roles and barriers to self-care).ConclusionThe experiences of women with GDM are unique and personal however this review highlights common experiences evident in the existing research. The proposed framework may be used by midwives in clinical assessment and care of women diagnosed with GDM.     

Women’s experiences of intrapartum care and recovery in relation to planned caesarean sections: An interview study

Problem and backgroundApproximately one third of women in high-income countries give birth by caesarean section (CS). Better understanding of women’s CS experiences is vital in identifying opportunities to improve women’s experience of care.AimTo identify opportunities for service improvement by investigating Australian women’s experiences of care and recovery when undergoing a planned CS.MethodsQualitative telephone interview study with 33 women who had a planned CS at one of eight Australian hospitals. Semi-structured interviews were conducted to elicit women’s perspectives, experiences and beliefs surrounding their planned CS. Interviews were transcribed verbatim and analysed inductively using NVivo-12.ResultsWomen’s experiences of CS care were mixed. Regarding intrapartum care, many women stated their planned CS was a positive experience compared to a previous emergency CS, but was scarier and more medicalised compared to vaginal birth. CS recovery was viewed more negatively, with women feeling unprepared. They reported disliking how CS recovery restricted their role as a mother, wanting more time in hospital, and greater support and continuity of care.DiscussionWomen reported largely positive intrapartum experiences of planned CS but relatively negative experiences of CS recovery. They wished for time in hospital and support from staff during recovery, and continuity of care.ConclusionBy incorporating shared decision-making antenatally, clinicians can discuss women’s birth expectations with them and better prepare them for their planned CS and recovery.     

Sexual Orientation and Sexual Health Care Needs: A Comparison of Women Beneficiaries in Outpatient Military Health Care Settings

ABSTRACT

The objectives of this study are to compare the sexual concerns, interest and experiences in discussing these concerns with their doctor for women of “Only Men” and “Some to Only Women” sexual orientation. A survey was mailed to women patients from two military outpatient settings, with 1,196 women responding. Of eligible respondents (N = 1,170), 90% reported “Only Men” and 10% reported “Some to Only Women” sexual orientation. Sexual concerns varied by sexual orientation, while interest and experience in discussing sexual concerns and desire for physicians to initiate the topic differed minimally. Women with “Some to Only Women” sexual orientation have both similar and differing sexual concerns compared to “male-only” oriented women. Larger primary care patient-based studies of sexual health care needs of sexual minorities are needed.     

‘No sugar’, ‘no junk food’, ‘do more exercise’ – moving beyond simple messages to improve the health of Aboriginal women with Hyperglycaemia in Pregnancy in the Northern Territory – A phenomenological study

BackgroundGlobally, rates of hyperglycaemia in pregnancy are highest among Indigenous women. The highest prevalence has been documented among Aboriginal women in the Northern Territory of Australia. Despite knowledge of this for over two decades, there has been very limited examination of the specific needs and experiences of Aboriginal women regarding this condition.QuestionHow do Aboriginal women with hyperglycaemia in pregnancy understand and experience this condition, and how can their care be improved?MethodsA phenomenological methodology underpinned semi-structured in-depth interviews with 35 Aboriginal women and seven health professionals across the Northern Territory. Data were inductively analysed.FindingsThe findings revealed that in general, participants in this study could recite simple health messaging regarding diabetes (e.g. ‘no sugar’), but many lacked in-depth knowledge and this affected the management of their condition. Nevertheless, many identified pregnancy as a powerful motivator for change, signalling scope to improve health messaging. Women consistently expressed the need for diabetes education that was culturally appropriate, a clear desire for maternity care that was family-centred, based on respectful relationships with the same care provider, and respected Aboriginal ways of knowing and being.ConclusionExisting health messaging around hyperglycaemia in pregnancy has limited reach with Aboriginal women in the Northern Territory. Reducing the burden of hyperglycaemia in pregnancy among these women requires a sustained commitment to redesign of maternity and diabetes care to incorporate the cultural and social context of women’s lives.     

Women’s experiences of health care utilization in cases of early pregnancy loss: A scoping review

BackgroundApproximately 25% of pregnancies end in miscarriage, most occurring within the first trimester (<13 weeks). For many women early pregnancy loss has implications for short- and long- term mental health, and women’s well-being following early pregnancy loss is impacted by their experiences within the healthcare setting. To improve quality of care, it is crucial to understand women’s’ experiences within the healthcare system in cases of early pregnancy loss.QuestionsWhat does the research literature tell us about the experiences of early pregnancy loss within healthcare settings? Are these experiences positive or negative? ‘How can care improve for those experiencing early pregnancy loss?’MethodsA scoping review of the research literature was undertaken. Three research databases were searched for relevant articles published in English since 2009, with key words related to ‘Experience’, ‘Healthcare’ and ‘Early Pregnancy Loss’. A thematic analysis was undertaken to identify and summarize key findings emerging from the research literature.FindingsTwenty-seven (27) articles met our inclusion criteria. Three main themes were identified: (1) issues related to communication, (2) challenges within care environments, and (3) inadequacies in aftercare.DiscussionThe literature suggests that women’s experiences related to healthcare for early pregnancy loss are largely negative, particularly within emergency departments. Recommendations to improve women’s experiences should extend beyond attempts to improve existing care structures, to include emerging environments and providers.ConclusionWomen’s experiences identified within the literature provide further insights on what women are seeking from their care, and how care models can be improved.     

Another country,another language and a new baby: A quantitative study of the postnatal experiences of migrant women in Australia

BackgroundGovernments and service providers have consistently acknowledged the importance of support for women and families in the transition to parenthood. Lower levels of satisfaction and concern about postnatal depression have highlighted women's needs at this time. Migrant women may also face relocation, distant family and support networks, language barriers and potentially discriminatory or culturally insensitive care.ObjectiveThe present study evaluates the unique contribution of migrant status, comparing the experience of this group to that of native-born English-speaking women.MethodSecondary analysis of data from a population-based survey of maternity care in Queensland. Experiences of 233 women born outside Australia who spoke another language at home were compared to 2722 Australian-born English-speaking women with adjustment for demographic differences.ResultsAfter adjustment, differences between the groups included physical, psychological aspects and perceptions of care. Women born outside Australia were less likely to report pain after birth was manageable, or rate overall postnatal physical health positively. They more frequently reported having painful stitches, distressing flashbacks and feeling depressed in the postnatal period. Few differences in ratings of care providers were found, however, women born outside Australia were less likely to feel involved in decisions and to understand their options for care. However, they were more likely to report being visited by a care provider at home after birth.ConclusionsThe findings represent an important addition to existing qualitative reports of the experiences of migrant women, reflecting poorer postnatal health, issues associated with migration and parenthood and highlighting areas for care improvement.     

Women from migrant and refugee backgrounds’ perceptions and experiences of the continuum of maternity care in Australia: A qualitative evidence synthesis

BackgroundWomen who were born overseas represent an increasing proportion of women giving birth in the Australian healthcare system.ProblemWomen from migrant and refugee backgrounds have an increased risk of poor pregnancy and birth outcomes, including experiences of care.AimTo understand how women from migrant and refugee backgrounds perceive and experience the continuum of maternity care (pregnancy, birth, postnatal) in Australia.MethodologyWe conducted a qualitative evidence synthesis, searching MEDLINE, CIHAHL, and PsycInfo for studies published from inception to 23/05/2020. We included studies that used qualitative methods for data collection and analysis, that explored migrant/refugee women’s experiences or perceptions of maternity care in Australia. We used a thematic synthesis approach, assessed the methodological limitations of included studies, and used GRADE-CERQual to assess confidence in qualitative review findings.Results27 studies met the inclusion criteria, representing women in Australia from 42 countries. Key themes were developed into 24 findings, including access to interpreters, structural barriers to service utilisation, experiences with health workers, trust in healthcare, experiences of discrimination, preferences for care, and conflicts between traditional cultural expectations and the Australian medical system.ConclusionThis review can help policy makers and organisations who provide care to women from migrant and refugee backgrounds to improve their experiences with maternity care. It highlights factors linked to negative experiences of care as well as factors associated with more positive experiences to identify potential changes to practices and policies that would be well received by this population.     

Birth environments for women with complex pregnancies: A mixed-methods systematic review

BackgroundBirth environments can help support women through labour and birth. Home-like rooms which encourage active birthing are embraced in midwifery-led settings. However, this is often not reflected in obstetric settings for women with more complex pregnancies.AimTo investigate the impact of the birth environment for women with complex pregnancies.MethodsThis was a mixed-methods systematic review, incorporating qualitative and quantitative research. A literature search was implemented across three databases (Medline, CINAHL, Embase) from the year 2000 to June 2021. Studies were eligible if they were based in an Organisation for Economic Cooperation and Development country and reported on birth environments for women with complex pregnancies. Papers were screened and quality appraised by two researchers independently.Findings30,345 records were returned, with 15 articles meeting inclusion criteria. Studies were based in Australia, the UK, and the USA. Participants included women and health professionals. Five main themes arose: Quality of care and experience; Supportive spaces for women; Supportive spaces for midwives; Control of the space; Design issues.DiscussionWomen and midwives found the birth environment important in supporting, or failing to support, a positive birth experience. Obstetric environments are complex spaces requiring balance between space for women to mobilise and access birthing aids, with the need for medical teams to have easy access to the woman and equipment in emergencies.ConclusionFurther research is needed investigating different users’ needs from the environment and how safety features can be balanced with comfort to provide high-quality care and positive experiences for women.     

Remote access and care: A comparison of Queensland women's maternity care experience according to area of residence

BackgroundThis study fills a gap in the literature with a quantitative comparison of the maternity care experiences of women in different geographic locations in Queensland, Australia.MethodData from a large-scale survey were used to compare women's care experiences according to Australian Standard Geographical Classification (major city, inner regional, outer regional, remote and very remote).ResultsCompared to the other groups, women from remote or very remote areas were more likely to be younger, live in an area with poorer economic resources, identify as Aboriginal and/or Torres Strait Islander and give birth in a public facility. They were more likely to travel to another city, town or community for birth. In adjusted analyses women from remote areas were less likely to have interventions such as electronic fetal monitoring, but were more likely to give birth in an upright position and be able to move around during labour. Women from remote areas did not differ significantly from women from major cities in their satisfaction with interpersonal care. Antenatal and postpartum care was lacking for rural women. In adjusted analyses they were much less likely to have booked for maternity care by 18 weeks gestation, to be telephoned or visited by a care provider in the first 10 days after birth. Despite these differences, women from remote areas were more likely to be breastfeeding at 13 weeks and confident in caring for their baby at home.ConclusionsFindings support qualitative assertions that remote and rural women are disadvantaged in their access to antenatal and postnatal care by the need to travel for birth, however, other factors such as age were more likely to be significant barriers to high quality interpersonal care. Improvements to maternity services are needed in order to address inequalities in maternity care particularly in the postnatal period.