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Table 2 Study characteristics of all included articles (qualitative and quantitative)

From: Immigrant women’s experiences of maternity-care services in Canada: a systematic review using a narrative synthesis

Author, Pub year Study aim Methodology qualitative studies Sample characteristics Key outcomes/findings Quality tool used and appraisal
Study characteristics of qualitative studies
1. Ahmed et al., 2008 [70] Refugee, asylum seeking, non-refugee and immigrant new mothers with depressive symptoms were interviewed in a qualitative study to better understand: (a) their experiences and attributions of depressive symptoms; (b) their experiences with healthcare providers and support services; (c) factors that facilitated or hindered help seeking; (d) factors that aided recovery; and (e) factors which were associated with women continuing to experience symptoms of depression. Semi-structured telephone interviews which were taped, transcribed, and analysed using a constant comparative approach. 10 immigrant mothers in Toronto, Ontario, who scored 10 or over on the Edinburgh Postpartum Depression Scale 7–10 days after giving birth, participated 12–18 months later. Two women had emigrated from China, 2 from India, 1 from Pakistan, 3 from South America, 1 from Egypt, and 1 from Haiti. Many women attributed their depressive symptoms to social isolation, physical changes, feeling overwhelmed and financial worries. They also had poor knowledge of community services. Barriers to care included stigma, embarrassment, language, fear of being labelled an unfit mother and the attitude of some staff. Facilitators to recovery included social support from friends, partners and family, community support groups, ‘getting out of the house’ and personal psychological adjustment. Personal and systematic barriers exist in new immigrant mothers obtaining care for symptoms of depression. Joanna Briggs Institute
Low
2. Morrow et al., 2008 [64] The study aimed to examine: (a) women’s experiences of depression after childbirth as described by the women themselves; (b) variables associated with psychosocial stress identified by the women as contributing to the experience of depression after childbirth; (c) the role of women’s family and community in the postpartum period; (d) the kinds of support sought by women in the postpartum period. Ethnographic narrative approach utilising semi-structured, open-ended interviews. 18 first-generation immigrant women in Vancouver, British Columbia (7 Mandarin-speaking women, 8 Cantonese-speaking women, 3 Punjabi-speaking women) and 1 second-generation Punjabi-speaking immigrant woman. The critical importance of the sociocultural context of childbirth in understanding postpartum depression suggests that an examination of women's narratives about their experiences of postpartum depression can broaden the understanding of the kinds of perinatal supports women need beyond healthcare provision and yet can also usefully inform the practice of healthcare professionals. Joanna Briggs Institute
Med–High
3. Reitmanova and Gustafson, 2008 [24] The study aimed to document and explore the maternity healthcare needs and barriers to accessing maternity health services from the perspective of immigrant Muslim women. In-depth semi-structured interviews. 6 immigrant Muslim women in St. John’s, Newfoundland. Women experienced discrimination, insensitivity and lack of knowledge about their religious and cultural practices. Health information was limited or lacked the cultural and religious specificity to meet their needs during pregnancy, labour and delivery and postpartum phases. There were also significant gaps between existing maternity health services and women’s needs for emotional support and culturally and linguistically appropriate information. This gap was further complicated by the functional and cultural adjustments associated with immigration. Joanna Briggs Institute
Med
4. Spitzer, 2004 [66] The study aimed to examine the relationships between nurses and visible (non-white) minority women giving birth in hospitals undergoing healthcare restructuring. Interviews and focus group interviews using a semi-structured interview guide. 19 new mothers who had given birth in an unnamed Canadian province (5 First Nations, 6 South Asian Canadian, 5 Vietnamese Canadian, and 3 Euro Canadian). Also, 11 obstetrical nurses (4 foreign born and 7 Canadian born). Nurses felt compelled to avoid interactions with patients deemed too costly in terms of time. Overwhelmingly, these patients were members of culturally marginalised populations whose bodies were read by nurses as potentially problematic and time consuming. As their calls for assistance went unanswered, visible minority women complained of feeling invisible. Taken in the context of historical and contemporary interethnic relations, these women regarded such avoidance patterns as evidence of racism. Joanna Briggs Institute
Low
5. Sutton et al., 2007 [60] Vietnamese women’s breastfeeding experiences and challenges were explored, as were their families’ needs for prenatal and postpartum health professional programs and services. In-depth, semi-structured interviews. 11 Vietnamese mothers of children younger than 2 years living in Middlesex—London, Ontario. Lack of knowledge and misinformation were major barriers to breastfeeding. Inability to communicate in English and a lack of effective transportation were key obstacles to the women’s ability to access mainstream prenatal and postpartum health programs and services. Standard nursing prenatal and postpartum services appear not to have reached this group of mothers effectively. Joanna Briggs Institute
Med
6. Grewal et al., 2008 [18] The study aimed to describe new immigrant Punjabi women’s perinatal experiences and the ways that traditional beliefs and practices are legitimised and incorporated into the Canadian healthcare context. Naturalistic qualitative descriptive and focus groups. 15 first-time mothers who had immigrated in the past 5 years to Canada from Punjab, India and had given birth to a healthy infant in the past 3 months in a large urban centre in British Columbia, Canada; 5 health professionals and community leaders also took part in a focus group. 3 major categories emerged including: the pervasiveness of traditional health beliefs and practices related to the perinatal period (e.g., diet, lifestyle, and rituals); the important role of family members in supporting women during the perinatal experiences; and the positive and negative interactions women had with health professionals in the Canadian healthcare system. Joanna Briggs Institute
Med–High
7. Merry et al., 2011 [71] The study aimed to gain greater understanding of the barriers that vulnerable migrant women face in accessing health and social services postpartum. Qualitative text data on services that claimant women received post-birth and notes (recorded by research nurses) about their experiences in accessing and receiving services were examined. Thematic analysis was conducted to identify common themes related to access barriers. 112 asylum seekers/refugee claimants in Canada. 51 in Montreal, mainly from Nigeria, Mexico and India. 61 participants in Toronto, mainly from Nigeria, Mexico, Colombia and St. Vincent. Of particular concern were the refusal of care for infants of mothers covered under IFHP, maternal isolation and difficulty for public health nurses to reach women postpartum. Also problematic was the lack of assessment, support and referrals for psychosocial concerns. Joanna Briggs Institute
Low–Med
8. Gagnon et al., 2010 [29] The study aimed to explore the inhibitors and facilitators of migrant women for following through with referrals for care. Semi-structured interviews. 25 women in Montreal, Quebec. 12 were asylum-seekers, 7 non-refugee immigrants, 5 refugees, and 1 Canadian-born. The 25 were born in 1 of 16 different countries (4—Pakistan, 3 each—Bangladesh and Sri Lanka, 2 each—India and Columbia, 1 each—the remaining 11 countries). Inhibitors included language barriers, transportation problems, scheduling appointments, absence of husband, absence of childcare, cold weather, perceived inappropriate referrals and cultural practice differences. Facilitators included choice of follow-up facilitator, appropriate services, empathetic professionals and early receipt of information. Joanna Briggs Institute
Med
9. Ardal et al., 2011 [62] The study aimed to: (a) explore the experience of non-English speaking mothers with preterm, very low birth weight (VLBW) infants (1,500 g); and to (b) examine mothers’ assessment of a peer support programme matching them with linguistically and culturally similar parent buddies. An exploratory, qualitative analysis based on grounded theory. In-depth interviews using semi-structured guide. 8 Spanish, Portuguese, Chinese and Tamil immigrant mothers in an urban Canadian teaching hospital. Study mothers experienced intense role disequilibrium during the unanticipated crisis of preterm birth of a VLBW infant; situational crises owing to the high-tech NICU environment and their infant’s condition; and developmental crises with feelings of loss, guilt, helplessness and anxiety. Language barriers compounded the difficulties. Parent buddies helped non-English speaking mothers mobilise their strengths. Culture and language are important determinants of service satisfaction for non-English-speaking mothers. Linguistically congruent parent-to-parent matching increases access to service. Joanna Briggs Institute
Low–Med
10. Wiebe and Young, 2011 [67] The study aimed to explore the parent (client/patient) perceptions of culturally congruent care within a tertiary neonatal intensive care unit based on interviews with culturally diverse families with hospitalised infants. Attempting to further develop a new conceptual approach called the ‘Culturally Congruent Care Puzzle”, by incorporating the client/parent perspective. Exploratory qualitative approach, grounded in an emic perspective, using open, non-directed interviews as much as possible. 21 families of diverse cultural origins, who had an infant in the neonatal intensive care unit in Edmonton, AB. Key themes that emerged as elements of culturally congruent care were: (a) a relationship of caring and trust between the provider and client, (b) respectful and appropriate communication, (c) having social and spiritual supports that were culturally responsive and accessible and (d) having a welcoming and flexible environment. Joanna Briggs Institute
Med
Study characteristics of quantitative studies
1. Kingston et al., 2011 [55] The study aimed to compare the maternity experiences of immigrant women (recent, <5 years and non-recent) with those of Canadian-born women. Secondary analysis of Maternity Experiences Survey with multivariable logistic regression. A stratified random sample of 6,421 women who had recently given birth was drawn from a sampling frame based on the 2006 Canadian Census of Population. The total weighted sample comprised 7.5% recent immigrants (<5 years), 16.3% non-recent immigrants (>5 years) and 76.2% Canadian-born women. Roughly 50% of the immigrants were born in Asia. Immigrant women reported experiencing less physical abuse and stress, and they were less likely to smoke or consume alcohol during and after pregnancy. They were more likely to report high levels of postpartum depression symptoms and were less likely to have access to social support, to take folic acid before and during pregnancy (due to lack of information), to rate their own and their infant’s health as optimal and to place their infants on their backs for sleeping. Fewer attended prenatal classes or travelled to give birth. Recent and non-recent immigrant women also had different experiences, suggesting that duration of residence in Canada plays a role in immigrant women’s maternity experiences. Crombie
Med–High
2. Brar et al., 2009 [52] The study aimed to assess the use of perinatal care services by newly immigrated South Asian women and Canadian-born women and to determine any perceived barriers to receiving care. Telephone survey consisting mainly of closed-ended questions. 2 groups of women in Calgary, Alberta: 30 South Asian women who had immigrated within the last 3 years and 30 Canadian-born women of any ethnicity. Most women believed they had received all necessary medical care. Language barriers were most commonly reported by South Asian women and were considered to be the most common barrier to receiving care. Crombie
Med–High
3. Sword et al., 2006 [69] The study aimed to describe immigrant women’s postpartum health, service needs, access to services, and service use during the first 4 weeks following hospital discharge compared to women born in Canada. Data were collected as part of a larger cross-sectional survey study. Self-administered questionnaires and structured telephone interviews. 1,250 culturally diverse women in Ontario, Canada. 31.4% were born outside of Canada. Immigrant women were significantly more likely than Canadian-born women to have low family incomes, low social support, poorer health, possible postpartum depression, learning needs that were unmet in hospital and a need for financial assistance. However, they were less likely to be able to get financial aid, household help and reassurance/support. There were no differences between groups in ability to get care for health concerns. Crombie
Med–High
4. Katz and Gagnon, 2002 [63] The study aimed to ascertain need for larger scale study on postpartum care for immigrants for whom health and/or social concerns have been identified. A descriptive, cross-sectional design was used to gather data from hospital and community records. 22 immigrant women. Families were not recorded as receiving optimal care. 40%–100% concerns not recorded as being resolved and 30%–100% of families were not recorded as receiving optimal care. Critical Appraisal Skills Programme modified cohort Med-High
5. Minde et al., 2001 [68] The study aimed to examine the extent to which physicians and nurses use their first postnatal contact with women to determine their psychosocial strengths and problems. Interactions were audio taped and analysed. Edinburgh Postnatal Depression Scale, the Symptom Checklist-90-Revised and the Working Model of the Child Interview (WMCI) also used. 42 consecutively born infants and their mothers in Montreal, Quebec. Recent non-Western mothers overrepresented among insecurely attached mothers. Crombie Med-High
6. Gagnon et al., 1997 [35] The study aimed to compare an early postpartum discharge programme versus standard postpartum care. A randomised controlled trial. Experimental intervention consisted of discharge 6–36 h postpartum with nursing care available by telephone or at home at 34–38 weeks’ gestation and at ≤48 h and at 3, 5, and 10 days postpartum. The control included a postpartum stay of 48–72 h and standard follow-up. 175 healthy women recruited at 32–38 weeks in Montreal, Quebec. 21.7% were recent immigrants. Early postpartum discharge coupled with prenatal, postnatal and home contacts leads to no apparent disadvantage. The programme may yield benefits for some mothers and infants, as it enhanced perceived maternal competence in recent immigrants. Critical Appraisal Skills Programme RCT
High
7. Gagnon et al., 2007 [30] The study aimed to determine whether women’s postnatal health concerns were addressed by the Canadian health system differentially based on migration status (refugee, refugee-claimant, immigrant and Canadian-born) or city of residence. Questionnaires and data extracted for hospital records. Questionnaires included visual analogue scale (VAS) for pain, the Edinburgh Postnatal Depression Scale (EPDS), the Personal Resources Questionnaire (PRQ) and the Abuse Assessment Scaler (AAS). 341 women of diverse migration status from Toronto, Montreal and Vancouver. Differences in care provision were identified, suggesting that women and their newborn infants living in the largest Canadian cities may require additional support in having their health and social concerns addressed. Critical Appraisal Skills Programme modified cohort (cross-sectional study)
High
8. Poole and Ting, 1995 [57] The study aimed to examine the relationship between cultural backgrounds and hospital maternity care. Two studies were conducted using semi-structured in-person interviews/questionnaires. The first study was comprised of 27 Euro-Canadian and 24 Indo-Canadian women. The second was comprised of 33 Euro-Canadian and 24 Indo-Canadian women. The first study demonstrated the effects for cultural background on psychosocial variables but not biomedical factors. The second study determined that Indo-Canadian women had learned fewer baby care and self-care procedures and that nurses believed them to be less likely to use the procedures they had learned. Crombie
Low–Med
9. Chalmers and Omer- Hashi, 2000 [53] The study aimed to explore perceptions of perinatal care and previous experiences with genital circumcision in Somali women who had recently given birth in Ontario. Close-ended format interviews. 432 immigrant Somali women in the greater Toronto region, Ontario, with previous female genital mutilation, who had given birth to a baby in Canada in the past 5 years. Women’s needs are not always adequately met during their pregnancy and birth care, and they are often unsatisfied with clinical practice and quality of care. Crombie
Med–High
10. Loiselle et al., 2001 [56] The study aimed to document mothers’ perceptions of breastfeeding information and support received from hospital and community-based health professionals in a multiethnic community. Telephone survey. 108 ethnically-diverse first-time breastfeeding mothers at 3 weeks postpartum. Professional support perceived as positive, despite many experts considering the practise less than optimal. Immigrants had lower prenatal class attendance. Immigrant mothers agreed more strongly that hospital staff helped them feel confident with breastfeeding. Significantly more immigrant women received a home visit. More immigrant mothers had their babies receive supplemental water or formula; received formula samples upon discharge; and had staff demonstrate how to express milk if needed. Community-care nurses were more often a source of information for immigrant mothers; more Canadian-born mothers received information from a specialist. Crombie
High
11. Chalmers and Omer-Hashi, 2002 [65] The study aimed to gain information about the perceptions of women with previous female genital mutilation (FGM) of their recent care during pregnancy and birth, as well as of their earlier genital mutilation experience. Close-ended format interviews. 432 immigrant Somali women in the greater Toronto region, Ontario, with previous female genital mutilation, who had given birth to a baby in Canada in the past 5 years. Findings suggest that women are frequently treated in ways that are perceived to be harsh and even offensive to cultural values. Women are, however, also appreciative of the clinical care they receive. There is a need to modify knowledge about female genital mutilation as well as attitudes towards women who have experienced this practice during perinatal care. Less interventionist clinical care and increased sensitivity for cross-cultural practices together with more respectful treatment are needed. Crombie
High
12. Stewart et al., 2008 [58] The study aimed to determine if postpartum depression (PPD) symptoms are more common in newcomer women than in Canadian-born women. Interview-assisted questionnaires for depression, social support, interpersonal violence and demographic information. A PPD variable was created based on a score of ≥10 on the Edinburgh Postnatal Depression Scale (EPDS), and a logistic regression analysis for PPD was performed. 495 consented to participate and 341 received home visits. 4 groups of women (65 refugees, 94 nonrefugee immigrants, 109 asylum seekers and 73 Canadian-born women) speaking any of the study languages and consecutively giving birth: Montreal, Toronto and Vancouver. All born outside Canada were <5 years in Canada. Immigrants, asylum seekers and refugees were significantly more likely than Canadian-born women to score ≥10 on the EPDS, with the regression model showing an increased risk (odds ratio) for refugee, immigrant and asylum-seeking women. Women with less prenatal care were also more likely to have an EPDS of ≥10. Newcomer women with EPDS scores of ≥10 had lower social support scores than Canadian-born women. Social support interventions should be tested for their ability to prevent or alleviate this risk. Crombie
Med–High
13. Wallace et al., 2004 This study had four objectives: (a) to gain information on the barriers, needs and experiences of the newly postpartum women of non-Canadian/culturally diverse backgrounds who use maternal newborn services in Calgary, specifically from the PLC (Peter Lougheed Hospital in NE Calgary); (b) to assess needs and to determine gaps in the current delivery model; (c) to determine conditions and/or services that would enhance the utilisation of perinatal education and prevention programs by ethnocultural communities; and (d) to provide recommendations for future changes in service delivery models that allow for culturally competent care. Survey study with questionnaire in hospital and approximately 2 weeks later. Sample was non-random, convenience sample of 65 women interviewed over 5 months in 2002. Nurses identified women who did not speak English as a first language and 2 research assistants speaking 8 languages approached the women. 12 ethnicities represented with largest groups being South Asian (44.6%), West Asian/Arab (18.5%) and Chinese (12.3%). Almost 60% moved to Canada within last 7 years; 22.4% within last 2 years. Prenatal care—78% stated no cultural barriers to prenatal care, but those identified were gender (n = 3) and language barriers (n = 3). 61% stated that their first preference was for a female doctor. None stated that cultural practices were discouraged. Of those trying to find a doctor of their ethnicity (n = 28), 83% were successful. Crombie
Prenatal care and information—98.5% received prenatal care, and 88% stated that it is very important. Mean weeks gestation found out pregnant was 6.2 and weeks contacted doctor was 7.5; 7.9 mean weeks at first prenatal appointment. 85% said that the physician explained things such that they could be understood and were open to questions from patients to clarify issues/concerns. Med–High
Accessing prenatal care—largest barrier was that they could not speak English very well (26.8%). Other issues identified by 10% or more were doctor only spoke English, office was too far away, did not have a way to get to doctor’s office and transportation too expensive. Only 7.7% said that they could not get a female doctor; and only 3.8% said they did not think they would feel welcome at the office/clinic.
Information on pregnancy—most women spoke to family physician or OB/GYN for information. Many (30%–40%) spoke to mother, in-laws and friends. 20% visited emergency for information. Only 5.8% stated public health nurse. No midwives or doulas.
Importance of receiving information—most women stated very important for numerous sources of receiving information including doctors, in-laws, mother, sister and friends.
Topics discussed—topics discussed less than 50% of the time included early bird prenatal classes, prenatal classes, low birth weight, group B streptococcus, support postpartum, birth control, baby care/ child restraints, new born screening and sexuality. Only 13% attended prenatal classes and less than 5% attended antenatal community care, the diabetic clinic and best beginnings. Child’s father identified as a great support by 90.6% of women (much more than other people).
Services at hospital—48.3% stayed longer than 72 h in the hospital, only 1 was discharged within 24 h (study recruitment tended to selectively recruit longer stay women.) 78.3% were satisfied with admission/discharge procedures at hospital.
Information gained whilst in hospital—95% got advice about care of their baby. Over 75% got advice about birth room care, breastfeeding, where to get help once at home, how to care for yourself, public health nurse visits and immunizations.
Helpfulness of advice received in hospital—most advice seen as very helpful; advice about care for baby least ‘very helpful’ with 73.1%. Topics discussed with public health nurse were comprehensive, except with respect to other resources for new parents (46.3% stated yes). Most women (90%) felt hospital staff was sensitive to cultural/religious beliefs.
Awareness of services—75.5% aware of prenatal classes; 63% of early bird (free) classes; approx 60% aware of other services.
Awareness of additional resources—92.3% were aware of book ‘Here through Maternity’, related to pregnancy resources in Calgary; about 60% aware of other resources.
Use of available services—only 23% of sample responded to these questions; approximately half attended prenatal classes but author noted that these classes are only offered for those having their first baby (and 45.3% of sample was having first baby).
Use of additional resources—most women used ‘Here through Maternity’ book, other books and several used libraries.
14. Jarvis et al., 2011 [54] The study aimed to assess the adequacy of prenatal care and perinatal outcomes for uninsured pregnant women at two primary care centres in Canada. A retrospective case comparison study. A modified Kotelchuck Index was used to assess adequacy of care. 71 uninsured women in Montreal within a multiethnic community (3 of these women were Canadian Citizens). 72 control subjects were randomly chosen from provincially insured women presenting for prenatal care during the same period. The study found that uninsured women presented for prenatal care 13.6 weeks later and had fewer blood tests, ultrasound screenings, cervical swabs, pap tests, genetic screening and visits with the healthcare providers (even when controlling for late initiation of prenatal care). There was no difference in the number who had physical examinations, the gestational age, birth weight, number of vaginal deliveries, number of inductions, use of epidural analgesia or attendance at the postpartum visit. The majority of uninsured women were categorised as having inadequate prenatal care utilisation. There was also a significant difference in the adequacy of received services. Critical Appraisal Skills Programme cohort
High