The influence of migration on women's satisfaction during pregnancy and birth: results of a comparative prospective study with the Migrant Friendly Maternity Care Questionnaire (MFMCQ)

Approaches for enhancing patient-reported experience measurement with ethnically diverse communities: a rapid evidence synthesis

BACKGROUND

Patient-reported experience measures (PREMs) are used to drive and evaluate unit and organisational-level healthcare improvement, but also at a population level, these measures can be key indicators of healthcare quality. Current evidence indicates that ethnically diverse communities frequently experience poorer care quality and outcomes, with PREMs data required from this population to direct service improvement efforts. This review synthesises evidence of the methods and approaches used to promote participation in PREMs among ethnically diverse populations.

METHODS

A rapid evidence appraisal (REA) methodology was utilised to identify the disparate literature on this topic. A search strategy was developed and applied to three major electronic databases in July 2022 (Medline; PsycINFO and CINAHL), in addition to websites of health agencies in Organisation for Economic Co-operation and Development countries via grey literature searches. A narrative evidence synthesis was undertaken to address the review question.

RESULTS

The review resulted in 97 included studies, comprised 86 articles from electronic database searches and 11 articles from the grey literature. Data extraction and synthesis identified five strategies used in PREM instruments and processes to enhance participation among ethnically diverse communities. Strategies applied sought to better inform communities about PREMs, to create accessible PREMs instruments, to support PREMs completion and to include culturally relevant topics. Several methods were used, predominantly drawing upon bicultural workers, translation, and community outreach to access and support communities at one or more stages of design or administration of PREMs. Limited evidence was available of the effectiveness of the identified methods and strategies. PREMs topics of trust, cultural responsiveness, care navigation and coordination were identified as pertinent to and frequently explored with this population.

CONCLUSIONS

The findings provide a basis for a maturity model that may guide change to increase participation of ethnically diverse communities in PREMs. In the short-medium term, health systems and services must be able to recognise and respond to cultural and linguistic diversity in the population when applying existing PREMs. In the longer-term, by working in collaboration with ethnically diverse communities, systems and services may co-create adapted or novel PREMs that tackle the factors that currently inhibit uptake and completion among ethnically diverse communities.

Immigrant women's experience of labor and birth

OBJECTIVE

To describe the childbirth experience of immigrant women in maternity hospitals in southern Brazil.

METHOD

Descriptive, qualitative study, Hybrid Thematic Oral History method, in two public maternity hospitals in Curitiba-PR; semi-structured interviews collected from March to December 2020. Analysis followed the proposed method.

RESULTS

The seven interviewees - collaborators immigrated from Venezuela, Haiti and Tunisia. Relevant themes emerged: 1) Surprises and feelings during the childbirth process, pointing out preferences, unexpected birth outcomes, factors related to the higher incidence of C-section and descriptions of sensations and feelings; 2) The care perceived by women and memories of experiences in the country of origin, with reports of previous childbirth experience, difficulties in the current childbirth and perceptions of the care received.

CONCLUSION

The childbirth process was experienced with expectation, accessing feelings and memories. The positive childbirth experience was favored by team care, participation in decision-making, well-informed prenatal care, bonding with the care team, effective communication and evidence-based obstetric practices. Challenges were perceived regarding cultural sensitivity in care.

What influences women's experiences of childbirth in Flanders? - A quantitative cross-sectional analysis of the Babies Born Better survey

OBJECTIVE

Labour and birth experiences are of great importance since these can have positive, but also negative effects on women's health and wellbeing. This is the first study, which investigated the factors that influence women's experiences of childbirth in Flanders, Belgium.

DESIGN

A cross-sectional quantitative analysis was used to examine primary data obtained by the Babies Born Better project. Data collection took place via an online survey from April 2018 until August 2018 in Flanders.

PARTICIPANTS

1414 women that gave birth across all birth settings between 2013 and 2018, who speak Flemish/Dutch were included. Participants were self-selected by filling out the Babies Born Better survey in 2018.

FINDINGS

The majority of the Flemish women included in this study reported a positive labour and birth experience. Analysis of the demographic variables showed that women who were single or not co-habiting reported a worse experience of labour and birth (P = 0.012). All obstetric factors included showed significant differences (P<0.01). Lastly, women were more likely to report a better experience when birth took place at home or in a midwifery unit and when the main care provider was a midwife (P<0.01). When controlled for significant variables from the univariate analysis, an impact on the birth experience was only found with the obstetric factors. A preterm (OR 0.544, 95%CI 0.362-0.817) and post term birth (OR 0.664, 95% CI 0.462-0.953) were found to reduce the chance of a good experience compared to a birth at term. In case of complications during pregnancy, women were less likely to report having had a good experience (OR 0.632, 95% CI 0.470 - 0.849). Medical interventions such as induction- (OR 0.346, 95% CI 0.241 - 0.497) and augmentation of labour (OR 0.318, 95% CI 0.218-0.463), an instrumental birth (OR 0.318, 95% CI 0.218-0.463) or a planned- (OR 0.349, 95% CI 0.205-0.596) or emergency caesarean section (OR 0.190, 95% CI 0.109-0.329) reduced the chances of women reporting to have had a good experience with care around labour and birth.

KEY CONCLUSIONS

The majority of women included in this study reported a good experience of care during labour and at birth. Certain obstetric factors such as having a straightforward pregnancy without complications, a physiological onset of labour at term without the need for augmentation and to give birth vaginally (without instrument) have shown a positive impact on women's reported birth experiences.

IMPLICATIONS FOR PRACTICE

Women's involvement in decision-making, especially when medical interventions are wanted or needed can improve positive birth experiences. More research is needed on how to support women and empower them, even more so in case of complications to ensure a sense of control and achievement.

Migrant-Native Disparities in Obstetric Neuraxial Analgesia Use: The Role of Host-Country Language Proficiency

BACKGROUND

Neuraxial analgesia (NA) is the most effective modality in managing labor pain with widespread availability in high-income countries. Previous research has reported a differential obstetric NA use among migrant and native women, but the contribution of language barriers is not well understood. We aimed to investigate whether host-country language proficiency among migrant women influences NA use and satisfaction with pain management during labor, when compared to natives.

METHODS

We conducted a secondary analysis of data collected from 1024 native and 1111 migrant women who had singleton vaginal deliveries between 2017 and 2019 and were enrolled in the nationwide Portuguese baMBINO prospective cohort study. Obstetric NA use, satisfaction with labor pain management, and migrants' Portuguese language proficiency were self-reported. Data were analyzed using robust multilevel Poisson regression, adjusted for maternal region of birth (characterized by the Human Development Index), age, and education.

RESULTS

Overall, 84.4% of native women gave birth with NA, compared to 81.6%, 71.3%, and 56.9% of migrant women with full, intermediate, and limited language proficiency, respectively. Compared to native women, migrants with intermediate (adjusted risk ratio [aRR] = 0.91 [95% confidence interval {CI}, 0.82-0.99]) and limited (aRR = 0.73 [95% CI, 0.56-0.94]) proficiency were less likely to receive NA. However, no significant differences were observed in pain management satisfaction by language proficiency level.

CONCLUSIONS

Compared to native women, we observed a differential obstetric NA use across migrant women with different host-country language proficiency levels in Portugal, without affecting satisfaction with labor pain management. Although defining the mechanisms underlying NA use discrepancies requires further research, our findings support systematically evaluating pregnant migrant women's linguistic skills and ensuring their access to adequate obstetric analgesia-related information and interpretation services.

Equal Alternatives or Lower Standards for Immigrant Women-Analyzing Obstetric Care for Immigrant Women in Berlin Within the Framework of Cultural Health Capital

In obstetric clinics in Berlin, Germany, more than half of the women are immigrants. The main objective of the qualitative study was to explore the staff's experiences with obstetric care for immigrants and juxtapose it with the immigrants' comments on their birth experiences. We analyze potential differences along the framework of a cultural health capital (CHC). Between May and August 2017, semi-structured interviews were carried out with 17 obstetricians and 17 midwives at four obstetric clinics in Berlin. The verbally transcribed interview material was subjected to a qualitative content analysis according to Mayring. Furthermore, a secondary data from an interview study was analyzed in the purpose of providing some insight into the practitioner study participant perspective. Between January and May 2017, in the postpartum ward at the Berlin Charité Campus Virchow Clinic, an interview study guided by the migrant-friendly maternity care questionnaire was conducted among 410 migrant and non-migrant women. For this study, the free-text comments on the pregnancy care were analyzed. The staff interviewees identified language barrier and legal status as risk factors for the late onset of obstetric care. CHC functioning potentially as alternatives to the established health care structures were voiced. Strong family ties among immigrant families bear a high potential for support. Gratefulness was voiced by the staff and immigrant patients as a source of satisfaction with care. Our study shows that obstetric care for immigrant women remains a challenge. CHC of immigrant women might partially compensate for exclusion.

Experiences of childbirth care among immigrant and non-immigrant women: a cross-sectional questionnaire study from a hospital in Norway

BACKGROUND

Immigrant women have higher risks for poor pregnancy outcomes and unsatisfactory birth experiences than the general population. The mechanisms behind these associations remain largely unknown, but they may result from differential care provided to immigrant women or unsatisfactory interactions with health providers. This study aimed to investigate immigrant and non-immigrant women's experiences of health care during childbirth, particularly assessing two dimensions: perceived general quality of care and attainment of health care needs during childbirth.

METHODS

This was a cross-sectional study carried out over 15 months in 2020 and 2021, and data were collected from a self-completed questionnaire. The labour and birth subscale from the Experience of Maternity Care questionnaire was used to assess the primary outcome of care experiences. A total of 680 women completed the questionnaire approximately within two days after birth (mean 2.1 days) at a hospital in Trondheim, in central Norway. The questionnaire was provided in eight languages.

RESULTS

The 680 respondents were classified as immigrants (n = 153) and non-immigrants (n = 527). Most women rated their quality of care during childbirth as high (91.5%). However, one-quarter of the women (26.6%) reported unmet health care needs during childbirth. Multiparous immigrant women were more likely than multiparous non-immigrant women to report that their health care needs were unmet during childbirth (OR: 3.31, 95% CI: 1.91-5.72, p < 0.001, aOR: 2.83, 95% CI: 1.53-5.18, p = 0.001). No other significant differences between immigrant versus non-immigrant women were found in subjective ratings of childbirth care experiences. Having a Norwegian-born partner and a high level of Norwegian language skills did not influence the immigrant women's experience of childbirth care.

CONCLUSIONS

Our findings indicate that many women feel they receive high-quality health care during childbirth, but a considerable number still report not having their health care needs met. Also, multiparous immigrant women report significantly more unmet health care needs than non-immigrants. Further research is required to assess immigrant women's childbirth experiences and for health care providers to give optimal care, which may need to be tailored to a woman's cultural background and individual expectations.

Host-country language proficiency and migrant-native disparities in prenatal care utilization: A nationwide study in Portugal

BACKGROUND

Migrant-native disparities in perinatal health and care utilization are well-established, yet most evidence comes from countries without universal health coverage. Migrant-specific factors potentially contributing to such disparities are seldom examined. We investigated the association between migration and host-country language proficiency and inadequate utilization of prenatal care (PNC) in Portugal.

METHODS

We used robust Poisson regression to analyze data from 1419 migrant and 2477 native women enrolled in the Portuguese Bambino cohort study who had given birth at a Portuguese public hospital between 2017 and 2019. Migrant women's language proficiency was self-rated for understanding, speaking, reading, and writing skills. PNC utilization inadequacy was assessed using three dimensions: initiation, number of visits, and the modified Adequacy of Prenatal Care Utilization (mAPNCU) Index score.

RESULTS

Migrant women were overall more likely to initiate PNC late and have inadequate/intermediate mAPNCU scores than natives. Migrant-native disparities in the number of PNC visits were only observed among recent migrants (≤5 years in Portugal). Full, intermediate, and limited Portuguese skills were associated with increasingly higher risks of late PNC initiation (aRR 1.34 [95%CI 1.20-1.50]); (aRR 1.52 [95%CI 1.28-1.80]); (aRR 1.91 [95%CI 1.52-2.40]), inadequate number of PNC visits (aRR 1.06 [95%CI 0.93-1.22]); (aRR 1.14 [95%CI 0.97-1.34]); (aRR 1.57 [95%CI 1.19-2.07]), and inadequate/intermediate mAPNCU scores (aRR 1.18 [95%CI 1.07-1.32]); (aRR 1.30 [95%CI 1.11-1.53]); (aRR 1.69 [95%CI 1.38-2.07]) compared with native Portuguese skills, respectively.

CONCLUSIONS

Migrant-native disparities in PNC utilization are present in Portugal, despite universal health coverage. Recent migrants and women with limited language competence are the most vulnerable to inadequate PNC use.

Satisfaction with maternity care among recent migrants: an interview questionnaire-based study

OBJECTIVE

To examine factors associated with recently migrated women's satisfaction with maternity care in urban Oslo, Norway.

DESIGN

An interview-based cross-sectional study, using a modified version of Migrant Friendly Maternity Care Questionnaire.

SETTING

Face-to-face interview after birth in two maternity wards in urban Oslo, Norway, from January 2019 to February 2020.

PARTICIPANTS

International migrant women, ≤5 years length of residency in Norway, giving birth in urban Oslo, excluding women born in high-income countries.

PRIMARY OUTCOME

Dissatisfaction of care during pregnancy and birth, measured using a Likert scale, grouped into satisfied and dissatisfied, in relation to socio-demographic/clinical characteristics and healthcare experiences.

SECONDARY OUTCOME

Negative healthcare experiences and their association with reason for migration.

RESULTS

A total of 401 women answered the questionnaire (87.6% response rate). Overall satisfaction with maternal healthcare was high. However, having a Norwegian partner, higher education and high Norwegian language comprehension were associated with greater odds of being dissatisfied with care. One-third of all women did not understand the information provided by the healthcare personnel during maternity care. More women with refugee background felt treated differently because of factors such as religion, language and skin colour, than women who migrated due to family reunification.

CONCLUSIONS

Although the overall satisfaction was high, for certain healthcare experiences such as understanding information, we found more negative responses. The negative healthcare experiences and factors associated with satisfaction identified in this study have implications for health system planning, education of healthcare personnel and strategies for quality improvement.

Mothers' experiences of perinatal care in Belgian public hospitals: exploring the social inequalities. Protocol for a cross-sectional survey

INTRODUCTION

In Europe, the social inequalities in perinatal health are usually found to be to the disadvantage of non-European immigrants and women with lower levels of education and income. Among the possible underlying mechanisms are inadequate access to healthcare services and suboptimal care. To explore this hypothesis in the Belgian context, our research will describe detailed maternal socioeconomic and migration characteristics, explore how these factors relate to each other, and how they relate to women's perinatal care trajectories and experiences of care.

METHODS

Using a modified version of the Migrant-Friendly Maternity Care Questionnaire, we will survey 900 mothers of Belgian nationality or a nationality from a North or Sub-Saharan African country, and having given birth in four maternity wards in Brussels. The questionnaire has been adapted to the study objectives and the Belgian context. Interviewers will administer the 116-item questionnaire to all women agreeing to participate and meeting inclusion criteria, within 14 days of having given birth. Clinical information will be extracted from hospital records.

ANALYSIS

We will estimate the associations of women's socioeconomic and migration characteristics with:Women's antenatal care trajectories (timing of first antenatal consultation, minimum recommended number of consultations, and problems accessing care).Obstetric practices such as episiotomies, emergency caesarean sections, and inductions.Patient experience such as feelings of discrimination, respect, and understanding of information.We will use descriptive statistics, multiple correspondence analysis, and simple and multiple logistic regressions.

ETHICS AND DISSEMINATION

Ethical approval has been obtained from the hospital Ethics Committees and from the Université libre de Bruxelles (No: P2017/055/B406201730877). Written informed consent will be sought from all participants.In addition to disseminating findings and recommendations to the scientific community through open-source journal articles and conferences, we will also address local organisations and healthcare professionals via a written report and seminars.

The influence of migration on women's use of different aspects of maternity care in the German health care system: Secondary analysis of a comparative prospective study with the Migrant Friendly Maternity Care Questionnaire (MFMCQ)

INTRODUCTION

Approximately 21% of Germany's inhabitants or their parents have been born abroad. There is evidence that immigrant women are starting antenatal care later than nonimmigrants. In Berlin, equality in health care access had improved until 2011-2012, leaving only women with Low German language proficiency and an insecure residence status particularly at risk. With the recent influx of refugees, we analyzed whether access to antenatal and postpartum care differs depending on immigration, residence status, income, and education.

METHODS

At our Berlin tertiary care center, a modified version of the Migrant Friendly Maternity Care Questionnaire was administered to women who delivered in the first half of 2017. Multivariate modeling compared nonimmigrant women, immigrants, and women who are direct descendants of immigrants.

RESULTS

The study included 184 nonimmigrant women, 214 immigrant women, and 62 direct descendants of immigrants. Germany is relatively good in prenatal care for immigrant women, as most are getting adequate prenatal care. However, 21% of immigrants compared with 11% of nonimmigrant women started pregnancy care after the first trimester (P = .03). Low income was a more powerful predictor than immigration status for starting prenatal care after the first trimester. Immigrant women (23%) were less informed on postpartum care availability than nonimmigrants (3%) and used less postpartum midwifery care.

CONCLUSIONS

When designing health care interventions for immigrant women, not only migration-specific factors should be considered but also low income as a barrier to access to maternity care.