Irish midwives' experiences of providing maternity care to non-Irish women seeking asylum

Suboptimal factors in maternal and newborn care for refugees: Lessons learned from perinatal audits in the Netherlands

INTRODUCTION

Refugees and their healthcare providers face numerous challenges in receiving and providing maternal and newborn care. Research exploring how these challenges are related to adverse perinatal and maternal outcomes is scarce. Therefore, this study aims to identify suboptimal factors in maternal and newborn care for asylum-seeking and refugee women and assess to what extent these factors may contribute to adverse pregnancy outcomes in the Netherlands.

METHODS

We conducted a retrospective analysis of national perinatal audit data from 2017 to 2019. Our analysis encompassed cases with adverse perinatal and maternal outcomes in women with a refugee background (n = 53). Suboptimal factors in care were identified and categorized according to Binder et al.'s Three Delays Model, and the extent to which they contributed to the adverse outcome was evaluated.

RESULTS

We identified 29 suboptimal factors, of which seven were related to care-seeking, six to the accessibility of services, and 16 to the quality of care. All 53 cases contained suboptimal factors, and in 67.9% of cases, at least one of these factors most likely or probably contributed to the adverse perinatal or maternal outcome.

CONCLUSION

The number of suboptimal factors identified in this study and the extent to which they contributed to adverse perinatal and maternal outcomes among refugee women is alarming. The wide range of suboptimal factors identified provides considerable scope for improvement of maternal and newborn care for refugee populations. These findings also highlight the importance of including refugee women in perinatal audits as it is essential for healthcare providers to better understand the factors associated with adverse outcomes to improve the quality of care. Adjustments to improve care for refugees could include culturally sensitive education for healthcare providers, increased workforce diversity, minimizing the relocation of asylum seekers, and permanent reimbursement of professional interpreter costs.

Community midwives' perspectives on perinatal care for asylum seekers and refugees in the Netherlands: A survey study

BACKGROUND

The rise of forced migration worldwide compels birth care systems and professionals to respond to the needs of women giving birth in these vulnerable situations. However, little is known about the perspective of midwifery professionals on providing perinatal care for forcibly displaced women. This study aimed to identify challenges and target areas for improvement of community midwifery care for asylum seekers (AS) and refugees with a residence permit (RRP) in the Netherlands.

METHODS

For this cross-sectional study, data were collected through a survey aimed at community care midwives who currently work or who have worked with AS and RRP. We evaluated challenges identified through an inductive thematic analysis of respondents' responses to open-ended questions. Quantitative data from close-ended questions were analyzed descriptively and included aspects related to the quality and organization of perinatal care for these groups.

RESULTS

Respondents generally considered care for AS and RRP to be of lower quality, or at best, equal quality compared to care for the Dutch population, while the workload for midwives caring for these groups was considered higher. The challenges identified were categorized into five main themes, including: 1) interdisciplinary collaboration; 2) communication with clients; 3) continuity of care; 4) psychosocial care; and 5) vulnerabilities among AS and RRP.

CONCLUSIONS

Findings suggest that there is considerable opportunity for improvement in perinatal care for AS and RRP, while also providing direction for future research and interventions. Several concerns raised, especially the availability of professional interpreters and relocations of AS during pregnancy, require urgent consideration at legislative, policy, and practice levels.

Providing sexual and reproductive health services to migrants in Southern Sweden: a qualitative exploration of healthcare providers' experiences

BACKGROUND

While a large body of research has focused on the challenges experienced by healthcare staff when providing sexual and reproductive health services, little attention has been paid to the ways healthcare providers navigate these challenges. This study examined healthcare providers' accounts of encounters when providing sexual and reproductive health (SRH) services to migrants in Southern Sweden. It sought to examine challenges and dilemmas experienced by healthcare providers, strategies used to navigate these challenges and dilemmas, and assumptions underlying participants' accounts.

METHODS

The data collection was conducted between September 2020 and March 2021. Qualitative thematic analysis was used to analyze thirty-one interviews with healthcare providers working in youth clinics and women healthcare clinics. The analysis was guided by a conceptual framework combining person-centered care approach, Foucault's concepts on power/knowledge, and theories to navigate diversity in healthcare setting: cultural competency and cultural humility.

RESULTS

Three themes were identified in the analysis: 1) Between person centeredness and cultural considerations; 2) Knowledge positions and patient involvement; and 3) beyond the dyadic interaction healthcare provider-patient. Some participants understood person-centered care as individualized care where the influence of culture on the encounter should be de-emphasized, whereas others tended to highlight this influence. Many participants viewed the influence of culture as primarily driven by migrants' cultural backgrounds, and as a source of challenges and dilemmas. Participants' strategies to navigate these perceived challenges and dilemmas included practicing cultural humility and seeking cultural competency. Knowledge positions also emerged as an important aspect of participants' accounts of encounters with migrants. Many participants experienced that migrant patients were lacking knowledge about the body and sexuality. This disadvantaged knowledge position affected migrant involvement in care. Additionally, the study shows how participants placed their experiences in a broader organizational and social context. Participants highlighted several organizational challenges to encountering migrants and discussed dilemmas stemming from the interplay between migrants' structural and individual disadvantages.

CONCLUSIONS

The study findings illuminate the complex links between person-centered care and two important dimensions of the encounters with migrants: culture and knowledge positions. They also shed the light on the organizational and structural challenges surrounding these encounters. These findings suggest that multilevel strategies are needed to improve the quality of encounters when providing SRH services to migrants. These strategies could include ensuring universal access to SRH services to migrants, adjusting the encounter duration when interpretation is needed, and providing necessary resources to healthcare providers to build their structural competency.

Language-supported labor ward visits for pregnant migrant women: Staff experiences in a Swedish hospital

INTRODUCTION

METHODS

RESULTS

CONCLUSIONS

Cultural competence and experiences of maternity health care providers on care for migrant women: A qualitative meta-synthesis

BACKGROUND

The United Nations Sustainable Development Goals 2030 aim to reduce health care inequity and maternal and infant mortality rates amongst marginalized populations. To provide adequate and culturally relevant maternity care for minority ethnic groups, it is imperative to examine health care providers' views on care for migrant women. We reviewed published accounts of views and experiences of maternity health care providers providing maternity care for migrant women as a way of exploring their cultural competency.

METHOD

A qualitative meta-synthesis was conducted. Systematic searches were conducted in five electronic databases from inception dates through February 2021. Qualitative data were analyzed using a framework thematic analysis based on Campinha-Bacote's five-component cultural competency model.

FINDINGS

Eleven studies were included. Findings were presented according to Campinha-Bacote's model: cultural awareness, cultural knowledge (personal responsibility, familial role and cultural influence, the influence of social and system factors, conflicting maternity care expectations), cultural encounter (language and communication), and cultural desire (establishing trust and going the extra mile, resources to boost culturally competent care).

DISCUSSION

Our findings can inform the design of high-quality behavioral change, health care management, sociological, and other relevant studies, along with reviews of what matters to service users about cultural responsiveness. Our data also suggest that health system constraints can exacerbate the lack of cultural competency. Improving the quality of care for migrant communities will necessitate a joint effort between health care organizations, health care providers, policymakers, and researchers in developing and implementing more culturally relevant maternity care policies and management interventions.

The Perinatal Journey of a Refugee Woman in Greece: A Qualitative Study in the Context of the ORAMMA Project to Elucidate Current Challenges and Future Perspectives

Migrant and refugee women face specific health risks and challenges during the perinatal period, presenting with complex physical, psychological, and mental health issues. Compassionate antenatal and postnatal care is urgently required across Europe given how outcomes during this period determine the health wellbeing throughout a person’s life. The current study aimed to describe the perinatal health care provided to refugee and migrant women in Greece, as well as to identify the barriers to delivering quality health care to these population groups. Data were gathered via qualitative research, and via document analysis, including grey literature research. Two focus groups were convened; one with five midwives in Athens (representing NGOs in refugee camps and public maternity hospitals) and another in Crete with twenty-six representatives of key stakeholder groups involved in the perinatal care of refugees and migrant women. Desk research was conducted with in a stepwise manner comprising two steps: (a) a mapping exercise to identify organizations/institutes of relevance across Greece, i.e., entities involved in perinatal healthcare provision for refugees and migrants; (b) an electronic search across institutional websites and the World Wide Web, for key documents on the perinatal care of refugee and migrant women that were published during the 10-year period prior to the research being conducted and referring to Greece. Analysis of the desk research followed the principles of content analysis, and the analysis of the focus group data followed the principles of an inductive thematic analysis utilizing the actual data to drive the structure analysis. Key findings of the current study indicate that the socioeconomic status, living and working conditions, the legal status in the host country, as well as providers’ cultural competence, attitudes and beliefs and communication challenges, all currently represent major barriers to the efficient and culturally appropriate provision of perinatal care. The low capacity of the healthcare system to meet the needs of women in these population groups in the context of maternal care in a country that has suffered years of austerity has been amply recorded and adds further contextual constraints. Policy reform is urgently required to achieve cultural competence, to improve transcultural care provision across maternity care settings, and to ensure improved maternal and children’s outcomes.

Factors influencing women's perceptions of choice and control during pregnancy and birth: a cross-sectional study

BACKGROUND

Women across the world value choice and control throughout their maternity care experiences. In response to this health policy and frameworks are adapting and developing. The concepts of choice and control are extrinsically complex and open to interpretation by healthcare professionals and service users, with the two not necessarily aligning. Depending on a number of factors, women's experiences of choice and control within the same maternity care system may be very different. This study aimed to investigate the factors influencing women's perceptions of choice and control during pregnancy and birth in Ireland.

METHODS

We conducted a cross-sectional study using an adapted version of the UK national maternity experience survey (National Perinatal Epidemiology Unit). During March - July 2017, a sample of 1277 women were recruited from the postnatal wards of three maternity units and a tertiary maternity hospital. Poisson regression was used to assess the association between twelve factors and a series of measures of the women's perception of choice and control.

RESULTS

Most women reported not having choice in the model or location of their maternity care but most reported being involved enough in decision-making, especially during birth. Women who availed of private maternity care reported higher levels of choice and control than those who availed of public maternity care. This factor was the most influential factor on almost all choice and control measures.

CONCLUSION

Most women experiencing maternity care in Ireland report not having choice in the model and location of care. These are core elements of the Irish maternity strategy and significant investment will be required if improved choice is to be provided. Availing of private maternity care has the strongest influence on a woman's perceived choice and control but many women cannot afford this type of care, nor may they want this model of care.

User-centred iterative design to develop an evidence-based communication application for maternity care

A record number of immigrants, many Arabic speaking, arrived in Sweden during the years 2015/2016. Immigrant women have a higher risk of pregnancy complications than native European women and cultural and communicative problems have been identified as a cause of such disparities. Maternity services are under pressure because of language and cultural barriers. Language translation programmes are sometimes used but these are not evidence-based so are not considered safe for use in maternity care. The aim of this research was to create an evidence-based app for communication with Arabic-speaking women in maternity care. User-centred iterative design was used to develop an evidence-based, fit-for-purpose app. Data were collected from midwives in a focus group interview, field observations and workshops. The iterative approach resulted in an evidence-based prototype that is currently being tested in the field.

Migrant health and language barriers: Uncovering macro level influences on the implementation of trained interpreters in healthcare settings

There is a knowledge translation gap between policies promoting equitable access to healthcare and person-centred care, and the use of untrained interpreters in cross-cultural consultations leading to disparities in health outcomes. An 11 member inter-sectoral working group met at four workshops to discuss and agree on levers and barriers to the provision of trained interpreters in healthcare settings in Ireland. The process was informed by Participatory Learning and Action (PLA) research to support inter-stakeholder dialogue and learning. Normalisation Process Theory (NPT) was used as a conceptual framework to analyse levers and barriers. The NPT analysis explored sense-making, engagement and enactment and found challenges with sense-making and engagement in senior level service planners, managers and governmental offices. This had negative impacts on other key actors, including healthcare providers, medical students and interpreters. This also meant that the enactment of interpreted consultations in practice settings was replete with barriers, most notably a lack of resources, training and supportive organisational structures. The emergent action plan focused on improving sense-making and engagement through inter-sectoral awareness raising, designed to stimulate a series of complementary levers for implementation. Combining PLA and NPT provided new insights into macro level influences on implementation work at the level of a national healthcare system. The approaches used in this study are applicable in other fields.

How to promote exclusive breastfeeding in Ireland: a qualitative study on views of Chinese immigrant mothers

BACKGROUND

The exclusive breastfeeding rate in Ireland is very low with extremely slow annual growth. The population of immigrants in Ireland is increasing. Improving exclusive breastfeeding practice among immigrants may contribute to the overall improvement of exclusive breastfeeding rates in Ireland. This study was conducted to elicit suggestions on improving exclusive breastfeeding rate for the first 6 months among Chinese immigrants in Ireland.

METHODS

Fourteen semi-structured in-depth interviews were conducted with Chinese immigrant mothers residing in Ireland, who breastfed exclusively for 4 to 6 months. Interviews were recorded and transcribed in Chinese. Data were analyzed using a qualitative thematic analysis. Themes were developed through categorization of codes and via in-depth discussion between two researchers.

RESULTS

Themes generated from the thematic content analysis were: 1) suggestions for new mothers: being strong mentally and getting support from family and friends; 2) suggestions for employers: creating a supportive workplace by setting up private rooms and breastmilk storage facilities; 3) suggestions for healthcare professionals: advocating breastfeeding in the hospital and addressing cultural differences by recruiting multilingual staff; 4) suggestions for the government: promoting breastfeeding by initiating societal and policy changes.

CONCLUSIONS

The key findings emerging from this study may be considered in the development of breastfeeding promotion strategies in Ireland. Our findings could also have implications for other English-speaking countries with low rates of exclusive breastfeeding.

Social exclusion and the perspectives of health care providers on migrants in Gauteng public health facilities, South Africa

BACKGROUND

Universal health coverage (UHC) for all people, regardless of citizenship, is a global priority. Health care providers are central to the achievement of UHC, and their attitudes and behaviour could either advance or impede UHC for migrants. Using a social exclusion conceptual framework, this study examined the perspectives of health care providers on delivering health services to migrants in public health facilities in Gauteng Province, South Africa.

METHODS

We used stratified, random sampling to select 13 public health facilities. All health care providers working in ambulatory care were invited to complete a self-administered questionnaire. In addition to socio-demographic information, the questionnaire asked health care providers if they had witnessed discrimination against migrants at work, and measured their perspectives on social exclusionary views and practices. Multiple regression analysis was used to identify predictors of more exclusionary perspectives for each item.

RESULTS

277 of 308 health care providers participated in the study-a response rate of 90%. The participants were predominantly female (77.6%) and nurses (51.9%), and had worked for an average of 6.8 years in their facilities. 19.2% of health care providers reported that they had witnessed discrimination against migrants, while 20.0% reported differential treatment of migrant patients. Exclusionary perspectives varied across the different items, and for different provider groups. Enrolled nurses and nursing assistants were significantly more exclusionary on a number of items, while the opposite was found for providers born outside South Africa. For some questions, female providers held more exclusionary perspectives and this was also the case for providers from higher levels of care.

CONCLUSION

Health care providers are critical to inclusive UHC. Social exclusionary views or practices must be addressed through enabling health policies; training in culture-sensitivity, ethics and human rights; and advocacy to ensure that health care providers uphold their professional obligations to all patients.

Facilitating Factors of Professional Health Practice Regarding Female Genital Mutilation: A Qualitative Study

Introduction: According to figures released by UNICEF (United Nations Children's Fund), more than 200 million girls and women have suffered female genital mutilation (FGM) in 30 African and Middle East countries. An increasing number of African women who come from ethnic groups where FGM is practised are arriving in Western countries. Healthcare professionals play a fundamental role in its prevention. Goals: To learn about the factors that healthcare professionals consider as facilitators for prevention and action when faced with female genital mutilation. Methods: A cross-sectional descriptive study developed on the basis of the qualitative methodological perspective, where 43 healthcare professionals participated. A series of analysis dimensions were established, based on which, the interview and discussion group scripts were designed. Results: Addressing FGM requires a series of structural adaptations of the healthcare system that facilitate the recording and monitoring of cases, both for treatment and for prevention. In addition, it is necessary to establish coordination between the healthcare, social services and education sectors. Conclusions: The existence of a protocol of action and training in its use is one of the key tools to take into account.

Transnationalism and care of migrant families during pregnancy, postpartum and early-childhood: an integrative review

Background

Migrant families’ transnational ties (i.e., connections to their countries of origin) may contribute to their hardships and/or may be a source of resiliency. A care approach that addresses these transnational ties may foster a positive identity and give coherence to experiences. We conducted an integrative review to determine what is known about transnational ties and the care of migrant families during pregnancy, postpartum and early childhood.

Methods

We searched 15 databases to identify literature reporting on a health or social program, service, or care experience of migrant families during pregnancy up to age five in a Western country (i.e., Canada, US, Australia, New Zealand or a European country). Information regarding if and how the service/program/care considered transnational ties, and care-providers’ perceptions of transnational ties, was extracted, analyzed and synthesized according to transnational ‘ways of belonging’ and ‘ways of being’.

Results

Over 34,000 records were screened; 69 articles were included. Care, programs and services examined included prenatal interventions (a mhealth app, courses, videos, and specialized antenatal care), doula support, maternity care, support groups, primary healthcare and psycho-social early intervention and early childhood programs. The results show that transnational ties in terms of ‘ways of belonging’ (cultural, religious and linguistic identity) are acknowledged and addressed in care, although important gaps remain. Regarding ‘ways of being’, including emotional, social, and economic ties with children and other family members, receipt of advice and support from family, and use of health services abroad, there is very little evidence that these are acknowledged and addressed by care-providers. Perceptions of ‘ways of belonging’ appear to be mixed, with some care-providers being open to and willing to adapt care to accommodate religious, cultural and linguistic differences, while others are not. How care-providers perceive the social, emotional and economic ties and/or the use of services back home, remains relatively unknown.

Conclusion

Significant knowledge gaps remain regarding care-providers’ perceptions of transnational ‘ways of being’ and whether and how they take them into account, which may affect their relationships with migrant families and/or the effectiveness of their interventions. Continued efforts are needed to ensure care is culturally safe for migrants.

Arabic-speaking women's experiences of communication at antenatal care in Sweden using a tablet application-Part of development and feasibility study

OBJECTIVES

The purpose of this study was to explore Arabic-speaking women´s experiences of communication at antenatal care in Sweden when using a tablet application (app).

DESIGN

The study is a part of a major research project, where a Swedish-Arabic app was developed to improve and facilitate communication between Arabic-speaking women and midwives. The first prototype was developed in 2017 and tested at six antenatal clinics in southeast of Sweden. Ten Arabic-speaking women were purposively recruited, and individual interviews were performed. Content analysis was used.

FINDINGS

Four main categories emerged: "Adapting the content to the patient group", "language and communication", "user-friendly" and "improvement proposal". The women reported that the content was educational, reliable and understandable. The information gave the women a sense of security. It was time effective and allowed opportunity for dialogue. Depending on language skills, there were different opinions as to whether the App should be a complement to having an interpreter or used separately.

KEY CONCLUSION

Arabic-speaking women perceived the App as being a communication tool despite their language skills in Swedish. There is a need for digital support for communication in maternity care.

Midwives' attitudes, beliefs and concerns about childhood vaccination: A review of the global literature

Vaccine hesitancy in industrialised countries is an area of concern. Health professionals play a significant role in parental vaccination decisions, however, to date the role of midwives has not been widely explored. This review sought to describe the attitudes and communication practices of midwives in developed countries towards childhood vaccines. Medline, Cinahl, PsychInfo, Embase and the grey literature were searched. Inclusion criteria were qualitative and quantitative studies reporting midwives' beliefs, attitudes and communication practices toward childhood vaccination. The search returned 366 articles, of which 359 were excluded by abstract. Two additional articles were identified from the grey literature and references, resulting in nine studies from five countries included in the review. Across the studies, the majority of midwives supported vaccination, although a spectrum of beliefs and concerns emerged. A minority expressed reservations about the scientific justification for vaccination, which focussed on what is not yet known rather than mistrust of current evidence. Most midwives felt that vaccines were safe; a minority were unsure, or believed they were unsafe. The majority of midwives agreed that childhood vaccines are necessary. Among those who expressed doubt, a commonly held opinion was that vaccine preventable diseases such as measles are relatively benign and didn't warrant vaccination against them. Finally, the midwifery model of care was shown to focus on providing individualised care, with parental choice being placed at a premium. The midwifery model care appears to differ in approach from others, possibly due to a difference in the underpinning philosophies. Research is needed to understand how midwives see vaccination, and why there appears to be a spectrum of views on the subject. This information will inform the development of resources tailored to the midwifery model of care, supporting midwives in advocating for childhood vaccination.

Preparedness of Health Care Professionals for Delivering Sexual and Reproductive Health Care to Refugee and Migrant Women: A Mixed Methods Study

Past research suggests that factors related to health care professionals' (HCPs) knowledge, training and competency can contribute to the underutilisation of sexual and reproductive health (SRH) care by refugee and migrant women. The aim of this study was to examine the perceived preparedness of HCPs in relation to their knowledge, confidence and training needs when it comes to consulting refugee and migrant women seeking SRH care in Australia. A sequential mixed methods design, comprising an online survey with 79 HCPs (45.6% nurses, 30.3% general practitioners (GPs), 16.5% health promotion officers, and 7.6% allied health professionals) and semi-structured interviews with 21 HCPs, was utilised. HCPs recognised refugee and migrant women's SRH as a complex issue that requires unique skills for the delivery of optimal care. However, they reported a lack of training (59.4% of nurses, 50% of GPs, and 38.6% of health promotion officers) and knowledge (27.8% of nurses, 20.8% of GPs, and 30.8% of health promotion officers) in addressing refugee and migrant women's SRH. The majority of participants (88.9% of nurses, 75% of GPs, and 76% of health promotion officers) demonstrated willingness to engage with further training in refugee and migrant women's SRH. The implications of the findings are argued regarding the need to train HCPs in culturally sensitive care and include the SRH of refugee and migrant women in university and professional development curricula in meeting the needs of this growing and vulnerable group of women.

Refugee and Immigrant Women's Experience of Postpartum Depression: A Meta-Synthesis

The aim of this work is to synthesize qualitative research on refugee and immigrant women's experiences of postpartum depression (PPD) to gain insight into the unique needs of this group of women. This population is more at risk of developing PPD due to a complexity of issues including pre- and postmigratory stressors; however, there is currently little research on this topic available to health care providers and policy makers. Thirteen articles met inclusion criteria, and five themes emerged from the meta-synthesis: (a) suffering in solitude, (b) the invisible illness, (c) cultural conceptualizations, (d) barriers to help seeking, and (e) facilitators of help seeking. Conclusions suggest immigrant women with PPD may lack understanding of their condition, are often isolated, are alone, fear stigmatization, and risk being considered an unfit mother. Raising awareness with health care providers of the meaning of PPD for immigrant women is key to the provision of effective care.

Challenges and facilitators for health professionals providing primary healthcare for refugees and asylum seekers in high-income countries: a systematic review and thematic synthesis of qualitative research

OBJECTIVES

To thematically synthesise primary qualitative studies that explore challenges and facilitators for health professionals providing primary healthcare for refugees and asylum seekers in high-income countries.

DESIGN

Systematic review and qualitative thematic synthesis.

METHODS

Searches of MEDLINE, EMBASE, PsycINFO, CINAHL and Web of Science. Search terms were combined for qualitative research, primary healthcare professionals, refugees and asylum seekers, and were supplemented by searches of reference lists and citations. Study selection was conducted by two researchers using prespecified selection criteria. Data extraction and quality assessment using the Critical Appraisal Skills Programme tool was conducted by the first author. A thematic synthesis was undertaken to develop descriptive themes and analytical constructs.

RESULTS

Twenty-six articles reporting on 21 studies and involving 357 participants were included. Eleven descriptive themes were interpreted, embedded within three analytical constructs: healthcare encounter (trusting relationship, communication, cultural understanding, health and social conditions, time); healthcare system (training and guidance, professional support, connecting with other services, organisation, resources and capacity); asylum and resettlement. Challenges and facilitators were described within these themes.

CONCLUSIONS

A range of challenges and facilitators have been identified for health professionals providing primary healthcare for refugees and asylum seekers that are experienced in the dimensions of the healthcare encounter, the healthcare system and wider asylum and resettlement situation. Comprehensive understanding of these challenges and facilitators is important to shape policy, improve the quality of services and provide more equitable health services for this vulnerable group.