Equality is a key aim for the NHS in the UK.1 Over one in four births (28.2%) in the UK is to a foreign-born woman (rising yearly).2 Fifty-six per cent of births in London in 2013 were to foreign-born women, creating superdiversity among maternity care clients.3 Of concern is the fact that immigrant women appear disproportionately in confidential inquiries into maternal and perinatal mortality, indicating possible deficits in the care pathways.4,5 Rapid demographic change and the need to maximise health potential in our diverse, multicultural UK society6 provides an urgent imperative in respect of drawing knowledge together in a systematic fashion. A synthesis of knowledge related to maternity care access and interventions is urgently required to inform policy and practice to appropriately configure interventions as per the NHS Midwifery 2020 vision, to guide the professional development of health-care professionals (HCPs) and to reshape care to ensure culturally congruent maternity care. The UK is in a period of superdiversity, defined as ‘distinguished by a dynamic interplay of variables among an increased number of new, small and scattered, multiple origin, transnationally connected, socio-economically differentiated and legally stratified immigrants7 largely arriving in the UK post 1990’. Consequentially, enhancements to maternity care for immigrant women will not only benefit these women but will also improve the health of future generations in the UK.5,6,8 Insights into and understanding of the ethnocultural orientation of immigrant women in maternity is critical because it contributes not only to successful integration and social cohesion, but also to social justice in health care.9–11 Moreover, the socioeconomic marginalisation and vulnerability of immigrant women may be exacerbated by pregnancy, making maternity a critical focus of attention for the health-care system.10,12,13
Why now?
A knowledge synthesis is required to build a coherent evidence base that elicits an understanding of the factors behind disparities in accessibility, acceptability and outcomes during maternity care that can be used to improve and reconfigure this care. Substantial diversity exists within immigrant women populations; however, examples of commonalities may be found (e.g. late bookings for antenatal care,4,14 higher maternal and perinatal mortality,4,5 poor care and discrimination,9 obesity,15 postpartum depression,10,16 low birth weights and poor birth outcome,17,18 and higher rates of gestational diabetes15). These problems create an economic burden for the NHS.19
Costs to the NHS
The effective and efficient use of precious NHS resources is vital to the UK, but the higher prevalence of poorer birth outcomes among immigrant populations increases costs for the NHS. Unfortunately, economic modelling of these costs is lacking, so definitive data cannot be provided.
An urgent imperative due to demographic change
This period of superdiversity in the UK means that many new and diverse groups now reside in this country.20 Historically, the UK has hosted communities within whom a relationship existed via colonisation and the establishment of the commonwealth. However, in particular, increasing migration from Eastern Europe and non-Commonwealth countries is rapidly changing the demography of the UK. If the nation is to realise the full health potential of these future citizens, the NHS urgently needs a synthesis of the knowledge related to immigrant experiences of access and interventions in maternity care. Moreover, addressing health inequalities is a major goal of current NHS directives. The directives entitled Equity and Excellence: Liberating the NHS21 and Midwifery 2020: Delivering Expectations22 demanded enhancements to patient experiences. Developing interventions to militate against inequalities can make major contributions towards redressing inequalities. At present, NHS maternity services are so pressed for resources that they may not be accessible and acceptable to immigrant women. To improve outcomes for these women, effective recommendations for future policies may well sit outside the NHS.
Theoretical framework
A theory of access to services developed by Gulliford et al.23 maps out four dimensions (Figure 1):
- service availability
- utilisation of services and barriers to access (which includes personal, financial and organisational barriers)
- relevance, effectiveness and access
- equity and access.
FIGURE 1 Gulliford theory of access.23 Reproduced from Higginbottom et al.24 © Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY. Published by BMJ. This is an open access article distributed in accordance with the Creative Commons Attribution 4.0 Unported (CC BY 4.0) license, which permits others to copy, redistribute, remix, transform and build upon this work for any purpose, provided the original work is properly cited, a link to the licence is given, and indication of whether changes were made. See: https://creativecommons.org/licenses/by/4.0/. The figure includes minor additions and formatting changes to the original figure. (Figure not reproduced here; see the original article.)
We used this theoretical model in our systematic review, which was based on a synthesis project funded by the National Institute for Health Research (NIHR). Unlike most access models in the USA, this framework reflects the philosophy of the NHS in that its key principles are to provide horizontal access (ensuring equality of access in the population) and vertical access (meeting the needs of particular groups in the population, such as minority ethnic groups). The application of these principles is influenced by availability, accessibility and acceptability. The Gulliford et al.23 model has been widely used in empirical research, with the main paper having been cited at least 386 times. With its emphasis on accessibility, acceptability, relevance and effectiveness, this model is entirely appropriate for assessing the provision of maternity services to minority ethnic groups. In this study, the theory of access was used in the configuration of the review findings.23
This approach correlates with the research recommendations of the National Institute for Health and Care Excellence (NICE) on access and models of service provision.25 Using a comprehensive theoretical framework was crucial, because previous reviews lacked comprehensiveness by addressing only women’s skilled use of maternity services,26 the early initiation of antenatal care by socially disadvantaged women,27 or the early initiation of antenatal care by black and minority ethnic (BME) women.27 Moreover, in these reviews it was unclear whether or not the women in the studies were immigrants. Our review addresses these deficits.
Policy relevance
Evidence-based health care demands synthesised evidence to ensure that the highest-quality evidence is used to appropriately configure maternity services.22 Synthesised evidence is also needed to realise the goals of the NHS National Maternity Review,6 which directly informs the NHS Five Year Forward View,1 the professional development of HCPs and organisational change.
Significance and wider context
Some UK locations have historically been destinations of choice for immigrants, but other rural and urban locations are increasing in diversity. These changes are resulting in challenges to the provision of maternity care. Ultimately, enhancements to maternity care for immigrant women benefit not only the women using the service, but also the health of future British generations. Listening and responding to the perspectives of these service users (via the research studies included in our review) will be essential for configuring services in ways that are culturally congruent and culturally safe.28 Understanding the ethnocultural orientations of immigrant women in maternity is crucial; it contributes to successful integration and social cohesion, and ultimately to social justice in health care.29,30 Women’s needs and rights are often marginalised within families, communities and legislation. Socioeconomic marginalisation and the subsequent vulnerability of immigrant women can be further exacerbated by pregnancy and childbirth, making these factors an important focus of attention for those concerned with enhancing maternal health.12,31–34 Critically important is the strategic commitment in the UK to improve maternity services for all service users.22 In this context, it is imperative to implement service models that are effective for the disadvantaged and to ensure that these services are appropriately personalised.
The UK is in a period of superdiversity,20 with a wide range of populations accessing UK maternity care. Facilitating the provision of appropriate health care for immigrant populations in the UK will be crucial for maximising their well-being and their health potential. Without the delivery of culturally appropriate and culturally safe maternal care, negative event trajectories may occur, ranging from simple miscommunications to life-threatening incidents,35 risking increased maternal and perinatal mortality. Indeed, immigrant women are over-represented in mortality statistics.11,36,37 Although recent reviews have focused on specific aspects of maternity care,26,27,38 they have not considered a comprehensive conceptualisation of access23 or the current superdiversity.20 Reconfiguration and redesign of NHS maternal services to meet the needs of immigrant women requires integration of all these aspects.
Globally, a considerable commonality exists among developed nations in the maternity care experiences of immigrant women: studies in the USA,17,39 Canada,13,40–43 Australia,44,45 Sweden46 and Germany10 all provided evidence of this in earlier international reviews led by Higginbottom et al.,10,12 Small et al.,8 and Gagnon et al.41 However, the international comparative reviews by Small et al.8 and Gagnon et al.41 focused on South Asian and Somali women in the UK, thereby reflecting more established groups of immigrants and not the more recent superdiversity and current immigration patterns. In addition, two of the national surveys included in the Small et al.8 and Gagnon et al.41 reviews did not specify the number of immigrant women, limiting the overall usefulness of those reviews. We have addressed this deficit in our current review.
Our experienced information scientist-assisted search strategy (see Appendix 1) established that a systematic review of immigrant-receiving countries in Europe found substantial disadvantages for immigrant women in all of their maternal outcomes. The risk of low birth weight was 43% higher, the risk of preterm delivery was 24% higher, the risk of perinatal mortality was 50% higher and the risk of congenital malformations was 61% higher.18 Providing appropriate maternity care successfully to immigrant women requires the legitimisation and incorporation of their pervasive traditional beliefs and practices to which they often adhere despite their new milieu.47 Their beliefs and practices related to maternity care may differ considerably from Western biomedical perspectives,9,48 and the women may also be affected by migration issues and language barriers.9,31,33–35,48,49 Maternity care interventions may mitigate many of these issues, thereby enhancing the health of the mothers and their children.
Providing culturally safe and relevant maternity care in an era of superdiversity
The provision of culturally safe50,51 and relevant maternity care is contingent on the recognition and comprehension of key theoretical concepts. In the following paragraphs we explore these key concepts in the context of superdiversity.
Cultural competence
Meeting the maternity care needs of diverse populations demands consideration of the issues of cultural safety and cultural competence. Leininger,52 a seminal theorist, described ‘culturally competent care as care that is sensitive and meaningful to the patients, that intersects well with their cultural beliefs, norms and values’. This type of care may consist of actions that identify, respect and promote the cultural uniqueness of each individual.53 These important behaviours may be enhanced by continuing education for nurses and other health-care providers.54 Although Leininger made an important contribution in this field in the last century, her work has been critiqued extensively,55 largely for its assumption that care and services will be improved by knowledge of different cultures without recognition of ‘the very complex ways in which race, socioeconomic status, gender and age may intersect’.56 The approach tends to promote culture negatively, potentially contributing to stereotypical attitudes and propagating power imbalances.57 Serrant-Green58 stressed that the diversity within all ethnic communities needs to be addressed.
The term cultural competence means different things to different people; it can be said to represent a diverse set of skills, knowledge, attitudes and behaviours. Cultural competence can operate at the level of the individual practitioner, within a service setting, and at the broader levels of the health-care organisation and in the wider health-care system.
Key dimensions of cultural competence are the following:
- knowledge about diversity in beliefs, practices, values and world views, both within and between groups and communities, and recognition of similarities and differences across individuals and groups, as well as the dynamic and complex nature of social identities (sometimes called cultural knowledge)
- acceptance of the legitimacy of cultural, social and religious differences, and valuing and celebrating diversity (sometimes called cultural awareness)
- awareness of one’s own identity, beliefs, values, social position, life experiences and so on, and their implications for the provision of care (sometimes called cultural awareness or reflexivity)
- understanding of power differentials and the need to empower service users (sometimes considered part of cultural awareness)
- the ability to empathise, show respect and engender trust in service users (sometimes called cultural sensitivity)
- recognition of social, economic and political inequalities and discrimination, and how these shape health-care experiences and outcomes for minority groups; and a commitment to address such inequities
- effective communication strategies, including resources for cross-lingual and cross-cultural communication
- resourcefulness and creativity to resolve issues arising during the provision of care across differences.59
Organisational cultural competence
Organisational cultural competence refers to the structures, processes and strategies that operate within health-care organisations, to ensure the delivery of high-quality care and equitable outcomes to all clients, regardless of their ethnic, cultural or religious identities. This type of competence usually encompasses critical reflection on the inner workings of the organisation, including the underlying ways of operating that serve the interests of the dominant group within society. Cultural competence at an organisational level involves the commitment of adequate resources to support appropriate responses at the service delivery level.
Cultural safety
Culture is one of the most difficult terms or concepts to define, but is usually taken to be the beliefs, values, practices and symbols that are recognised by individuals who belong to a particular ethnic group. Although our focus here is on cultural safety,51 the issue of intersectionality must be acknowledged, because in reality a number of axes of inequality exist. For example, social class, ‘race’, ethnicity and gender intersect with culture and may increase the vulnerability60 of women in accessing maternity care services. Focusing on a narrow definition of culture when providing health care may lead to the stereotyping of clients and potentially to an inability of the practitioner to deal with diversity. Cultural safety aims to address these deficits by considering the historical and social processes that impact power relationships within and beyond health care.50,51 Cultural safety is achieved when programmes, instruments, procedures, methods and actions are implemented in ways that do not harm any members of the culture or ethnocultural group who are the recipients of care.61,62 Those within the culture are best placed to know what is or is not safe for their culture, which suggests the need for increased dialogue with immigrant women and a need for collaborative partnership approaches.63,64
Cultural safety was first conceptualised in New Zealand by Dr Irihapeti Ramsden, a Maori nurse, in response to a need to acknowledge the impact of colonisation on the Maori population and its lasting effects in the provision of health care.63 Ramsden conceptualised cultural safety as a product of nursing and midwifery education that facilitates culturally safe care as defined by the recipients.50 Cultural safety has been endorsed by the Nursing Council of New Zealand64 and has been a key component of international nursing and midwifery education since the early 1990s. The concept is less commonly used in the UK context, although it seems to be eminently transferable and has a strong empirical basis which other models do not have. Hence, it has been adopted as the cultural safety model by statutory bodies in both New Zealand and Canada.62
In the current period of superdiversity3,20 in the UK, responding to diverse needs of immigrant women in maternity care is an urgent imperative.8,37 It would seem necessary to draw on the concepts of cultural safety51 and cultural competence65 in order to provide optimal care, the fundamental axioms and precepts being that the values and norms of the host community determine the service configuration and in fact NHS employees are the bearers of these cultural norms via professional practice. Other nation states, notably Canada,62 Australia and New Zealand,50,63 have integrated the key dimensions of cultural safety (e.g. into professional education for HCPs). Intersecting the primacy of host community values is the idea within the notion of cultural safety, that power dimensions exist between the dominant cultural groups and new ethnocultural groups, resulting in unequal power dimensions in the health-care interaction. These unequal power dimensions often have historical antecedents; an exemplar of this is the notion that Commonwealth immigrants arriving in the UK, and in sociological terms, may be regarded as ‘the other’. Culturally competent and safe care demands not just a focus on individual professional practice, but an embedding of the principles of culturally safe and competent maternity care at the organisational level via policies, procedures, guidelines, education and training of health professionals.
How is an immigrant defined: international and UK perspectives
Defining the term immigrant is complex and lacks consensus. Internationally, the term ‘immigrant’ is defined in various ways. For example, according to the Canadian Council for Refugees, an immigrant is an individual who relocates to permanently reside in Canada.66 The Canadian Council for Refugees further explains that a person is a permanent resident if the right to live permanently in Canada is granted by the government to that person. The entry of the person into Canada may be as an immigrant or as a refugee. This definition indicates that in Canada an immigrant is defined on the basis of their legal residence status.
In Australia, the United Nations (UN) definition of international migration67 is used to define an immigrant. Accordingly, a person is an immigrant if they are born outside Australia and have been (or are expected to be) living in Australia for a period of ≥ 12 months.68
In the USA, the Department of Homeland Security is responsible for collecting data on immigrants. According to the Department of Homeland Security, immigrants are foreign-born individuals and they are required to obtain legal permanent residence in the USA.69 Here, the foreign-born individuals are the individuals who are not US citizens at the time of their birth. This definition includes naturalised US citizens, legal permanent residents (immigrants), temporary migrants (foreign students), humanitarian migrants (refugees and asylum seekers) and persons residing illegally in the USA.69 This definition indicates that the USA defines immigrants according to different categories (e.g. permanent and short-term residence).
In the UK, there is inconsistency in defining the term ‘immigrant’ in different data sources and data sets relating to migration.70 The terms immigrant and migrant are often used interchangeably to confer the same meaning. For example, the Annual Population Survey of Workers and Labour Force Survey71 uses country of birth as a basis for defining a ‘migrant’. According to these data sources, a person born outside the UK is classified as a ‘migrant’. However, many workers born outside the UK may become British citizens over a period of time.
A second source of data on migrants is applications made for obtaining a National Insurance number. This data source defines a migrant on the basis of nationality. Accordingly, applicants that hold nationality other than the UK are migrants. However, similar to the above, the nationality of a person is also subject to change over a period of time and, in some instances, individuals may acquire dual citizenship of a different nation state.
A third and important source of data on migrants is the Office for National Statistics (ONS). The ONS classifies migrants’ data in two data sets (i.e. short-term international migrant and long-term international migrant). Here ‘long term’ means holding the intention of staying > 1 year, whereas ‘short term’ is the intention of staying < 1 year. This suggests that the ONS considers the length of stay of a person in the UK important in determining migrant status. The classification of migrants into short and long term is recommended by the UN. The ONS uses the UN definition of long-term international migrant and estimates migrants both inside and outside the UK. Accordingly, a migrant is a person who relocates and changes his or her country of residence for a minimum of 12 months; therefore, the country of destination in essence becomes the country of usual residence.72 In long-term international migration data, students and asylum seekers are also included, which is not the case in the USA.
Immigrants and the UK NHS
In service provision, the NHS follows rules set by the central government that determine an immigrant’s entitlement to free NHS care. These rules relate to the kind of services and the immigration status of the user.73 This approach suggests that an asylum-seeker woman may not be entitled to full maternity care because of immigration status.74 Furthermore, the collection of data on ‘immigrants’ in the health-care setting is not well established and the NHS usually collects data on ethnicity and nationality and not on the migration-related variables such as length of stay and country of origin.
Researchers in the University of Oxford’s Centre on Migration, Policy and Society have defined immigrants in health-care research based on ‘country of birth’, with recent immigrants being foreign-born individuals who have been living in the UK for ≤ 5 years.75 Similarly, in another briefing paper on the health of migrants in the UK,74 researchers from the Centre on Migration, Policy and Society defined migrants as all those born outside the UK. The authors acknowledged that currently it is challenging to achieve a comprehensive understanding of migrants’ health due to the lack of evidence on migration-related variables (e.g. country of birth, length of stay in the UK, immigration status).
The statement of NICE, which provides clinical guidelines for health-care practice in the UK, is worth noting here. NICE,25 in its guidelines Pregnancy and Complex Social Factors: A Model for Service Provision for Pregnant Women with Complex Social Factors, identified recent migrant women having complex social needs. NICE defined a recent migrant as a woman who moved to the UK within the previous 12 months. In the guidelines, migrant women are conflated with asylum seekers, refugees and those lacking English-language proficiency. This suggests that there is implicit acceptance of the term migrant women in health care in respect of being born outside the UK, being in the purview of immigration control and having deficits in English-language proficiency.
Defining immigrants in health-care research
There is no consensus on the operational definition of ‘immigrants’ in the health-care research literature. For example, Urquia and Gagnon76 conducted a review of the literature (2000–9) to explore how the term ‘immigrants’ is defined in health-care research. The authors noted heterogeneity and ambiguity in the terminologies used in the field. The authors documented the following definition for international migrants:
A change of residence involving the spatial movement of persons across country borders. The change of residence may result in a new permanent residence (if the person is allowed to reside indefinitely within a country) or a temporary residence, as in . . . of international students and contract labour migrant workers . . .
The above definition is based on ‘length of stay’ and includes asylum seekers and refugees; however, in this definition the terms ‘permanent’ and ‘temporary’ are not further defined and specified. In fact, the authors are based in Canada, and therefore their definition may be mediated by Canadian perspectives on migration, which are somewhat different from those in the UK.
There are studies in which an immigrant is classified on the basis of country of birth. For example, Small et al.8 published a systematic and comparative review of studies on women’s health in five developed countries, including the UK. For the purposes of their review, the authors defined ‘immigrant women as those women not themselves born in the country in which they are giving birth’.8 In another study on maternity care,77 the author used similar terms (i.e. Somali-born women in the Finland context). This suggests that being born outside the country in which a women gives birth is the main defining factor. Salt78 has consistently used a definition of immigrant ‘as a person born outside the UK’ in his work. This is similar to a case in the US context, in which a systematic review on the health of immigrant women79 defined immigrant as ‘foreign born’.
In some other studies, the researchers have used broader terms to define immigrants. For example, an integrative review of the literature examining the potential influence of HCPs’ attitudes and behaviours on health-care disparities80 used a ‘broad definition’ and included all groups that, owing to ethnicity, place of birth, citizenship, residence status or the related variables, have minority status in the country in which they reside. The same approach is taken by a meta-synthesis81 undertaken on refugee and immigrant women’s experience of postpartum depression in three major European countries with high levels of immigration (Germany, Italy and the UK). The authors of this aforementioned meta-synthesis noted that there is inconsistency in the use of the term immigrant and thus ‘extended the inclusion criteria to all articles, where research had been undertaken on “ethnic minorities”, “migrants”, “refugees” and “asylum seekers” in the given country‘.81
It is observed that ‘nationality’ is also used in maternity care-related research to classify immigrant women. For example, acknowledging the challenge of categorising immigrant and ethnic minority women, Jentsch et al.82 used ‘overseas nationals’ in their study. In another review, Collins et al.83 excluded papers that looked at second-generation immigrant women and those whose samples were selected only on the basis of ethnicity rather than immigration. In the UK, the terms ‘old’ and ‘new’ migrants are also used when talking about the demographic diversity and challenges of delivering public services, including health care.7
Immigrant women in our proposal for the National Institute for Health Research
Our proposal submitted to NIHR noted various features of immigrant women in the UK that are related to the aforementioned discussion. The proposal acknowledged heterogeneity and diversity in the immigration pattern of immigrant women in the UK. The proposal highlights a variety of reasons for migration, diversity in country of birth and length of stay in the UK:
Our review is focused on immigrant women. This is heterogeneous group with migratory pattern that might be related to economic migration, the transgression of human rights and war, or have origins in the UK’s colonial history . . . The UK is in a period of superdiversity that is new and more diverse migrant groups (this includes both recent migrants and those who have been settled in the UK for many years) are resident in the UK, creating challenges for the National Health Service [NHS]. Increasing migration from Eastern Europe and non-commonwealth countries means that the synthesis of knowledge related to immigrant experiences of maternity care interventions and access is an urgent imperative because of rapidly changing demography and the potential to realise health potential of future citizens.
The operational definition of an immigrant women used in this review
The preceding paragraphs suggests that the term ‘immigrant’ is defined in various ways in different countries and by different authors. However, two features are frequently referred to in these definitions (i.e. country of birth and length of stay). These factors are also noted in NICE guidelines on the provision of maternity care25 and are important in the entitlement, access and ability to use health care in the UK. For example, if you are born outside the UK, it is likely that you are knowledgeable about the UK health-care provision.
We adopted the following definition of an immigrant woman for our review and to inform our inclusion and exclusion criteria. A woman is an immigrant if she:
- is born outside the UK
- has lived in the UK for > 12 months or had the intention to live in the UK for ≥ 12 months (or more) when she first entered.
Therefore, we included studies on immigrant women in which the population studied fulfilled these two criteria. According to this definition, studies on population groups of foreign students, asylum seekers, recent legal refugees and immigrants, and illegal immigrants will also be eligible for inclusion. In many cases the study populations/sample may not be accurately and fully described. We therefore used linguistic ability (e.g. the need for an interpreter) as a proxy for immigrant status. Notwithstanding all of these perspectives, we acknowledge that the term ‘immigrant women’ is generic and refers to a highly heterogeneous group of individuals, with a complex and vast array of ethnocultural orientation, linguistic skills abilities, motivations for migration and socioeconomic status. However, there may be a commonality of experience in respect of the use of and familiarity with maternity care services in the UK. What is profoundly critical is the over-representation of immigrant women in maternal and perinatal mortality statistics.