Midwifery ∎ (∎∎∎∎) ∎∎∎–∎∎∎

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Pregnancy, childbirth and motherhood: A meta-synthesis of the lived experiences of immigrant women Sandra Benza (MPH student), Pranee Liamputtong, PhD (Professor)n School of Public Health and Human Biosciences, La Trobe University, Bundoora, Victoria 3086, Australia

art ic l e i nf o

a b s t r a c t

Article history: Received 24 September 2013 Received in revised form 25 December 2013 Accepted 2 March 2014

Introduction: pregnancy, childbirth and motherhood are natural processes that bring joy to individual women and families. However, for many migrant women, becoming a mother while attempting to settle in a new country where the culture is different, can be a challenge for them. Aim: to identify and synthesise qualitative research studies that explore the perceptions of pregnancy, childbirth and motherhood, and lived experiences of migrant women in their new home country. Methods: the seven steps of Noblit and Hare's meta-ethnography was used to conduct the metasynthesis. Searches for literature of qualitative studies were conducted in May and June 2013 using PubMed, CINAHL, Google Scholar and La Trobe University databases. Studies published in English addressing pregnancy, childbirth and motherhood experiences of women from immigrant backgrounds met the inclusion criteria. Findings: 15 studies published between 2003 and 2013 related to the pregnancy, childbirth and motherhood experiences for women from migrant backgrounds were eligible for the meta-synthesis. Four major themes were identified as common in all the qualitative studies: expectations of pregnancy and childbirth; experiences of motherhood; encountering confusion and conflict with beliefs; and dealing with migration challenges. Conclusions: migrant women's pregnancy, childbirth and motherhood experiences are influenced by societal and cultural values, and they vary depending on the adjustment process in the new home country. The provision of culturally sensitive maternal health services enhances positive outcomes of a healthy mother and healthy infant. Supportive structures that address the issue of language and cultural barriers seem to promote antenatal clinic attendance, prevent pregnancy and childbirth complications, and enhance their positive motherhood experiences. Implications: women from immigrant backgrounds have the right to receive adequate and sensitive health care during the childbearing and childrearing times regardless of their migrant status. & 2014 Elsevier Ltd. All rights reserved.

Keywords: Metasynthesis Childbirth Motherhood Migrant women

Contents Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 Methodology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 Findings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 Expectations of pregnancy and childbirth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 Antenatal care perceptions and experiences . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 Experiences of giving birth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 Pregnancy outcomes and post partum experiences . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 Experiences of motherhood . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 Encountering confusion and conflict with beliefs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 Dealing with migration challenges. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

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Corresponding author. E-mail address: [email protected] (P. Liamputtong, PhD).

http://dx.doi.org/10.1016/j.midw.2014.03.005 0266-6138/& 2014 Elsevier Ltd. All rights reserved.

Please cite this article as: Benza (MPH student), S., Liamputtong, PhD, P., Pregnancy, childbirth and motherhood: A meta-synthesis of the lived experiences of immigrant women. Midwifery (2014), http://dx.doi.org/10.1016/j.midw.2014.03.005i

S. Benza (MPH student), P. Liamputtong, PhD / Midwifery ∎ (∎∎∎∎) ∎∎∎–∎∎∎

2

Discussion . . . . . . . . . . Implications for health Conflict of interest. . . . References . . . . . . . . . .

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Introduction Pregnancy, childbirth and motherhood are natural processes that bring joy to individual women and families (Liamputtong, 2006, 2007; Hoang and Kilpatrick, 2009; Murray et al., 2010). However, for many migrant women, becoming a mother while attempting to settle in a new country where the culture is different can be a challenge for them (Liamputtong, 2006; Hoban and Liamputtong, 2013). Globalisation and other forces worldwide have resulted in population movement which contributes to diversity in many societies (Higginbottom et al., 2013). When migrant women settle into a new country, they bring with them embedded cultural values and traditional beliefs of pregnancy and birthing practices (Liamputtong, 2006; Carolan and Cassar, 2008; Grewal et al., 2008; Hill et al., 2011). Culture, according to Wikberg and Bondas (2010, p. 1), refers to ‘a pattern of learned but dynamic values and beliefs that gives meaning to experiences and influences the thoughts and actions of individuals of an ethnic group’. Although cultural beliefs and traditional practices may have some effects on the universal biological event of childbearing, the main goal in all cultures is to ensure the safe health and well-being of the mother and infant (Liamputtong and Naksook, 2003a; Liamputtong, 2007; Hoang and Kilpatrick, 2009). These cultural values, and traditional beliefs and practices have been seen to influence the experiences of migrant women (Liamputtong and Naksook, 2003a; DeSouza, 2005; Carolan and Cassar, 2008; Ettowa, 2012). As evidenced in existing studies, some migrant women from the Horn of Africa experience difficulties with childbirth because of their beliefs or effects of female genital mutilation (FGM) practices (Straus et al., 2007; Carolan and Cassar, 2008; Murray et al., 2010; Hill et al., 2011; Higginbottom et al., 2013). This has created challenges for midwives and doctors in the new countries leading to poor pregnancy outcomes due to requirements for the procedures to be followed before childbirth. Migrant women, without extended family, also find themselves isolated, lonely and unable to cope with a newborn at home (Liamputtong and Naksook, 2003a; DeSouza, 2005; Liamputtong, 2006; Hoban and Liamputtong, 2013). Post partum period is the most crucial stage during pregnancy and childbirth because of the care requirements of the mother and newborn (DeSouza, 2005; Hoban and Liamputtong, 2013). Lack of support during this period could lead to emotional burden among migrant women (Hoban and Liamputtong, 2013). There is evidence that migrant women tend to be treated negatively and are likely to experience feelings of inadequacy as well as resent health care systems which lead to poor maternal health outcomes (DeSouza, 2005; Bollini et al., 2006; Straus et al., 2007; Carolan and Cassar, 2008; Hill et al., 2011). Moreover, migrant women, being the minority group in a society, experience social oppression, racial discrimination, disempowerment and negative interactions with health care givers (Carolan and Cassar, 2008). Besides the language barriers to health care (Reitmanova and Gustafson, 2007; Straus et al., 2007; Murray et al., 2010), there is a lack of continuity in post partum care for migrant women (Small et al., 2002; Hoban and Liamputtong, 2013). In seeking to understand the pregnancy, childbirth and motherhood experiences of migrant women, qualitative studies have been

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conducted in different western countries. Qualitative research is essential when little is known about the issue (Liamputtong, 2013a). The approach has been seen to be useful for allowing health care providers to have an in-depth understanding about the lived experiences of migrant mothers regarding childbirth, childrearing practices and experiences (Liamputtong, 2010, 2013a). To date, there has not been any systematic analysis of the lived experiences of migrant mothers so that a stronger evidence-based knowledge can be gained. We contend that a metasynthesis of qualitative evidence is essential if we aim to have a strong evidence for health care practices (Seers, 2012; Liamputtong, 2013b). A metasynthesis assists in the creation of new knowledge in the childbearing and childrearing practices of immigrant mothers, as Beck (2011) puts it; a metasynthesis is a critical analysis in a new body of knowledge. In this paper, we provide our synthesis of qualitative studies that examined the lived experiences of pregnancy, childbirth and motherhood among migrant women who have resettled in a western country.

Methodology We adopted the metasynthesis methodology developed by Noblit and Hare (1988). This involves the following stages: ascertaining the area of interest; deciding what is relevant to area of interest; identifying the metaphors and emerging themes from the studies; comparing and contrasting concepts; themes and metaphors by initiating reciprocal and refutational translations; and finally translating findings of each study into one. A systemic search was undertaken using PubMed, CINAHL, Google Scholar and La Trobe University databases. The search period for the relevant literature was conducted from May to June 2013. The following search terms were used in various combinations, ‘migrant women’, ‘pregnancy’, ‘childbirth’, ‘motherhood’ and ‘qualitative’ study to conduct the searches in titles, abstracts or keywords. On the basis of the metasynthesis methodology (Bondas et al., 2013), we selected studies using qualitative methodology solely and displayed the concepts and themes of migrant women's childbearing and motherhood experiences. Good quality qualitative research studies published in English and addressed the experiences of pregnancy, childbirth and motherhood of women from immigrant backgrounds that were published between 2003 and 2013 and met the inclusion criteria were included in our analysis. The quality of each paper was appraised using the Critical Appraisal Skills Programme (CASP) (see http://www.caspinterna tional.org/mod_product/uploads/CASP%20Qualitative%20Research %20Checklist%2031.05.13.pdf). The in-depth data was analysed using a thematic analysis to identify, analyse and report new patterns or themes within the data (published materials) (Braun and Clarke, 2006; Liamputtong, 2013a). Initially, we performed open coding where codes were first developed and named. Then, axial coding was applied to develop the final themes within the data. This was done by re-organising the codes which we have developed from the data during open coding in new ways by making connections between categories and sub categories. This resulted in new themes which are used to

Please cite this article as: Benza (MPH student), S., Liamputtong, PhD, P., Pregnancy, childbirth and motherhood: A meta-synthesis of the lived experiences of immigrant women. Midwifery (2014), http://dx.doi.org/10.1016/j.midw.2014.03.005i

Qualitative study Qualitative study Qualitative study Qualitative study Qualitative study Ethnography Qualitative study Qualitative study Qualitative study Qualitative study Qualitative study Qualitative study Qualitative study Qualitative study Qualitative study – 20–42 – 18–40 21–30 25–45 27–42 – 23–30 20–50þ 20–50þ – 20–40 25–40 23–57 Bollini et al. (2006) Carolan and Cassar (2008) DeSouza (2005) Ettowa (2012) Grewal et al. (2008) Higginbottom et al. (2013) Hill et al. (2011) Hoang and Kilpatrick (2009) Hoban and Liamputtong (2013) Liamputtong and Naksook (2003a) Liamputtong and Naksook (2003b) Liamputtong (2006) Murray et al. (2010) Reitmanova and Gustafson (2007) Straus et al. (2007)

Switzerland Australia New Zealand Canada Canada Canada United States of America Tasmania Australia Australia Australia Australia Australia Canada United Kingdom

Turkish, Portuguese and Swiss African Indian African Indian African Somali Asian Cambodian Thai Thai Southeast Asian African Muslim Somali

40 18 7 8 15 12 18 10 20 30 30 91 10 6 8

Research design Sample size Race/ethnicity

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

Antenatal care perceptions and experiences Migrant women revealed anxiety, fear, distrust and suspicion from antenatal care experiences when accessing health care systems in their adopted countries. These are evidenced in 11 studies (DeSouza, 2005; Reitmanova and Gustafson, 2007; Straus et al., 2007; Carolan and Cassar, 2008; Grewal et al., 2008; Murray et al., 2010; Hoang and Kilpatrick, 2009; Hill et al., 2011; Ettowa, 2012; Higginbottom et al., 2013; Hoban and Liamputtong, 2013).

Country

It was evident in 14 studies (Liamputtong and Naksook, 2003b; DeSouza, 2005; Bollini et al., 2006; Liamputtong, 2006; Reitmanova and Gustafson, 2007; Straus et al., 2007; Carolan and Cassar, 2008; Grewal et al., 2008; Murray et al., 2010; Hoang and Kilpatrick, 2009; Hill et al., 2011; Ettowa, 2012; Higginbottom et al., 2013; Hoban and Liamputtong, 2013) that the migrant women's expectations of pregnancy and childbirth were shaped by the experiences from their country of origin. These women had a multitude of cultural frameworks about childbirth and practices emanating from traditional knowledge or a different way of life. These studies also revealed that important factors for a good pregnancy depended on family and community supportive networks through sharing advice. These expectations can be categorised into three sub-themes.

Authors/year

Expectations of pregnancy and childbirth

No.

The qualitative studies included in this meta-synthesis were conducted in six countries (seven in Australia, four in Canada, one in USA, one in UK, one in New Zealand, and one in Switzerland). Eleven studies focused on the pregnancy and birth experiences of the migrant women including interactions with health care providers, use of maternity services and care during the postpartum period. Four studies focused on post partum period including the positive and negative aspects in the new country. Motherhood experiences were included in almost all studies. 323 participants were included in these 15 studies and the women were from Turkey, Portugal, India, Somalia, Cambodia, China, Vietnam, Thailand, Sudan, Eritrea, Ethiopia, Liberia and Kenya. Most studies were conducted using an in-depth interviewing method but four adopted the focus group method (Table 1). The following four major themes and three subthemes emerged from these studies: expectations of pregnancy and childbirth (antenatal care perceptions and experiences, experiences of giving birth and pregnancy outcomes, and postnatal experiences); experiences of motherhood; encountering confusion and conflict with beliefs; and dealing with migration challenges.

Table 1 A comparison of demographic and methodological characteristics of individual studies used in the meta-synthesis.

Findings

Age range

Data collection

explain the lived experiences of the participants. The emerging themes are presented in the findings section. The quality of the research papers was agreed upon by both authors after determining the inclusion and exclusion criteria and appraising the quality of each paper. Then a meta-synthesis was conducted to allow for a deeper interpretation of previous qualitative study findings to produce a comprehensive understanding of the childbearing and childrearing issues from the migrant women's perspective. The availability of qualitative study papers addressing pregnancy, childbirth and motherhood experiences of women from migrant backgrounds allowed both authors to review, integrate and synthesise the findings in order to combine the knowledge gained from these individual studies. The thematic analysis to understand the pregnancy, childbirth and motherhood as well as the lived experiences of migrant women was done by both authors and consensus was reached through discussions.

Focus groups In-depth interviews In-depth semi-structured interviews In-depth semi-structured interviews Focus group interviews Focus group interviews Focus group interviews Semi-structured interviews Ethnographic semi-structured and unstructured interviews Ethnographic interviews and participant observation Ethnographic interviews and participant observation Ethnographic in-depth interviews Semi-structured interviews In-depth semi-structured interviews In-depth narrative interviews

S. Benza (MPH student), P. Liamputtong, PhD / Midwifery ∎ (∎∎∎∎) ∎∎∎–∎∎∎

Please cite this article as: Benza (MPH student), S., Liamputtong, PhD, P., Pregnancy, childbirth and motherhood: A meta-synthesis of the lived experiences of immigrant women. Midwifery (2014), http://dx.doi.org/10.1016/j.midw.2014.03.005i

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S. Benza (MPH student), P. Liamputtong, PhD / Midwifery ∎ (∎∎∎∎) ∎∎∎–∎∎∎

Main issues included: financial needs associated with the pregnancy, lack of recognition of antenatal care by migrant women in their new home country; lack of familiarity with multiple health providers; and not knowing what to expect during childbirth. For example, a participant in Ettowa's study (2012, p. 34) remarked that: It was pretty nerve wracking…I was nervous. I didn't really know what to do. I took the classes but when it came down to doing it, I didn't do what I was supposed to do. I was just trying to get it over and done with. But I forgot all that and was happy to see my baby when the time came Some African women expressed their anxieties surrounding the trauma encountered during childbirth by the women who had undergone female genital mutilation (Straus et al., 2007; Murray et al., 2010). The compounding factors included the lack of familiarity of this intervention by the midwives and doctors. One participant in the study of Straus et al. (2007, p. 183) said: When she is pregnant for the first time, all she will be thinking is how am I going to have my baby, do they know how to cut it? The scar has to be cut before birth. However, some participants expressed their appreciation of an improved quality of life in a new country (Carolan and Cassar, 2008; Hill et al., 2011; Higginbottom et al., 2013). One participant who migrated from Africa expressed: I like living here the food is available. I have nothing to worry about. You can get education no one will come into your house and kill you. (Carolan and Cassar, 2008, p. 195) Hence, these migrant mothers saw resettlement as a priority over their childbearing needs. Migrant women also reported experiences of babies born at home or refugee camps in the presence of other women who are not midwives. Hence, they were surprised and confused by the attention during antenatal care in their new homeland (Carolan and Cassar, 2008; Hoang and Kilpatrick, 2009; Hill et al., 2011; Higginbottom et al., 2013). However, other migrant women voiced appreciation of the advanced technology with scientific evidence during the antenatal period which contrasted with the traditional advice they received in their home countries which they believe has no logic (DeSouza, 2005; Carolan and Cassar, 2008; Hill et al., 2011). A participant in Hill et al.'s study (2011, p. 76) shared her opinion of the value of advanced technology: My pregnancy was the worst so I couldn't stay home…. If I was in Africa I would die, because the whole nine months I was sick. So, how could I stay home? It could kill me. I got TPN in the hospital. Other issues affecting the pregnancy expectations of the migrant women included the loss of rituals at confirmation of pregnancy, previous knowledge of their bodies and previous pregnancies, the lifestyle and diet of a pregnant woman based on their culture (DeSouza, 2005; Reitmanova and Gustafson, 2007; Straus et al., 2007; Grewal et al., 2008; Murray et al., 2010). Some migrant women expressed the painful loss of endless care provided by their extended family as part of traditional ritual practices to celebrate pregnancy. Greta, one participant in a study by DeSouza (2005, p. 89) remarked: Everyone else does things for you and you know in that way you are just pampered. You get all these supposedly nourishing treats and foods and things you know. You know things like that…being here makes you think of all the things that you take for granted back home.

Experiences of giving birth The voices of migrant women describing their experiences of giving birth in their new homeland are apparent in 10 studies (Liamputtong and Naksook, 2003b; Bollini et al., 2006; Reitmanova and Gustafson, 2007; Straus et al., 2007; Carolan and Cassar, 2008; Hoang and Kilpatrick, 2009; Murray et al., 2010; Hill et al., 2011; Ettowa, 2012; Higginbottom et al., 2013). These immigrant mothers described labour pain as a natural expectation for women and were relieved after the baby was born: Even though the pain was hard, it felt more natural, and even though I screamed and everything, it still felt good once I saw my baby. (Ettowa, 2012, p. 33) Migrant women also expressed their preference of giving birth naturally (Higginbottom et al., 2013) and the use of other more traditional methods to relieve pain such as walking or drinking hot or cold tea (Murray et al., 2010). Other issues relating to experiences of giving birth for migrant women included: the confidence in capacity to give birth naturally; the ability to deal with pain and self-control; reluctance to ask questions regarding care from health workers who appear rushed; preference for silence during childbirth to demonstrate stoicism; and delaying going to hospital when in labour for fear of caesarean section. In a study by Higginbottom et al. (2013, p. 5), one participant revealed: And we have something also in our tribe. If you're going to have the baby you don't have to cry and do all kind of this funny stuff, because they're going to sing a song about you that you're a chicken or something…You can't cry. You can't do this funny face and this kind of stuff…You have to be strong for it. Migrant women also revealed their adoption of western culture by having husbands present during childbirth a practice that did not happen in their original country and suggested that this helped with the provision of emotional and physical support during birth of the baby. A woman in Hoang and Kilpatrick (2009, p. 6) elaborated how the husband's involvement during childbirth had been different in the new country: My husband stayed with me during my labour and I felt to be supported and especially when my English was not good enough to communicate with midwives and doctors. I felt that now my husband has a great sympathy for women when they are in labour because he witnessed what his wife went through. When narrating their experiences of giving birth, immigrant women expressed anxieties about childbirth including birthing positions. These anxieties resulted from mixed feelings based on these women's beliefs and customs. A women in the study conducted by Murray et al. (2010, p. 466), who was accustomed to kneeling or squatting to give birth, mentioned that: In the village in Africa when you are having a baby you are sitting down like this (motions squatting). Yeah, but here it is very different. You sleep (lie in bed), and that makes her scared. Migrant women also talked about fears of childbirth complications due to female circumcision (Hill et al., 2011). When sharing the importance of deinfibulation prior to childbirth, a participant in Hill et al. (2011, p. 77) explained: Most Somali women want to be cut because back home that's what they do. You(r) doctors say ‘no, the baby will cut itself.’ That will damage me cause it will crack everywhere, that's what happened. I ripped all the way down to my bottom. Migrant women expressed their strong desire to be looked after by female health care providers. However, as they realised

Please cite this article as: Benza (MPH student), S., Liamputtong, PhD, P., Pregnancy, childbirth and motherhood: A meta-synthesis of the lived experiences of immigrant women. Midwifery (2014), http://dx.doi.org/10.1016/j.midw.2014.03.005i

S. Benza (MPH student), P. Liamputtong, PhD / Midwifery ∎ (∎∎∎∎) ∎∎∎–∎∎∎

that the health care system in the new country was different to what they were used to, they accepted to be looked after by male health care providers as well: In Africa you cannot accept any man or whatever, but, I guess, I was like I say, ‘Yeah that one is Australia, it's not Africa. It's a doctor. He's come to check the baby, yeah, nothing’ (Murray et al., 2010, p. 465).

Pregnancy outcomes and post partum experiences It is evident from 11 studies that migrant women had great concern about the continuity with care post partum (Liamputtong and Naksook, 2003b; DeSouza, 2005; Liamputtong, 2006; Reitmanova and Gustafson, 2007; Straus et al., 2007; Grewal et al., 2008; Hoang and Kilpatrick, 2009; Murray et al., 2010; Higginbottom et al., 2013; Hill et al., 2011; Hoban and Liamputtong, 2013). Some women reported their experience of worse health after childbirth because they did not have an opportunity to observe the post partum traditional practices such as the confinement period in their culture (Liamputtong and Naksook, 2003b). According to studies by Grewal et al. (2008) and DeSouza (2005), the women described the period of rest after childbirth as a cultural practice that enhanced the woman's healing process in order to regain strength. Some migrant women also suggested that physical health was of utmost importance as they had to be strong after childbirth in order to look after themselves, the infant and the other children once they returned home. This was expressed by one participant in Murray et al.'s study (2010, p. 467): ‘You can have help here, but you have five children at home’. First-time mothers attempted to keep in touch with family for social and emotional support as well as guidance on breast feeding practices and care of the newborn (DeSouza, 2005; Hill et al., 2011; Hoban and Liamputtong, 2013). Furthermore, the preference for natural birth ensured a speedy recovery and enabled the migrant women to get back to their busy lifestyles. This was particularly important for those women who could not afford a long time out of work or whose husbands had to return to work soon after the baby was born (Grewal et al., 2008; Hoang and Kilpatrick, 2009; Murray et al., 2010; Hill et al., 2011).

Experiences of motherhood Women from migrant backgrounds expressed their concerns and experiences of raising children in a foreign country in 14 studies (Liamputtong and Naksook, 2003a,b; DeSouza, 2005; Liamputtong, 2006; Reitmanova and Gustafson, 2007; Straus et al., 2007; Carolan and Cassar, 2008; Grewal et al., 2008; Hoang and Kilpatrick, 2009; Murray et al., 2010; Hill et al., 2011; Ettowa, 2012; Higginbottom et al., 2013; Hoban and Liamputtong, 2013). Their negative experiences of motherhood resulted from settlement issues, lack of extended family to help with housework and childcare while studying or working, unstable living conditions, heavy work as immigrants, and conflicts in disciplinary methods between cultures. Thus, the motherhood role proved more challenging, as one woman in Liamputtong (2006, p. 40) commented: ‘Being a mother is more difficult than being a father. We have many kinds of responsibilities. We have to work hard to take care of our children…at the same time we may have to work to gain additional income’. However, women also observed the changes that occurred with their partners. A participant in DeSouza's study (2005, p. 98) expressed the changes noted in husbands who had limited childrearing role in the country of origin:

5

No, not really because he is by nature caring and a family man so I would have got a shock if he didn't lift a finger. The extent to which he went about was great because as you say the typical Goan male, husband, father is not very involved in child rearing. They don't really take a very active part. These studies also revealed that migrant women were concerned about their struggle to become good mothers based on good morals and values without family and kinship ties. These issues were the result of the lack of physical help and advice due to a different lifestyle. One participant in Liamputtong's study (2006, p. 46) remarked: Being a mother alone is already difficult and responsibly, so it is extremely hard when you have to be two things, a mother and a migrant, at once. You were born and grew up in a country in which the tradition and culture are totally opposite to that of the country in which your children are growing up. However, some migrant women also revealed positive experiences of being a mother, starting with the pride of being able to have a child and having children as a form of security in future: Naturally, when you have children, you have someone to take care of you when you are old. They can serve food to you (if you can't cook anymore). If you are sick, you have children to look after you. (Liamputtong, 2006, p. 36) Some of the women expressed their faith in God for the ability to have children (Hill et al., 2011; Ettowa, 2012). When describing the childbearing experiences and spiritual connectedness, a woman in Ettowa's study (2012, p. 34) declared that: I really believe in God, and I don't believe that anybody can have kids without Him. I believe that people who have kids are blessed….god blesses people with kids. That really means something to me. Other participants received help from neighbours and friends for guidance for their mothering roles in a new country. Studies suggested that migrant women who had adequate support would have better satisfaction when becoming a mother (DeSouza, 2005; Hoang and Kilpatrick, 2009). However, a lack of support in an unfamiliar environment could also lead to stress and depression (Liamputtong and Naksook, 2003a; DeSouza, 2006; Hoang and Kilpatrick, 2009; Straus et al., 2007; Hoban and Liamputtong, 2013): Nobody could give me a hand to look after my newborn baby. At night the baby was crying nonstop. When the baby was small, I got up so often that I could not remember how many times each night I got up. I forgot. When the baby was crying I did not know how to look after my baby. (Hoban and Liamputtong, 2013, p. 5) Encountering confusion and conflict with beliefs Women from diverse migrant backgrounds hold their traditional and religious views and practices for pregnancy, childbirth and motherhood. This was evident in 13 studies (Liamputtong and Naksook, 2003a,b; DeSouza, 2005; Liamputtong, 2006; Reitmanova and Gustafson, 2007; Straus et al., 2007; Carolan and Cassar, 2008; Grewal et al., 2008; Hoang and Kilpatrick, 2009; Murray et al., 2010; Hill et al., 2011; Higginbottom et al., 2013; Hoban and Liamputtong, 2013). The confusion and conflict that migrant women seemed to encounter included the use of analgesia and instruments during childbirth, intrusion of privacy when they have to share rooms with other mothers in hospital settings, being attended to by male health workers or having

Please cite this article as: Benza (MPH student), S., Liamputtong, PhD, P., Pregnancy, childbirth and motherhood: A meta-synthesis of the lived experiences of immigrant women. Midwifery (2014), http://dx.doi.org/10.1016/j.midw.2014.03.005i

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S. Benza (MPH student), P. Liamputtong, PhD / Midwifery ∎ (∎∎∎∎) ∎∎∎–∎∎∎

procedures that are in contravention with their cultural beliefs such as vaginal swabs. Migrant women had the desire to preserve their culture and tradition while trying to embrace the valuable knowledge of the new homeland. For example, a participant in Carolan and Cassar's study (2008, p. 196) suggested that: In my culture, it is [not good] to breastfeed a baby when you are pregnant with another one but in Australia you should continue …I didn't know … maybe it is bad for the baby…. Post partum depression and the harm which might affect the infant were difficult to understand by some migrant women. There are issues of stigma and taboo surrounding mental health issues in many cultures prompting rejection by the community. Migrant women expressed feeling stressed from the pressures surrounding motherhood in their new homeland. However they also tended to hide their feelings. One woman in Hill et al. (2011, p.77) acknowledged this feeling: ‘We hide our feelings. Expressing them is a sign of weakness’. However, these feelings may not be seen as post partum depression by health providers leaving the women to deal with it themselves: Like when my husband comes home from work. I go out and it's snowing but I sit out there without the jacket or nothing because I feel like I'm burning inside. And I talk to the psychologist who said ‘she's okay,’ it's just the pressure and all. (Hill et al., 2011, p. 77) Migrant women also revealed their anxieties regarding adherence to medical advice about nutritional requirements during pregnancy and breast feeding while maintaining religious practices such as fasting (Reitmanova and Gustafson, 2007; Hill et al., 2011): Like when I was pregnant during Ramadan [the month of fasting] and I asked my doctor about fasting. She told me ‘I don't like to tell you not to fast’. I prefer if there can be some Muslim physician who can give them more information about such topics. They don't understand it. If they have more ideas about the issue it will be better. (Reitmanova and Gustafson, 2007, p. 107) These studies also suggested that the lack of assertive skills for some migrant women resulted in them agreeing to any instructions given by health care givers, even if the instructions were against their traditional beliefs and cultural practices (Hoang and Kilpatrick, 2009): After my baby was delivered, the nurse asked me to have a shower immediately. I knew I was not supposed to do it but I was reluctant not to do it because I did not want to be against what they told me. (Hoang and Kilpatrick, 2009, p. 7) Additionally, some mothers mentioned how they agreed to raise their children according to the husband's expectations' although it was against their wishes in order to avoid conflict when navigating between parallel beliefs (Liamputtong and Naksook, 2003a). Nevertheless, not all migrant women felt obliged to compromise their cultural beliefs when it came to health care recommendations. This meant that participants were happy to follow their beliefs and were not intimidated by Western health practices, as one participant in a study by Higginbottom et al. (2013, p. 7) expressed: ‘It's my tradition. I believe in it, you know …I have to do what I believe’. As evidenced in the study of DeSouza (2005), some migrant mothers resisted other parenting practices such as

having a separate room for the infant, and practised what they deemed culturally appropriate. Dealing with migration challenges On the basis of 12 studies (Liamputtong and Naksook, 2003a; Bollini et al., 2006; Liamputtong, 2006; Reitmanova and Gustafson, 2007; Straus et al., 2007; Carolan and Cassar, 2008; Grewal et al., 2008; Hoang and Kilpatrick, 2009; Murray et al., 2010; Hill et al., 2011; Higginbottom et al., 2013; Hoban and Liamputtong, 2013), adapting to a new way of life while holding onto own traditional values and beliefs were some of the migration challenges faced by women from immigrant backgrounds. These studies revealed that migrant women experienced a sense of fear and isolation from insulting and insensitive remarks, stereotype and prejudice by those providing maternity care from the western health care system (DeSouza, 2005; Reitmanova and Gustafson, 2007; Carolan and Cassar, 2008; Grewal et al., 2008). These studies suggested that migrant women experienced stereotyped judgements because of their lack of knowledge about pregnancy or childbirth and their illiteracy. Women from immigrant backgrounds were perceived to be un-informed about family planning methods based on the number of their children: You see their faces. You feel it that they think you are stupid and you don't know anything about this world. (Reitmanova and Gustafson, 2007, p. 107) Additionally, migrant women reported feelings of abandonment when they failed to access maternity care, other social services or express their needs due to language barriers (DeSouza, 2005; Hoang and Kilpatrick, 2009; Murray et al., 2010). One participant in Hoang and Kilpatrick (2009: 7) raised the issues of communication problems: I did not go to antenatal classes because my English was not good. When I came to see the midwives, they could not understand me and I could not understand them. Migrant women express how communication issues have impacted on their understanding of what was happening during maternal health visits (Murray et al., 2010). This was suggested by one participant in Murray et al. (2010: 463) pointed out: ‘When you don't speak the language, you lack a lot of things’. Nevertheless, although migrating to a new country brings opportunities for a better life, migrant women in these studies revealed their sense of loss for family and friends who are left in their original countries who would help during the post natal period or with looking after the children. This was expressed by one woman in a study by Hoang and Kilpatrick (2009: 6): I felt lonely, isolated because I did not have many friends and my family is not here. I had only two friends to come to see me when I came back from hospital. It was very different with what I experienced in Vietnam. I did not get any support from anyone. I did all the housework and looked after my two children by myself. Other challenges expressed by women of migrant background included transport problems if they had to attend antenatal appointments or other pressing issues such as looking after other young children (Reitmanova and Gustafson, 2007; Hill et al., 2011). However, these experiences were perceived by health care providers as a lack of commitment among the mothers and have resulted in the health care of these migrant women not being met (Table 2).

Please cite this article as: Benza (MPH student), S., Liamputtong, PhD, P., Pregnancy, childbirth and motherhood: A meta-synthesis of the lived experiences of immigrant women. Midwifery (2014), http://dx.doi.org/10.1016/j.midw.2014.03.005i

No. Study

Expectations of pregnancy and childbirth Antenatal care perceptions and experiences

Experiences of giving birth

Pregnancy outcomes and postnatal experiences –

Experiences of motherhood

Encountering confusion and Dealing with migration conflict with beliefs challenges

Unstable living conditions, heavy work, socio-economic factors

–

1

Bollini et al. (2006)

–

Stressful event

2

Carolan and Cassar (2008)

Confidence in capacity to give birth, labour – pain integral to childbirth

–

Resettlement is a priority, shock and surprise to some procedures

3

DeSouza (2005)

–

Lack of support

Role of extended family destroyed by migration

Loss of culture and tradition, knowledge of the west became valuable

–

4

Ettowa (2012)

–

–

Grewal et al. (2008)

Childbirth a positive experience, unique and spiritually guided –

–

5

Pregnancy not special, difficult to comprehend complexities of care Loss of rituals, evidence-based practice over traditional beliefs Mixed emotions of joy and sadness Lifestyle, diet and rituals

Traditional health beliefs

Language barriers, positive and negative interactions with health staff, feeling abandoned

6

Higginbottom et al. (2013)

Pregnancy natural event no need for special intervention

7

Hill et al. (2011)

8

Hoang and Kilpatrick (2009) Hoban and Liamputtong (2013) Liamputtong and Naksook (2003a,b) Liamputtong (2003)

Pregnancy is part of life, value of antenatal care Confusion, anxiety, conflicting expectations Anxious about giving birth

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10

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Life changes forever, sense of responsibility Settlement issues, acculturalisation, Childbirth celebration, hot foods for healing and extended family role recovery, ‘chilia’ – a 40 day rest to regain strength Women's assertion of rights viewed as Silence as a result of social control, hidden Hot things reduce pain and speed recovery disrespectful by husbands, reluctance to contraception, fear of caesarean section bottle feed versus breast feeding birth, kneeling or squatting to give birth Lack of control with childbirth, Female circumcision worries Husbands not present at birth

–

–

Presence of husband at birth

–

–

Resist analgesia and instruments during childbirth, use of hot water for swelling The desire to breast feed Reliance on extended family for emotional More faith in God than and physical support science, post partum depression non-existent Traditional confinement Role of family and community support Traditional views and practices

Inadequate post partum follow up, difficulties with infant care Poor health from blood loss, traditional confinement practices –

12

Liamputtong (2006)

–

–

Limited access to health and social services

13

Murray et al. (2010)

Fear, distrust and suspicion

Pain, control, interactions, pain control, positive and negative interactions with caregivers, shy and reluctant to question about care, labor pain natural and an expectation

Natural birth preferable to caesarean section birth

Language barriers, loneliness and isolation, feelings of racism and discrimination Migration challenges

Difficult access to and reception of maternity care

Language barriers, challenges of the health care system Language and cultural barriers to maternal care

Lack of support and care, homesick

Traditional post partum practice

Language barriers

Pride in motherhood, lack of freedom and restriction, husbands limited role in childrearing Being a mother and wife in a new land, role of extended family,

Motherhood essential part of marriage

–

Having children provides security in future, responsibility and commitment, conflict of disciplinary methods, taking care of children and a career, family and kinship ties No extended family, no extended family for support, busy lifestyles with housework, childcare and study

S. Benza (MPH student), P. Liamputtong, PhD / Midwifery ∎ (∎∎∎∎) ∎∎∎–∎∎∎

Please cite this article as: Benza (MPH student), S., Liamputtong, PhD, P., Pregnancy, childbirth and motherhood: A meta-synthesis of the lived experiences of immigrant women. Midwifery (2014), http://dx.doi.org/10.1016/j.midw.2014.03.005i

Table 2 Individual metaphors as related to overarching themes.

Desire to preserve culture and Social isolation and tradition loneliness, challenges of migration Language problems Good motherhood instil moral values and religious beliefs, cultural conflict

Pharmacological worries that A sense of fear and isolation, language barriers pharmacological pain relief may be harmful to infant, Female genital mutilation and pain

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S. Benza (MPH student), P. Liamputtong, PhD / Midwifery ∎ (∎∎∎∎) ∎∎∎–∎∎∎

8

Not informed of social support services

Embedded cultural beliefs Lack of continuity of care No family support, marital breakdown 15

Experiences of giving birth Antenatal care perceptions and experiences

Preference for a female midwife/doctor Antenatal classes Reitmanova and Gustafson failure to meet expectations, financial (2007) needs associated with pregnancy Female circumcision worries Straus et al. Lack of trust and (2007) familiarity with multiple health professionals, feeling insecure 14

No. Study

Table 2 (continued )

Expectations of pregnancy and childbirth

Pregnancy outcomes and postnatal experiences

Experiences of motherhood

Getting help from neighbours and friends

Intrusion of privacy, religious beliefs (fasting and pregnancy)

Encountering confusion and Dealing with migration conflict with beliefs challenges

Lack of communication, language limitations, inattentive care, insulting and insensitive remarks, stereotypes and prejudice Stereotype and negative attitudes, communication barriers, isolation and depression

Discussion Migrants have traditional values and beliefs which may affect the way they view and experience the new cultural environment (Hoang and Kilpatrick, 2009). According to Ettowa (2012), childbearing, among other life transitions, has a special meaning in the lives of the woman and her family. Often, the antenatal and post partum beliefs are dependent on culture, social and individual factors (Selin, 2009). There are traditional beliefs and practices that women need to adhere to in order to ensure healthy pregnancy and positive maternal health outcomes (Liamputtong, 2000, 2007; Carolan and Cassar, 2008; Higginbottom et al., 2013). Several studies suggest that most migrant mothers wish to be able to observe rest and confinement according to their traditional and cultural beliefs after giving birth (Liamputtong and Naksook, 2003a,b; DeSouza, 2005; Grewal et al., 2008). However, traditional practices of rest and confinement may not be feasible in western countries because of different lifestyles. It is clear that social support networks are needed for migrant women in the absence of extended family to minimise stress and risk of postnatal depression (DeSouza, 2005; Hoang and Kilpatrick, 2009; Hoban and Liamputtong, 2013). Studies reveal that the differences in traditional childbirth beliefs and practices between migrant women and women from the new country often lead to conflict between health care providers and the migrant women (Carolan and Cassar, 2008; Hoang and Kilpatrick, 2009; Higginbottom et al., 2013). These studies also reveal that cultural insensitivity is the fundamental issue that fails to meet the pregnancy, childbirth and motherhood expectations of migrant women (DeSouza, 2005; Reitmanova and Gustafson, 2007; Carolan and Cassar, 2008 Grewal et al., 2008). Women from immigrant backgrounds have also raised language and cultural barriers as some of the challenges leading to their failure in accessing health care services in the new countries (Bollini et al., 2006; Carolan and Cassar, 2008). These barriers pose as a great challenge on the women who are already struggling to adjust in an unfamiliar environment. These language barriers and cultural considerations often impact on birthing treatment preferences and motherhood expectations which differ amongst countries (Potter et al., 2011). This synthesis suggests that the transition of migration can result in feelings of isolation, loneliness and depression from lack of support (Bollini et al., 2006; Straus et al., 2007; Hill et al., 2011; Hoban and Liamputtong, 2013). This is most significant during the post partum period when the woman is recovering from birth and at the same time taking on their motherhood role (Hoban and Liamputtong, 2013). In a new country, migrant women are unable to maintain some traditional practices such as dietary and physical measures to restore their health after childbirth because there is no extended family to provide this crucial support for them (Liamputtong and Naksook, 2003a,b; DeSouza, 2005; Grewal et al., 2008). Due to this lack of support, some studies suggest that migrant mothers are at risk of experiencing emotional stress during their childbearing years (Hoban and Liamputtong, 2013). Migrant motherhood is also stressful for most women when they are discriminated against because of different parenting beliefs to the cultural norms in the new country (De Souza, 2006). Studies indicate negative experiences of antenatal care in host countries among migrant women (DeSouza, 2005; Reitmanova and Gustafson, 2007; Straus et al., 2007; Hoang and Kilpatrick, 2009; Murray et al., 2010). The lack of familiarity with the new health care systems and the negative experiences encountered in accessing maternity health services, often lead to fear, anxiety, confusion and unmet antenatal care needs (Liamputtong, 2006; Hoang and Kilpatrick, 2009; Murray et al., 2010). In addition, some migrant women in the studies express that they are treated with prejudice and experience racial

Please cite this article as: Benza (MPH student), S., Liamputtong, PhD, P., Pregnancy, childbirth and motherhood: A meta-synthesis of the lived experiences of immigrant women. Midwifery (2014), http://dx.doi.org/10.1016/j.midw.2014.03.005i

S. Benza (MPH student), P. Liamputtong, PhD / Midwifery ∎ (∎∎∎∎) ∎∎∎–∎∎∎

stereotyping when accessing maternity services which then impacts on their attendance of these appointments (Straus et al., 2007; Carolan and Cassar, 2008). In contrast, findings from some studies also suggest that some women from immigrant backgrounds have positive experiences during their childbearing and childrearing period. On the basis of some studies some migrant women believe labour pain to be an integral part of childbirth irrespective of where it occurs (Carolan and Cassar, 2008; Murray et al., 2010; Ettowa, 2012; Higginbottom et al., 2013). Some also women from immigrant backgrounds also express their preference for natural childbirth over caesarean births as they wish to recover faster in order to look after the other children (Murray et al., 2010). Some migrant women agree to have their husbands during childbirth; a practice that would not happen in their original country (Liamputtong and Naksook, 2003b; Hoang and Kilpatrick, 2009). Additionally, some women from immigrant backgrounds choose and are able to continue their cultural and traditional practices regardless of their new social environment as they see this as an important part of their lives in a new homeland (Liamputtong and Naksook, 2003a; Liamputtong, 2006). For some migrant mothers, motherhood brings joy to them and it is true their mothering role assists them to settle in a new country better (Liamputtong, 2006).

Implications for health care At the simplest level, we contend that health professionals may exhibit some support for migrant women through the service they provide for them. It is evident from this synthesis that migrant women wish to receive more emotional support during pregnancy, as one participant in Reitmanova and Gustafson (2007: 104) remarked: ‘I would appreciate if my doctor is not so busy and talks to me for a while. It's just a routine. We didn't talk at all about my feelings’. For many migrant women, language barriers prevent them from gaining the knowledge of services available for them in a new country and their limited language skills also impact on their assertiveness to express their needs and preferences. This requires the provision of interpreting services, social support and linguistically informed services for culturally sensitive approaches. Carolan and Cassar (2008) suggest that the presence of interpreters during pregnant women visits could enhance antenatal visits among migrant women. There is a need to improve cross-cultural training for health care providers. For example, knowledge in dealing with migrant women who have been circumcised will help to prevent birthing complications (Straus et al., 2007). This will enhance the health providers' understanding of the birth related behaviours that are related to cultural and traditional practices. Adequate health education targeting specific communities (Bollini et al., 2006; Grewal et al., 2008) need the involvement of lay outreach workers who have the same cultural ties with the migrant community and preferably have the same language background. Public health interventions to improve the reproductive health of migrant women need to focus on improving communication between health care providers and migrants in order to inform them about the services available. Further research is needed to establish information needs of the migrant women and address issues of limited literacy and language skills (Carolan and Cassar, 2008). Health providers also need to take into consideration traditional practices that enhance good health outcomes for both mother and child such as cultural diets and post partum rest (DeSouza, 2005) as maternal health needs differ and these differences may be based on the woman's cultural background. Although health providers cannot do much to address some

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cultural issues, their awareness would enhance a better understanding of women from migrant backgrounds (Liamputtong Rice, 1993). For example, cultural competence on the part of health providers and encouraging patient participation are important factors when managing women who have undergone female genital mutilation (Murray et al., 2010). Improving the health and well-being of migrant women requires establishment of good relationships for them to open up so they can express their cultural and personal needs (Liamputtong and Naksook, 2003a). Higginbottom et al. (2013) suggest that engaging with immigrant community leaders helps to address the gaps identified in the lack of cultural competency and sensitivity by health care givers. Learning about the values, beliefs and practices of migrant women will enhance the improvement of meaningful childbearing and motherhood experiences and prevent the misunderstandings that currently exist between health care providers and women from immigrant backgrounds (Ettowa, 2012). We contend that women from immigrant backgrounds have the right to receive adequate and sensitive health care during the childbearing and childrearing times regardless of their social status (Potter et al., 2011).

Conflict of interest There is no conflict of interest of this paper.

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Please cite this article as: Benza (MPH student), S., Liamputtong, PhD, P., Pregnancy, childbirth and motherhood: A meta-synthesis of the lived experiences of immigrant women. Midwifery (2014), http://dx.doi.org/10.1016/j.midw.2014.03.005i