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Experiences of nurses caring for maternal immigrant and refugee women: a qualitative systematic review protocol

Kassam, Shahin1,2; Marcellus, Lenora1,2; Butcher, Diane2,3

Author Information
doi: 10.11124/JBISRIR-D-19-00222
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Migration is a global priority affecting over 250 million people and their families.1 Fueled by multiple forces, including sociopolitical and economic complexities, migration has recently been identified as a determinant of health.2 The link between migration and health underpins international initiatives such as the United Nations Sustainable Development Goals.3 Implemented in 2015, the Sustainable Development Goals’ blueprint maps out goals centered on enhancing the well-being of people around the world. Improving health and reducing inequity are among the goals to be addressed by the year 2030. Situating these goals within migration facilitated a call for an integration of migrant health needs across multi-sectoral government policies.4 Establishing and building on a research agenda to inform migrant health policy and professional development has also been prioritized within the recent Global Consultation on Migration and Health held in Sri Lanka.3,5 Within this investment into researching migrant health, inquiring into how programs and policies influence health was also emphasized.3

To better understand the link between migration and health, the research team will draw on the International Organization of Migration's definition of “migrant” and “immigrant.” The words are often used synonymously in migration discourse and refer to people who move across international borders from their habitual residence for voluntary or involuntary reasons.6 This review will focus on involuntary migration. Migrating involuntarily means a person is forced to move away from their habitual residence. Forcible displacement is driven by political and socioeconomic issues such as war and persecution. People forced into migrating are identified by the United Nations High Commissioner of Refugees (UNHCR) as internally displaced, asylum seekers, or refugees.7 Global statistics state that over 68 million people are forcibly displaced. Of this unprecedented number, over 3 million seek asylum and almost 30 million are refugees,7 with numbers rising every year.

Immigrant and refugee maternal women

Women represent half of the world's refugee population.7,8 Research reveals that most of these women are of child-bearing age, and are pregnant, mothering, or both.9 The experience of health during pregnancy, childbirth, and post-birth is defined by the World Health Organization (WHO) as maternal health.10 Therefore, the concept of “maternal women” includes any woman experiencing maternal health. This review initially focused on the phenomenon of maternal health among forcibly displaced populations including refugees and asylum seekers; however, due to the limited generation of studies, the broader concept of “immigrant” was included in this review. Although preliminary search results identified that review authors combined forcibly displaced groups, such as asylum seekers, within their inquiries into refugees and immigrants, it is important to note the wide diversity in immigrant conceptualizations. These are influenced by factors including political context, socioeconomic status, and plurality in culture and language. As a result, this review will focus specifically on studies involving immigrant and refugee maternal women who have migrated involuntarily.

Maternal health experiences among immigrant and refugee women are poorer than non-displaced women. Immigrant and refugee women experience higher rates of HIV, limited prenatal care, poor social support, abuse, preterm birth, low-birth-weight infants, stillbirths, maternal mental health concerns, cesarean delivery, and maternal mortality.11,12 These glaring inequities are widely recognized by prominent global organizations such as the WHO and the UNHCR. Current global development goals reflect the need to address disrupting disparities, promote maternal health, and understand capacities of countries to manage disparate health issues.13

Understanding nurses’ perspectives

This review will consider studies that include nurses working across diverse health care settings and providing care to immigrant and refugee maternal women. Within this review, the authors will draw on the International Council for Nurses’ (ICN) policies where nurses are defined as those who have been educated within a basic and generalized nursing program and have been authorized by a regulatory organization to practice nursing in their country.14 A large focus of current literature addresses health issues faced by immigrants and refugees. Although there is a limited focus on understanding the experience of care provision through health care provider perspectives, some studies have attempted to understand nursing attitudes and experiences.15,16 With nurses being recognized as leaders and pivotal actors within interdisciplinary teams, exploring nursing experiences has the potential to reveal structural facilitators and barriers to equitable care provision.17,18 Nurses are well-situated within health care systems to connect with immigrant and refugee women seeking maternal care. Advocating for equity and social justice as well as facilitating care toward meeting the health needs of vulnerable populations are values central to the nursing discipline.18 Nursing has been declared a discipline that can provide care to immigrant and refugee populations across varying health care contexts efficiently, effectively, and equitably.17

With current literature focusing primarily around health outcomes, there is a paucity of systematic reviews of nursing perspectives related to immigrant and refugee maternal health. Appraising and synthesizing what is known about nurse perspectives on care provision is an upstream approach to understanding maternal health. O’Mahony and Clark19 support this claim in their finding that further inquiry into nursing perspectives can highlight tensions between equity-oriented competencies and policies ridden with inequity. Therefore, critically exploring nursing experiences as a knowledge source has the potential to inform health systems and influence equitable care provision. Through this review, the research team also aims to understand what knowledge is missing related to providing nursing care to immigrant and refugee maternal women. In addition, diverse terminologies used to conceptualize the concepts of “nurse,” “immigrant,” and “refugee” will also be captured.

A preliminary search of PROSPERO, MEDLINE, the Cochrane Database of Systematic Reviews, and the JBI Database of Systematic Reviews and Implementation Reports was conducted and no current or in-progress systematic reviews on the topic were identified.

The objective of this systematic review is to identify and describe nurses’ experiences of care provided to immigrant and refugee maternal women across health care settings.

Review question

What are the experiences of nurses providing care within various health care delivery contexts to immigrant and refugee mothers who are pregnant and/or mothering?

Inclusion criteria


This review will consider qualitative studies that include nurses providing care to immigrant and refugee maternal women in diverse health care settings. The specific immigrant populations nurses care for include maternal women who have involuntarily migrated due to forcible displacement, and maternal immigrant women who are have low proficiency in the language of their new country, are ethnically/culturally diverse, and/or live in poverty. The ICN definition of nurses will facilitate capturing the various conceptualizations and titles of nurses used in this review. Health care workers that fall outside of this definition will not be included in this review.

Phenomena of interest

This review will consider studies that explore nurses’ experiences of providing care to maternal immigrant and refugee women who are pregnant or mothering. The focus of this review is on nurses providing maternal health care among involuntary immigrants as well as refugees and asylum seekers. Studies exploring nurses’ experiences caring for immigrants with low literacy levels, who are ethnically/culturally diverse and/or live in poverty will also be considered.


This review will consider studies that describe the experiences of nurses working in any health care delivery environment where maternal immigrant and refugee women receive care, including rural and urban locations. Care settings can range from acute care to community care environments. Examples of acute care settings include labor and delivery and emergency room units situated within a hospital. Public health centers, volunteer health centers, and women's homes are examples of community care environments.

Types of studies

This review will consider studies that focus on qualitative data, as well as interpretive studies that draw on the experiences of nurses working with immigrant and refugee maternal women including, but not limited to, designs such as phenomenology, grounded theory, ethnography, action research, and feminist research.

This review will also consider critical studies that explore experiences of nurses providing care to immigrant and refugee maternal women including, but not limited to, designs such as action research.

Studies published in peer-reviewed academic journals as well as unpublished and gray literature sources will be considered.


The proposed systematic review will be conducted in accordance with JBI methodology for systematic reviews of qualitative evidence.20 This review has been registered with PROSPERO: CRD42019137922.

Search strategy

The search strategy will aim to locate both published and unpublished studies including gray literature. Examples of unpublished data that will be considered include press information and position statements. A preliminary limited search of CINAHL, PsycINFO and MEDLINE (EBSCO) was undertaken to identify articles regarding the topic of this review. In collaboration with a university research librarian, the text words contained in the titles and abstracts of relevant articles, and the index terms used to describe the articles were used to develop a preliminary search strategy for CINAHL, PsycINFO and MEDLINE. Details of the CINAHL search strategy and records retrieved are outlined in Appendix I. The search strategy, including all keywords identified through subject headings or Medical Subject Headings (MeSH), and index terms, will be adapted for each information source. A second search using these identified keywords and index terms will be applied across all included information sources. The third search will include screening for additional studies among the reference lists of all studies selected for critical appraisal.

Databases to be searched within the online reference tool EBSCO host include CINAHL, PsycINFO, MEDLINE, PubMed, Web of Science, and Social Science Citation Index. Unpublished and gray literature sources to be searched include Google Scholar, ICN position statements, and press information as well as WHO reports.

Study abstracts published in English will be captured within the data extraction tool and reported within the Summary of Findings. Management of these abstracts will not include translating full texts. However, the authors will summarize how many English-language abstracts were found. This search is not a historical analysis, and preliminary searches revealed sources published after 2002. Thus, date limits will be set for sources published from January 2000 onward.

Study selection

Following the search, all identified citations will be collated and uploaded into EndNote X9.2 (Clarivate Analytics, PA, USA) and duplicates removed. Titles and abstracts will then be screened by two independent reviewers for assessment against the inclusion criteria for the review. Potentially relevant studies will be retrieved in full and their citation details imported into the JBI System for the Unified Management, Assessment and Review of Information (JBI SUMARI; JBI, Adelaide, Australia). The full text of selected citations will be assessed in detail against the inclusion criteria by two independent reviewers. Reasons for exclusion of full-text studies that do not meet the inclusion criteria will be recorded and reported in the systematic review. Any disagreements that arise between the reviewers at each stage of the study selection process will be resolved through discussion or with a third reviewer. The results of the search will be reported in full in the final systematic review and presented in a Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow diagram.21

Assessment of methodological quality

Eligible studies will be critically appraised by two independent reviewers for methodological quality using the standard JBI Critical Appraisal Checklist for Qualitative Research.20 Any disagreements that arise between the reviewers will be resolved through discussion or with a third reviewer. The results of the critical appraisal will be reported in narrative form and in tables and visual maps.

All studies, regardless of methodological quality results, will undergo data extraction and synthesis (where possible). Following appraisal, the primary and secondary reviewers will meet and review critical appraisal results. The third reviewer will assist in resolving any disagreements that may arise. Methodological quality will be discussed and visually displayed through a critical appraisal results table.

Data extraction

Data will be extracted from studies included in the review by two independent reviewers using an adapted JBI data extraction tool (see Appendix II). Adaptation will support capturing diverse understandings of the following concepts: “nurse,” “immigrant,” and “refugee.” The data extraction tool has been modified to capture details regarding participants, populations being care for, health care context, geographical location, study methods, and the phenomena of interest relevant to the review objective. This includes health care setting, terminology used to describe and identify nurse participants, as well as how mothers who are immigrants and refugees are described. Characteristics of immigrants that will be extracted include involuntary migrant status, literacy level, socioeconomic status, and ethnic/cultural location. Findings, and their illustrations, will be extracted and assigned a level of credibility. Any disagreements that arise between the reviewers will be resolved through discussion or with a third reviewer.

Data synthesis

Qualitative research findings will, where possible, be pooled using JBI SUMARI with the meta-aggregation approach.22,23 This will involve the aggregation or synthesis of findings to generate a set of statements that represent that aggregation, through assembling and categorizing the findings on the basis of similarity in meaning. These categories will then be subjected to a synthesis in order to produce a single comprehensive set of synthesized findings that can be used as a basis for evidence-based practice. Where textual pooling is not possible, the findings will be presented in narrative and visual forms. The process of synthesizing and finalizing findings and their accompanying descriptions will occur through consensus between the authors.

Assessing confidence in the findings

The final synthesized findings will be graded according to the ConQual approach for establishing confidence in the output of qualitative research synthesis and presented in a Summary of Findings.24 The Summary of Findings includes the major elements of the review and details how the ConQual score is developed. Included in the Summary of Findings will be the title, population, phenomena of interest, and context for the specific review (see Appendix III). Each finding from the review will then be presented, along with the type of research informing it and an evaluation of dependability and credibility using the ConQual24 ranking system.


Dr. Carol Gordon at McPherson Library, University of Victoria, for assistance in developing the search strategy.

University of Victoria School of Nursing for providing JBI doctoral student funding for Comprehensive Systematic Review training.

Queen's Collaboration for Health Care Quality: A JBI Centre of Excellence for providing systematic review training.

This project contributes toward a Ph.D. nursing degree for the corresponding author, SK.

Appendix I: Search strategy

Database CINAHL Complete (EBSCOhost)

Search conducted: December 2019

Appendix II: Data extraction instrument

Appendix III: Summary of findings


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immigrant; maternal; migrant; nurse; refugee

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