Experiences of nurses caring for involuntary migrant maternal women: a qualitative systematic review : JBI Evidence Synthesis

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EVIDENCE SYNTHESES

Experiences of nurses caring for involuntary migrant maternal women: a qualitative systematic review

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

Author Information
doi: 10.11124/JBIES-21-00181
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Abstract

Summary of Findings

figure1

Introduction

Global fragility has created multiple humanitarian crises, including individuals and families being forced to leave their homes due to war, persecution, and climate change. In the previous 10 years, 100 million people have been forced to involuntarily migrate away from their homes worldwide.1 Drawing on the United Nations High Commissioner for Refugees and the United Nations International Organization of Migration, populations that are forcibly displaced from their home countries due to political and socioeconomic issues such as war, climate change and/or persecution are defined as involuntary migrants.1,2 Those who migrate involuntarily are grouped into varying legal categorizations depending on the country they are being settled within. Such categories include “refugee,” “internally displaced,” and/or “stateless,” depending on the settlement country policies.1 While these categories can be used interchangeably within media and migrant discourse, each category is tied to a specific country's network of intersecting policies, which dictate and impact health and well-being.1,2

Half of the global forcibly displaced population consists of women and girls, many of whom are of child-bearing age, pregnant, or mothering.1 The health and well-being of women who are experiencing pregnancy, birth, or post-birth is defined by the World Health Organization (WHO) as “maternal health.”3 This definition informs this review in conceptualizing “maternal women” as women experiencing maternal health. As per WHO guidelines, post-birth care is conceptualized as care provided by nurses for six weeks after a woman has experienced childbirth and has transitioned into mothering processes.3

The concept of mothering within this review is defined through the seminal works of Chris Bobel as a social construction of women who birth and move through processes of child-rearing within their unique sociocultural contexts.4 The term “involuntary migrant maternal women” is therefore a focus within this review and used throughout to specifically reflect women experiencing forcibly displaced migrant status as well as pregnancy, birth, or post-birth and mothering. The focus of this review was on women only, which was driven by the participants in the included studies.

The state of a woman's maternal health is inextricably linked to her migration journey and migration status. Involuntary migration journeys are fraught with risk where maternal women are often subjected to trauma and violence. These women seek safety within host and settlement countries, and often require maternal health care. Involuntary migrant maternal women experience higher rates of HIV, mortality, cesarean delivery, mental health concerns, varying forms of abuse, limited prenatal care. and poor social support.5,6 In addition, this population of maternal women experience cultural and linguistic barriers within their host and settlement countries. Populations forcibly displaced are disproportionately disadvantaged socioeconomically than those migrating voluntarily, and often live in impoverished conditions.7,8 Care provided to involuntary migrant maternal women is therefore critical to ensure engagement with complex health issues and enhancement of health trajectories.

Nurses are well-positioned across varying health care delivery environments to provide the necessary care to this population of maternal women. Recognized as pivotal members within multidisciplinary teams, nurses have the potential to integrate broader health determinants within their care provision.9 Within this review, nurses were defined as individuals educated within nursing programs and authorized by their country's regulatory practice organizations to provide care.9 Nursing care provision was defined by drawing on International Council of Nurses (ICN) policies, where health promotion, illness prevention, advocacy, research, education, and participation in health system management and policy development are central.9 This definition also inclusively captures nurses working across a broad system of health care contexts, ranging from acute and chronic care to primary and community care settings.9 This definition excludes disciplines that do not align with this ICN definition, such as midwives, social workers, and doulas. Although, in many countries, some care providers function as nurse-midwives where midwifery education and a subsequent midwifery role has been assumed, the midwifery discipline differs from nursing in its philosophy and scope of practice.10

Within current literature, researchers have explored health care professional and nursing experiences of working with involuntary migrant maternal women.11 Within several global reports, nurses have been identified as part of interdisciplinary teams working collaboratively toward addressing multi-layered health issues.12,13 In addition, studies have also been conducted exploring barriers to care provision among nurses. These include cultural and linguistic barriers, where lack of understanding languages spoken and traditional practices were encountered by nurses.14,15 Understanding nurse experiences has been ascertained as critical to identifying barriers embedded within structural forces, such as policies and practice directives.16 Multiple studies have been conducted highlighting adverse health outcomes and barriers faced by populations forcibly displaced. Researchers have explored nurses’ experiences of caring for involuntary migrant maternal women within a wide variety of disciplines, including population and public health15; nursing17; women's, families’, and children's health18; and cultural anthropology.19 A lack of systematic reviews exploring nurse experiences of caring for involuntary migrant maternal women was identified within our preliminary reviews of current literature. As a result, the objective of this review was to identify, appraise, and synthesize qualitative evidence focused on nurse experiences with involuntary migrant maternal women across health care delivery environments.

A preliminary search of PROSPERO, MEDLINE, the Cochrane Database of Systematic Reviews and the JBI Database of Systematic Reviews and Implementation Reports was conducted in September 2019 and again in September 2021 revealing systematic reviews focused on experiences of care from migrant women's and community-based doulas’ perspectives. However, none focused on nurses’ care provision experiences, and no current or in-progress systematic reviews on the topic of nurses’ experiences of caring for involuntary migrant women were identified.

The overarching review objective was to identify and describe the experiences of nurses providing care to involuntary migrant maternal women within various health care delivery environments.

Review question

What are the experiences of nurses providing care within various health care delivery environments to involuntary migrant women who are pregnant and/or mothering?

Inclusion criteria

Participants

This review considered studies that included nurses involved in caring for involuntary migrant pregnant and/or mothering women within diverse health care settings. Drawing on ICN policies,9 nurses were defined as being educated within a generalized program and authorized to practice nursing in their country. Participants within this review were nurses working with women who involuntarily migrated and were pregnant and/or mothering. Studies that revealed findings from interdisciplinary groups that included nurses were also included in this review when data were explicitly attributed to nurses. Studies that did not capture nurse voices in their findings and did not explicate involuntary migration backgrounds of maternal women being cared for were excluded. Studies that did not focus on maternal women's health care were also excluded.

Phenomena of interest

This review considered studies that explored nurses’ experiences of providing care to involuntary migrant women who were pregnant and/or mothering. Understanding the multiple ways care is provided globally by nurses to the unique needs of this culturally and linguistically diverse population was a central interest. Rather than focusing on singular aspects of caregiving, such as providing sexual and reproductive care, the general experience of care provision was addressed.

Context

This review considered studies that were conducted within various urban and rural health care delivery contexts, which included acute and community health care environments. Hospital units, community health clinics, antenatal and maternity clinics, physician offices, and humanitarian settlements with clusters of densely populated refugee camps are examples of study settings where nurses cared for involuntary migrant women who were pregnant and/or mothering.

Types of studies

This review considered studies that focused on peer-reviewed qualitative data, including, but not limited to, designs such as grounded theory, ethnography, case study, and interpretive descriptive. For studies that used quantitative and qualitative approaches, only the qualitative data were extracted and analyzed.

Methods

This systematic review was conducted in accordance with JBI methodology for systematic reviews of qualitative evidence.20 This review was conducted in accordance with an a priori protocol registered in PROSPERO (CRD42019137922).21 The title of this review deviated from the protocol to provide clarity on the focus of forced migration status among maternal women being cared for by nurses.

Search strategy

The search strategy aimed to locate published primary studies and gray literature. A three-step search strategy was utilized in this review. First, an initial limited search of CINAHL (EBSCO), PsycINFO (EBSCO), and MEDLINE (EBSCO) was conducted in September 2019, followed by analysis of the text words contained in the title and abstract and the index terms used to describe the articles. A second search was undertaken in January 2020 and included all identified keywords and index terms, and was adapted for each included information source. This second search strategy was rerun in January 2021 using the same search strategy to ensure up-to-date identification of literature. This revealed an additional two studies that were included in the review. The full search strategies are provided in Appendix I. The third search involved screening the reference lists of all studies selected for critical appraisal for additional studies.

Search terms were devised in consultation with the first reviewer's university librarian. This consultation led to including the terms “health care providers” and “health care workers” in the search strategy for some databases to capture nurses working within interdisciplinary teams. Due to the prevalence of nurses working within interdisciplinary teams, experiences of nurses made explicit by study authors were included despite the interdisciplinary context. This inclusion of terms was a deviation from the protocol.

Only studies published in English were included due to the unavailability of professional translation services. Studies published from January 2000 to January 2021 were included, as this review was not a historical analysis; preliminary searches revealed sources were published from 2002 onward.

The databases that were searched included CINAHL (EBSCO), PsycINFO (EBSCO), MEDLINE (EBSCO), PubMed (NLM), Web of Science including Social Science Citation Index, and Google Scholar. The use of gray literature in this review was to complement and support findings. A gray literature search strategy was devised using Google, and targeted specific global nursing organization websites that contained position statements, reports, and press information (see Appendix I). Sources were located through keyword searches based on our database search strategies. No unpublished studies were found in the gray literature search.

Study selection

Following the search, all identified citations were collated and uploaded into EndNote v.X9.2 (Clarivate Analytics, PA, USA) and Covidence (Veritas Health Innovation, Melbourne, Australia), and duplicates were removed. Following a pilot test, titles and abstracts were screened by two independent reviewers (SK, DB) for assessment against the inclusion criteria for the review. Potentially relevant studies were 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).22 Full-text studies that did not meet the inclusion criteria were excluded, and reasons for their exclusion are provided in Appendix II. Any disagreements that arose between reviewers were resolved through discussion.

Assessment of methodological quality

Eligible studies were critically appraised by two independent reviewers (SK and DB) for methodological quality using the standard JBI critical appraisal checklist for qualitative research.23 Any disagreements that arose between the reviewers were resolved through discussion. A third reviewer was available to assist with disagreements, but was not required.

After both independent reviewers completed the study appraisal, the reviewers discussed each article and assigned scores. Differences in scores were reviewed by examining how each reviewer interpreted the appraisal tool question. The JBI methodology for systematic reviews of qualitative evidence was consulted for clarification.20 Discussion on the philosophical approach of each reviewer being situated within critical feminism also took place, which informed application of inclusion and exclusion criteria. Most studies did not address theoretical position or researcher influence on research. Fundamental criteria for excluding studies on the basis of methodological quality included adequate representation of participant voice. Adequate representation of participant voice was approached within studies that pooled nurses’ experiences with other multidisciplinary team members through identifying and extracting data that were clearly stated by study authors as directly derived from participants identified as nurses.

Data extraction

Qualitative data were extracted from studies included in the review by two independent reviewers (SK and DB) using an adapted JBI data extraction tool (see Appendix III).20 The data extracted included specific details about the following characteristics:

  • methodology used;
  • participants (number of nurses included, gender, migration history, and race/ethnicity);
  • phenomena of interest;
  • characteristics of involuntary migrants;
  • health care setting and nursing role;
  • country in which study was conducted.

Extracting terms used for “nurse,” “immigrant,” and “refugee” was omitted, and is a deviation from the protocol, as this would be more appropriate to conduct within a scoping review. Instead, roles of nurses as described in the included studies were extracted to contextually expand participants’ experiences. Additionally, participant characteristics, including gender, migration history, and race/ethnicity, were extracted to expand on participant context. The number of nurses included in participant study samples was extracted due to broader search terms needed within certain databases (see Appendix I). This captured nurses working within interdisciplinary teams and the need to identify how many nurses from these teams were included.

Characteristics of involuntary migrant maternal women were extracted to identify migrant discourse within studies, which informed analysis of this review. Findings, and their illustrations, were extracted as themes and/or subthemes as identified and interpreted by the author(s) of each study. Each finding was supported by an illustration, which was an extracted verbatim quote from a study participant. A level of credibility was assigned for each finding: unequivocal (U), which means the finding is accompanied by an illustration that is undoubtedly associated with the finding and is not open to challenge; credible (C), which means the finding is accompanied by an illustration but lacks clear association with the finding; or not supported (NS), which is when a finding is not supported by data.24 All findings were found to be unequivocal within this review.

As this review is a component of a doctoral dissertation, the data extraction process was completed independently; however, the second reviewer accessed extracted findings and provided consistent support and ongoing feedback. Data extraction was guided by intersectionality as a theoretical lens to highlight social variables, including, but not limited to, gender, race, and migrant status. Situated within critical feminist theories, intersectionality guided thinking within data extraction toward identification of variables that interconnect to shape nurses’ experiences of caring for involuntary migrant maternal women.25 To minimize errors during this process, definitions of each level of credibility were discussed between the two reviewers, and ongoing dialogue occurred during data extraction and synthesis. Any disagreements that arose between the reviewers were resolved through discussion. A third reviewer was available to assist with this process, but was not needed.

Data synthesis

Qualitative research findings were identified and, where possible, pooled using JBI SUMARI with the meta-aggregation approach.24,26 Meta-aggregation is the process of generating a synthesized finding, which is an interpretive description of a grouping of categorized findings. This involved the aggregation or synthesis of 115 findings to generate a set of statements that represented that aggregation through assembling the findings and categorizing these findings based on similarity in meaning. This process included listing all findings and grouping findings with similar meanings. Assigning category titles to groupings was the next analytical step that occurred iteratively through referring back to the review question and phenomena of interest as well as to the illustration of each finding. This analytical process occurred repeatedly using whiteboards, poster boards, and cue cards to map findings visually and thoughtfully into a final set of categories. Theoretical guidance informing this process was drawn from Patricia Hill Collins’ interpretations of intersectionality, which illuminates what is happening within social problems, focusing on under-represented complexities such as gender, race, and migrant status, and how they contribute to oppression.25 This same analytical process was used when subjecting categories to a synthesis in order to produce a single comprehensive set of synthesized findings that could be used as a basis for evidence-based practice.

All findings included in this synthesis were unequivocal. With this review being part a doctoral dissertation for SK, the data synthesis process of grouping and categorizing findings was completed by SK and discussed with DB. Numerous discussions regarding analytical steps occurred between them throughout the data extraction and synthesis processes via email and videoconferencing. A journal was also kept by SK to trace the decision-making processes used during meta-aggregation.

Assessing confidence in the findings

The final synthesized findings were graded according to the ConQual approach for establishing confidence in the output of qualitative research synthesis and presented in a Summary of Findings.26 The Summary of Findings includes the major elements of the review and details how the ConQual score was developed. Included in the table are the title, participants, phenomena of interest, and context for this specific review. Each synthesized finding from this review is presented, along with the type of research informing it, scores for dependability and credibility, and the overall ConQual score.

Results

Study inclusion

As illustrated in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow diagram (Figure 1),27 the search strategy conducted in January 2020 across selected databases identified 4079 studies. The search strategy was updated in January 2021 and two additional studies met inclusion criteria. With these additions, the total number of information sources identified was 4081. After titles and abstracts were screened for eligibility and duplicates removed, 4021 were excluded for being irrelevant to the phenomena of interest and not meeting inclusion criteria. The 60 remaining articles were imported from EndNote to Covidence and screened for inclusion. Twenty-four studies did not meet the inclusion criteria and were removed.

F1
Figure 1:
Search results and study selection and inclusion process27

Full-texts of the remaining 36 articles were screened by the primary and secondary reviewers. Due to population, phenomena of interest, and study designs not meeting inclusion criteria, 13 studies were excluded. See Appendix II for further exclusion details. The remaining 23 studies were imported into JBI SUMARI for critical appraisal. Prior to appraisal, the reference lists of these studies were screened and no additional studies were identified as meeting inclusion criteria. Critical appraisal for methodological quality was conducted by the primary and secondary reviewers using the JBI critical appraisal checklist for qualitative research.23 No further studies were excluded.

Gray literature used within this review did not include unpublished studies. Using gray literature to support findings within an area where minimal research has been conducted is supported by Benzies et al.28 The use of gray literature as a complementary and supportive source is also advised within JBI and systematic review guidance.20 Therefore, unpublished gray literature was applied to reinforce review findings and included WHO press information and ICN position statements.12,29-32

Methodological quality

Based on the results of the JBI critical appraisal checklist for qualitative research,23 the included studies were deemed moderate by both the primary and secondary reviewers. Each study was scored on 10 questions: 12 studies scored 8 “Yes” responses,14,15,18,19,33-40 7 studies scored 9 “Yes” responses,17,41-46 and 4 studies scored 10 “Yes” responses.11,47-49 The primary and secondary reviewers discussed each study to resolve any discrepancies. Discussing standards for inclusion from the theoretical approach of intersectionality was central to these resolutions.

In an effort to avoid premature exclusion of studies,50 the reviewers erred on the side of inclusion by avoiding narrow conceptions of appraisal. This entailed not specifying any particular appraisal questions as essential for inclusion for this review. However, adequate participant voice was imperative to guide decision-making for inclusion and quality to ensure nurses’ experiences were captured. Methodological quality scoring was also impacted by epistemological differences in studies included where an objectivist approach to inquiry seemed to be assumed. Objectivism guides researchers toward assuming non-influential effects on the research and supports generation of knowledge without highlighting the values of the researcher.51

As illustrated in Table 1, 35% of studies met Q6, which asks: Is there a statement locating the researcher culturally or theoretically? In addition, 30% met Q7, which asks: Is the influence of the researcher on the research, and vice-versa, addressed? The primary and secondary reviewers discussed whether to include studies not meeting Q6 or Q7 a priori. Reasons for some researchers not locating themselves within their inquiries or addressing their influence on their studies may have been their potential objectivist philosophical stances that assume natural separation of themselves from the data. To minimize exclusion of diverse epistemological perspectives, the primary and secondary reviewers decided to include studies that did not meet the Q6 and Q7 criteria questions. This decision aligned with the reviewers’ intersectionality underpinnings that influenced an inclusive approach to this review. Q8 was the only eliminatory question, as it represented capturing participant voices, which was central to this review. All 23 studies met this appraisal question.

Table 1 - Critical appraisal of eligible qualitative studies
Study Q1 Q2 Q3 Q4 Q5 Q6 Q7 Q8 Q9 Q10
Degni et al. 42 Y Y Y Y Y Y N Y Y Y
Drennan & Joseph 33 Y Y Y Y Y N N Y Y Y
Ganann et al. 17 Y Y Y Y Y Y N Y Y Y
Jean-Baptiste et al. 14 Y Y Y Y Y N N Y Y Y
Kurth et al. 15 Y Y Y Y Y N N Y Y Y
Kynoe et al. 46 Y Y Y Y Y N Y Y Y Y
Leppälä et al. 49 Y Y Y Y Y Y Y Y Y Y
Lyberg et al. 41 Y Y Y Y Y Y N Y Y Y
Lyons et al. 38 Y Y Y Y Y N N Y Y Y
Ng & Newbold 34 Y Y Y Y Y N N Y Y Y
Nithianandan et al. 44 Y Y Y Y Y Y N Y Y Y
Origlia Ikhilor et al. 47 Y Y Y Y Y Y Y Y Y Y
Peláez et al. 11 Y Y Y Y Y Y Y Y Y Y
Reynolds & White 39 Y Y Y Y Y N N Y Y Y
Rifai et al. 36 Y Y Y Y Y N N Y Y Y
Riggs et al. 18 Y Y Y Y Y N N Y Y Y
Sarker et al. 40 Y Y Y Y Y N N Y Y Y
Seo 19 Y Y Y Y Y N N Y Y Y
Skoog et al. 37 Y Y Y Y Y N N Y Y Y
Teng et al. 35 Y Y Y Y Y N N Y Y Y
Willey et al. 43 Y Y Y Y Y N Y Y Y Y
Winn et al. 48 Y Y Y Y Y Y Y Y Y Y
Yelland et al. 45 Y Y Y Y Y N Y Y Y Y
Total % 100 100 100 100 100 35 30 100 100 100
Y = Yes; N = No; U = Unclear; JBI Critical Appraisal Checklist for Qualitative Research
Q1 = Is there congruity between the stated philosophical perspective and the research methodology?
Q2 = Is there congruity between the research methodology and the research question or objectives?
Q3 = Is there congruity between the research methodology and the methods used to collect data?
Q4 = Is there congruity between the research methodology and the representation and analysis of data?
Q5 = Is there congruity between the research methodology and the interpretation of results?
Q6 = Is there a statement locating the researcher culturally or theoretically?
Q7 = Is the influence of the researcher on the research, and vice-versa, addressed?
Q8 = Are participants, and their voices, adequately represented?
Q9 = Is the research ethical according to current criteria or, for recent studies, is there evidence of ethical approval by an appropriate body?
Q10 = Do the conclusions drawn in the research report flow from the analysis, or interpretation, of the data?

Characteristics of included studies

All studies were approached using qualitative methods. However, one study was a mixed methods inquiry,15 and six studies provided minimal details on which qualitative approach was assumed.18,39,40,44,45,49 The remainder of the studies in this review were described as using qualitative hermeneutic,46 naturalistic descriptive,42 exploratory,14,33,34,47 interpretive descriptive,17,48 explanatory,35 descriptive,43 inductive,36,37 ethnography,19 both descriptive and exploratory,41 grounded theory,38 and case study.11 While all studies included understanding nurses’ experiences as part of their phenomena of interests, five studies focused explicitly on nurses.33,36,37,43,46

At least 186 nurses participated in the 23 studies included in this review. The exact number of nurses that participated in all 23 studies is unknown, as six studies did not identify the number of nurses included within their multidisciplinary samples.17,19,38-40,45 Nine studies clearly articulated the sex of their participants who were nurses as being female.15,34,35,37,41,42,47-49 Three studies briefly mentioned the race and/or ethnicity of their participants14,35,44 and three studies alluded to their participants’ migration histories.17,33,35

Results of analyzing geographical distribution of the reviewed studies indicated most studies taking place in Canada11,17,34,35,48 and Australia.18,43-45 Several took place within varying parts of Europe, including Finland,42,49 the United Kingdom,33,39 Switzerland,15,47 Sweden,36,37 Ireland,38 and Norway.41,46 One study was conducted in Bangladesh,40 one was conducted in Thailand,19 and one was completed in the United States.14 Most studies took place within community health clinical settings.14,15,17,33-37,39,42,44,48,49 Four of these settings were specialized to target involuntary migrant populations.35,39,44,48 Other study settings included hospitals,11,19,38,46 a densely populated humanitarian settlement site (community of refugee camps),40 and a university.41 Four studies did not provide specific study setting details.18,43,45,47

A broad range of nursing roles were described across the 23 studies appraised within this review. These included antenatal nurse,19 psychiatric nurse,42 family planning nurse,42 maternity nurse,42 maternal and child health nurse,18,43-45 maternity care professional,49 chronic disease nurse,48 nursing-midwifery team (nurses working alongside midwives),15 public health nurse,35,36,41,49 registered nurse,35,49 registered nurse with specialist training,36 specially trained in management of prenatal and postnatal care for women,41 certified nurse specialist,46 obstetric nurse,19 child health services nurse,37 early childhood nurse,45 practical nurse,35 delivery nurse,19 labor and delivery nurse,48 nurse,11,14,39,40,46,47 auxiliary nurse,38 nurse practitioner,34 nurse manager,11 perinatal mental health nurse,44 postpartum and neonatal care nurse,19 and neonatal intensive care unit nurse.46 Three studies, all conducted in Australia, identified refugee health nurses18,44,45 who specifically cared for involuntary migrants. However, many studies in this review pooled nurses into general terms of maternity care professional,49 health professional,11,34,39,45,47 service/health care provider,17,40,45,48 home visitor,14 and health visitor.33

Studies included in this review characterized involuntary migrants predominantly as having varying migrant statuses. These included categories of refugee,11,17-19,33,40,42-45,47,48 quota refugee,49 asylum seeker,15,17,33,37-39,42-44,47,49 immigrant,11,14,17,34-37,41,42,46 humanitarian migrant,18,43,45,49 undocumented immigrant,11,14 undocumented migrant,19 non-citizen,19 non-citizen other,19 stateless people,19 and newcomer.17,35,49 One study used the term Forcibly Displaced Myanmar Nationals as coined by the Bangladesh government to indicate non-citizenship status of Rohingya refugees.40

Having low literacy skills,11,14,15,17-19,34-36,38,39,41,43-49 and being a cultural and ethnic minority11,17-19,33-36,38,41,42,44-46,48 were also characteristics used to described involuntary migrants. Involuntary migrants were also described as having socioeconomic issues,11,14,19,33,40,41,45 which included living in poverty11,19,33,40,41,45 and living in precarious housing developments.14,19,40,45 Characteristics of involuntary migrant women also included having experienced trauma, loss, and violence within contexts of war and persecution.11,15,33,39-41,43-45,48 Five studies mentioned exposure to gender-based violence.15,33,39,40,45,48 Two studies described the dependency of involuntary migrant maternal women on their spouses.35,36 Brief descriptions of involuntary migrant maternal women experiencing racism and discrimination were mentioned in four studies.11,33,38,43 One study's findings included descriptions of involuntary migrant maternal women's strengths where these women were viewed as ready to learn and transition into mothering in a new country despite facing hardships of forced displacement.19 Other descriptors of involuntary migrant maternal women within this review included experiencing isolation,19,35,36,39 having low education levels,41,42,48 and experiencing fear and uncertainty related to uncertain futures.15 Appendix IV outlines further details of study characteristics.

Review findings

From the 23 studies included in this review, 115 findings were extracted that addressed the experiences of nurses caring for involuntary migrant maternal women. Most studies within this review included nurses within samples of interdisciplinary teams. The number of nurses who participated within these study samples were thus explicated within these studies.11,14,15,18,33-37,41-44,46-49 Six studies did not explicate the number of nurses involved in their studies and pooled them into multidisciplinary group participant samples.17,19,38-40,45 All findings were graded as “unequivocal” (U), as they were all supported by verbatim illustrations and therefore not open to challenge.

The 115 findings were aggregated into four categories based on similarity of meaning, concepts, or ideas voiced within the illustrations. Meta-synthesis of categories occurred through considering similarities in meaning across all 115 findings. This process was grounded within the critical theoretical assumptions of intersectionality. As a result, aggregation was informed and association between findings and categories were guided toward highlighting intersecting social variables within nurses’ experiences of caring for involuntary migrant maternal women. This meta-synthesis process generated two synthesized findings: i) Nurses integrate cultural and linguistic diversity within practice; and ii) Nurses assess for inequities resulting from forced migration on maternal women. Appendix V presents a meta-aggregation of the four categories with their associated findings. A complete list of study findings and illustrations is presented in Appendix VI. Similarity of meaning informing each synthesized finding is included within these appendices. The following is a presentation of the two generated synthesized findings. Each synthesized finding is summarized, followed by the associated categories and explanations.

Synthesized finding 1: Nurses integrate cultural and linguistic diversity within practice

This synthesized finding was constructed through aggregation of two categories supported by 64 unequivocal findings (see Appendix V). This synthesis reflects the need for culturally sensitive care through understanding the role of family members within women's health experiences. In being sensitive to diverse ways in which health issues are communicated among varying cultures, nurses increased their understanding of post-traumatic stress and pre-migration trauma and violence affecting the health of involuntary migrant maternal women. Communication through interpreters was described as situationally beneficial within nursing care experiences. However, this synthesis draws attention to limitations in interpretation service use and ethical considerations to integrate into nursing care practice. Further explanation of each category is described below.

Category 1.1: Centering care around culture

This category was constructed from 29 findings where nurses described their experiences of integrating cultural sensitivity within care provision and pursuing ways to further their understanding of diverse cultures among involuntary migrant women. Many nurses were sensitive to ensuring involuntary migrant maternal women felt they were cared for despite having ethnic and cultural differences.11,19,42,43 While some nurses recognized the presence of essentialist prejudices within nursing care delivery,11,37 many nurses described employing cultural sensitivity through looking beyond differences and listening.17,33,37,41,43 In addition to recognizing differences in cultural traditions, nurses also expressed a desire to understand how culture affected women's maternal care practices. Centering care delivery around a woman's cultural preferences was described by many nurses as an approach to integrating cultural awareness. This occurred by adapting care delivery protocols and policies to support cultural practices of involuntary migrant maternal women. Examples of employing flexibility within care provision included inquiring into and integrating women's care practices within delivery of health information.

…I often ask them too ‘What culturally would you do in your own country’ so you’ve got, that my education level increases to, like for something like the safe sleeping you know what their norm is so then you can say ‘Well, this is what, that's okay but in Australia you might do this a bit differently because the weather's so much colder here than in Africa as well’. We wrap the babies… So find out what their normal is before trying to change it,43(p.3392)

When caring for women, many nurses described prioritizing the mother's belief systems over their own. This included being open to women's spiritual and cultural beliefs around maternal and infant well-being, infant loss, and bereavement.38 Many nurses described being open to learning new meanings of social practices to facilitate supportive relationships with involuntary migrant maternal women.17,35,41,42,45 Being open to new meaning promoted dialogue around issues women were not accustomed to speaking about.

Many nurses described how involuntary migrant maternal women communicated mental health concerns as feelings rather than as clinical diagnoses of depression or anxiety. Additionally, some nurses described how some women avoided mental health discussions for fear of being labeled as “crazy”35 for not feeling happiness during joyous events such as childbirth. Screening tools such as the Edinburgh Postnatal Depression Scale were perceived as inadequate for addressing diverse cultural conceptualizations of mental health.45 Instead, many nurses described learning culturally appropriate words related to mental health through centering care around women's dialogue.43,45 This approach promoted culturally sensitive conversations and dialogue leading to further understanding of a woman's health concerns. Effects of using culturally sensitive language included discovering issues of post-traumatic stress and experiences of pre-migration trauma that impacted coping during pregnancies, antenatal appointments, and physical examinations.11,41,43,44

In providing care, some nurses acknowledged sociocultural influences, such as family dynamics, as shaping involuntary migrant maternal women's traditional practices.44 Other nurses described how family members, such as mothers-in-law or husbands, were sources of health information for women.37 Fully understanding all nuances of particular cultures was voiced as being impractical.33 However, many nurses described focusing care provision on heightening values of respect, trust, and inclusivity.17,33,37,41,42

Category 1.2: Communicating through language barriers

This category was constructed through 35 findings where nurses described language as a barrier within care provision and what strategies assisted in communicating health information across this barrier. Some nurses empathized with involuntary migrant maternal women in their need to sustain their identities while learning a new language and integrating into a new sociocultural environment.11 Partnering with other disciplines was a strategy nurses employed to reduce language and cultural barriers toward enhancing care. Examples of disciplines nurses collaborated with to address language barriers included psychologists,33 social workers48 and interpreters.15,18,33,36,41-43,46-48 Accessing translation services was described by some nurses as both beneficial and limiting. Benefits of working with interpreters included nurses being able to communicate clearly with women.18,36 Channeling information through an interpreter provided some nurses with a sense of security that health information was being understood.36 However, working with interpreters limited establishment of trusting relationships with women.38

Additional limitations involved nurses needing to be sensitive to cultural dynamics between interpreters and women. Once women expressed discomfort or mistrust of an interpreter, nurses within one study stated they would intervene and schedule a new appointment with a new interpreter.36 Another significant limitation for nurses in this review was the inaccessibility of interpreters.15,38 The amount of time needed for many nurses working in acute settings to find an interpreter was challenging.48 When interpreters were not available in these settings, ultrasounds, x-rays, and blood tests were relied upon to visually communicate physical health issues among involuntary migrant maternal women. Interpreter inaccessibility was also described as challenging within acute care contexts involving rapid-paced care provision and use of technology that was unfamiliar to most involuntary migrant women.

When you’re in the delivery and there's an acute situation, and you’ve got to do a vacuum or the obstetrics, the obstetrician has to come in […], sometimes there's no time to go get the language line phone, and then be put on hold, having to have a back and forth conversation translated, back to do you understand what the risks are. So, that's one of the barriers, it is the language in acute care.48(p.6)

Across health care settings, many nurses discussed using visual aids as a creative solution to communicating when interpreter services were not available. Common language such as hand gestures and body language, including smiles and nodding heads, were used to facilitate communication within acute care facilities.38,43,46,48 Some nurses also described how words were not necessary “to see that someone cares for your child. The handling is quite universal.”46(p.2225)

In the absence of interpreters, several nurses described approaches such as Google Translate and interpretation through family members as inadequate and inappropriate ways to communicate across language barriers.34,46 Many nurses found that providing care through a family member led to mistranslation where women end up not receiving the entirety of health information being provided.34 Mistranslation and misunderstanding of information being provided were described by a number of nurses as compromising confidentiality and quality of care.34,46,48 Ethical issues raised included ensuring confidentiality through conducting discreet sexual and reproductive health assessments.33,34,42 Several nurses discouraged relying on family or friends for translation to preserve women's confidentiality.36 In addition, many nurses scrutinized professional conduct of interpreters through observance of competent interactions with mothers and adherence to commitments of privacy.36,39

Synthesized finding 2: Nurses assess for inequities resulting from forced migration on maternal women

This synthesized finding was constructed through aggregation of two categories supported by 51 unequivocal findings (see Appendix V). Nurses’ experiences of caring involved managing the effects of migrant policies that generated inequitable access to health and social supports among involuntary migrant maternal women. Mitigation of such inequities included addressing health determinants, such as social isolation and migrant status. Nurses’ experiences of care demonstrated unique skill sets to assess pre-migration experiences and connect women to networks of social and health support. Further explanation of each category is described below.

Category 2.1: Seeing and acting on the impacts of migration on women's health

This category was supported by 16 unequivocal findings describing nurses’ views on how migrant status impacted women's health and affected care provision. Many nurses described ways to mitigate inequities stemming from migrant policies, including addressing social isolation as a health determinant hindered by limited access to social supports.11,14,45 Although several nurses described receiving little formal training on how to assess a person's migrant status, nurses viewed migrant status as impacting women's broader health determinants.11,35,48,49 Housing instability and living in poverty were often witnessed by many nurses where involuntary migrant maternal women had inadequate access to food and clothing.11,33,40 Several nurses also recognized migrant policies as impacting receipt of fair and equitable care among involuntary migrant maternal women.

…if you don’t have a Canadian status, well, you will have no rights at all, they have literally nothing, not even access to legal recourses because they cannot even claim for refugee status. These people, it's sad what I am going to say, but they just live in the shadows, in all possible senses!11(p.5)

Many nurses observed migrant status as a barrier to accessing comprehensive health insurance, which consequentially hindered access to health care supports.11,14,19,48 For example, several nurses observed that involuntary migrant maternal women avoided seeking prenatal care due to unaffordability.11,14 Being ineligible for services addressing social isolation was also observed by some nurses as an impact of migrant status.14,48

While several nurses understood how migrant status affected service eligibility, they also described social isolation as a predisposing factor to postnatal depression among involuntary migrant women.14,17 Many nurses voiced how caring for involuntary migrant maternal women included addressing depression and anxiety stemming from precarious migrant status and migration away from family supports.17,35,45 Some nurses were aware of the importance of addressing isolation, especially among involuntary migrant women who were separated from their communities. Specific to this separation was being detached from female support circles who provided essential care provision during women's experiences of maternal health.11,45 Care provision included spending time on understanding pre-migration experiences and geographical backgrounds.11,33,43,45 Connecting women to local community was a strategy most nurses used to address lack of social support. Nurses centered their care on connecting women socially as well as to systems for health care provision.33,43,47,48

Category 2.2: Harnessing nursing knowledge to orchestrate care

This category was supported by 35 unequivocal findings where nurses described themselves as harnessing their understanding of complex maternal health issues and health systems to meet the health needs of involuntary migrant women. This understanding fostered coordinating and connecting women to health and social systems, with an overarching goal of facilitating community integration. Nurses also voiced how these care provision activities were constrained by organizational shortcomings.

Many nurses stated that knowing all intricacies of health systems was challenging. However, they embraced their role, which included providing clear information on finding a family doctor or midwife to provide antenatal, perinatal, and postpartum care.17,39,40,43,48 In doing so, most nurses found that they had to start from the beginning, as most involuntary migrant maternal women had little understanding of how health needs were addressed in their host country.17,33,39,43 Several nurses described women's antenatal care as limited due to having diminished access to health services within war-torn countries.39,49 These women were thereby considered as having high-risk pregnancies and needing care pathways fitting their complex needs. Most nurses found that they were among the first health providers contacted by involuntary migrant maternal women and provided a gateway for these women into the health system.17,33,39,43 Ensuring timely maternal follow-up and close monitoring due to limited pre-migration antenatal care were thus viewed as critical to nurses’ care provision.

Several nurses described their understanding of maternal health issues as significant to coordinating the appropriate care needed.19,33,39,48 Nurses faced multiple complex health issues among involuntary migrant maternal women. One such complex issue involved exposure to trauma and violence. Some nurses described pre-migration trauma and violence as contributing to discomfort among involuntary migrant maternal women in conversing and receiving tests related to sexual and reproductive health.33,34,42 While several nurses expressed a lack of comfort in knowing how to engage in women's experiences of trauma and sexual violence, care provision centered on being sensitive and attentive to women's emotional well-being during clinical interactions.11,42 Many nurses emphasized the need for establishing trusting relationships with women to foster disclosure of experiences of trauma and violence.14,33,42,45 Assurance of confidentiality and consistent emotional support were ways nurses established trust.

A number of nurses voiced understanding of relational care as essential to provision of care.14,42,45 Maternal involuntary migrant women increased engagement with the health system when strong relationships were formed with nurses. Establishing trust was challenging, with many women arriving from countries where public health systems were non-existent and government officials were feared.33 Anxiety related to dealing with government was acknowledged by nurses and mitigated through aiming for continuity of care and clarification of their role within the health system.18,33,34,39 Continuity of care was voiced as critical in providing relational care. However, service administration processes that deterred continuity of care were described as disruptive to developing therapeutic relationships between nurses and women, and promoted disengagement of women from care provision.17,40,44,48,49

Nurses described other constraints, including lack of organizational commitment to enhancing clinical processes so that more time could be allocated to care for women with multiple health issues.17,44 Without capacity to spend time and energy with this group of women who often experienced serious trauma-related mental health issues, as well as language and cultural barriers, many nurses were left fatigued and exhausted.

How much extra time do you need to allocate when you get …a high…a positive?… you need to have the capacity within your system to manage it if you’ve got someone who's suicidal… (ID 23; HP).44(p.6)

Listening to stories of the atrocities associated with forced migration left some nurses emotionally exhausted and traumatized. Receiving emotional support from informal sources, such as peers, was described as being a central need for nurses caring for involuntary migrant maternal women.33

Discussion

This synthesis of qualitative evidence summarized 115 findings from 23 critically appraised studies into two synthesized findings that captured geographical variation and diverse care delivery contexts. The generated synthesized findings were informed theoretically by intersectionality,25 and magnify the knowledge nurses use and how nurses enact health care provision when working with complexities among involuntary migrant maternal women. Additionally, this review highlights how nurses drew primarily on experiential learning to understand complexities unique to forced migration among women. Awareness of these complexities can contribute to understanding how health care provision is being fostered and impeded by broader forces such as migration policy.

In this review, many nurses described how they engaged with diverse cultural practices and limited literacy skills. While some nurses voiced discomfort with understanding different cultural traditions,35,37,38 others embraced diversity through being open to new understanding of maternal health as well as being flexible in care delivery protocols.17,41,45 In doing so, nurses centered care delivery around women's cultural preferences. This supports previous research findings articulating cultural competence as necessary to mitigating cultural discrimination that occurs unknowingly.52-54 Researchers have attributed culturally safe health care provision to equitable service delivery and better health outcomes.55 Although study participants within this review did not address how cultural safety was promoted broadly within organizational protocols and policies, most recognized the need to integrate cultural awareness within direct patient care provision.

In addition to being flexible and open to different ways of conceptualizing health and health practices, nurses also described experientially learning about the impacts of migrant status and exposure to trauma and violence on women. Integrating trauma-informed care within delivery of service to involuntary migrant women was voiced by nurses as challenging due to lack of organizational guidance.11,33,44 Although the impacts of trauma on women's health have been well-documented,56-59 current literature suggests that nurses are limited in their understandings of trauma-informed care practices.60,61 While the findings of this review highlighted nurses voicing lack of professional practice support related to understanding trauma-informed care among women with precarious migrant status, studies in this review also highlighted nurse's drawing on their tacit and experiential knowledge to ensure compassionate care provision.

Through caring for women with multiple complexities, nurses engaged with health determinants that affected the well-being of involuntary migrant maternal women and their infants. Social isolation, impacts of exposure to trauma and violence, and diminished access to prenatal care (eg, due to limited health insurance and/or pre-migration contexts of conflict where access to health services was limited) were identified by nurses as shaping how they provided care. As supported by previous research, nurses have the capacity to understand and address disparate health issues faced by women living with multiple layers of adversity.62,63 Despite having minimal training on understanding migrant status, many nurses within this review demonstrated the ability to identify issues of inequity and poor health outcomes due to the effects of migrant policy on health insurance and ineligibility of social support services.11,14,17,19,38,48 However, understanding the meaning of each migrant status category within the context of a country's migrant and health policies is essential to understanding how structural policies are contributing to inequitable health experiences among involuntary migrant maternal women.

In addition to capturing the diverse migrant status categories that described involuntary migrant women, the multiple roles assumed by nurse participants within studies included in this review were extracted. While many nurses’ experiences centered around maternal–child nursing practice roles, it is significant to note the presence of other specialist practice roles, such as psychiatric nursing and chronic disease nursing. This finding highlights how maternal women with precarious migrant status can require complex care from specialist practices for health issues extending beyond the scope of maternal health and into other physical, emotional, or social needs. As a result, nurses working across health care system sectors need to have awareness of health impacts on women with precarious migrant status and integrate this knowledge into care provision tools. This aligns with O’Mahony and Clark's16 findings that nurses need more education to care for the mental health needs among involuntary migrant maternal women. This finding also extends the ICN position12,32 of nurses being central to refugee and migrant care within crisis contexts to include the multi-sectoral health care system contexts around the world.

More focus is needed beyond the crisis context to provide informed nursing care for involuntary migrant maternal women within transition and settlement care provision situations. Additionally, the ICN position statement32 pays minimal attention to the presence of exposure to trauma and violence among involuntary migrant women. As a result, integration of trauma and violence-informed competencies within international and local nursing associations is elemental to enhancing nursing practice and education.

Strengths and limitations

This review included studies that were limited in at least six ways: i) the small number of studies focused solely on nurses; ii) consideration of gender and race constructs; iii) geographical study distribution; iv) excluding studies published in languages other than English; v) exclusion of nurses caring for involuntary migrant women who experienced loss of pregnancy, loss of an infant, abortion, or other non-reproductive-related health issues; and vi) exclusion of midwives and/or nurse-midwives.

First, it was identified that many researchers included nurses as part of an interdisciplinary team of health care professionals, health care providers, maternity care professionals, or service providers.11,14,17-19,34,35,38-42,44,45,47-49 Findings centered explicitly on nurses’ experiences were extracted from the 18 studies that included nurses working within interdisciplinary team members as study participants. This occurred through identifying and extracting data, which were clearly stated by authors as derived from nurses’ experiences. Therefore, a strength of this review is the inclusion of studies that explored nurses’ experiences while working within contexts of interdisciplinary teams. However, the limitation within this review is the small number of studies found that solely focus on nurses experiences.33,36,37,43,46 Effects of this limitation included reduced nurses’ experiences and diminished contributions of nursing knowledge to health care sciences. Consequential to the prioritization of dominant biomedical ideas and beliefs is the overlooking of the distinct, action-oriented effects of nursing knowledge on the health of complex populations.

Another limitation within studies identified in this review is the minimal mention of race and gender as a health determinant. This limitation surfaced through the theoretical guidance of intersectionality,25 which purports the need to view experiences as complex where social variables including gender, race, and migrant status interplay to generate inequitable impacts. Since the rise of critical feminist theories such as intersectionality, gaps in literature have been confronted where axes of race and gender in particular have been ignored or superficially integrated.64 Multiple forces are at play within this gap where race and gender intersect to reflect racism and oppression.65 Current literature describes impacts of race, including discrimination, as fueling negative effects on the health of involuntary migrant population.32,66 However, few studies within this review explicitly recognized how race and gender were considered within care provision. Study participants were described primarily by their sex only, creating a unilateral depiction of nurses. Although some studies considered migration histories of nurse participants, few considered race, gender, ethnicity, or language skills.

Unilateral foci perpetuate superficial understanding67 of how race, gender, ethnicity, and culture work together to shape care provision. Such superficiality risks misinterpretation of results and consequential suppression of vulnerabilities experienced by populations such as involuntary maternal migrant women.67 As a result, terms such as race and gender are undergoing critical re-shaping to prevent unintended disregard of disproportionately experienced health issues. For example, international nursing guidance includes paying attention to how race is integrated into care provision and how discrimination creates barriers to accessing health among involuntary migrant populations.12,32

Lastly, geographic distribution of studies within this review centered on high-income, Northern European, North American, and Australian contexts. This reflects Western and Eurocentric approaches to inquiries within this review. Although one study was conducted in Thailand and one in Bangladesh, this review does not reflect globally diverse approaches to inquiry, to nurse experiences of care provision among involuntary migrant maternal women, or to the varying socioeconomic and political forces that shape a country's migration and health policies.

Methodological limitations of this review pertain to inclusion criteria that determined identification of relevant studies. Including studies published only in the English language may have resulted in overlooking relevant studies. Additionally, including studies only published in English may have contributed to the lack of geographical variety. Although two studies were conducted outside of Europe, North America, and Australia, this review has been shaped by Western and Eurocentric ideas of health, migration, and nursing.

Another methodological limitation of this study is the inclusion of nurses caring for involuntary migrant maternal women who experienced pregnancy, birth, or post-birth. These criteria excluded nurses caring for involuntary migrant women's health in general, such as women who had experienced pregnancy loss, infant loss, abortion, or other non-reproductive-related health issues. Within this same limitation is the inclusion of those identified and educated as nurses as per the ICN definition. This excluded midwives who may work similarly to nurses, but whose discipline differs from nursing in its history and scope of practice.

Conclusions

The central objective of this review was to identify, appraise, and synthesize qualitative evidence inquiring into nurses’ experiences of caring for involuntary migrant maternal women. The resulting meta-aggregation of appraised evidence generated two synthesized findings summarizing current knowledge: nurses integrate cultural and linguistic diversity within practice, and nurses assess for inequities resulting from forced migration on maternal women. The need for integrating understanding across the health care system sectors of how precarious migrant status impacts women's health is essential to provide informed nursing care. Articulating the presence of nurses within multidisciplinary teams, as well as the scope of their role, is essential to capturing the unique knowledge nurses use within varying contexts of care provision. While involuntary migrant maternal women are cared for within maternal health care environments, this review identifies diverse hospital-based and community care contexts where this population of women also receive care. This review also draws attention to the various ways nurses experienced the impacts of precarious migrant status among involuntary migrant maternal women.

The synthesized findings in this qualitative review reveal nurses’ experiences of various challenges centered around providing care across cultural and linguistic diversity. Nurses oriented their care provision to women's cultural traditions and flexed protocols to create culturally safe approaches. Many creative strategies based on experiential learning were identified by nurses as ways to address language barriers. Nurses also recognized the impact of precarious migrant status on women's health. Social isolation, effects from exposure to varying forms of trauma and violence, and diminished access to care due to limited health insurance and cultural and linguistic barriers were health issues nurses encountered within care provision. As a result, nurses drew on clinical, relational, and population health knowledge to focus care provision on reducing barriers and facilitating connection to social and health systems.

Nurses described developing insights over time around needing to understand how migrant status shaped the barriers women faced, thus allowing them to deliver effective and equitable care. These findings align with guiding documents describing nurses’ roles as including health promotion focused on addressing disparities through a culturally competent lens.12,68 However, nurses voiced broader constraints to fulfilling their roles, including a lack of organizational commitment to the development of administrative and clinical processes targeting enhanced capacity among nurses.

The findings of this review have the capacity to inform migration and health policy through learning from the experiences of nurses who have identified health disparities among maternal women. The findings also have capacity to inform professional practice through providing continuous education opportunities related to understanding health determinants faced by involuntary migrant maternal women, such as precarious migrant status and impacts of exposure to trauma and violence. This review is positioned to inform organizational policy to question how administrative and clinical processes accommodate nurses’ care provision needs as well as to question how cultural and language barriers are being addressed in culturally sensitive ways.

Recommendations for practice and policy

The Summary of Findings within this review reported moderate dependability and high credibility of the findings included. Confidence levels for the synthesized findings were assessed as moderate using the ConQual approach.26 The following practice and policy recommendations have been graded according to the JBI Grades of Recommendations69 and are based on the findings of this review.

  • The impact of migrant policies on the health of involuntary migrant women should be integrated into nursing education curriculum and ongoing professional development across acute and community professional practice. This includes teaching nurses how to assess migrant status, and how the status contributes to barriers among women accessing health services. (Grade A)
  • Providing nurses with ongoing education and support related to the integration of trauma and violence-informed care within practice is recommended. Organizations can assist with this by developing policies that include administrative support to facilitate nurses’ ability to provide continuity of care. Initiatives should aim to promote disclosure of trauma and violence exposure among migrant maternal women and to prevent their disengagement with health care systems. (Grade A)
  • Exploring innovative strategies to overcome language barriers between migrant women and nurses in acute and community health contexts when interpreter services are unavailable, or when the woman does not feel comfortable with the interpreter, is advised. Examples include visual aids and body language. Risks associated with using family members as translators need to be integrated within policy development. (Grade A)
  • To ensure the safe provision of care, clinical pathways should address the complexity of health issues experienced among involuntary migrant maternal women. This includes the need for timely health follow-up and close monitoring due to minimal antenatal care, and the need for interdisciplinary partnerships to streamline care and facilitate access to services. (Grade A)

Recommendations for research

Based on study characteristics and limitations, the following recommendations focus on areas for further inquiry as well as methodological approaches.

  • Further research that employs methodologies addressing structural barriers is needed to understand the effects of institutional policies on nursing care provision and on the health outcomes among involuntary migrant maternal women. Framed by an intersectionality lens, this research recommendation has potential to unearth directives that perpetuate barriers and promote discriminatory practices that impact health outcomes. Critical policy analysis and institutional ethnography are recommended approaches to inquire into broader institutional effects on care provision that impact involuntary migrant maternal women.
  • Further inquiry is needed to examine nurses’ experiences of providing care to involuntary migrant maternal women within acute care settings. This research recommendation entails exploring facilitators and barriers to care within rural and urban acute care settings, including emergency rooms and intensive care units. It also entails exploring nurses’ understanding of how precarious migrant status impacts involuntary migrant maternal women's health. Within research inquiries involving interdisciplinary teams, it is recommended that nurses’ voices are made distinct and explicit through articulation of their roles and unique knowledge base.

Acknowledgments

Dr. Carol Gordon, University of Victoria Librarian and Head of Distance Learning and Research, for her steady support. SK's doctoral committee members Dr. Joyce O’Mahony from Thompson Rivers University and Dr. Nancy Clark from the University of Victoria for their continuous support.

This project contributes toward a PhD Nursing degree for SK.

Funding

The University of Victoria Centre for Evidence-Informed Nursing and Healthcare: A JBI Centre of Excellence provided doctoral student funding for comprehensive systematic review training.

Declarations

The authors of this review work to improve diversity and inclusion in research. All authors work within a critical feminist philosophy and adopted intersectionality as an analytical lens within this review.

SK's background is in public health nursing and her program of research is centered on forcibly displaced women's health and well-being.

LM's research and scholarship focuses on supporting pregnant and newly parenting women experiencing multiple adversities and their families in their transition to parenting. She holds a particular focus on the issue of substance use during pregnancy.

DB supports ongoing systematic review activities in addition to acting as a peer reviewer of JBI Evidence Synthesis. Her doctoral work focused on registered nurses’ and licensed practical nurses’ experiences of working together.

Author contributions

This review is a component of SK's doctoral dissertation. Data extraction was completed independently; however, DB accessed extracted findings and provided consistent support and ongoing feedback. SK and DB collaborated on analysis design and performed the analysis under DB's supervision. Writing of the manuscript was conducted by SK with consistent support and supervision provided by DB and LM.

Appendix I: Search strategy

CINAHL Complete (EBSCO)

Search conducted on January 13, 2021

figure3

MEDLINE with full text (EBSCO)

Search conducted on January 13, 2021

figure4

PsycINFO (EBSCO)

Search conducted on January 13, 2021

figure5

PubMed (United States National Library of Medicine)

Search conducted on January 13, 2021

figure6

Web of Science (Clarivate)

Web of Science Core Collection including Social Science Citation Index

Search conducted on January 21, 2021

figure7

Google Scholar

Search conducted January 21, 2021

figure8

Gray Literature Search

Google

Search conducted January 21, 2021

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Appendix II: Studies ineligible following full-text review

1. Burchill J. Safeguarding vulnerable families: work with refugees and asylum seekers. Community Pract. 2011;84(2):23-6.

Reason for exclusion: This study does not identify nurses as being included in sample and does not present all findings.

2. Chen C-I, Huang M-C. Exploring the growth trajectory of cultural competence in Taiwanese paediatric nurses. J Clin Nurs. 2018;27(23-24):4331-9.

Reason for exclusion: Although these nurses indirectly cared for families through their pediatric patients, the care being inquired into is not relative to maternal health.

3. Dos Santos SLS. Undeserving mothers? Shifting rationalities in the maternal healthcare of undocumented Nicaraguan migrants in Costa Rica. Anthropol Med. 2015;22(2):191-201.

Reason for exclusion: Data presented in this study did not present findings on nurse experiences.

4. Griffiths R, Emrys E, Finney CL, Eagar S, Smith M. Operation safe haven: the needs of nurses caring for refugees. Int J Nurs Pract. 2003;9(3):183-90.

Reason for exclusion: Did not inquire into caring for involuntary migrant maternal women.

5. LaMancuso K, Goldman RE, Nothnagle M. “Can I ask that?”: perspectives on perinatal care after resettlement among Karen refugee women, medical providers, and community-based doulas. J Immigrant Minority Health. 2016;18(2):428-35.

Reason for exclusion: Data presented in this study drew on experiences of doulas and interpreters; no findings on nurse experiences.

6. McKnight P. Australian study reveals challenges faced by maternal and child health nurses in caring for refugee families. Evid Based Nurs. 2019;22(3):80.

Reason for exclusion: Ineligible study design: commentary.

7. Mengesha ZB, Perz J, Dune T, Ussher J. Talking about sexual and reproductive health through interpreters: the experiences of health care professionals consulting refugee and migrant women. Sex Reprod Healthc. 2018;16:199-205.

Reason for exclusion: Unilateral focus on sexual and reproductive health; did not inquire into caring for involuntary migrant maternal women.

8. Mengesha ZB, Perz J, Dune T, Ussher J. Preparedness of health care professionals for delivering sexual and reproductive health care to refugee and migrant women: a mixed methods study. Int J Environ Res Public Health. 2018;15(1):174.

Reason for exclusion: Unilateral focus on sexual and reproductive health; did not inquire into caring for involuntary migrant maternal women.

9. Oucho JO, Ama NO. Immigrants’ and refugees’ unmet reproductive health demands in Botswana: perceptions of public healthcare providers. Sth Afr Fam Pract. 2009;51(3):237-43.

Reason for exclusion: Unilateral focus on sexual and reproductive health; did not inquire into caring for involuntary migrant maternal women.

10. Payne A. Sexual assault nurse examiner forensic examinations for immigrant victims: a case study. J Forensic Nurs. 2018;14(2):112-16.

Reason for exclusion: Ineligible participant population.

11. Ruiz-Casares M, Rousseau C, Laurin-Lamothe A, Rummens J, Zelkowitz P, Crépeau F, et al. Access to health care for undocumented migrant children and pregnant women: the paradox between values and attitudes of health care professionals. Matern Child Health J. 2013;17(2):292-8.

Reason for exclusion: Ineligible study design.

12. Vanthuyne K, Meloni F, Ruiz-Casares M, Rousseau C, Ricard-Guay A. Health workers’ perceptions of access to care for children and pregnant women with precarious immigration status: health as a right or a privilege? Soc Sci Med. 2013;93:78-85.

Reason for exclusion: Health care provision of maternal women not focused on; unclear if nurses were involved.

13. Yelland J, Riggs E, Szwarc J, Casey S, Duell-Piening P, Chesters D, et al. Compromised communication: a qualitative study exploring Afghan families and health professionals’ experience of interpreting support in Australian maternity care. BMJ Qual Safety. 2016;25(4):1-9.

Reason for exclusion: Data presented in this study drew on experiences of midwives and medical practitioners; no findings on nurse experiences.

Appendix III: Data extraction instrument

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Appendix IV: Characteristics of included studies

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Appendix V: Meta-aggregation tables

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Appendix VI: Study findings and illustrations

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Keywords:

involuntary migrant; maternal; nurse; qualitative; women

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