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Women from migrant and refugee backgrounds’ perceptions and experiences of the continuum of maternity care in Australia: A qualitative evidence synthesis

Open AccessPublished:August 21, 2021DOI:https://doi.org/10.1016/j.wombi.2021.08.005

      Abstract

      Background

      Women who were born overseas represent an increasing proportion of women giving birth in the Australian healthcare system.

      Problem

      Women from migrant and refugee backgrounds have an increased risk of poor pregnancy and birth outcomes, including experiences of care.

      Aim

      To understand how women from migrant and refugee backgrounds perceive and experience the continuum of maternity care (pregnancy, birth, postnatal) in Australia.

      Methodology

      We conducted a qualitative evidence synthesis, searching MEDLINE, CIHAHL, and PsycInfo for studies published from inception to 23/05/2020. We included studies that used qualitative methods for data collection and analysis, that explored migrant/refugee women’s experiences or perceptions of maternity care in Australia. We used a thematic synthesis approach, assessed the methodological limitations of included studies, and used GRADE-CERQual to assess confidence in qualitative review findings.

      Results

      27 studies met the inclusion criteria, representing women in Australia from 42 countries. Key themes were developed into 24 findings, including access to interpreters, structural barriers to service utilisation, experiences with health workers, trust in healthcare, experiences of discrimination, preferences for care, and conflicts between traditional cultural expectations and the Australian medical system.

      Conclusion

      This review can help policy makers and organisations who provide care to women from migrant and refugee backgrounds to improve their experiences with maternity care. It highlights factors linked to negative experiences of care as well as factors associated with more positive experiences to identify potential changes to practices and policies that would be well received by this population.

      Keywords

      Statement of significance

      Problem or issue
      Women from migrant and refugee backgrounds represent an increasing proportion of women giving birth in Australia.
      What is already known
      Overseas-born women have an increased risk of poor pregnancy outcomes and services may not be adequately serving them.
      What this paper adds
      A rigorous synthesis of existing studies. An analysis of patterns concerning the experiences and perceptions of women from migrant and refugee backgrounds across the continuum of maternal healthcare.

      Background

      Context

      Due to trends in globalisation and migration, an increasing proportion of women giving birth in high-income countries are born overseas themselves [
      • Navodani T.
      • Gartland D.
      • Brown S.J.
      • Riggs E.
      • Yelland J.
      Common maternal health problems among Australian-born and migrant women: a prospective cohort study.
      ]. In 2017, women born in non-English speaking countries made up 27% of women giving birth in Australia, up from 18% in 2007 [
      • Australian Institute of Health and Welfare
      Australia’s Mothers and Babies - 2017 in Brief.
      ]. Australia’s migration patterns are changing, with the number of migrants from South and Central Asia almost doubling between 2013 and 2018, while migration from the Western Europe and Oceania regions decreasing by around 25% []. The rates of refugee resettlements in Australia from Africa remain consistent but have been overtaken by conflict-impacted countries in the Middle East [
      • Department of Home Affairs
      Discussion Paper: Australia’s Humanitarian Program 2019-2020.
      ]. These trends are significant because migrant populations in Australia experience barriers to accessing healthcare, which are most challenging for migrant groups not fluent in English [
      • Hoang H.
      Language and cultural barriers of Asian migrants in accessing maternal care in Australia.
      ]. Since more women from non-English speaking backgrounds are giving birth in Australia, this represents an important public health issue.
      Pregnancy and childbirth are complex because they are both biomedical yet also hold deep cultural significance for women and their families [
      • Hoang H.T.
      • Le Q.
      • Kilpatrick S.
      Having a baby in the new land: a qualitative exploration of the experiences of Asian migrants in rural Tasmania, Australia.
      ]. How women perceive care they experience during this time is informed by their cultural background and conceptions of motherhood [
      • Benza S.
      • Liamputtong P.
      Becoming an’ Amai’: meanings and experiences of motherhood amongst Zimbabwean women living in Melbourne, Australia.
      ]. Cultural values influence what women understand as their role as a mother, their preferences for pregnancy and childbirth, and what is appropriate behaviour for health workers, their family members and themselves throughout pregnancy and birth [
      • Owens C.
      • Dandy J.
      • Hancock P.
      Perceptions of pregnancy experiences when using a community-based antenatal service: a qualitative study of refugee and migrant women in Perth, Western Australia.
      ]. Given the sizable proportion of women giving birth in Australia who were born overseas, it is important that the Australian healthcare system and its policies are responsive to the needs of these women. This is because it is not only ethical for health workers and authorities to ensure that healthcare is culturally competent, but it is necessary to build trust with migrant populations and ensure they will access appropriate care when needed to prevent poor health outcomes [
      • Betancourt J.R.
      • Corbett J.
      • Bondaryk M.R.
      Addressing disparities and achieving equity: cultural competence, ethics, and health-care transformation.
      ]. It is critical we improve understanding of how this population perceives and experiences the continuum of maternity care in Australia [
      • Metusela C.
      • Ussher J.
      • Perz J.
      • Hawkey A.
      • Morrow M.
      • Narchal R.
      • et al.
      "In my culture, we don’t know anything about that": sexual and reproductive health of migrant and refugee women.
      ].

      How this review supplements what is already known in this area

      Women from migrant and refugee backgrounds are more likely to have additional challenges during the maternity period compared to Australian-born women, such as language barriers, isolation from culture and family, and discrimination when accessing services [
      • Hennegan J.
      • Redshaw M.
      • Kruske S.
      Another country, another language and a new baby: a quantitative study of the postnatal experiences of migrant women in Australia.
      ]. Migrant women have described the process of seeking maternity care in Australia as confusing and distressing [
      • Benza S.
      • Liamputtong P.
      Becoming an’ Amai’: meanings and experiences of motherhood amongst Zimbabwean women living in Melbourne, Australia.
      ,
      • Renzaho A.
      • Oldroyd J.
      Closing the gap in maternal and child health: a qualitative study examining health needs of migrant mothers in Dandenong, Victoria, Australia.
      ], particularly when medical advice conflicts with traditional practices [
      • Carolan M.
      • Cassar L.
      Antenatal care perceptions of pregnant African women attending maternity services in Melbourne, Australia.
      ]. Women who are born in non-English speaking countries, particularly those from refugee backgrounds, are at higher risk of poor underlying health which can make maternal care more complex [
      • Carolan M.
      Pregnancy health status of sub-Saharan refugee women who have resettled in developed countries: a review of the literature.
      ]. Further, there is evidence that migrant status is associated with an increased risk of poor maternal health outcomes, especially with regard to post-partum depression and intimate partner violence [
      • Navodani T.
      • Gartland D.
      • Brown S.J.
      • Riggs E.
      • Yelland J.
      Common maternal health problems among Australian-born and migrant women: a prospective cohort study.
      ].
      There are also disparities with regards to maternal health service utilisation. Women from non-English speaking countries are less likely to have an antenatal visit in the first trimester compared to Australian-born women [
      • Australian Institute of Health and Welfare
      Australia’s Mothers and Babies - 2017 in Brief.
      ]. A potentially related issue of concern is that migrant status is associated with a higher risk of having low birth weight babies even after being resettled for some time [
      • Carolan M.
      Pregnancy health status of sub-Saharan refugee women who have resettled in developed countries: a review of the literature.
      ], suggesting that these inequities persist over time after resettlement. Female migrants from certain settings are also more likely to have undergone female genital mutilation or cutting (FGM/C) than the general population, which requires specialised management during childbirth [
      • Varol N.
      • Dawson A.
      • Turkmani S.
      • Hall J.J.
      • Nanayakkara S.
      • Jenkins G.
      • et al.
      Obstetric outcomes for women with female genital mutilation at an Australian hospital, 2006-2012: a descriptive study.
      ]. Together, this suggests that women from migrant and refugee backgrounds are a population particularly susceptible to poor maternal health experiences and outcomes.
      Primary qualitative studies exploring the experiences of women from refugee and migrant backgrounds giving birth in Australia have typically focused on specific communities, and are often limited to women from a specific country or region and currently residing in a particular geographical area of Australia. While this provides valuable cultural context and information for developing targeted interventions, it is challenging to draw broader conclusions about migrant and refugee women’s experiences with maternity care in Australia and, therefore, to develop state-wide or national strategies. Mainstream health services in Australia cater to diverse communities so there is a need to understand the experiences of these populations more broadly.

      Why is it important to do this review?

      With women born outside Australia making up an increasing proportion of women giving birth in the Australian medical system [
      • Australian Institute of Health and Welfare
      Australia’s Mothers and Babies - 2017 in Brief.
      ], it is important to understand their experiences and perceptions of care. Memories associated with pregnancy and birth are often powerful and long lasting [
      • Murray L.
      • Windsor C.
      • Parker E.
      • Tewfik O.
      The experiences of African women giving birth in Brisbane, Australia.
      ] and experiences can influence how women perceive and engage with health services going forward [
      • Carolan M.
      • Cassar L.
      Antenatal care perceptions of pregnant African women attending maternity services in Melbourne, Australia.
      ]. To our knowledge, no systematic reviews have focused solely on the experiences of women from refugee and migrant backgrounds who experience maternal health care in Australian. Policies, practices and attitudes related to both maternal health care and migrant and refugee communities differ between countries, so it is important to develop a comprehensive and specific understanding of the issue in the Australian context to identify avenues for improvement. Therefore, we have conducted a qualitative evidence synthesis (QES; systematic review of qualitative studies) to explore how women from migrant and refugee backgrounds perceive and experience the continuum of maternal health care, including pregnancy, birth and the first year postpartum, in Australia. This QES places migrant women’s experiences as articulated in their own words at the heart of the analysis. While clinical data and statistics are useful for measuring some outcomes, qualitative data and analysis is best placed to develop an understanding of how women think and feel about the care they receive and how this impacts them on a personal level.

      Objectives

      This QES aimed to understand how the continuum of maternal healthcare in Australia, through pregnancy, birth and the first year with a new baby, is perceived and experienced by women who were born outside Australia. It had the following objectives:
      • 1
        To describe, assess and synthesise qualitative evidence regarding the experiences and perspectives of migrant and refugee women about pregnancy, birth and the postnatal period in the Australian context;
      • 2
        To explore how the findings of this QES can be used to inform policy and strategy and clinical practice.

      Method

      This QES was conducted according to the Cochrane Effective Practice and Organisation of Care template [
      • Lewin S.
      • Booth A.
      • Glenton C.
      • Munthe-Kaas H.
      • Rashidian A.
      • Wainwright M.
      • et al.
      Applying GRADE-CERQual to qualitative evidence synthesis findings: introduction to the series.
      ] and reported according to the ENTREQ (Enhancing transparency in reporting the synthesis of qualitative research) statement (see Appendix 1) [
      • Tong A.
      • Flemming K.
      • McInnes E.
      • Oliver S.
      • Craig J.
      Enhancing transparency in reporting the synthesis of qualitative research: ENTREQ.
      ].

      Criteria for considering studies

      Types of studies

      Studies were eligible for inclusion if they were published primary research that used qualitative methods for both data collection (e.g. interviews, focus groups and document analysis) and data analysis (e.g. thematic analysis, content analysis and grounded theory). Studies which analyse qualitative data using quantitative methods, (e.g. using descriptive statistics), were excluded. Mixed-methods studies were eligible for inclusion if it was possible to isolate the qualitative data. Studies were eligible for inclusion if they were in the published academic or grey literature.

      Topic of interest

      Studies were eligible for inclusion if they had a primary focus on women from migrant and refugee backgrounds and exploring their experiences and perceptions of maternity care in Australia. Types and stages of care encompassed in the continuum of maternal healthcare included: antenatal care, perinatal and childbirth care; and postnatal or postpartum care, up to 12 months after birth [
      • Renzaho A.
      • Oldroyd J.
      Closing the gap in maternal and child health: a qualitative study examining health needs of migrant mothers in Dandenong, Victoria, Australia.
      ]. This includes care that occurs in public and private clinics and hospitals, as well as at home. We initially planned on including the pre-conception period and fertility or contraceptive services. However, during the search and screening processes it become clear that this would make too large a number of studies eligible for inclusion, and thus threaten the integrity of the analysis. While studies which included one or more participants who experienced health complications during pregnancy and birth were eligible for inclusion, studies that exclusively focused on issues such as diabetes were excluded as they were not focused on maternal health care. These exclusions are indicated in the PRISMA diagram (Fig. 1).
      Fig. 1
      Fig. 1PRISMA diagram depicting the flow of included studies from search strategy, exclusions and final inclusions.

      Types of participants

      Studies were eligible for inclusion if their primary participants were women from migrant and refugee backgrounds residing in Australia. We focused on migrants who resettled in Australia after being born in another country regardless of the age that migration occurred or how long ago they arrived [
      • Metusela C.
      • Ussher J.
      • Perz J.
      • Hawkey A.
      • Morrow M.
      • Narchal R.
      • et al.
      "In my culture, we don’t know anything about that": sexual and reproductive health of migrant and refugee women.
      ]. A refugee is defined as someone who meets the above conditions but also arrived in Australia under a humanitarian program after leaving their birth country due to conflict, natural disaster or other crisis situation [
      • Carolan M.
      Pregnancy health status of sub-Saharan refugee women who have resettled in developed countries: a review of the literature.
      ].

      Search methods for identification of studies

      Electronic searches

      Electronic searches were conducted in the Medline, CINAHL and PsycINFO databases on 23 May 2020. The search strategy for each database was developed based on the inclusion criteria and research objectives, and in consultation with a research librarian, and is available in Appendix 2.

      Searching other resources and grey literature

      We reviewed the reference lists of included studies in order to identify any additional qualitative studies relevant to this review and conducted a forward citation search of included studies in Google Scholar. We searched for grey literature using OpenGrey (www.opengrey.eu/) and The Grey Literature Report (www.greylit.org/). Inclusion criteria for grey literature was the same as for journal publications.

      Selection of studies

      Two review authors (HB and MVC) independently assessed the titles and abstracts of the identified records using Covidence [
      • Veritas Health Innovation
      Covidence Systematic Review Software.
      ] to evaluate eligibility. We then retrieved the full text of all the papers identified as potentially relevant, and two review authors (HB and MVC) assessed these papers independently using Covidence. Any disagreements were resolved by discussion or by involving the third author (MAB).

      Data extraction

      Relevant data from each study was recorded in a data extraction form tailored for this QES. The data extraction was conducted by two authors (HB and MVC) and crosschecked for accuracy. Extracted data included:
      • Descriptive information about the study objectives and the stage or stages of the maternal care continuum it focuses on;
      • Descriptive details about the participants, including birth country;
      • Descriptive information about the setting and context;
      • Information about the study design; and
      • Qualitative themes and findings identified by the authors and participant quotations.

      Assessing the methodological limitations of included studies

      Two review authors (HB and MVC) independently assessed each included study for methodological limitations using an adaptation of the Critical Appraisal Skills Programme (CASP) tool [

      CASP. CASP Checklists 2018 Available from: https://casp-uk.net/casp-tools-checklists/.

      ], which includes the following domains:
      • 1
        Was there a statement of the aims of the research?
      • 2
        Given the aim of the study, was a qualitative methodology appropriate?
      • 3
        Was the research design appropriate to address the aims of the research?
      • 4
        Was the recruitment strategy appropriate to the aims of the research?
      • 5
        Was the relationship between the researcher and participants adequately considered?
      • 6
        Have ethical issues been taken into consideration?
      • 7
        Was the data analysis sufficiently rigorous?
      • 8
        Were the findings supported by the evidence?
      • 9
        How valuable is the research?
      The two authors conducting the assessment (HB and MVC) compared results and resolved any discrepancies through discussion or by involving the third author (MAB).

      Data management, analysis and synthesis

      This QES utilised a thematic synthesis approach to conducting a qualitative evidence synthesis as described by Thomas and Harden [
      • Thomas J.
      • Harden A.
      Methods for the thematic synthesis of qualitative research in systematic reviews.
      ]. This method is an adaptation of thematic analysis, which is a common technique performed on primary qualitative data, and involves familiarisation with the data, coding the results of the primary studies, developing themes and using this to conceptualise further understanding and hypotheses [
      • Thomas J.
      • Harden A.
      Methods for the thematic synthesis of qualitative research in systematic reviews.
      ].
      We chose three high quality studies [
      • Owens C.
      • Dandy J.
      • Hancock P.
      Perceptions of pregnancy experiences when using a community-based antenatal service: a qualitative study of refugee and migrant women in Perth, Western Australia.
      ,
      • Murray L.
      • Windsor C.
      • Parker E.
      • Tewfik O.
      The experiences of African women giving birth in Brisbane, Australia.
      ,
      • Liamputtong P.
      • Watson L.F.
      The Meanings and Experiences of Cesarean Birth Among Cambodian, Lao and Vietnamese Immigrant Women in Australia.
      ] that have a clear connection to the QES objectives to serve as the basis of our initial code list [
      • Bohren M.A.
      • Munthe-Kaas H.
      • Berger B.O.
      • Allanson E.E.
      • Tunçalp Ö.
      Perceptions and experiences of labour companionship: a qualitative evidence synthesis.
      ]. We proceeded to conduct line-by-line “free” coding to assist in the translation of concepts between studies and build up the code bank as more studies and themes are analysed [
      • Thomas J.
      • Harden A.
      Methods for the thematic synthesis of qualitative research in systematic reviews.
      ]. We coded themes and sub-themes from original data (such as direct participant quotes) and instances when authors have summarised original data. This data was typically found in the results section. We did not code author comments in the discussion section. Some included studies also featured quotes and summarised data from health workers, but these were not extracted as the focus of this synthesis is on women’s experiences from their own perspectives. Coding was conducted in NVivo [
      • Bohren M.A.
      • Munthe-Kaas H.
      • Berger B.O.
      • Allanson E.E.
      • Tunçalp Ö.
      Perceptions and experiences of labour companionship: a qualitative evidence synthesis.
      ]. All text assigned the same code was examined and a hierarchical tree structure of relationships between themes was created [
      • Thomas J.
      • Harden A.
      Methods for the thematic synthesis of qualitative research in systematic reviews.
      ]. This was used to develop hypotheses about maternal care experiences and perceptions that go beyond the original findings of the included studies to develop new ideas [
      • Thomas J.
      • Harden A.
      Methods for the thematic synthesis of qualitative research in systematic reviews.
      ].

      Assessing our confidence in the QES findings

      Two of the authors (HB and MVC) used the GRADE-CERQual (Confidence in the Evidence from Reviews of Qualitative research) approach to assess confidence in each review finding [
      • Lewin S.
      • Booth A.
      • Glenton C.
      • Munthe-Kaas H.
      • Rashidian A.
      • Wainwright M.
      • et al.
      Applying GRADE-CERQual to qualitative evidence synthesis findings: introduction to the series.
      ]. CERQual assesses confidence in the evidence, based on four key components.
      • 1
        Methodological limitations of included studies: the extent to which there are concerns about the design or conduct of the primary studies that contributed evidence to an individual review finding [
        • Munthe-Kaas H.
        • Bohren M.A.
        • Glenton C.
        • Lewin S.
        • Noyes J.
        • Tuncalp O.
        • et al.
        Applying GRADE-CERQual to qualitative evidence synthesis findings-paper 3: how to assess methodological limitations.
        ].
      • 2
        Coherence of the review finding: an assessment of how clear and cogent the fit is between the data from the primary studies and a review finding that synthesises those data. By cogent, we mean well supported or compelling [
        • Colvin C.J.
        • Garside R.
        • Wainwright M.
        • Munthe-Kaas H.
        • Glenton C.
        • Bohren M.A.
        • et al.
        Applying GRADE-CERQual to qualitative evidence synthesis findings-paper 4: how to assess coherence.
        ].
      • 3
        Adequacy of the data contributing to a review finding: an overall determination of the degree of richness and quantity of data supporting a review finding [
        • Glenton C.
        • Carlsen B.
        • Lewin S.
        • Munthe-Kaas H.
        • Colvin C.J.
        • Tuncalp O.
        • et al.
        Applying GRADE-CERQual to qualitative evidence synthesis findings-paper 5: how to assess adequacy of data.
        ].
      • 4
        Relevance of the included studies to the review question: the extent to which the body of evidence from the primary studies supporting a review finding is applicable to the context (perspective or population, phenomenon of interest, setting) specified in the review question [
        • Noyes J.
        • Booth A.
        • Lewin S.
        • Carlsen B.
        • Glenton C.
        • Colvin C.J.
        • et al.
        Applying GRADE-CERQual to qualitative evidence synthesis findings-paper 6: how to assess relevance of the data.
        ].
      After assessing each of the four components, we made a judgement about the overall confidence in the evidence supporting the review finding as high, moderate, low, or very low [
      • Lewin S.
      • Bohren M.
      • Rashidian A.
      • Munthe-Kaas H.
      • Glenton C.
      • Colvin C.J.
      • et al.
      Applying GRADE-CERQual to qualitative evidence synthesis findings-paper 2: how to make an overall CERQual assessment of confidence and create a Summary of Qualitative Findings table.
      ]. The final assessment was based on consensus among the authors. All findings started as high confidence and were graded down if there were important concerns regarding any of the CERQual components [
      • Glenton C.
      • Bohren M.
      • Downe S.
      • Paulsen E.
      • Lewis S.
      EPOC Qualitative Evidence Synthesis: Protocol and Review Template.
      ].

      Review author reflexivity

      The QES was conducted primarily as part of one author’s (HB) Master of Public Health (MPH) research project. HB chose this topic after discovering limited maternal health policies to support women from migrant and refugee backgrounds at both governmental and organisational levels. As such, she comes to this QES with the assumption that the needs of this population are not adequately met and therefore need further exploration. This may have influenced her interpretation of the data, so the assistance of additional authors (MVC and MAB) was engaged. We discussed the importance of being aware of our biases and committed to regularly assess these throughout the process. Further comments on reflexivity are included in the results section.

      Results

      The PRISMA flow diagram (Fig. 1) documents the search results and the process of screening and selecting studies for inclusion [
      • Glenton C.
      • Bohren M.
      • Downe S.
      • Paulsen E.
      • Lewis S.
      EPOC Qualitative Evidence Synthesis: Protocol and Review Template.
      ]. In total, 27 studies met the inclusion criteria and were included [
      • Hoang H.T.
      • Le Q.
      • Kilpatrick S.
      Having a baby in the new land: a qualitative exploration of the experiences of Asian migrants in rural Tasmania, Australia.
      ,
      • Owens C.
      • Dandy J.
      • Hancock P.
      Perceptions of pregnancy experiences when using a community-based antenatal service: a qualitative study of refugee and migrant women in Perth, Western Australia.
      ,
      • Renzaho A.
      • Oldroyd J.
      Closing the gap in maternal and child health: a qualitative study examining health needs of migrant mothers in Dandenong, Victoria, Australia.
      ,
      • Carolan M.
      • Cassar L.
      Antenatal care perceptions of pregnant African women attending maternity services in Melbourne, Australia.
      ,
      • Murray L.
      • Windsor C.
      • Parker E.
      • Tewfik O.
      The experiences of African women giving birth in Brisbane, Australia.
      ,
      • Liamputtong P.
      • Watson L.F.
      The Meanings and Experiences of Cesarean Birth Among Cambodian, Lao and Vietnamese Immigrant Women in Australia.
      ,
      • Carolan M.
      • Cassar L.
      Pregnancy care for African refugee women in Australia: attendance at antenatal appointments.
      ,
      • Chu C.M.
      Postnatal experience and health needs of chinese migrant women in Brisbane, Australia.
      ,
      • Correa-Velez I.
      • Ryan J.
      Developing a best practice model of refugee maternity care.
      ,
      • Hoban E.
      • Liamputtong P.
      Cambodian migrant women’s postpartum experiences in Victoria, Australia.
      ,
      • Joseph J.
      • Liamputtong P.
      • Brodribb W.
      Postpartum breastfeeding experiences in the traditional‐biomedical crossroads: a qualitative study using drawing with Vietnamese and Myanmarese refugee women in Australia.
      ,
      • Mohale H.
      • Sweet L.
      • Graham K.
      Maternity health care: the experiences of Sub-Saharan African women in Sub-Saharan Africa and Australia.
      ,
      • Niner S.
      • Kokanovic R.
      • Cuthbert D.
      Displaced mothers: birth and resettlement, gratitude and complaint.
      ,
      • Rao V.S.
      • Dahlen H.G.
      • Razee H.
      Indian migrant women’s experiences of motherhood and postnatal support in Australia: a qualitative study.
      ,
      • Riggs E.
      • Davis E.
      • Gibbs L.
      • Block K.
      • Szwarc J.
      • Casey S.
      • et al.
      Accessing maternal and child health services in Melbourne, Australia: reflections from refugee families and service providers.
      ,
      • Riggs E.
      • Muyeen S.
      • Brown S.
      • Dawson W.
      • Petschel P.
      • Tardiff W.
      • et al.
      Cultural safety and belonging for refugee background women attending group pregnancy care: an Australian qualitative study.
      ,
      • Rolls C.
      • Chamberlain M.
      From east to west: Nepalese women’s experiences.
      ,
      • Russo A.
      • Lewis B.
      • Joyce A.
      • Crockett B.
      • Luchters S.
      A qualitative exploration of the emotional wellbeing and support needs of new mothers from Afghanistan living in Melbourne, Australia.
      ,
      • Shafiei T.
      • Small R.
      • McLachlan H.
      Women’s views and experiences of maternity care: A study of immigrant Afghan women in Melbourne, Australia.
      ,
      • Shafiei T.
      • Small R.
      • McLachlan H.
      Immigrant Afghan women’s emotional well-being after birth and use of health services in Melbourne, Australia.
      ,
      • Small R.
      • Rice P.L.
      • Yelland J.
      • Lumley J.
      Mothers in a new country: the role of culture and communication in Vietnamese, Turkish and Filipino women’s experiences of giving birth in Australia.
      ,
      • Stapleton H.
      • Murphy R.
      • Correa-Velez I.
      • Steel M.
      • Kildea S.
      Women from refugee backgrounds and their experiences of attending a specialist antenatal clinic. Narratives from an Australian setting.
      ,
      • Stewart D.E.
      • Das V.
      • Seibold M.
      Birth and empowerment: A qualitative study of the childbirth experience of Filipino migrant women in Brisbane, Australia.
      ,
      • Tsianakas V.
      • Liamputtong P.
      Prenatal testing: the perceptions and experiences of Muslim women in Australia.
      ,
      • Turkmani S.
      • Homer C.S.E.
      • Dawson A.J.
      Understanding the experiences and needs of migrant women affected by female genital mutilation using maternity services in Australia.
      ,
      • 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.
      ,
      • Yelland J.
      • Riggs E.
      • Wahidi S.
      • Fouladi F.
      • Casey S.
      • Szwarc J.
      • et al.
      How do Australian maternity and early childhood health services identify and respond to the settlement experience and social context of refugee background families?.
      ]. These studies took place between 1998 and 2020. Appendix 3 reports the characteristics of included studies.
      Twenty two studies used qualitative methods only [
      • Hoang H.T.
      • Le Q.
      • Kilpatrick S.
      Having a baby in the new land: a qualitative exploration of the experiences of Asian migrants in rural Tasmania, Australia.
      ,
      • Owens C.
      • Dandy J.
      • Hancock P.
      Perceptions of pregnancy experiences when using a community-based antenatal service: a qualitative study of refugee and migrant women in Perth, Western Australia.
      ,
      • Renzaho A.
      • Oldroyd J.
      Closing the gap in maternal and child health: a qualitative study examining health needs of migrant mothers in Dandenong, Victoria, Australia.
      ,
      • Carolan M.
      • Cassar L.
      Antenatal care perceptions of pregnant African women attending maternity services in Melbourne, Australia.
      ,
      • Murray L.
      • Windsor C.
      • Parker E.
      • Tewfik O.
      The experiences of African women giving birth in Brisbane, Australia.
      ,
      • Liamputtong P.
      • Watson L.F.
      The Meanings and Experiences of Cesarean Birth Among Cambodian, Lao and Vietnamese Immigrant Women in Australia.
      ,
      • Carolan M.
      • Cassar L.
      Pregnancy care for African refugee women in Australia: attendance at antenatal appointments.
      ,
      • Chu C.M.
      Postnatal experience and health needs of chinese migrant women in Brisbane, Australia.
      ,
      • Hoban E.
      • Liamputtong P.
      Cambodian migrant women’s postpartum experiences in Victoria, Australia.
      ,
      • Joseph J.
      • Liamputtong P.
      • Brodribb W.
      Postpartum breastfeeding experiences in the traditional‐biomedical crossroads: a qualitative study using drawing with Vietnamese and Myanmarese refugee women in Australia.
      ,
      • Mohale H.
      • Sweet L.
      • Graham K.
      Maternity health care: the experiences of Sub-Saharan African women in Sub-Saharan Africa and Australia.
      ,
      • Niner S.
      • Kokanovic R.
      • Cuthbert D.
      Displaced mothers: birth and resettlement, gratitude and complaint.
      ,
      • Rao V.S.
      • Dahlen H.G.
      • Razee H.
      Indian migrant women’s experiences of motherhood and postnatal support in Australia: a qualitative study.
      ,
      • Riggs E.
      • Davis E.
      • Gibbs L.
      • Block K.
      • Szwarc J.
      • Casey S.
      • et al.
      Accessing maternal and child health services in Melbourne, Australia: reflections from refugee families and service providers.
      ,
      • Riggs E.
      • Muyeen S.
      • Brown S.
      • Dawson W.
      • Petschel P.
      • Tardiff W.
      • et al.
      Cultural safety and belonging for refugee background women attending group pregnancy care: an Australian qualitative study.
      ,
      • Rolls C.
      • Chamberlain M.
      From east to west: Nepalese women’s experiences.
      ,
      • Russo A.
      • Lewis B.
      • Joyce A.
      • Crockett B.
      • Luchters S.
      A qualitative exploration of the emotional wellbeing and support needs of new mothers from Afghanistan living in Melbourne, Australia.
      ,
      • Stewart D.E.
      • Das V.
      • Seibold M.
      Birth and empowerment: A qualitative study of the childbirth experience of Filipino migrant women in Brisbane, Australia.
      ,
      • Tsianakas V.
      • Liamputtong P.
      Prenatal testing: the perceptions and experiences of Muslim women in Australia.
      ,
      • Turkmani S.
      • Homer C.S.E.
      • Dawson A.J.
      Understanding the experiences and needs of migrant women affected by female genital mutilation using maternity services in Australia.
      ,
      • 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.
      ,
      • Yelland J.
      • Riggs E.
      • Wahidi S.
      • Fouladi F.
      • Casey S.
      • Szwarc J.
      • et al.
      How do Australian maternity and early childhood health services identify and respond to the settlement experience and social context of refugee background families?.
      ], typically interviews and focus group discussions. Five used mixed methods [
      • Correa-Velez I.
      • Ryan J.
      Developing a best practice model of refugee maternity care.
      ,
      • Shafiei T.
      • Small R.
      • McLachlan H.
      Women’s views and experiences of maternity care: A study of immigrant Afghan women in Melbourne, Australia.
      ,
      • Shafiei T.
      • Small R.
      • McLachlan H.
      Immigrant Afghan women’s emotional well-being after birth and use of health services in Melbourne, Australia.
      ,
      • Small R.
      • Rice P.L.
      • Yelland J.
      • Lumley J.
      Mothers in a new country: the role of culture and communication in Vietnamese, Turkish and Filipino women’s experiences of giving birth in Australia.
      ,
      • Stapleton H.
      • Murphy R.
      • Correa-Velez I.
      • Steel M.
      • Kildea S.
      Women from refugee backgrounds and their experiences of attending a specialist antenatal clinic. Narratives from an Australian setting.
      ], typically qualitative interviews and surveys or clinical data. Included studies were assessed for methodological limitations using CASP [

      CASP. CASP Checklists 2018 Available from: https://casp-uk.net/casp-tools-checklists/.

      ]. Key concerns which emerged were typically in relation to reflexivity, research design and ethical considerations. The full critical appraisal table is available in Appendix 4.
      Six studies focused only on the antenatal period [
      • Owens C.
      • Dandy J.
      • Hancock P.
      Perceptions of pregnancy experiences when using a community-based antenatal service: a qualitative study of refugee and migrant women in Perth, Western Australia.
      ,
      • Carolan M.
      • Cassar L.
      Antenatal care perceptions of pregnant African women attending maternity services in Melbourne, Australia.
      ,
      • Carolan M.
      • Cassar L.
      Pregnancy care for African refugee women in Australia: attendance at antenatal appointments.
      ,
      • Riggs E.
      • Muyeen S.
      • Brown S.
      • Dawson W.
      • Petschel P.
      • Tardiff W.
      • et al.
      Cultural safety and belonging for refugee background women attending group pregnancy care: an Australian qualitative study.
      ,
      • Stapleton H.
      • Murphy R.
      • Correa-Velez I.
      • Steel M.
      • Kildea S.
      Women from refugee backgrounds and their experiences of attending a specialist antenatal clinic. Narratives from an Australian setting.
      ,
      • Tsianakas V.
      • Liamputtong P.
      Prenatal testing: the perceptions and experiences of Muslim women in Australia.
      ], five focused only on the perinatal period [
      • Murray L.
      • Windsor C.
      • Parker E.
      • Tewfik O.
      The experiences of African women giving birth in Brisbane, Australia.
      ,
      • Liamputtong P.
      • Watson L.F.
      The Meanings and Experiences of Cesarean Birth Among Cambodian, Lao and Vietnamese Immigrant Women in Australia.
      ,
      • Niner S.
      • Kokanovic R.
      • Cuthbert D.
      Displaced mothers: birth and resettlement, gratitude and complaint.
      ,
      • Small R.
      • Rice P.L.
      • Yelland J.
      • Lumley J.
      Mothers in a new country: the role of culture and communication in Vietnamese, Turkish and Filipino women’s experiences of giving birth in Australia.
      ,
      • Stewart D.E.
      • Das V.
      • Seibold M.
      Birth and empowerment: A qualitative study of the childbirth experience of Filipino migrant women in Brisbane, Australia.
      ] and seven focused only on the postpartum period [
      • Chu C.M.
      Postnatal experience and health needs of chinese migrant women in Brisbane, Australia.
      ,
      • Hoban E.
      • Liamputtong P.
      Cambodian migrant women’s postpartum experiences in Victoria, Australia.
      ,
      • Joseph J.
      • Liamputtong P.
      • Brodribb W.
      Postpartum breastfeeding experiences in the traditional‐biomedical crossroads: a qualitative study using drawing with Vietnamese and Myanmarese refugee women in Australia.
      ,
      • Rao V.S.
      • Dahlen H.G.
      • Razee H.
      Indian migrant women’s experiences of motherhood and postnatal support in Australia: a qualitative study.
      ,
      • Riggs E.
      • Davis E.
      • Gibbs L.
      • Block K.
      • Szwarc J.
      • Casey S.
      • et al.
      Accessing maternal and child health services in Melbourne, Australia: reflections from refugee families and service providers.
      ,
      • Russo A.
      • Lewis B.
      • Joyce A.
      • Crockett B.
      • Luchters S.
      A qualitative exploration of the emotional wellbeing and support needs of new mothers from Afghanistan living in Melbourne, Australia.
      ,
      • Shafiei T.
      • Small R.
      • McLachlan H.
      Immigrant Afghan women’s emotional well-being after birth and use of health services in Melbourne, Australia.
      ]. The remaining nine studies covered two or more periods [
      • Hoang H.T.
      • Le Q.
      • Kilpatrick S.
      Having a baby in the new land: a qualitative exploration of the experiences of Asian migrants in rural Tasmania, Australia.
      ,
      • Renzaho A.
      • Oldroyd J.
      Closing the gap in maternal and child health: a qualitative study examining health needs of migrant mothers in Dandenong, Victoria, Australia.
      ,
      • Correa-Velez I.
      • Ryan J.
      Developing a best practice model of refugee maternity care.
      ,
      • Mohale H.
      • Sweet L.
      • Graham K.
      Maternity health care: the experiences of Sub-Saharan African women in Sub-Saharan Africa and Australia.
      ,
      • Rolls C.
      • Chamberlain M.
      From east to west: Nepalese women’s experiences.
      ,
      • Shafiei T.
      • Small R.
      • McLachlan H.
      Women’s views and experiences of maternity care: A study of immigrant Afghan women in Melbourne, Australia.
      ,
      • Turkmani S.
      • Homer C.S.E.
      • Dawson A.J.
      Understanding the experiences and needs of migrant women affected by female genital mutilation using maternity services in Australia.
      ,
      • 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.
      ,
      • Yelland J.
      • Riggs E.
      • Wahidi S.
      • Fouladi F.
      • Casey S.
      • Szwarc J.
      • et al.
      How do Australian maternity and early childhood health services identify and respond to the settlement experience and social context of refugee background families?.
      ]. Almost all studies focused on the public healthcare system or community-based services, but one study also explored experiences in the private system [
      • Rao V.S.
      • Dahlen H.G.
      • Razee H.
      Indian migrant women’s experiences of motherhood and postnatal support in Australia: a qualitative study.
      ].
      All states and territories in Australia, except the Northern Territory, were represented. We included one study each from the Australian Capital Territory [
      • Rao V.S.
      • Dahlen H.G.
      • Razee H.
      Indian migrant women’s experiences of motherhood and postnatal support in Australia: a qualitative study.
      ], New South Wales [
      • Turkmani S.
      • Homer C.S.E.
      • Dawson A.J.
      Understanding the experiences and needs of migrant women affected by female genital mutilation using maternity services in Australia.
      ], South Australia [
      • Mohale H.
      • Sweet L.
      • Graham K.
      Maternity health care: the experiences of Sub-Saharan African women in Sub-Saharan Africa and Australia.
      ], Western Australia [
      • Owens C.
      • Dandy J.
      • Hancock P.
      Perceptions of pregnancy experiences when using a community-based antenatal service: a qualitative study of refugee and migrant women in Perth, Western Australia.
      ] and Tasmania [
      • Hoang H.T.
      • Le Q.
      • Kilpatrick S.
      Having a baby in the new land: a qualitative exploration of the experiences of Asian migrants in rural Tasmania, Australia.
      ], six from Queensland [
      • Murray L.
      • Windsor C.
      • Parker E.
      • Tewfik O.
      The experiences of African women giving birth in Brisbane, Australia.
      ,
      • Chu C.M.
      Postnatal experience and health needs of chinese migrant women in Brisbane, Australia.
      ,
      • Correa-Velez I.
      • Ryan J.
      Developing a best practice model of refugee maternity care.
      ,
      • Joseph J.
      • Liamputtong P.
      • Brodribb W.
      Postpartum breastfeeding experiences in the traditional‐biomedical crossroads: a qualitative study using drawing with Vietnamese and Myanmarese refugee women in Australia.
      ,
      • Stapleton H.
      • Murphy R.
      • Correa-Velez I.
      • Steel M.
      • Kildea S.
      Women from refugee backgrounds and their experiences of attending a specialist antenatal clinic. Narratives from an Australian setting.
      ,
      • Stewart D.E.
      • Das V.
      • Seibold M.
      Birth and empowerment: A qualitative study of the childbirth experience of Filipino migrant women in Brisbane, Australia.
      ], and sixteen from Victoria [
      • Renzaho A.
      • Oldroyd J.
      Closing the gap in maternal and child health: a qualitative study examining health needs of migrant mothers in Dandenong, Victoria, Australia.
      ,
      • Carolan M.
      • Cassar L.
      Antenatal care perceptions of pregnant African women attending maternity services in Melbourne, Australia.
      ,
      • Liamputtong P.
      • Watson L.F.
      The Meanings and Experiences of Cesarean Birth Among Cambodian, Lao and Vietnamese Immigrant Women in Australia.
      ,
      • Carolan M.
      • Cassar L.
      Pregnancy care for African refugee women in Australia: attendance at antenatal appointments.
      ,
      • Hoban E.
      • Liamputtong P.
      Cambodian migrant women’s postpartum experiences in Victoria, Australia.
      ,
      • Niner S.
      • Kokanovic R.
      • Cuthbert D.
      Displaced mothers: birth and resettlement, gratitude and complaint.
      ,
      • Riggs E.
      • Davis E.
      • Gibbs L.
      • Block K.
      • Szwarc J.
      • Casey S.
      • et al.
      Accessing maternal and child health services in Melbourne, Australia: reflections from refugee families and service providers.
      ,
      • Riggs E.
      • Muyeen S.
      • Brown S.
      • Dawson W.
      • Petschel P.
      • Tardiff W.
      • et al.
      Cultural safety and belonging for refugee background women attending group pregnancy care: an Australian qualitative study.
      ,
      • Rolls C.
      • Chamberlain M.
      From east to west: Nepalese women’s experiences.
      ,
      • Russo A.
      • Lewis B.
      • Joyce A.
      • Crockett B.
      • Luchters S.
      A qualitative exploration of the emotional wellbeing and support needs of new mothers from Afghanistan living in Melbourne, Australia.
      ,
      • Shafiei T.
      • Small R.
      • McLachlan H.
      Women’s views and experiences of maternity care: A study of immigrant Afghan women in Melbourne, Australia.
      ,
      • Shafiei T.
      • Small R.
      • McLachlan H.
      Immigrant Afghan women’s emotional well-being after birth and use of health services in Melbourne, Australia.
      ,
      • Small R.
      • Rice P.L.
      • Yelland J.
      • Lumley J.
      Mothers in a new country: the role of culture and communication in Vietnamese, Turkish and Filipino women’s experiences of giving birth in Australia.
      ,
      • Tsianakas V.
      • Liamputtong P.
      Prenatal testing: the perceptions and experiences of Muslim women in Australia.
      ,
      • 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.
      ,
      • Yelland J.
      • Riggs E.
      • Wahidi S.
      • Fouladi F.
      • Casey S.
      • Szwarc J.
      • et al.
      How do Australian maternity and early childhood health services identify and respond to the settlement experience and social context of refugee background families?.
      ]. Only one study was conducted in exclusively rural settings [
      • Hoang H.T.
      • Le Q.
      • Kilpatrick S.
      Having a baby in the new land: a qualitative exploration of the experiences of Asian migrants in rural Tasmania, Australia.
      ], one took place in both urban and rural areas [
      • Rolls C.
      • Chamberlain M.
      From east to west: Nepalese women’s experiences.
      ] and 25 were conducted in urban or suburban contexts [
      • Owens C.
      • Dandy J.
      • Hancock P.
      Perceptions of pregnancy experiences when using a community-based antenatal service: a qualitative study of refugee and migrant women in Perth, Western Australia.
      ,
      • Renzaho A.
      • Oldroyd J.
      Closing the gap in maternal and child health: a qualitative study examining health needs of migrant mothers in Dandenong, Victoria, Australia.
      ,
      • Carolan M.
      • Cassar L.
      Antenatal care perceptions of pregnant African women attending maternity services in Melbourne, Australia.
      ,
      • Murray L.
      • Windsor C.
      • Parker E.
      • Tewfik O.
      The experiences of African women giving birth in Brisbane, Australia.
      ,
      • Liamputtong P.
      • Watson L.F.
      The Meanings and Experiences of Cesarean Birth Among Cambodian, Lao and Vietnamese Immigrant Women in Australia.
      ,
      • Carolan M.
      • Cassar L.
      Pregnancy care for African refugee women in Australia: attendance at antenatal appointments.
      ,
      • Chu C.M.
      Postnatal experience and health needs of chinese migrant women in Brisbane, Australia.
      ,
      • Correa-Velez I.
      • Ryan J.
      Developing a best practice model of refugee maternity care.
      ,
      • Hoban E.
      • Liamputtong P.
      Cambodian migrant women’s postpartum experiences in Victoria, Australia.
      ,
      • Joseph J.
      • Liamputtong P.
      • Brodribb W.
      Postpartum breastfeeding experiences in the traditional‐biomedical crossroads: a qualitative study using drawing with Vietnamese and Myanmarese refugee women in Australia.
      ,
      • Mohale H.
      • Sweet L.
      • Graham K.
      Maternity health care: the experiences of Sub-Saharan African women in Sub-Saharan Africa and Australia.
      ,
      • Niner S.
      • Kokanovic R.
      • Cuthbert D.
      Displaced mothers: birth and resettlement, gratitude and complaint.
      ,
      • Rao V.S.
      • Dahlen H.G.
      • Razee H.
      Indian migrant women’s experiences of motherhood and postnatal support in Australia: a qualitative study.
      ,
      • Riggs E.
      • Davis E.
      • Gibbs L.
      • Block K.
      • Szwarc J.
      • Casey S.
      • et al.
      Accessing maternal and child health services in Melbourne, Australia: reflections from refugee families and service providers.
      ,
      • Riggs E.
      • Muyeen S.
      • Brown S.
      • Dawson W.
      • Petschel P.
      • Tardiff W.
      • et al.
      Cultural safety and belonging for refugee background women attending group pregnancy care: an Australian qualitative study.
      ,
      • Russo A.
      • Lewis B.
      • Joyce A.
      • Crockett B.
      • Luchters S.
      A qualitative exploration of the emotional wellbeing and support needs of new mothers from Afghanistan living in Melbourne, Australia.
      ,
      • Shafiei T.
      • Small R.
      • McLachlan H.
      Women’s views and experiences of maternity care: A study of immigrant Afghan women in Melbourne, Australia.
      ,
      • Shafiei T.
      • Small R.
      • McLachlan H.
      Immigrant Afghan women’s emotional well-being after birth and use of health services in Melbourne, Australia.
      ,
      • Small R.
      • Rice P.L.
      • Yelland J.
      • Lumley J.
      Mothers in a new country: the role of culture and communication in Vietnamese, Turkish and Filipino women’s experiences of giving birth in Australia.
      ,
      • Stapleton H.
      • Murphy R.
      • Correa-Velez I.
      • Steel M.
      • Kildea S.
      Women from refugee backgrounds and their experiences of attending a specialist antenatal clinic. Narratives from an Australian setting.
      ,
      • Stewart D.E.
      • Das V.
      • Seibold M.
      Birth and empowerment: A qualitative study of the childbirth experience of Filipino migrant women in Brisbane, Australia.
      ,
      • Tsianakas V.
      • Liamputtong P.
      Prenatal testing: the perceptions and experiences of Muslim women in Australia.
      ,
      • Turkmani S.
      • Homer C.S.E.
      • Dawson A.J.
      Understanding the experiences and needs of migrant women affected by female genital mutilation using maternity services in Australia.
      ,
      • 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.
      ,
      • Yelland J.
      • Riggs E.
      • Wahidi S.
      • Fouladi F.
      • Casey S.
      • Szwarc J.
      • et al.
      How do Australian maternity and early childhood health services identify and respond to the settlement experience and social context of refugee background families?.
      ].
      Participants came to Australia as migrants or refugees from 42 different countries of origin across Africa, Asia and the Middle East. Most studies focused on participants from countries classified as low and middle income, with only three representing high income countries [
      • Hoang H.T.
      • Le Q.
      • Kilpatrick S.
      Having a baby in the new land: a qualitative exploration of the experiences of Asian migrants in rural Tasmania, Australia.
      ,
      • Chu C.M.
      Postnatal experience and health needs of chinese migrant women in Brisbane, Australia.
      ,
      • Tsianakas V.
      • Liamputtong P.
      Prenatal testing: the perceptions and experiences of Muslim women in Australia.
      ]. While studies with participants from high-income European and North American countries were eligible for inclusion, no such study met the criteria for inclusion, despite these countries being considerable sources of migration to Australia []. For a complete overview of countries represented by each study, see Appendix 3. Nine studies exclusively focused on women from refugee backgrounds [
      • Carolan M.
      • Cassar L.
      Pregnancy care for African refugee women in Australia: attendance at antenatal appointments.
      ,
      • Correa-Velez I.
      • Ryan J.
      Developing a best practice model of refugee maternity care.
      ,
      • Joseph J.
      • Liamputtong P.
      • Brodribb W.
      Postpartum breastfeeding experiences in the traditional‐biomedical crossroads: a qualitative study using drawing with Vietnamese and Myanmarese refugee women in Australia.
      ,
      • Niner S.
      • Kokanovic R.
      • Cuthbert D.
      Displaced mothers: birth and resettlement, gratitude and complaint.
      ,
      • Riggs E.
      • Davis E.
      • Gibbs L.
      • Block K.
      • Szwarc J.
      • Casey S.
      • et al.
      Accessing maternal and child health services in Melbourne, Australia: reflections from refugee families and service providers.
      ,
      • Riggs E.
      • Muyeen S.
      • Brown S.
      • Dawson W.
      • Petschel P.
      • Tardiff W.
      • et al.
      Cultural safety and belonging for refugee background women attending group pregnancy care: an Australian qualitative study.
      ,
      • Russo A.
      • Lewis B.
      • Joyce A.
      • Crockett B.
      • Luchters S.
      A qualitative exploration of the emotional wellbeing and support needs of new mothers from Afghanistan living in Melbourne, Australia.
      ,
      • Stapleton H.
      • Murphy R.
      • Correa-Velez I.
      • Steel M.
      • Kildea S.
      Women from refugee backgrounds and their experiences of attending a specialist antenatal clinic. Narratives from an Australian setting.
      ,
      • Yelland J.
      • Riggs E.
      • Wahidi S.
      • Fouladi F.
      • Casey S.
      • Szwarc J.
      • et al.
      How do Australian maternity and early childhood health services identify and respond to the settlement experience and social context of refugee background families?.
      ]. For some studies, it was not stated whether the participants were refugees or non-humanitarian migrants, while for others, both groups were included as participants. Migrants and refugees are not a homogenous population, but, because we did not have enough information to accurately categorise most participants, our analysis does not separate them into subgroups based on this factor.

      Confidence in the review findings

      Of the 24 review findings below, one was graded as high confidence, 14 as moderate confidence and nine as low confidence using the CERQual approach [
      • Lewin S.
      • Booth A.
      • Glenton C.
      • Munthe-Kaas H.
      • Rashidian A.
      • Wainwright M.
      • et al.
      Applying GRADE-CERQual to qualitative evidence synthesis findings: introduction to the series.
      ]. Full assessments for each finding are available in Table 1.
      Table 1Summary of qualitative findings table and CERQUal assessments.
      #Summary of review findingStudies contributing to the review findingCERQual assessment (confidence in the findings)Explanation of CERQual assessment
      Factors influencing communication and understanding
      Language Barrier
      1Communication - Limited English proficiency made it challenging for women to communicate during appointments and hospital care as well as to receive maternal health education. This limited proficiency in turn contributed to distress and fear as women were unable to understand what was happening and how to request services.Carolan and Cassar, 2007, Chu, 2005, Hoang et al., 2009, Liamputtong and Watson, 2006, Mohale et al., 2017, Murray et al., 2010, Niner et al., 2013, Owens et al., 2016, Renzaho and Oldroyd, 2014, Riggs et al., 2012, Riggs et al., 2017, Small et al., 1999, Stewart et al., 1998, Yelland et al., 2016, Stapleton et al., 2013Moderate confidenceNo to very minor concerns on coherence, minor concerns on methodological limitations, minor concerns on relevance and minor concerns on adequacy.
      2Informed consent - The language barrier impeded some women’s ability to give informed consent for treatment, as they did not understand what treatment they were going to receive or why it was recommended.Liamputtong and Watson, 2006, Niner et al., 2013, Shafiei et al., 2012Low confidenceNo to very minor concerns on coherence, minor concerns on methodological limitations, moderate concerns on relevance (all studies Victorian and urban; only South East Asia and Middle East represented in area of birth) and serious concerns on adequacy (3 of 27 studies included; 1 relatively thin, 1 relatively thick and 1 thick data).
      3Translated health resources - Translated health resources were often not made available to women who needed them either because they did not exist or women were not informed they had the option of reading information in their preferred language.Correa-Velez and Ryan, 2012, Hoang et al., 2009, Riggs et al., 2012, Stewart et al., 1998Low confidenceNo to very minor concerns on coherence, minor concerns on methodological limitations, minor concerns on relevance and serious concerns on adequacy (4 of 27 studies included; 1 thin, 1 relatively thick and 2 thick data).
      4Assertiveness - Women often experienced challenges in asserting their wishes and asking questions of staff because they were not proficient in English or thought it inappropriate to question health workers, who were viewed as authority figures.Chu, 2005, Hoang et al., 2009, Liamputtong and Watson, 2006, Murray et al., 2010, Niner et al., 2013, Riggs et al., 2017, Shafiei et al., 2012, Small et al., 1999, Tsianakas and Liamputtong, 2002, Turkmani et al., 2020Moderate confidenceNo to very minor concerns on coherence, minor concerns on methodological limitations, minor concerns on relevance and minor concerns on adequacy.
      Interpreters
      5Value of interpreters - Women valued interpreters as they allowed women limited English proficiency to engage with health workers and to have greater input into their care.Carolan and Cassar, 2007, Correa-Velez and Ryan, 2012, Joseph et al., 2019, Small et al., 1999, Yelland et al., 2016Low confidenceNo to very minor concerns on coherence, minor concerns on relevance, moderate concerns on methodological limitations (study design, recruitment, reflexivity, ethics and data analysis) and serious concerns on adequacy (5 of 27 studies included; 2 thin and 3 relatively thick data).
      6Appropriate interpreters - When they were available, interpreting services are not always perceived as appropriate due to the demographics or dialect of the interpreter, or a general mistrust in the service.Correa-Velez and Ryan, 2012, Mohale et al., 2017, Small et al., 1999, Yelland et al., 2016Low confidenceNo to very minor concerns on coherence, minor concerns on relevance, moderate concerns on methodological limitations (study design, reflexivity, ethics and data analysis) and serious concerns on adequacy (4 of 27 studies included; 2 thin, 1 relatively thick data and 1 thick data).
      7Absence of interpreters - Despite their value, interpreters were frequently not present during appointments and hospital care. This absence often left women distressed and without agency, unable to communicate with their carers or understand the treatments they were receiving.Carolan and Cassar, 2007, Correa-Velez and Ryan, 2012, Hoban and Liamputtong, 2013, Liamputtong and Watson, 2006, Murray et al., 2010, Niner et al., 2013, Riggs et al., 2012, Riggs et al., 2017, Shafiei et al., 2012, Small et al., 1999, Yelland et al., 2016Moderate confidenceNo to very minor concerns on coherence, minor concerns on methodological limitations, minor concerns on relevance and minor concerns on adequacy.
      8Informal interpreters - In the absence of a professional interpreter, husbands and other family members often served as informal interpreters during appointments. The use of informal interpreters was comfortable and acceptable for some women but concerning to others about due to embarrassment over sharing sensitive health matters or the family member incompletely relaying information.Hoban and Liamputtong, 2013, Murray et al., 2010, Owens et al., 2016, Riggs et al., 2017, Small et al., 1999, Yelland et al., 2016Moderate confidenceNo to very minor concerns on coherence, minor concerns on methodological limitations, minor concerns on relevance and moderate concerns on adequacy (6 of 27 studies included; 1 thin, 1 relatively thin, 2 relatively thick and 2 thick data).
      Factors influencing experiences of and satisfaction with care
      Accessibility
      9Transport - Some women experienced transport-related barriers to accessing care due to an inability to drive or lack of access to a vehicle.Hoban and Liamputtong, 2013, Murray et al., 2010, Owens et al., 2016, Riggs et al., 2017, Small et al., 1999, Yelland et al., 2016Low confidenceNo to very minor concerns on coherence, minor concerns on methodological limitations, minor concerns on relevance and serious concerns on adequacy (5 of 27 studies included; 2 thin, 1 relatively thin, 1 relatively thick and 1 thick data).
      10Appointments - Some women found the practice of attending appointments to be challenging due to unfamiliar expectations around timeliness and long wait times.Chu, 2005, Correa-Velez and Ryan, 2012, Mohale et al., 2017, Owens et al., 2016, Riggs et al., 2012, Shafiei et al., 2012, Stapleton et al., 2013Moderate confidenceNo to very minor concerns on coherence, minor concerns on methodological limitations, minor concerns on relevance and moderate concerns on adequacy (5 of 27 studies included; 2 thin, 1 relatively thin, 1 relatively thick and 3 thick data).
      Women’s experiences of care
      11Specialist services - Women who had access to specialist clinics and services, such as an African women’s clinic, a co-designed program for women from refugee backgrounds or dedicated maternal and child health centres, viewed these more favourably than mainstream services. These specialist services were appreciated due to understanding staff, appointment flexibility and a friendly atmosphereCarolan and Cassar, 2007, Carolan and Cassar, 2010, Owens et al., 2016, Riggs et al., 2017Low confidenceNo to very minor concerns on coherence, minor concerns on methodological limitations, minor concerns on relevance and serious concerns on adequacy (4 of 27 studies included; 1 relatively thin, 2 relatively thick and 1 thick data).
      12Continuity of carer - Women valued continuity of carer because of the ability to develop trusting relationships with health worker. Women who did not experience continuity of care lamented having to engage with unfamiliar health workers at each appointment.Correa-Velez and Ryan, 2012, Mohale et al., 2017, Murray et al., 2010, Owens et al., 2016, Rao et al., 2019, Riggs et al., 2012, Riggs et al., 2017, Stapleton et al., 2013, Turkmani et al., 2020Moderate confidenceNo to very minor concerns on coherence, minor concerns on methodological limitations, minor concerns on relevance and minor concerns on adequacy.
      13Time with health workers - Women sometimes felt they did not get sufficient time with health workers in mainstream healthcare settings. This prevented them from asking questions about their care, receiving additional information and being able to talk about their emotional wellbeing.Carolan and Cassar, 2007, Carolan and Cassar, 2010, Murray et al., 2010, Owens et al., 2016, Shafiei et al., 2012, Shafiei et al., 2015Moderate confidenceNo to very minor concerns on coherence, minor concerns on relevance, minor concerns on methodological limitations and moderate concerns on adequacy (6 of 27 studies included; 2 thick and 4 thin data).
      Experience with health workers
      14Midwives and doctors - Midwives and nurses were generally viewed as kind and helpful by women. Midwives and nurses were sometimes contrasted favourably with doctors who were sometimes seen as rushed and less personable.Carolan and Cassar, 2007, Carolan and Cassar, 2010, Murray et al., 2010, Owens et al., 2016, Shafiei et al., 2012, Shafiei et al., 2015Moderate ConfidenceNo to very minor concerns on coherence, minor concerns on methodological limitations, minor concerns on relevance and minor concerns on adequacy.
      15Social support - Migrating to Australia means that some women lacked the social support during pregnancy, birth and the post-partum period they might have expected in their home country. This made the relationship with between women and health workers more important.Joseph et al., 2019, Owens et al., 2016, Rao et al., 2019, Stapleton et al., 2013Low confidenceNo to very minor concerns on relevance, no to very minor relevance on coherence, minor concerns on methodological limitations and serious concerns on adequacy (4 of 27 studies included; 2 thin, 1 relatively thick and 1 thick data).
      Trust
      16Trust in health workers - Health workers in Australia were trusted by some women, who viewed them as highly knowledgeable. However, others held concerns about their intentions.Carolan and Cassar, 2007, Carolan and Cassar, 2010, Correa-Velez and Ryan, 2012, Liamputtong and Watson, 2006, Niner et al., 2013, Owens et al., 2016, Riggs et al., 2017, Rolls and Chamberlain, 2004, Shafiei et al., 2012, Tsianakas and Liamputtong, 2002, Turkmani et al., 2020, Joseph et al., 2019, Murray et al., 2010, Russo et al., 2015Moderate ConfidenceNo or very minor concerns on coherence, minor concerns on methodological limitations, minor concerns on relevance and minor concerns on adequacy.
      17Trust in medicine and technology - Some women expressed mistrust and scepticism towards modern Western medical technology and drugs due to concerns these interventions could be harmful to their babies. Meanwhile, others appreciated having access to more advanced medical care than would be available in their birth countries.Carolan and Cassar, 2010, Correa-Velez and Ryan, 2012, Murray et al., 2010, Stewart et al., 1998, Tsianakas and Liamputtong, 2002, Niner et al., 2013, Rolls and Chamberlain, 2004, Russo et al., 2015, Shafiei et al., 2012Low confidenceNo or very minor concerns on coherence, minor concerns on relevance, moderate concerns on methodological limitations (study design, ethics, reflexivity, analysis and evidence) and moderate concern on adequacy (9 of 27 studies included; 6 thin and 3 thick data).
      Discrimination
      18Hostility and discrimination - Many women reported experiencing hostile treatment which was characterised by some as discrimination while others references a more vague sense of being unwelcome.Carolan and Cassar, 2007, Carolan and Cassar, 2010, Chu, 2005, Murray et al., 2010, Niner et al., 2013, Riggs et al., 2017, Russo et al., 2015, Shafiei et al., 2012, Shafiei et al., 2015, Small et al., 1999, Stewart et al., 1998, Tsianakas and Liamputtong, 2002Moderate confidenceNo or minor concerns on coherence, minor concerns on relevance, minor concerns on adequacy and moderate concerns on methodological limitations (study design, recruitment, ethics, reflexivity, analysis and evidence).
      Navigating cultural crossroads
      Preferences and expectations for care
      19Female health workers - Women from a broad range of cultural backgrounds expressed a strong preference for female health workers due to cultural beliefs about appropriate behaviour between men and women. Women who had male health workers often found the experience uncomfortable and distressing.Murray et al., 2010, Owens et al., 2016, Russo et al., 2015, Shafiei et al., 2012, Shafiei et al., 2015, Stewart et al., 1998, Yelland et al., 2016Moderate confidenceNo or very minor concerns on coherence, minor concerns on methodological limitations, minor concerns on relevance and moderate concerns on adequacy.
      20Pain relief - Many women held strong preferences for vaginal birth and traditional, non-pharmacological pain relief. This was because they perceived the pain associated with labour and vaginal birth to be an important element of their experience as women.Carolan and Cassar, 2010, Mohale et al., 2017, Murray et al., 2010, Shafiei et al., 2012, Turkmani et al., 2020Low confidenceNo to minor concerns on coherence, minor concerns on methodological limitations, minor concerns on relevance and serious concerns on adequacy (5 of 27 studies; 3 thick and 2 thin data)
      21Medical interventions - Women preferred to avoid medical interventions during the labour process, such as induction, augmentation and caesarean section, as much as possible because these were seen as largely unnecessary, even during extended labour.Carolan and Cassar, 2010, Liamputtong and Watson, 2006, Murray et al., 2010, Shafiei et al., 2012, Stapleton et al., 2013, Turkmani et al., 2020Moderate confidenceNo or very minor concerns on coherence, minor concerns on methodological limitations, minor concerns on relevance and moderate concerns on adequacy (6 of 27 studies included; 1 thin, 1 relatively thin, 2 relatively thick and 2 thick data).
      22Traditional practices - Most women wanted and expected to be able to maintain traditional practices related to pregnancy, birthing and post-partum, such as keeping themselves warm, limiting bathing and confinement, within the context of the Australian healthcare system. An inability to maintain these traditions was associated with sadness and anxiety.Chu, 2005, Joseph et al., 2019, Liamputtong and Watson, 2006, Niner et al., 2013, Renzaho and Oldroyd, 2014, Russo et al., 2015, Small et al., 1999, Stewart et al., 1998, Turkmani et al., 2020High confidenceNo or very minor concerns on coherence, minor concerns on methodological limitations, minor concerns on relevance and minor concerns on adequacy (9 of 27 studies included; 1 thin data, 1 relatively thin data and 7 thick data).
      Dealing with conflicting beliefs and practices
      23Cultural conflict - Women frequently reported struggling with whether to comply with advice from Australian doctors and midwives, who were seen as knowledgeable professionals, that contradicted traditional cultural practices which were often passed on by respected older female relatives. Women reported having a deep appreciation for care that allowed them to combine both traditional and Australian biomedical approaches to maternal healthcare.Carolan and Cassar, 2010, Chu, 2005, Hoang et al., 2009, Joseph et al., 2019, Liamputtong and Watson, 2006, Murray et al., 2010, Niner et al., 2013, Rao et al., 2019, Renzaho and Oldroyd, 2014, Russo et al., 2015, Small et al., 1999, Stapleton et al., 2013, Stewart et al., 1998Moderate confidenceNo or very minor concerns on coherence, no or very minor concerns on adequacy, minor concerns on methodological limitations and minor concerns on relevance.
      24FGM/C - Women who have undergone FGM/C almost universally reported negative experiences with Australian health workers who they perceived as being surprised and unequipped to deal with their condition, making the women feel abnormal and anxious as a result.Carolan and Cassar, 2007, Correa-Velez and Ryan, 2012, Murray et al., 2010, Stapleton et al., 2013, Turkmani et al., 2020Moderate confidenceNo or very minor concerns on coherence, minor concerns on methodological limitations, minor concerns on relevance and moderate concerns on relevance (5 studies included; 3 thick and 2 thin data).

      Qualitative evidence synthesis

      This section presents the QES findings (Table 1) arranged under three emergent domains: factors influencing communication and understanding, factors influencing experiences of and satisfaction with care and navigating cultural crossroads (Fig. 2).
      Fig. 2
      Fig. 2Diagram describing the relationships between the key themes and findings, women and the health workers and the healthcare system, emphasising the centrality of communication and understanding.

      Factors influencing communication and understanding

      Themes relating to communication and understanding were present in almost all studies. This reflects its centrality to how women experience and perceive care. Sub-themes analysed include the language barrier related to English proficiency and experiences with and access to interpreters.

      Language barriers

      Finding 1: Communication - Limited English proficiency made it challenging for women to communicate during appointments and hospital care as well as to receive maternal health education. This limited proficiency in turn contributed to distress and fear as women were unable to understand what was happening and how to request services (Moderate confidence) [
      • Hoang H.T.
      • Le Q.
      • Kilpatrick S.
      Having a baby in the new land: a qualitative exploration of the experiences of Asian migrants in rural Tasmania, Australia.
      ,
      • Owens C.
      • Dandy J.
      • Hancock P.
      Perceptions of pregnancy experiences when using a community-based antenatal service: a qualitative study of refugee and migrant women in Perth, Western Australia.
      ,
      • Renzaho A.
      • Oldroyd J.
      Closing the gap in maternal and child health: a qualitative study examining health needs of migrant mothers in Dandenong, Victoria, Australia.
      ,
      • Murray L.
      • Windsor C.
      • Parker E.
      • Tewfik O.
      The experiences of African women giving birth in Brisbane, Australia.
      ,
      • Liamputtong P.
      • Watson L.F.
      The Meanings and Experiences of Cesarean Birth Among Cambodian, Lao and Vietnamese Immigrant Women in Australia.
      ,
      • Carolan M.
      • Cassar L.
      Pregnancy care for African refugee women in Australia: attendance at antenatal appointments.
      ,
      • Chu C.M.
      Postnatal experience and health needs of chinese migrant women in Brisbane, Australia.
      ,
      • Mohale H.
      • Sweet L.
      • Graham K.
      Maternity health care: the experiences of Sub-Saharan African women in Sub-Saharan Africa and Australia.
      ,
      • Niner S.
      • Kokanovic R.
      • Cuthbert D.
      Displaced mothers: birth and resettlement, gratitude and complaint.
      ,
      • Riggs E.
      • Davis E.
      • Gibbs L.
      • Block K.
      • Szwarc J.
      • Casey S.
      • et al.
      Accessing maternal and child health services in Melbourne, Australia: reflections from refugee families and service providers.
      ,
      • Riggs E.
      • Muyeen S.
      • Brown S.
      • Dawson W.
      • Petschel P.
      • Tardiff W.
      • et al.
      Cultural safety and belonging for refugee background women attending group pregnancy care: an Australian qualitative study.
      ,
      • Small R.
      • Rice P.L.
      • Yelland J.
      • Lumley J.
      Mothers in a new country: the role of culture and communication in Vietnamese, Turkish and Filipino women’s experiences of giving birth in Australia.
      ,
      • Stapleton H.
      • Murphy R.
      • Correa-Velez I.
      • Steel M.
      • Kildea S.
      Women from refugee backgrounds and their experiences of attending a specialist antenatal clinic. Narratives from an Australian setting.
      ,
      • Stewart D.E.
      • Das V.
      • Seibold M.
      Birth and empowerment: A qualitative study of the childbirth experience of Filipino migrant women in Brisbane, Australia.
      ,
      • Turkmani S.
      • Homer C.S.E.
      • Dawson A.J.
      Understanding the experiences and needs of migrant women affected by female genital mutilation using maternity services in Australia.
      ,
      • 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.
      ]. This came from the difficulty both in understanding what was being said [
      • Renzaho A.
      • Oldroyd J.
      Closing the gap in maternal and child health: a qualitative study examining health needs of migrant mothers in Dandenong, Victoria, Australia.
      ,
      • Murray L.
      • Windsor C.
      • Parker E.
      • Tewfik O.
      The experiences of African women giving birth in Brisbane, Australia.
      ,
      • Liamputtong P.
      • Watson L.F.
      The Meanings and Experiences of Cesarean Birth Among Cambodian, Lao and Vietnamese Immigrant Women in Australia.
      ,
      • Small R.
      • Rice P.L.
      • Yelland J.
      • Lumley J.
      Mothers in a new country: the role of culture and communication in Vietnamese, Turkish and Filipino women’s experiences of giving birth in Australia.
      ] and the ability to be understood themselves [
      • Niner S.
      • Kokanovic R.
      • Cuthbert D.
      Displaced mothers: birth and resettlement, gratitude and complaint.
      ,
      • Riggs E.
      • Davis E.
      • Gibbs L.
      • Block K.
      • Szwarc J.
      • Casey S.
      • et al.
      Accessing maternal and child health services in Melbourne, Australia: reflections from refugee families and service providers.
      ,
      • Small R.
      • Rice P.L.
      • Yelland J.
      • Lumley J.
      Mothers in a new country: the role of culture and communication in Vietnamese, Turkish and Filipino women’s experiences of giving birth in Australia.
      ]. Limited English proficiency made routine aspects of maternity care, like booking appointments or attending antenatal classes, intimidating and caused some women to forgo these altogether [
      • Hoang H.T.
      • Le Q.
      • Kilpatrick S.
      Having a baby in the new land: a qualitative exploration of the experiences of Asian migrants in rural Tasmania, Australia.
      ,
      • Riggs E.
      • Davis E.
      • Gibbs L.
      • Block K.
      • Szwarc J.
      • Casey S.
      • et al.
      Accessing maternal and child health services in Melbourne, Australia: reflections from refugee families and service providers.
      ]. Women describe communication challenges as exacerbating the anxiety and fear the already felt about labour and birth [
      • Murray L.
      • Windsor C.
      • Parker E.
      • Tewfik O.
      The experiences of African women giving birth in Brisbane, Australia.
      ,
      • Niner S.
      • Kokanovic R.
      • Cuthbert D.
      Displaced mothers: birth and resettlement, gratitude and complaint.
      ,
      • Riggs E.
      • Davis E.
      • Gibbs L.
      • Block K.
      • Szwarc J.
      • Casey S.
      • et al.
      Accessing maternal and child health services in Melbourne, Australia: reflections from refugee families and service providers.
      ,
      • Small R.
      • Rice P.L.
      • Yelland J.
      • Lumley J.
      Mothers in a new country: the role of culture and communication in Vietnamese, Turkish and Filipino women’s experiences of giving birth in Australia.
      ,
      • Stapleton H.
      • Murphy R.
      • Correa-Velez I.
      • Steel M.
      • Kildea S.
      Women from refugee backgrounds and their experiences of attending a specialist antenatal clinic. Narratives from an Australian setting.
      ]. Some found the experience of being unable to communicate, especially during labour, to be “scary” and isolating [
      • Murray L.
      • Windsor C.
      • Parker E.
      • Tewfik O.
      The experiences of African women giving birth in Brisbane, Australia.
      ,
      • Niner S.
      • Kokanovic R.
      • Cuthbert D.
      Displaced mothers: birth and resettlement, gratitude and complaint.
      ,
      • Riggs E.
      • Davis E.
      • Gibbs L.
      • Block K.
      • Szwarc J.
      • Casey S.
      • et al.
      Accessing maternal and child health services in Melbourne, Australia: reflections from refugee families and service providers.
      ,
      • Small R.
      • Rice P.L.
      • Yelland J.
      • Lumley J.
      Mothers in a new country: the role of culture and communication in Vietnamese, Turkish and Filipino women’s experiences of giving birth in Australia.
      ,
      • Stapleton H.
      • Murphy R.
      • Correa-Velez I.
      • Steel M.
      • Kildea S.
      Women from refugee backgrounds and their experiences of attending a specialist antenatal clinic. Narratives from an Australian setting.
      ].
      Finding 2: Informed consent - The language barrier impeded some women’s ability to give informed consent for treatment, as they did not understand what treatment they were going to receive or why it was recommended (Low confidence) [
      • Liamputtong P.
      • Watson L.F.
      The Meanings and Experiences of Cesarean Birth Among Cambodian, Lao and Vietnamese Immigrant Women in Australia.
      ,
      • Niner S.
      • Kokanovic R.
      • Cuthbert D.
      Displaced mothers: birth and resettlement, gratitude and complaint.
      ,
      • Shafiei T.
      • Small R.
      • McLachlan H.
      Women’s views and experiences of maternity care: A study of immigrant Afghan women in Melbourne, Australia.
      ]. Several studies include accounts of women who did not fully understand the potential risks and benefits of the procedures they were agreeing to due to their lack of English proficiency and inadequate allowances for this made by healthcare providers [
      • Liamputtong P.
      • Watson L.F.
      The Meanings and Experiences of Cesarean Birth Among Cambodian, Lao and Vietnamese Immigrant Women in Australia.
      ,
      • Niner S.
      • Kokanovic R.
      • Cuthbert D.
      Displaced mothers: birth and resettlement, gratitude and complaint.
      ,
      • Shafiei T.
      • Small R.
      • McLachlan H.
      Women’s views and experiences of maternity care: A study of immigrant Afghan women in Melbourne, Australia.
      ]. Sometimes the women’s husbands signed consent forms on their behalf [
      • Liamputtong P.
      • Watson L.F.
      The Meanings and Experiences of Cesarean Birth Among Cambodian, Lao and Vietnamese Immigrant Women in Australia.
      ,
      • Shafiei T.
      • Small R.
      • McLachlan H.
      Women’s views and experiences of maternity care: A study of immigrant Afghan women in Melbourne, Australia.
      ], but they also did not comprehend or explain to their wives the nature of procedure, including for serious procedures like hysterectomy [
      • Shafiei T.
      • Small R.
      • McLachlan H.
      Women’s views and experiences of maternity care: A study of immigrant Afghan women in Melbourne, Australia.
      ].
      Finding 3: Translated health resources - Translated health resources were often not made available to women who needed them either because they did not exist or women were not informed they had the option of reading information in their preferred language (Low confidence) [
      • Hoang H.T.
      • Le Q.
      • Kilpatrick S.
      Having a baby in the new land: a qualitative exploration of the experiences of Asian migrants in rural Tasmania, Australia.
      ,
      • Correa-Velez I.
      • Ryan J.
      Developing a best practice model of refugee maternity care.
      ,
      • Riggs E.
      • Davis E.
      • Gibbs L.
      • Block K.
      • Szwarc J.
      • Casey S.
      • et al.
      Accessing maternal and child health services in Melbourne, Australia: reflections from refugee families and service providers.
      ,
      • Stewart D.E.
      • Das V.
      • Seibold M.
      Birth and empowerment: A qualitative study of the childbirth experience of Filipino migrant women in Brisbane, Australia.
      ]. If information in the woman’s preferred language was available from healthcare providers, this was not always offered and women did not know to ask for it [
      • Hoang H.T.
      • Le Q.
      • Kilpatrick S.
      Having a baby in the new land: a qualitative exploration of the experiences of Asian migrants in rural Tasmania, Australia.
      ,
      • Correa-Velez I.
      • Ryan J.
      Developing a best practice model of refugee maternity care.
      ,
      • Riggs E.
      • Davis E.
      • Gibbs L.
      • Block K.
      • Szwarc J.
      • Casey S.
      • et al.
      Accessing maternal and child health services in Melbourne, Australia: reflections from refugee families and service providers.
      ]. In one case, a participant found out later that there were translated resources available in her language, indicating that materials which do exist may not be proactively offered [
      • Hoang H.T.
      • Le Q.
      • Kilpatrick S.
      Having a baby in the new land: a qualitative exploration of the experiences of Asian migrants in rural Tasmania, Australia.
      ].
      Finding 4: Assertiveness - Women often experienced challenges in asserting their wishes and asking questions of staff because they were not proficient in English or thought it inappropriate to question health workers, who were viewed as authority figures (Moderate confidence) [
      • Hoang H.T.
      • Le Q.
      • Kilpatrick S.
      Having a baby in the new land: a qualitative exploration of the experiences of Asian migrants in rural Tasmania, Australia.
      ,
      • Murray L.
      • Windsor C.
      • Parker E.
      • Tewfik O.
      The experiences of African women giving birth in Brisbane, Australia.
      ,
      • Liamputtong P.
      • Watson L.F.
      The Meanings and Experiences of Cesarean Birth Among Cambodian, Lao and Vietnamese Immigrant Women in Australia.
      ,
      • Chu C.M.
      Postnatal experience and health needs of chinese migrant women in Brisbane, Australia.
      ,
      • Niner S.
      • Kokanovic R.
      • Cuthbert D.
      Displaced mothers: birth and resettlement, gratitude and complaint.
      ,
      • Riggs E.
      • Muyeen S.
      • Brown S.
      • Dawson W.
      • Petschel P.
      • Tardiff W.
      • et al.
      Cultural safety and belonging for refugee background women attending group pregnancy care: an Australian qualitative study.
      ,
      • Shafiei T.
      • Small R.
      • McLachlan H.
      Women’s views and experiences of maternity care: A study of immigrant Afghan women in Melbourne, Australia.
      ,
      • Small R.
      • Rice P.L.
      • Yelland J.
      • Lumley J.
      Mothers in a new country: the role of culture and communication in Vietnamese, Turkish and Filipino women’s experiences of giving birth in Australia.
      ,
      • Tsianakas V.
      • Liamputtong P.
      Prenatal testing: the perceptions and experiences of Muslim women in Australia.
      ,
      • Turkmani S.
      • Homer C.S.E.
      • Dawson A.J.
      Understanding the experiences and needs of migrant women affected by female genital mutilation using maternity services in Australia.
      ]. Many participants cited not speaking English proficiently as the primary cause of these difficulties, being more comfortable as passive participants in their care rather than attempting to take on a more active role by communicating in a language they were not fluent in [
      • Murray L.
      • Windsor C.
      • Parker E.
      • Tewfik O.
      The experiences of African women giving birth in Brisbane, Australia.
      ,
      • Liamputtong P.
      • Watson L.F.
      The Meanings and Experiences of Cesarean Birth Among Cambodian, Lao and Vietnamese Immigrant Women in Australia.
      ,
      • Niner S.
      • Kokanovic R.
      • Cuthbert D.
      Displaced mothers: birth and resettlement, gratitude and complaint.
      ,
      • Shafiei T.
      • Small R.
      • McLachlan H.
      Women’s views and experiences of maternity care: A study of immigrant Afghan women in Melbourne, Australia.
      ,
      • Turkmani S.
      • Homer C.S.E.
      • Dawson A.J.
      Understanding the experiences and needs of migrant women affected by female genital mutilation using maternity services in Australia.
      ]. Other reasons were also given, such as in one study with participants from Asian backgrounds described their lack of assertiveness as a cultural trait [
      • Hoang H.T.
      • Le Q.
      • Kilpatrick S.
      Having a baby in the new land: a qualitative exploration of the experiences of Asian migrants in rural Tasmania, Australia.
      ]. Further, a number of participants expressed a feeling that questioning health workers was impolite, as they were viewed as authority figures with higher social status [
      • Murray L.
      • Windsor C.
      • Parker E.
      • Tewfik O.
      The experiences of African women giving birth in Brisbane, Australia.
      ,
      • Riggs E.
      • Muyeen S.
      • Brown S.
      • Dawson W.
      • Petschel P.
      • Tardiff W.
      • et al.
      Cultural safety and belonging for refugee background women attending group pregnancy care: an Australian qualitative study.
      ,
      • Tsianakas V.
      • Liamputtong P.
      Prenatal testing: the perceptions and experiences of Muslim women in Australia.
      ,
      • Turkmani S.
      • Homer C.S.E.
      • Dawson A.J.
      Understanding the experiences and needs of migrant women affected by female genital mutilation using maternity services in Australia.
      ].

      Interpreters

      Finding 5: Value of interpreters - Women valued interpreters as they allowed women limited English proficiency to engage with health workers and to have greater input into their care (Low confidence) [
      • Carolan M.
      • Cassar L.
      Pregnancy care for African refugee women in Australia: attendance at antenatal appointments.
      ,
      • Correa-Velez I.
      • Ryan J.
      Developing a best practice model of refugee maternity care.
      ,
      • Joseph J.
      • Liamputtong P.
      • Brodribb W.
      Postpartum breastfeeding experiences in the traditional‐biomedical crossroads: a qualitative study using drawing with Vietnamese and Myanmarese refugee women in Australia.
      ,
      • Small R.
      • Rice P.L.
      • Yelland J.
      • Lumley J.
      Mothers in a new country: the role of culture and communication in Vietnamese, Turkish and Filipino women’s experiences of giving birth in Australia.
      ,
      • 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.
      ]. When made available, professional interpreters were positively received by most women [
      • Carolan M.
      • Cassar L.
      Pregnancy care for African refugee women in Australia: attendance at antenatal appointments.
      ,
      • Correa-Velez I.
      • Ryan J.
      Developing a best practice model of refugee maternity care.
      ,
      • Joseph J.
      • Liamputtong P.
      • Brodribb W.
      Postpartum breastfeeding experiences in the traditional‐biomedical crossroads: a qualitative study using drawing with Vietnamese and Myanmarese refugee women in Australia.
      ,
      • Small R.
      • Rice P.L.
      • Yelland J.
      • Lumley J.
      Mothers in a new country: the role of culture and communication in Vietnamese, Turkish and Filipino women’s experiences of giving birth in Australia.
      ]. Having an interpreter also decreased fear and confusion for some women as the interpreter was able to explain what was happening and why medical staff were taking the actions they were [
      • Carolan M.
      • Cassar L.
      Pregnancy care for African refugee women in Australia: attendance at antenatal appointments.
      ,
      • Joseph J.
      • Liamputtong P.
      • Brodribb W.
      Postpartum breastfeeding experiences in the traditional‐biomedical crossroads: a qualitative study using drawing with Vietnamese and Myanmarese refugee women in Australia.
      ].
      Finding 6: Appropriate interpreters - When they were available, interpreting services are not always perceived as appropriate, due to the demographics or dialect of the interpreter, or a general mistrust in the service (Low confidence) [
      • Correa-Velez I.
      • Ryan J.
      Developing a best practice model of refugee maternity care.
      ,
      • Mohale H.
      • Sweet L.
      • Graham K.
      Maternity health care: the experiences of Sub-Saharan African women in Sub-Saharan Africa and Australia.
      ,
      • Small R.
      • Rice P.L.
      • Yelland J.
      • Lumley J.
      Mothers in a new country: the role of culture and communication in Vietnamese, Turkish and Filipino women’s experiences of giving birth in Australia.
      ,
      • 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.
      ]. Women who did have an interpreter present during their birth or appointments sometimes reported feeling uncomfortable with the service provided. Women cited a range of reasons for this, including the provision of male or very young interpreters, who were not viewed as culturally appropriate [
      • Correa-Velez I.
      • Ryan J.
      Developing a best practice model of refugee maternity care.
      ,
      • 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.
      ], interpreters from a different dialect background [
      • Correa-Velez I.
      • Ryan J.
      Developing a best practice model of refugee maternity care.
      ,
      • 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.
      ], incorrect relaying of information [
      • Small R.
      • Rice P.L.
      • Yelland J.
      • Lumley J.
      Mothers in a new country: the role of culture and communication in Vietnamese, Turkish and Filipino women’s experiences of giving birth in Australia.
      ] and a mistrust in the confidentiality of the service [
      • Mohale H.
      • Sweet L.
      • Graham K.
      Maternity health care: the experiences of Sub-Saharan African women in Sub-Saharan Africa and Australia.
      ].
      Finding 7: Absence of interpreters - Despite their value, interpreters were frequently not present during appointments and hospital care. This absence often left women distressed and without agency, unable to communicate with their carers or understand the treatments they were receiving (Moderate confidence) [
      • Murray L.
      • Windsor C.
      • Parker E.
      • Tewfik O.
      The experiences of African women giving birth in Brisbane, Australia.
      ,
      • Liamputtong P.
      • Watson L.F.
      The Meanings and Experiences of Cesarean Birth Among Cambodian, Lao and Vietnamese Immigrant Women in Australia.
      ,
      • Carolan M.
      • Cassar L.
      Pregnancy care for African refugee women in Australia: attendance at antenatal appointments.
      ,
      • Correa-Velez I.
      • Ryan J.
      Developing a best practice model of refugee maternity care.
      ,
      • Hoban E.
      • Liamputtong P.
      Cambodian migrant women’s postpartum experiences in Victoria, Australia.
      ,
      • Niner S.
      • Kokanovic R.
      • Cuthbert D.
      Displaced mothers: birth and resettlement, gratitude and complaint.
      ,
      • Riggs E.
      • Davis E.
      • Gibbs L.
      • Block K.
      • Szwarc J.
      • Casey S.
      • et al.
      Accessing maternal and child health services in Melbourne, Australia: reflections from refugee families and service providers.
      ,
      • Riggs E.
      • Muyeen S.
      • Brown S.
      • Dawson W.
      • Petschel P.
      • Tardiff W.
      • et al.
      Cultural safety and belonging for refugee background women attending group pregnancy care: an Australian qualitative study.
      ,
      • Shafiei T.
      • Small R.
      • McLachlan H.
      Women’s views and experiences of maternity care: A study of immigrant Afghan women in Melbourne, Australia.
      ,
      • Small R.
      • Rice P.L.
      • Yelland J.
      • Lumley J.
      Mothers in a new country: the role of culture and communication in Vietnamese, Turkish and Filipino women’s experiences of giving birth in Australia.
      ,
      • 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.
      ]. Women often gave birth and received treatments without an interpreter present to facilitate communication with staff [
      • Murray L.
      • Windsor C.
      • Parker E.
      • Tewfik O.
      The experiences of African women giving birth in Brisbane, Australia.
      ,
      • Liamputtong P.
      • Watson L.F.
      The Meanings and Experiences of Cesarean Birth Among Cambodian, Lao and Vietnamese Immigrant Women in Australia.
      ,
      • Carolan M.
      • Cassar L.
      Pregnancy care for African refugee women in Australia: attendance at antenatal appointments.
      ,
      • Correa-Velez I.
      • Ryan J.
      Developing a best practice model of refugee maternity care.
      ,
      • Hoban E.
      • Liamputtong P.
      Cambodian migrant women’s postpartum experiences in Victoria, Australia.
      ,
      • Niner S.
      • Kokanovic R.
      • Cuthbert D.
      Displaced mothers: birth and resettlement, gratitude and complaint.
      ,
      • Riggs E.
      • Davis E.
      • Gibbs L.
      • Block K.
      • Szwarc J.
      • Casey S.
      • et al.
      Accessing maternal and child health services in Melbourne, Australia: reflections from refugee families and service providers.
      ,
      • Riggs E.
      • Muyeen S.
      • Brown S.
      • Dawson W.
      • Petschel P.
      • Tardiff W.
      • et al.
      Cultural safety and belonging for refugee background women attending group pregnancy care: an Australian qualitative study.
      ,
      • Shafiei T.
      • Small R.
      • McLachlan H.
      Women’s views and experiences of maternity care: A study of immigrant Afghan women in Melbourne, Australia.
      ,
      • Small R.
      • Rice P.L.
      • Yelland J.
      • Lumley J.
      Mothers in a new country: the role of culture and communication in Vietnamese, Turkish and Filipino women’s experiences of giving birth in Australia.
      ,
      • 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.
      ]. Sometimes participants recount being told that interpreters were not available [
      • Liamputtong P.
      • Watson L.F.
      The Meanings and Experiences of Cesarean Birth Among Cambodian, Lao and Vietnamese Immigrant Women in Australia.
      ,
      • Niner S.
      • Kokanovic R.
      • Cuthbert D.
      Displaced mothers: birth and resettlement, gratitude and complaint.
      ,
      • Small R.
      • Rice P.L.
      • Yelland J.
      • Lumley J.
      Mothers in a new country: the role of culture and communication in Vietnamese, Turkish and Filipino women’s experiences of giving birth in Australia.
      ,
      • 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.
      ] or there was significant waiting required [
      • Carolan M.
      • Cassar L.
      Pregnancy care for African refugee women in Australia: attendance at antenatal appointments.
      ,
      • Riggs E.
      • Davis E.
      • Gibbs L.
      • Block K.
      • Szwarc J.
      • Casey S.
      • et al.
      Accessing maternal and child health services in Melbourne, Australia: reflections from refugee families and service providers.
      ], and the unavailability may be exacerbated in the evenings or weekends. In one study it was stated that interpreting services were available but participants were not aware of this [
      • Murray L.
      • Windsor C.
      • Parker E.
      • Tewfik O.
      The experiences of African women giving birth in Brisbane, Australia.
      ].
      Finding 8: Informal interpreters - In the absence of a professional interpreter, husbands and other family members often served as informal interpreters during appointments. The use of informal interpreters was comfortable and acceptable for some women but concerning to others about due to embarrassment over sharing sensitive health matters or the family member incompletely relaying information (Moderate confidence) [
      • Owens C.
      • Dandy J.
      • Hancock P.
      Perceptions of pregnancy experiences when using a community-based antenatal service: a qualitative study of refugee and migrant women in Perth, Western Australia.
      ,
      • Murray L.
      • Windsor C.
      • Parker E.
      • Tewfik O.
      The experiences of African women giving birth in Brisbane, Australia.
      ,
      • Hoban E.
      • Liamputtong P.
      Cambodian migrant women’s postpartum experiences in Victoria, Australia.
      ,
      • Riggs E.
      • Muyeen S.
      • Brown S.
      • Dawson W.
      • Petschel P.
      • Tardiff W.
      • et al.
      Cultural safety and belonging for refugee background women attending group pregnancy care: an Australian qualitative study.
      ,
      • Small R.
      • Rice P.L.
      • Yelland J.
      • Lumley J.
      Mothers in a new country: the role of culture and communication in Vietnamese, Turkish and Filipino women’s experiences of giving birth in Australia.
      ,
      • 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.
      ]. When the woman’s English was not proficient enough to allow her to communicate with staff, their husbands [
      • Owens C.
      • Dandy J.
      • Hancock P.
      Perceptions of pregnancy experiences when using a community-based antenatal service: a qualitative study of refugee and migrant women in Perth, Western Australia.
      ,
      • Murray L.
      • Windsor C.
      • Parker E.
      • Tewfik O.
      The experiences of African women giving birth in Brisbane, Australia.
      ,
      • Hoban E.
      • Liamputtong P.
      Cambodian migrant women’s postpartum experiences in Victoria, Australia.
      ,
      • Riggs E.
      • Muyeen S.
      • Brown S.
      • Dawson W.
      • Petschel P.
      • Tardiff W.
      • et al.
      Cultural safety and belonging for refugee background women attending group pregnancy care: an Australian qualitative study.
      ,
      • Small R.
      • Rice P.L.
      • Yelland J.
      • Lumley J.
      Mothers in a new country: the role of culture and communication in Vietnamese, Turkish and Filipino women’s experiences of giving birth in Australia.
      ,
      • 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.
      ] or other family members [
      • Murray L.
      • Windsor C.
      • Parker E.
      • Tewfik O.
      The experiences of African women giving birth in Brisbane, Australia.
      ,
      • Hoban E.
      • Liamputtong P.
      Cambodian migrant women’s postpartum experiences in Victoria, Australia.
      ,
      • 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.
      ] often interpreted during appointments and labour instead of a professional interpreter. While some women found this an acceptable or even preferable alternative to formal interpreters as they were more comfortable with someone they had an existing relationship with compared to a stranger [
      • Murray L.
      • Windsor C.
      • Parker E.
      • Tewfik O.
      The experiences of African women giving birth in Brisbane, Australia.
      ,
      • Small R.
      • Rice P.L.
      • Yelland J.
      • Lumley J.
      Mothers in a new country: the role of culture and communication in Vietnamese, Turkish and Filipino women’s experiences of giving birth in Australia.
      ,
      • 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.
      ], others identified issues with this form of interpreting. These included discomfort with discussing private matters through their husband or family member as they would not normally share intimate health concerns with them [
      • Murray L.
      • Windsor C.
      • Parker E.
      • Tewfik O.
      The experiences of African women giving birth in Brisbane, Australia.
      ,
      • 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.
      ]. Women whose husbands interpreted for them noted that they didn’t always interpret the entire conversation, either because they did not understand or because they only relayed the information they wanted their wife to know [
      • Owens C.
      • Dandy J.
      • Hancock P.
      Perceptions of pregnancy experiences when using a community-based antenatal service: a qualitative study of refugee and migrant women in Perth, Western Australia.
      ,
      • Small R.
      • Rice P.L.
      • Yelland J.
      • Lumley J.
      Mothers in a new country: the role of culture and communication in Vietnamese, Turkish and Filipino women’s experiences of giving birth in Australia.
      ,
      • 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.
      ].

      Factors influencing experiences of and satisfaction with care

      What women experienced across the continuum of maternal healthcare and how they perceived its suitability and quality was naturally a prominent theme. This broad theme includes a large number of factors which influenced study participants’ perception and experience of the care they received. Sub-themes analysed include the accessibility of services; women’s experiences with different models of care; experiences and preferences regarding health workers; trust in health workers and medical technology; and experiences of discrimination.

      Accessibility

      Finding 9: Transport - Some women experienced transport-related barriers to accessing care due to an inability to drive or lack of access to a vehicle (Low confidence) [
      • Owens C.
      • Dandy J.
      • Hancock P.
      Perceptions of pregnancy experiences when using a community-based antenatal service: a qualitative study of refugee and migrant women in Perth, Western Australia.
      ,
      • Chu C.M.
      Postnatal experience and health needs of chinese migrant women in Brisbane, Australia.
      ,
      • Correa-Velez I.
      • Ryan J.
      Developing a best practice model of refugee maternity care.
      ,
      • Riggs E.
      • Davis E.
      • Gibbs L.
      • Block K.
      • Szwarc J.
      • Casey S.
      • et al.
      Accessing maternal and child health services in Melbourne, Australia: reflections from refugee families and service providers.
      ,
      • Stapleton H.
      • Murphy R.
      • Correa-Velez I.
      • Steel M.
      • Kildea S.
      Women from refugee backgrounds and their experiences of attending a specialist antenatal clinic. Narratives from an Australian setting.
      ]. Several struggled with using public transport, which proved difficult to navigate especially with young children [
      • Owens C.
      • Dandy J.
      • Hancock P.
      Perceptions of pregnancy experiences when using a community-based antenatal service: a qualitative study of refugee and migrant women in Perth, Western Australia.
      ,
      • Chu C.M.
      Postnatal experience and health needs of chinese migrant women in Brisbane, Australia.
      ,
      • Correa-Velez I.
      • Ryan J.
      Developing a best practice model of refugee maternity care.
      ,
      • Riggs E.
      • Davis E.
      • Gibbs L.
      • Block K.
      • Szwarc J.
      • Casey S.
      • et al.
      Accessing maternal and child health services in Melbourne, Australia: reflections from refugee families and service providers.
      ,
      • Stapleton H.
      • Murphy R.
      • Correa-Velez I.
      • Steel M.
      • Kildea S.
      Women from refugee backgrounds and their experiences of attending a specialist antenatal clinic. Narratives from an Australian setting.
      ], while others relied on their husbands to drive them, which typically required the husband to take leave from work and sacrifice income [
      • Owens C.
      • Dandy J.
      • Hancock P.
      Perceptions of pregnancy experiences when using a community-based antenatal service: a qualitative study of refugee and migrant women in Perth, Western Australia.
      ,
      • Stapleton H.
      • Murphy R.
      • Correa-Velez I.
      • Steel M.
      • Kildea S.
      Women from refugee backgrounds and their experiences of attending a specialist antenatal clinic. Narratives from an Australian setting.
      ]. Conversely, conveniently located clinics were favoured as women could reach them via simple bus trips or by walking [
      • Carolan M.
      • Cassar L.
      Pregnancy care for African refugee women in Australia: attendance at antenatal appointments.
      ,
      • Riggs E.
      • Muyeen S.
      • Brown S.
      • Dawson W.
      • Petschel P.
      • Tardiff W.
      • et al.
      Cultural safety and belonging for refugee background women attending group pregnancy care: an Australian qualitative study.
      ].
      Finding 10: Appointments - Some women found the practice of attending appointments to be challenging due to unfamiliar expectations around timeliness and long wait times (Moderate confidence) [
      • Owens C.
      • Dandy J.
      • Hancock P.
      Perceptions of pregnancy experiences when using a community-based antenatal service: a qualitative study of refugee and migrant women in Perth, Western Australia.
      ,
      • Chu C.M.
      Postnatal experience and health needs of chinese migrant women in Brisbane, Australia.
      ,
      • Correa-Velez I.
      • Ryan J.
      Developing a best practice model of refugee maternity care.
      ,
      • Mohale H.
      • Sweet L.
      • Graham K.
      Maternity health care: the experiences of Sub-Saharan African women in Sub-Saharan Africa and Australia.
      ,
      • Riggs E.
      • Davis E.
      • Gibbs L.
      • Block K.
      • Szwarc J.
      • Casey S.
      • et al.
      Accessing maternal and child health services in Melbourne, Australia: reflections from refugee families and service providers.
      ,
      • Shafiei T.
      • Small R.
      • McLachlan H.
      Women’s views and experiences of maternity care: A study of immigrant Afghan women in Melbourne, Australia.
      ,
      • Stapleton H.
      • Murphy R.
      • Correa-Velez I.
      • Steel M.
      • Kildea S.
      Women from refugee backgrounds and their experiences of attending a specialist antenatal clinic. Narratives from an Australian setting.
      ]. Prompt attendance at specific appointment times was a new expectation for some women whose previous pregnancies had been in countries where drop-in appointments without bookings were standard [
      • Owens C.
      • Dandy J.
      • Hancock P.
      Perceptions of pregnancy experiences when using a community-based antenatal service: a qualitative study of refugee and migrant women in Perth, Western Australia.
      ,
      • Correa-Velez I.
      • Ryan J.
      Developing a best practice model of refugee maternity care.
      ,
      • Mohale H.
      • Sweet L.
      • Graham K.
      Maternity health care: the experiences of Sub-Saharan African women in Sub-Saharan Africa and Australia.