Conceptualising the prevention of adverse obstetric outcomes among immigrants using the ‘three delays’ framework in a high-income context

Abstract

Women from high-mortality settings in sub-Saharan Africa can remain at risk for adverse maternal outcomes even after migrating to low-mortality settings. To conceptualise underlying socio-cultural factors, we assume a 'maternal migration effect' as pre-migration influences on pregnant women's post-migration care-seeking and consistent utilisation of available care. We apply the 'three delays' framework, developed for low-income African contexts, to a high-income western scenario, and aim to identify delay-causing influences on the pathway to optimal facility treatment. We also compare factors influencing the expectations of women and maternal health providers during care encounters. In 2005-2006, we interviewed 54 immigrant African women and 62 maternal providers in greater London, United Kingdom. Participants were recruited by snowball and purposive sampling. We used a hermeneutic, naturalistic study design to create a qualitative proxy for medical anthropology. Data were triangulated to the framework and to the national health system maternity care guidelines. This maintained the original three phases of (1) care-seeking, (2) facility accessibility, and (3) receipt of optimal care, but modified the framework for a migration context. Delays to reciprocal care encounters in Phase 3 result from Phase 1 factors of 'broken trust, which can be mutually held between women and providers. An additional factor is women's 'negative responses to future care', which include rationalisations made during non-emergency situations about future late-booking, low-adherence or refusal of treatment. The greatest potential for delay was found during the care encounter, suggesting that perceived Phase 1 factors have stronger influence on Phase 3 than in the original framework. Phase 2 'language discordance' can lead to a 'reliance on interpreter service', which can cause delays in Phase 3, when 'reciprocal incongruent language ability' is worsened by suboptimal interpreter systems. 'Non-reciprocating care conceptualisations', 'limited system-level care guidelines', and 'low staff levels' can additionally delay timely care in Phase 3.

How do ethnic minority patients experience the intercultural care encounter in hospitals? A systematic review of qualitative research

“…First of all, the narratives of ethnic minority patients provide evidence for describing the intercultural care encounter as a dynamic and circular process rather than as a one-off action with a unidirectional outcome. Patients, each with their own background and culture of care, actively participate with caregivers when being admitted to the hospital, assessed, treated and discharged [43, 54, 58]. Each intercultural care encounter is understood as a dynamic and ongoing relational process which might take on different forms.…”

“…Other studies describe how conflicting expectations, unresolved difficulties or misunderstandings, unresolved mistrust and the inability of overcoming barriers can lead to a disengagement or disconnection in the care relationship by patients and/or caregivers [35, 36, 50, 55, 57, 58, 60–64]. …”

Increased risk of severe maternal morbidity (near‐miss) among immigrant women in Sweden: a population register‐based study

“…A theoretical model has been proposed to understand barriers to good care for immigrant women, including miscommunication and mistrust as important aspects. 34 Consistent use of professional interpreters, individual plans for obstetric care and the establishment of sociocultural sensitive guidelines are suggested to improve quality of care for immigrant women. 34 To further understand the web of causation behind the increased risk of near-miss morbidity in our study, audit studies of barriers and quality of care may be useful.…”

Next generation maternal health: external shocks and health-system innovations

“…Migrant women from LICs and conflict settings can face communication barriers and suboptimal care from providers, or might not trust the health system resulting in higher maternal morbidity and mortality than for native-born women in most, although not all, populations and contexts. 57,58 …”