Louis Osarogiagbon, Aljohn Aquino

Communication Challenges of Pregnant Immigrant Women during Perinatal Period- A Literature Review

Helsinki Metropolia University of Applied Sciences

Bachelor of Health Science

Degree Programme in Nursing

Bacherlor Thesis

31.03.2017

Abstract

Author(s) Title Number of Pages Date

Louis Osarogiagbon, Aljohn Aquino Communication Challenges of Pregnant Immigrant Women dur-ing Perinatal Period- A Literature Review. 27 pages, 5 pages of Appendix 31 March 2017

Degree Bachelor of Health Science

Degree Programme Degree Programme in Nursing

Specialisation option Nursing

Instructor(s)

Niina Eklöf, senior lecturer

Migration of people across international borders has been increasing in the past decades. Less than half of the total immigrants across the world are women of childbearing age. Preg-nant immigrant women in need of maternity care are often faced by many challenges. In this thesis, we describe the communication challenges faced by pregnant immigrant women dur-ing the perinatal period and the consequences of these challenges. The aim of this thesis is to improve the communication between pregnant immigrant women and the healthcare pro-vider. In this bachelor thesis, CINAHL and Medline databases were used to search articles to pro-vide answers to the research questions. The search yielded articles of which eleven were taken into inclusion criteria. The articles were analyzed using the principles of inductive con-tent analysis. The findings for communication challenges are divided into three main categories: (1) Verbal and Nonverbal communication challenges, (2) The use of interpreter, and (3) Cultural barri-ers to communication whilst findings for consequences are grouped into three main catego-ries: (1) Non-compliance, (2) Lack of self-control, and (3) Patient-Provider relationship. In-terestingly, the use of interpreters emerged as suboptimal, raised patients’ confidentiality concerns and in most cases did not improve communication. Patient-provider relationships were hard to establish due to language difficulties. Healthcare providers should be educated to be culturally competent. Interpreting services should be utilized and there is a need to train more competent interpreters. Patient education about maternity care services is necessary for a good pregnancy outcome. Further research about how to optimize the use of interpreters is recommended.

Keywords immigrant women, pregnancy, communication challenges

Abstract

Tekijät Otsikko Sivunmäärä Aika

Louis Osarogiagbon, Aljohn Aquino Raskaana olevien maahanmuuttajanaisten kommunikoinnin haasteet perinataaliaikana – kirjallisuuskatsaus. 25 sivua, 5 sivua liitettä 31.3. 2017.

Tutkinto Sairaanhoitaja AMK

Koulutusohjelma Hoitotyö

Suuntautumisvaihtoehto Sairaanhoitaja

Ohjaaja(t)

Niina Eklöf, seniori lehtori

Ihmisten muutto maasta toiseen on lisääntynyt viime vuosikymmenien aikana. Alle puolet maahanmuuttajista on synnytysiässä olevia naisia. Raskaana olevat maahanmuuttajanaiset kohtaavat usein suuria haasteita äitiyshuollossa. Tässä opinnäytetyössä olemme pyrkineet kuvaamaan kommunikointiongelmia, joita raskaana olevat maahanmuuttajanaiset kohtaa-vat perinataalikauden aikana sekä näiden ongelmien seurauksia. Tämän opinnäytetyömme tavoite on parantaa kommunikointia raskaana olevien maahanmuuttajanaisten ja terveyden-huoltohenkilöstön välillä. Opinnäytetyössä käytetty CINAHL ja Medline-tietokantoja joista, valitsimme yksitoista artik-kelia. Nämä artikkelit käytetty artikkelien analysoinnissa, johon käytettiin induktiivisen sisäl-lön analyysin periaatteita. Tutkimuksissa nousi esiin kolme suurinta kommunikointiin liittyvää haastetta: (1) Sanallinen ja ei-sanallinen kommunikointi, (2) tulkin käyttö ja (3) kulttuuri erot. Kommunikointiongelmien seuraukset voidaan puolestaan jakaa kolmeen ryhmään: (1) hoitohenkilökunnan ohjeiden noudattamatta jättäminen, (2) itsekontrollin puute ja (3) potilas-hoitajasuhde. Potilas-hoita-jasuhdetta oli vaikea luoda kieliongelmien vuoksi. Terveydenhuoltohenkilökuntaa pitäisi kouluttaa tietoiseksi eri kulttuureista. Tulkkauspalve-luja on voitava hyödyntää ja päteviä tulkkeja on koulutettava lisää. Potilaiden valistaminen äitiyshuollosta on välttämätöntä, jotta raskausaika sujuisi ongelmitta. Lisätutkimus tulkkien käytön optimoimisesta olisi suositeltavaa.

Avainsanat maahanmuuttajanaiset, kommunikointiongelmia, raskaus

Contents

1 Introduction 1

2 Background 2

2.1 Communication in health care 2

2.2 Pregnancy, antenatal, perinatal and health care. 2

2.3 Immigrant 4

2.4 Interpreter 5

3 Purpose and Aim of the Bachelor Thesis, Study Questions 6

4 Data Collection Methods and Data Analysis 6

4.1 Literature Review 6

4.2 Data collection 7

4.3 Inclusion and Exclusion Criteria 8

4.4 Data analysis 9

5 Findings 10

5.1 Communication Challenges 10

5.1.1 Verbal and Nonverbal Communication Challenges 10

5.1.2 The use of interpreter 11

5.1.3 Cultural Barriers to Communications 12

5.2 Consequences of Communication Challenges 13

5.2.1 Non-compliance 13

5.2.2 Lack of self-control 14

5.2.3 Patient-Providers Relationships 15

6 Discussion 18

6.1 Discussion about the findings 18

6.1.1 Communication Challenges 18

6.1.2 Consequences arising from communication challenges 19

6.2 Discussions on Ethical Considerations 21

6.3 Discussions on Validity 22

7 Conclusion 22

References 24

Appendices

Appendix 1. Selected Articles

1

1 Introduction

Globalization is becoming a norm in our modern society. Immigration has increased in

the past fifteen years (International Migration Report, UN 2015). People are moving from

one country to another in search of work, spouse, studies or running away from harm

and violence. The United Nations (UN) reported that in 2015, the number of immigrants

has reached 244 million. Most of these immigrants live in Europe and Asia, hosting about

74 and 75 million respectively, while North America hosts 54 million. More than half of

immigrants came from middle income countries and women comprise just less than half

of the total number of immigrants. (International Migration Report, UN 2015.) In Finland,

according to a report by the Finnish Immigration Services (2015) there were 231,295

foreign nationals living legally. This number includes immigrant workers, students and

refugees. In the same year, 14,286 foreigners were residing illegally in Finland. This

same year (2015) also saw the influx of refugees applying for asylum in Finland. The

number was 32,476 persons of which 19% are women. (European Migration Network

2016.)

Moving to a foreign country places immigrant women into a different culture and lan-

guage. These immigrant women are exposed to different challenges in accessing

healthcare in their host countries, especially during pregnancy. The health care needs of

immigrant women are different from those of the local women population. They have

more difficulties in obtaining health services due to their social, cultural and economic

conditions (Papadopoulos 2006:52). According to the World Health Organization’s

(2017) study in Europe from 1966 to 2004, immigrant women were at 43% higher rate of

giving birth to an under-weight child and they were 24% more likely to deliver pre-term

baby and 50% of perinatal mortality. The report also stated that they have 61% chances

of having a child with “congenital malformations” than local women.

Communication challenges are one of the most difficult barriers faced by pregnant immi-

grant women. Communication facilitates the ability of people to understand and improve

methods to better their situations. (Bach & Grant 2009:8-9.) Thus, the purpose of this

thesis is to describe the communication challenges faced by pregnant immigrant women

during perinatal period. This thesis also aims to examine the consequences arising from

these communication challenges.

2

2 Background

2.1 Communication in health care

Communication is defined as “the act or process of using words, sounds, signs, or be-

haviors to express or exchange information or to express your ideas, thoughts, feelings,

etc., to someone else” (Merriam-Webster Online). In the healthcare profession, commu-

nication is an important aspect of daily work. Effective communication is the key to a

trustworthy relationship between care provider and patient, it enhances the quality of

care and patient safety. (England & Morgan 2012.) Communication is an essential part

of being human and it is a dual action that involves receiving and giving out information.

It embodies, not just the verbal part which is the language but also the nonverbal such

as body movement, eye contact, personal space, posture, touch, etc. (England & Morgan

2012).

Culture influences a person on how he or she communicates, which is mostly seen in

their non-verbal communication. Nonverbal communication takes 70% of communica-

tion, which increases the probability of miscommunication between the patient and nurse

(England & Morgan 2012) especially in a multicultural setting. Cross-cultural communi-

cation knowledge is needed to improve nurse`s understanding of different cultural back-

grounds. Knowledge of oral and non-oral communication, perception of space, distance,

touch, time, environmental settings etc., as applicable to others from different cultures.

The ability to communicate with significant others in cross-cultural settings, should not

be judgmental of other cultures. (Andrews & Boyle 2012:23-25).

In a multicultural care setting, communication challenges are more likely to arise when a

nurse and a patient do not share the same language or culture. Communication between

the nurse and patient is important to deliver the utmost care needed by the patient. (Hig-

ginbottom, Mumtaz, O’Brien, Paton, Safipour & Yohani 2015.) Communication between

a nurse and a client could be as simple as listening or sitting by the bedside of a client.

In addition, it should include putting together accurate problem solving nursing expertise

such as collecting information from family members of the client, diagnoses, proper plan-

ning of care, implementation and evaluation. (Riley 2012:10.)

2.2 Pregnancy, antenatal, perinatal and health care.

3

Pregnancy is simply defined as “being with a child, gestational period can last from the

last menstrual period to parturition is 280 days or 40 weeks” (Brooker 2005). Early-

gestation pregnancy discovery can happen by accident in a visit to healthcare provider

or the woman can make the findings by the use of “urine-based home pregnancy tests”.

In most women, amenorrhea is a common sign or symptom of presumed pregnancy or

pregnancy. The diagnosis of pregnancy is a life changing experience for both couples, it

could be a welcome news or a source of devastation. Additionally, some women may

experience mixed feelings as she struggles to adjust her life to the role of motherhood

(Farley, Jordan, & Tharpe 2013:41-42.) Social and cultural factors influence how a cou-

ple handles pregnancy. Many women at this stage would not be familiar with the

healthcare system in handling their situation. Therefore, patient education should be cen-

tered on how to evaluate each patient as an individual. Symptoms and common discom-

forts (breast tenderness, fatigue, nausea or vomiting, urinary frequency etc.) associated

with pregnancy should be discussed openly. Similarly, patient education should be pro-

vided for signs of complications such as pain or cramping and bleeding. In addition, in-

formation about the medical history, medications, allergies, sexually transmittable dis-

eases, nutrition, vitamin supplement, physical exercises, prenatal yoga, should be rou-

tinely given to couples. Assessment of risks factors easily associated with cultural and

social background is paramount during pregnancy. Risk factors generally linked to ad-

dictive behaviors such as diet, smoking, cultural habits that do not promote positive preg-

nancy outcome, should be avoided. (Farley et al. 2013:41-49.)

Antenatal is defined as “the time from conception to birth” by the Churchill Livingstone’s

Dictionary of Nursing (Brooker 2005). This period is crucial in the life of pregnant mother

and the unborn baby. It is the time to provide health education information and prenatal

care to have a successful pregnancy outcome. The pregnant woman has to work in col-

laboration with her healthcare providers in a continuous program that caters for her bio-

physical, psychosocial and educational needs of her and her family. The contents of

antenatal or prenatal care are tailored to health needs of the women. (Farley et al.

2013:41-42.)

The aim of antenatal care is to monitor the progress, evaluate and to take a holistic

approach to the health of the woman, promote public health awareness for the family.

Additionally, exchanging information, advocating for the woman’s rights to services dur-

ing pregnancy, preparing the woman for the challenges of motherhood and providing

information about infant feeding or breastfeeding. (Cooper & Fraser 2009:263-265.)

4

Perinatal, according to Churchill Livingstone’s Dictionary of Nursing (Brooker 2005), is

relating to the time around birth, weeks before birth and week afterward. According to

the World Health Organization (WHO), perinatal is defined as the period that is right

before and after the birth of the child. In order to have a successful pregnancy outcome

and avoid perinatal death, a high standard of care should be provided at three main

levels: individual (pregnant woman), hospital and governmental. In addition, “skills such

as communication and interpersonal relationships” are important if the woman is to ap-

preciate her role in pregnancy, labour and puerperium. However the medical advances,

if the woman out of ignorance or social disability do not follow the recommendations of

medical workers, high chances of negative pregnancy outcome can occur. (Beischer,

Colditz & Mackay 1997:149.)

2.3 Immigrant

The United Nations Statistic Division (2017) categorizes immigrant into two folds: (a) a

person that relocate to a country that is not his usual country of residence for up to or

more than 12 months is regarded as long-time international immigrant. (b) While any

person that moves to a country that is not his usual place of residence for up to 3 months

but less than 12 months is regarded as short-term international immigrant. For someone

to fall into these categories following reasons for relocating should not include: holiday,

visits to meet friends and relatives, recreation, business, religious pilgrimage or to re-

ceive medical care. Simply put immigrant is someone living outside his country of birth.

(UN. 2015.)

The top four migrants hosting nations are: The United States of America 47 million, Ger-

many and The Russian Federation host 12 million each while Saudi Arabia hosts 10

million (UN 2015). United Nations international reports on migration (2015) puts women

population percentage of international immigration at 48 percent but immigration into

Europe and North American women outnumbered male immigrant population.

A refugee, as defined by the UNHCR 1951 article 1 treaty, is someone who has a genu-

ine reason to be afraid, unable or unwilling to return to his or her country based on hard

evidence that he or she would face maltreatment due to his or her race, religion, opinion,

nationality, social or political affiliation. The UNHCR (2015) estimates that there are more

than 21.3 million refugees worldwide. In 2014, Turkey became the host of the largest

5

population of refugees worldwide (1.6 million) followed by Pakistan (1.5 million), Lebanon

(1.2 million) Iran (1 million) Ethiopia and Jordan 0.7million respectively. The top three

sources of refugee countries in the world are Syria (3.9 million), Afghanistan (2.6 million)

and Somalia (1.1 million). There is an increasing confusion in the use of terminology of

refugee and asylum seekers. Asylum seekers are those who have applied for protection

or sanctuary and are waiting for decision as regards their application. Over 1 million

people apply for asylum yearly. (UNHCR 2017.)

2.4 Interpreter

An interpreter, is someone who works translating spoken languages between people

who speak different languages. An interpreter advances communication between people

by mediating and interpreting both ways. While a translator is someone who converts

written language into another language in a written form. In both professions, a deep

understanding of the language and culture of the people involved is crucial. (Canadian

Pediatric Society 2017.) The use of interpreter is mandated by Finnish Law (Laki potilaan

asemasta ja oikeuksista; 17.8.1991/785) and is recommended when the healthcare pro-

vider and the patient do not share or speak the same language (Cherry & Jacob

2014:193-194). According to Riley (2012:51) use of medical interpreters increases the

quality of care given to the patient. Medical interpreter is defined as someone who spe-

cializes in translating patients’ health documents and doing face to face interpretation.

The medical interpreter should have the ability to interpret medical terminologies and

procedures fluently in both languages. (The National Board of Certification for Medical

Interpreters 2016.) Cherry & Jacob (2014) indicated that it is the responsibility of the

nurses and the hospital in general to know information about medical interpreting ser-

vices to be able to help patients understand hospital procedures and policies. In general,

family member should not be used as interpreters, except in an emergency. According

to the NHS (2014), patient’s right of consent obtained in a life-threatening situation, using

family members or patient’s friends, should be fully interpreted to the patient once the

situation is under control using a certified interpreter. In some cultures, patients do not

want to indulge certain health information to other family members (Riley 2012; Cherry

& Jacob 2014) and in other cultures it is an invasion of privacy if people, other than the

family, of the same ethnicity interpret (Cherry & Jacob 2014). Underage members of the

family should never be considered as interpreters (Cherry & Jacob 2014).

In order to attain maximum benefits for patients there are several methods of using in-

terpreters: face-to-face interpreting, professional interpretation by phone, informal face-

6

to-face interpretation, bilingual professional and cultural mediators. Whichever method

of interpretation employed, patient’s safety, confidentiality and privacy should not be

jeopardized (European Observatory on Health Systems and Policies Series 2011). Inter-

preter’s role is to facilitate communication between care provider and the patient and not

to dictate communication. He should equally have a profound knowledge of the

healthcare system and medical terminology. In addition, he should be able to understand

and translate nonverbal communications. Therefore, if it is face-to-face interpretation, it

is recommended that sitting position should be triangular seating arrangement that would

enable clear view on nonverbal communications and signs (Canadian Paediatric Society

2017).

3 Purpose and Aim of the Bachelor Thesis, Study Questions

The purpose of this bachelor thesis is to describe the communication challenges faced

by pregnant immigrant women during perinatal. The aim of this thesis is to improve the

communication between pregnant immigrant women and the healthcare provider.

Study Questions:

1. What are the communication challenges faced by pregnant immigrant women

during perinatal?

2. What are the consequences that arise from these communication challenges?

4 Data Collection Methods and Data Analysis

4.1 Literature Review

This bachelor thesis is a literature review, which should answer the research question

posted by the researchers (Gerrish & Lacey 2010; Thomas 2009). Gerrish & Lacey

(2010) further describe the three main phases of the literature review: sorting the “wheat

from the chaff”, identifying key points; results; themes, and writing up the findings. In the

first phase, the data should be thoroughly scrutinized to pass the inclusion criteria. After

this, the data are to be analyzed and then put into different categories. They further

(2010) described this analysis as Reissman’s thematic analysis. In thematic analysis,

data is “organized, labeled and grouped together into themes” (Gerrish & Lacey

2010:195). Thomas (2009) outlined that writing the literature review is same as writing a

7

story comprising a beginning, middle and an end. He suggested that literature review

should be presented in this way.

4.2 Data collection

Literature review data collection requires the researcher to cast his net has wide as pos-

sible in order to have a comprehensive information to work with. The researcher should

also collect data from reliable sources e.g. CINAHL, MEDLINE with access to peer-re-

viewed journals, academic journals and the data should be up-to-date. (Parahoo 2014.)

Qualitative data analysis is a continuous procedure that starts from the collecting data to

concluding the research. Data collection methods will be based on using evidence-based

scientific literatures, to answer the research questions. It involves clear recording of data

collecting processes, database, time and date. (Gerrish & Lacey 2010:22-23.)

The data used in this bachelor thesis was collected using systematic approach through

CINAHL and MEDLINE databases. The search terms (table 1) were communication chal-

lenges OR communication barriers OR communication difficulties OR language chal-

lenges OR language barriers OR language difficulties. We further combined our search

with AND Immigrant women OR Immigrant female OR migrant women OR migrant fe-

male OR refugee women AND Maternity OR pregnancy OR childbirth OR perinatal. The

same search terms were applied in both databases to achieve necessary results. The

search is limited to English language, academic journal and 2006-2016. After carefully

reading through the titles, abstracts and contents, eleven articles are selected and used

for data analysis. (Appendix 1)

8

Table 1. Database searches.

Database Search terms Limits Hits reviewed from title & abstract

reviewed by con-tent

Fi-nal

CINAHL 13.01.17

Communication chal-lenges OR Communi-cation barriers OR communication diffi-culties OR language challenges OR lan-guage barriers OR language difficulties

AND

Immigrant women OR Immigrant female OR migrant women OR migrant female OR refugee women

AND

Maternity OR preg-nancy OR childbirth OR perinatal

2006-2016

English lan-guage

28 16 15 9

MEDLINE

13.01.17

Communication chal-lenges OR Communi-cation barriers OR communication diffi-culties OR language challenges OR lan-guage barriers OR language difficulties

AND

Immigrant women OR Immigrant female OR migrant women OR migrant female OR refugee women

AND

Maternity OR preg-nancy OR childbirth OR perinatal

2006-2016

English lan-guage

28 2 2 2

TOTAL

56 18 17 11

4.3 Inclusion and Exclusion Criteria

Research materials sampling are undertaken to eliminate the potentials of samples con-

tamination or bias that could weaken the strength of evidence. A meticulous planning of

inclusion or exclusion criteria will help strengthen and sharpen the body of evidence, by

9

so doing, the researcher increases the accuracy and observation of the findings. (Haber

& Lobiondo-Wood 2010:223-224.)

In this thesis our inclusion criteria were specifically directed towards pregnant immigrant

women during antenatal, perinatal and hospitalization during childbirth. Immigrant

women who were proficient in the local language were excluded. Additionally, immigrant

women who have never experienced antenatal and perinatal and childbirth in a foreign

country were excluded.

Furthermore, materials of our research articles are limited to a period from 2006 to 2016.

In order to gathered the most up-to-date reliable materials. Other inclusion criteria were

articles written in English language, available in full-text, peer reviewed, respectable ac-

ademic journals, scientific journals and researched articles. We excluded professional

journals and literature review articles, as well as teenage immigrant pregnant women or

girls. At the end, articles that particularly provided answers to our study question were

chosen. (Table 2)

Table 2. Inclusion and exclusion criteria

4.4 Data analysis

In this thesis, we are applying the principles of inductive data analysis or inductive con-

tent analysis. According to Parahoo (2014:368-370) this data analysis comprises six

stages: researchers familiarizing themselves with the data, “generating initial codes,

searching for themes, reviewing themes, defining and naming themes”, and writing the

report. These methods help the researcher to first “open up” or break the data into as

many categories as possible. Then group data together to a manageable size base on

Inclusion Criteria Exclusion Criteria

English language Full-text 2006-2016 Academic journal Peer-reviewed Scientific journal Researched article pregnant immigrant women with

childbirth experience in hospitals

Professional journals Literature reviewed articles - 3 articles Pregnant immigrant women proficient in

the language Articles not related to the study question Teenage pregnant immigrant girls immigrant women who have never expe-

rienced childbirth in a foreign country

10

their similarities. The categories are then put together to give a comprehensive under-

stand which the research can analysis back and forth before writing the report. Gerrish

& Lacey (2010:423-424) states that researchers should familiarized themselves with the

data both in the collecting and analyzing stages. In order to allow the data to lead to “a

deep understanding” of the study. Applying the principles of qualitative data analysis

(different categories) with the purpose of reaching a scientific conclusion. (Gerrish &

Lacey 2010:423-424.)

The findings were grouped into categories. For the first study question, data were

grouped into three main categories, as shown in Table 3: Verbal and Nonverbal com-

munication challenges, the use of interpreters and Cultural barriers to communications.

While the second study question was also divided into three main categories, as shown

in Table 4: Noncompliance, Lack of self-control and Patient-Provider relationship. Fur-

thermore, these main categories are divided into sub categories.

5 Findings

5.1 Communication Challenges

The data search yielded eleven articles in total, relevant to our research questions. The

results were grouped into two categories according to our research questions: what are

the communication challenges of pregnant immigrant women during perinatal period and

what are the consequences that rises from them? The consequences are separated from

the challenges in this thesis findings report. This section is divided into three sub cate-

gories (Table 3): (1) Verbal and Non-verbal communication challenges, (2) The use of

interpreters, and (3) Cultural barriers to communications.

5.1.1 Verbal and Nonverbal Communication Challenges

The lack of proficiency of the local language, or normally called as language barrier, is

the most common verbal communication challenge faced by pregnant immigrant women

in their host countries (Barolia, Chiu, Higginbottom, Mumtaz, O’Brien, Paton, Safipour &

Yohani 2016; Binder, Borne, Essen & Johnsdotter 2012; Briscoe & Lavender 2009; Cas-

tro, Llorca, Paz-Zulueta, Ruiz & Santibanez 2015; El Ansari, Degni, Essen, Suominen &

Vehviläinen-Julkunen 2012; Dickerson, Kim & Seo 2014; Higginbottom, Mumtaz,

11

O’Brien, Paton, Safipour & Yohani 2015; Kilpatrick, Hoang & Le 2009; Murray, Parker &

Windsor 2010). Briscoe et al. (2009) and El Ansari et al. (2012) stated that pregnant

immigrant women who participated in these researches could not communicate with their

healthcare provider effectively because of language and cultural differences. In addition,

unfamiliarity of the medical system and poor health literacy in the host countries due to

language barrier has affected communication adversely (Dickerson et al. 2014).

Nonverbal communication, such as gestures, symbols, hand waving, body language and

the tone of the voice were widely used by the healthcare providers and patient to com-

municate, due to the absence of common language. The use of medical mask, surgical

gowns escalated fear in the mind of the patient about her condition. (Briscoe et al.

2009:20) Briscoe et al. (2009) further explained that some healthcare providers used

sign language to communicate with the patients when no common language and inter-

preters are available, leaving the patients unsure whether they understood what the

healthcare providers really meant. Cultural differences of some Somali women and their

Finnish healthcare provider affected their communication. Somali women wanted hugs

and touching as part of their interaction, something that they are used to in their country,

which was not a way of communication with patients in Finland. (El Ansari et al. 2012.)

5.1.2 The use of interpreter

The use and need of interpreters came up in several articles findings (Barolia et al. 2016;

Binder et al. 2012; El Ansari et al. 2012; Higginbottom et al. 2015; Kilpatrick et al. 2009;

Iliadi 2008; Murray et al. 2010). Competency of the interpreters were constantly dis-

cussed and found wanting knowledge of medical terminologies and procedures of the

interpreters were questionable (Binder et al. 2012; El Ansari et al. 2012). They pointed

out that being knowledgeable in one language, is not enough to be competent in inter-

preting. Some healthcare providers described the interpreting services as “a leap of faith”

(Binder et al. 2012:1176). The use of interpreters posed great ethical challenges about

the confidentiality of patients added to this is the closeness of some communities and

the “atypical” nature of some languages which make it impossible to have an interpreter

that does not know the patient (Higginbottom et al. 2015). Binder et al. (2012) find out

that discussing with the interpreter is like talking to or sharing patient's information with

all the members of the communities.

12

In addition, the use of interpreter were time consuming, expensive, impractical at times

(Barolia et al. 2016; Binder et al. 2015; Higginbottom et al. 2015). Furthermore, the pres-

ence of an interpreter inside the labour room heightens the anxiety of the patient and

could hamper the communication between healthcare worker and the patient (Higginbot-

tom. 2015). Binder et al. (2015) findings supported the fact that local culture of the inter-

preter can influence interpretation in negative way. The gender of the interpreter was

seen as hindrance by both the healthcare provider and patients to their communication.

The patients preferred having same sex interpreter as it makes them communicate easily

with the healthcare providers. (Binder et al. 2012:1178.)

The use of family members, especially underage children were reported to be unethical,

traumatic experience for the patient and the children. Sensitive medical conditions such

as asking an underage child to interpreter ultrasound image of a deformed fetus to her

mother (the patient) was more traumatic to the child then the mother. (Barolia et al. 2016;

Binder et al. 2015; El Ansari et. al. 2012.) The use of interpreters were seen as neces-

sary, unfortunately interpreting services were not available (Iliadi 2008; Kilpatrick et al.

2009.) while in some cases, interpreting services were underutilized (Barolia et al 2016;

Murray et al. 2010).

5.1.3 Cultural Barriers to Communications

Religion and culture negatively hindered communication between some Somali women

and their healthcare provider. They were not comfortable discussing with male gynae-

cologist/obstetrician childbirth or shaking hands with male health care provider. (El An-

sari 2012:337). Binder et al. (2012:1178) studied that even with the presence of an inter-

preter, cultural and religious barriers were predominantly hindering communication be-

tween healthcare provider and patient. In the same study (2012:1177), participants pre-

ferred to be cared for by someone of their ethnical background rather than their host

country care provider. Kilpatrick et al. (2009:7) stated that, in some Asian cultures, ex-

pressing oneself is seen as a taboo, therefore some Asians participants, were reluctant

in seeking and accessing maternity care.

13

Table 3. Communication Challenges

Findings Main Categories

Limited competence in English lan-guage

insufficient knowledge in Spanish lan-guage

low language efficiency lack of common language gestures, sign languages, waving

hands lack of written information in other lan-

guages other than the host countries language

Verbal and Nonverbal Commu-nication Challenges

underutilization of interpreting ser-vices

unavailability of interpreters gender differences of interpreters time consuming and cost of interpret-

ing professionalism (privacy/breach of

confidentiality) trustworthiness of interpreters interpreters knowledge of medical

terms use of relative as interpreters use of underage children as interpret-

ers

Use of Interpreters

patients prefer to talk with women physicians

patients prefer same sex interpreter hugging and touching cultural and religious differences

Cultural Barriers to Communi-cation

5.2 Consequences of Communication Challenges

The consequences of communication challenges are evident in all the articles. The fol-

lowing main categories came up in our findings: non-compliance, lack of self-control, and

patient-provider relationship. As shown in Table 4, the main categories were further di-

vided into sub-categories.

5.2.1 Non-compliance

Non-Compliance with visits

14

In most cases language barrier led to non-compliance with antenatal care. This pre-

vented participants from attending prenatal classes. As a result, affected their attitude

towards maternity care and prevented them from obtaining the necessary information

and knowledge that could have helped them in their pregnancies. (Barolia et al. 2016;

Castro et al. 2015; Iliadi 2008; Kilpatrick et al. 2009.) Iliadi (2008) stated women are more

likely to attend antenatal consultation if care givers speak same language. As a conse-

quence of the use of family members as interpreters, some participants felt ashamed of

asking questions in front of family members about their pregnancies. This hampered

them from obtaining information from health care providers. (Iliadi 2008:175.) Castro et

al. (2015:63-65) emphasized a high rate of non-compliance with antenatal care in African

immigrant women who did not understand Spanish language, consequently, they were

referred to the social workers.

5.2.2 Lack of self-control

Misunderstandings

Breakdown in communication leading to misunderstandings, between patients and

healthcare providers due to lack of common language was also highlighted in several

studies (Binder et al. 2012; Briscoe et al. 2009; Dickerson et al. 2014; Higginbottom et

al. 2015; Murray et al. 2010; Wojnar 2015). The presence of language barrier plus the

lack of interpreters added to more misunderstandings. Participants pretended to under-

stand procedures but did not complied with given instructions and follow up treatment

recommendations. (Higginbottom et al. 2015:9; Murray et al. 2010:463.) In a study by

Briscoe et al. (2009:20), participants misunderstood the meaning of the actions of the

healthcare providers about the use of formula milk for feeding the child. Participants

thought that formula milk was better than breastfeeding because the nurses were giving

it to them. However, in reality the nurses wanted to show that formula milk is not recom-

mended for use (Briscoe et al. 2009:20).

Decision Making

One of the major consequences leading from language barrier is participants’ lack of

control over their situation. Furthermore, due to the lack of information participants were

unable to actively participate in decision making thus limiting their choices especially

during labour and delivery. (Binder et al. 2012; Dickerson et al. 2014:310-311; Murray et

al. 2010; Wojnar 2015.) Participants felt perplexed and scared because of no mutual

understanding between the healthcare providers and them during childbirth caused by

15

mishap in communication (Wojnar 2015:362). In addition, participants showed complete

lack of understanding, they were uninformed, vulnerable, and unaware of service expec-

tation (Binder et al. 2012; Higginbottom et al. 2015; Wojnar 2015:362-363). Murray et al.

(2010) described the participants showing anxiety, displeasure, and dismay as a conse-

quence of not knowing or lacking the information about the maternity healthcare system.

Access to Maternity Services

Most participants had difficulties in accessing maternal care due to communication bar-

riers (Kilpatrick 2009). According to Barolia et al. (2016) and Iliadi (2008) many women

had difficulties in obtaining information during their perinatal visits. Due to language pro-

ficiency level communication between healthcare provider and receiver were not helpful.

Participant felt “lost” because they had no understanding and no information about the

maternity services in their host countries (Barolia et al. 2016). Dickerson et al. (2014:312-

314) stated that the Korean participants could not access maternity health services in-

formation directly from their American healthcare providers, but instead they relied on

their fellow Koreans for information. They sought information from the internet and other

Korean maternity literature, which unfortunately were not useful in the American

healthcare system (Dickerson et al. 2014).

5.2.3 Patient-Providers Relationships

Patients Feelings

Distrust of the healthcare system and personnel led to low satisfaction of care, emotional

distress, feeling worthlessness, frustration and lack of therapeutic relationship with care

providers (Briscoe et al. 2009; El Ansari et al. 2012; Wojnar 2015). Binder et al.

(2012:1175-1176) described the personal dilemma of patients, feeling of being rejected

and ignored by the care providers due to communication challenges. Due to communi-

cation challenges, the therapeutic relationship between some Somali women and their

care provider were adversely impaired. Furthermore, the presence of a third person or

interpreter further constrained the building of a good relationship. (El Ansari et al.

2012:336.) Personal preference of same-sex interpreter and healthcare provider also

negatively affected dialogue between patients and providers (Binder et al 2012:1178).

According to Higginbottom et al. (2015:301), any breakage in the relationship of

healthcare provider and patient caused by communication challenge snowballed into to-

tal mistrust of the healthcare provider and the system in general. Time factor hindered

16

the building of personal relationship between health providers and care receivers (Dick-

erson et al. 2014:311). Language barrier led to patients’ mistrust of the entire healthcare

system, some participants were more likely to trust their whole local community than the

health care system (Wojnar 2015:365).

Healthcare Providers’ Feelings

The substandard services provided by the interpreters led to many healthcare providers

dissatisfied, uncertain of how much information was correctly interpreted to the patients

(Binder et al. 2012:1180 & El Ansari et al. 2012:334). Binder et al. (2012:1176) described

attending to immigrant women patients as time consuming. El Ansari et al. (2012:334-

336) stated that healthcare providers equally felt uncomfortable providing personal med-

ical information about the patient in the presence of an interpreter. Barolia et al. (2016)

indicated as well that the presence of an interpreter can cause ethical issues and breach

of patient’s privacy. In addition, healthcare providers find it difficult to develop personal

relationship with immigrant women. Some male healthcare providers felt, “humiliated,

insulted” and discriminated against by some Somali women by rejecting services from

them. (El Ansari et al. 2012:337.) Healthcare provider feel overwhelmed and helpless

when dealing with immigrant women who could not understand them (Barolia et al.

2016:6).

17

Table 4. Consequences of Communication Challenges

Findings Sub Categories Main Categories

non-compliances with antena-tal visits

difficulties and/or inability to visit prenatal classes due to language barrier (*LB)

delayed antenatal visits

Non-Compliance with visits

Non Compliance

misunderstandings about in-structions of healthcare provid-ers

pretending to understand the procedure

lack of understanding of proce-dure

misunderstanding the meaning of actions

Misunderstandings Lack of self-control

lack of or limited ability to make own decision

minimal control over the situa-tion

lack of informed consent due to LB

unaware of health opportuni-ties available to them

Decision Making

no or little knowledge about the maternity healthcare sys-tem

difficulties or inability in obtain-ing necessary information

difficulties in obtaining mater-nity services

Access to maternity services

healthcare providers feel immi-grant women care demanding

uncomfortable to discuss infor-mation with an interpreter

Healthcare provid-ers’ feelings

Patient- Provider relationship

little or no personal relation-ship with healthcare providers

lack of emotional support from healthcare provider

inability to express themselves freely due to LB

mistrust /lack of trust of healthcare personnel and sys-tem

feeling of being rejected feeling lost and lonely

Patients’ Feelings

18

6 Discussion

6.1 Discussion about the findings

The results of this thesis findings are generated from the articles that were used to find

answers to our research questions: (1) what are the communication challenges face by

pregnant immigrant women during perinatal period? (2) What are the consequences that

arise from these communication challenges? Our results led us to divide the discussion

into two sections communication challenges and their consequences.

6.1.1 Communication Challenges

Verbal and Nonverbal Communication Challenges

The human aspect of healthcare such as social and emotional support from the

healthcare providers is still highly significant. In order to achieve good relationship, com-

munication plays a crucial role in building a working relationship between healthcare pro-

viders and patients. As stated earlier in the background, communication can either be

verbal or non-verbal. Its challenges arise when two people do not speak a common lan-

guage. Our results show that verbal communication challenges, such as language bar-

rier, are predominant in all the articles (Barolia et al. 2016; Binder et al. 2012; Briscoe et

al. 2009; Castro et al. 2015; Dickerson et al. 2014; El Ansari et al. 2012; Kilpatrick et al.

2009; Higginbottom et al. 2015; Murray et al. 2010). Immigrant women who could not

speak their host countries’ language were at the risk of not receiving good care. In the

study by Briscoe et al. (2009), nonverbal actions such as use of sign language to com-

municate with immigrant women who could not speak their language proved to be more

useless than helpful.

The use of interpreters

The use of interpreters was also seen as a barrier to the communication between pa-

tients and providers, in addition to these verbal and non-verbal communication chal-

lenges. Even though interpreters provided relief to both healthcare provider and immi-

grant woman, their use were sometimes “suboptimal, time consuming” and their profes-

sionalism and trustworthiness were questionable. In some cases there were no interpret-

ing services available (Iliadi 2008:175) or these services were not fully utilized (Barolia

et al. 2016; Murray et al. 2010). Healthcare providers should be aware of the interpreting

19

services in order to ease communication barriers. The dominant finding present in most

articles was the use of family members, especially underage children, as interpreters.

This possess ethical and confidentiality issues (Barolia et al. 2016 & El Ansari et al.

2015). The use of underage children is unacceptable and morally wrong and can cause

traumatic experiences for these children as well (Binder et al. 2012 & El Ansari et al.

2015). Additionally, family members might not be familiar with medical terminologies

which can affect the outcome and decision making of the care. The interpreter’s

knowledge of medical terminology and their ability to translate in their host countries’

languages in some case were poor and unreliable. (Binder et al. 2012:1176 & El Ansari

et al. 2012:334.) It should be noted that, being fluent in one language does not neces-

sarily means that one has the language skills needed to interpret. Competences training

knowledge in medical terminologies, confidentiality, patient safety, and how the

healthcare system works is important.

Cultural Barriers to Communications

Results from this thesis show that culture and religion affected the communication be-

tween the healthcare provider and pregnant immigrant women. El Ansari et al. (2012)

pointed out that immigrant women would rather have a female healthcare provider than

a male one due to their religious beliefs. Binder et al. (2012:1178) further stressed out

that male interpreter also can affect communication between healthcare provider and

patient due to cultural differences. Some pregnant immigrant women would rather have

a female interpreter with them. Care providers should be culturally competent to be able

to care for pregnant immigrant women. Knowledge about other cultures is necessary to

build trust and alleviate fear. On the other hand, immigrant women should be sanitized

about the culture of their host country and be informed about the impracticality of always

having their preferred gender health provider.

6.1.2 Consequences arising from communication challenges

Non-compliance

Adherence to medical advices is very important in order to have a successful pregnancy

outcome both for mother and the child (Farley et al. 2013:41-42). The pregnant immigrant

woman should work in collaboration with the health care providers. Working with

healthcare system requires understanding of how the system works. Inability to follow

the recommendations due to language barriers have significant implications for the care

providers and patients as shown in Table 3. Proficiency in the local language was highly

20

related to good maternity care, attendance of prenatal class (Castro et al. 2015; Dicker-

son et al. 2014; Iliadi 2008). Significant number of pregnant immigrant women who failed

to attend the numbers of the recommended prenatal classes were hindered by language

barriers. In other words, they were not able to receive proper information about their

pregnancies and maternity services available to them. They had limited knowledge about

service expectations and were unable to optimize the healthcare system to their full ad-

vantages. In some cases, according to Castro et al. (2015), due to the high risk factors

faced by some non-compliant immigrant women, they had to be reported to social

healthcare workers in order to avoid complications during pregnancy and childbirth. Fur-

thermore, lack of interpreting services in antenatal classes led to non-compliance and

underutilization of services. In light of this, antenatal classes should be organized to meet

the need of pregnant immigrant women by using interpreting services, literature materi-

als available in different languages. In addition, healthcare providers with multicultural

background should be encouraged to give patient education.

Lack of self-control

Another major consequence resulting from communication challenges is the lack of self-

control (Barolia et al. 2016; Briscoe et al. 2009; Dickerson et al. 2014; Higginbottom et

al. 2015; Kilpatrick et al. 2009 Wojnar 2015). Most of the articles reported that immigrant

women were not in control of their situations. Most of the immigrant women were unable

to participant in decision making and giving informed consent. For instance, participant

had no knowledge of service expectation and hospital policy (Wojnar. 2015). This re-

sulted in the patient’s breakdown after Caesarean section during childbirth, as she was

requesting for her uterus which had been taken out surgically to be given back to her. In

addition, they agreed to procedures that they did not really understand. They also did

not follow recommendations given to them (Murray et al. 2010).

Patient-Provider Relationship

The relationship between patient and healthcare provider is the pillar upon which good

healthcare, trust and good pregnancy outcome can be built. Unfortunately, this relation-

ship was negatively impacted by communication barriers (Binder et al. 2012; Barolia et

al. 2016; Dickerson et al. 2014; Murray et al. 2010). Many pregnant immigrant women

complained about lack of relationship and emotional support from their healthcare pro-

viders. They felt rejected, “fed-up”, “lonely and lost”, furthermore, they were unable to

express themselves freely to the healthcare providers. This completely led them to mis-

trust of the healthcare workers and the system entirely (Binder et al. 2012; Briscoe et al.

21

2009; Dickerson. 2014; Murray, et al. 2010; Wojnar 2015). In addition, the healthcare

providers felt that communication challenges heighten the emotional and care demand

of pregnant immigrant women (Binder et al. 2012; Barolia et al. 2016; El Ansari et al.

2012). Care providers felt exhausted, time demanding and they were unsure about how

much immigrant women knew about the healthcare system. Moreover, the use of inter-

preters put further constrains on the relationship and also raised confidentiality and eth-

ical concerns (Barolia et al. 2016; Cherry & Jacob. 2014; El Ansari et al. 2015).

6.2 Discussions on Ethical Considerations

Ethical consideration of literature review was taken into account in order to maintain ac-

ceptable ethical standard. Articles gathered in this literature review, each material used

were meticulously evaluated to have carried out their research in ethically required pro-

cedures. The due processes of gathering and evaluating samples were done. However,

if the research is into data already in public domain, (such as in our literature review)

approval of ethical committee is not needed. (Day, Maltby, McGarry. & Williams.

2010:336-350.) In order to meet ethical standards, the data collection processes and the

data collected reflect the following ethical standards: Purpose, what scientific and ethical

purpose does the research serviced. Data are from trustworthy sources and that sam-

ples are ethically collected and analysed. We ensured that the background literature pro-

vided a “clear rationale” for the research and also to know if the research methods an-

swered the researched questions (Day et al. 2010).

Furthermore, the guidelines set by Metropolia University of Applied Sciences Helsinki, in

accordance with The Finnish Advisory Board on Research Integrity (2014) was followed.

This mandates that we properly use references, data should not be manipulated, fabri-

cated or intentionally misinterpreted. The works of others are clearly attributed to the

legitimate author. Conflict of interest in literature used were carefully looked at and re-

ported if found. Findings are presented in fairness, objectivity, transparent, variability and

in all honesty (Finnish Advisory Board on Research Integrity 2014). The ethical principles

of nursing researches are completely taken into consideration. In thesis, the beneficence

of the research, which demands that research study should be of great benefit to the

general public was adhered to (Parahoo 2014). The principles of inductive content anal-

ysis were used to arrive at findings of this thesis. Data were fairly, objectively collected

and analysed. Moreover, we did not intentionally, manipulate data to reach a predeter-

mined results or findings.

22

6.3 Discussions on Validity

Validity is the foundation of research (Day et al. 2010:245-246). According to Cohen,

Manion, & Morrison (2007:133-163) validity of research hinges upon: transparency in

data collection and analyzing process, the ability of the samples to provide scientific an-

swer to the study question/s, researchers are more concerned about validity, reliability

and ethical consideration in the process rather than the outcome of the research result,

the purpose. In this thesis, the readers was kept unbiasedly informed throughout the

research processes. Methods of ensuring validity of research such as appraisal of re-

search articles, authors and database sources are maintained. The strengths, weak-

nesses, the limitations of evidences and their possible interference and threats in the

results are documented. (Haber & Lobiondo-Wood 2010:288-306.)

In this thesis, validity of literature review is the cornerstone. Bias in studies can affect the

validity of the result. Therefore, methods of samples collection, analysis and interpreta-

tion was unbiased. The quality of literature articles, authors, date of publications, peers-

reviewed and the scientific journals and the database source and how the articles answer

the study questions are ethically sound. (Haber & Lobiondo-Wood. 2010:288-305). The

use of two databases, CINAHL and Medline, ensures that the articles used in this bach-

elor thesis are authentic and ethically searched. Furthermore, articles used in this thesis

are found to be reliable. The limitation of this bachelor thesis is that, this is a learning

process for the authors and might have unintentionally overlooked some areas, which

needed more attention.

7 Conclusion

The migration of people from different parts of the world has surged and it is expected to

continue in the foreseeable future (International Migration Report, UN 2015). Its impact

on health care services has tremendously affected the communication between

healthcare provider and their clients. Communication remains as the backbone of devel-

oping and furthering the relationship between pregnant immigrant women and health

care workers. Culture and communication are intertwined together in forming the pattern

of communicating. (Andrews & Boyle 2012; Bach & Grant 2009; England & Morgan

2012.) Many pregnant immigrant women and their care provider could not connect ef-

fectively in this area.

23

In the absence of a common language, non-compliance with antenatal care, lack of

knowledge of service expectations and care procedures prevented these women from

participating in decision making. Consequently, the relationship between providers and

patients suffered greatly.

The use of interpreting services were viewed in too negative light. Their services were

mostly seen as suboptimal, unreliable, unprofessional and sometimes seen as breaching

the confidentiality of the patients. (Barolia et al. 2016; Binder et al. 2012; Briscoe et al.

2009; Castro et al. 2015; El Ansari et al. 2012; Dickerson et al. 2014; Higginbottom et al.

2015; Kilpatrick et al. 2009; Murray et al. 2010.) We are convinced that their role in the

health care services is highly needed and beneficial to the patient and care provider.

Therefore, further research is needed to study their roles and their contribution to health

care services and how they can affect the communication between healthcare providers

and patients.

24

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Appendix 1. Selected Articles

Articles Objective Methodology Findings

Barolia, R., Chiu, Y., Higgin-bottom, G., Mumtaz, Z., O’Brien, B., Paton, P., Safi-pour, J. & Yohani, S. 2016

An ethnographic investiga-tion of the maternity healthcare experience of immigrants in rural and ur-ban Alberta, Canada. Canada

To generate new under-standing of the processes that keep immigrant disad-vantages in maternity healthcare. To conceive possible inter-ventions that might improve maternity experiences and outcomes for immigrant women in Canada.

Ethnography research study of 86 recruits ( IW,´HCP, SSP) Semi-structured indi-vidual and focused group in-terviews

Limited English language knowledge affected the ability of the immigrant women to interact, express their feelings, understand medical terms, and participant in planning care with care providers. Furthermore, language barriers lead to intimidation, lack of participation in pre-natal classes, underutilization of services and unnecessary repetition medical screening for the same illness. Interpreting services were present but underused.

Binder, P., Borne, Y., Es-sen, B., & Johnsdotter, S., 2012

Shared Language Is Essen-tial: Communication in Multi-ethnic Obstetric Care Set-ting Sweden

Focuses on communication and conceptions of obstetric care looking at the hypothe-sis that immigrant women prefer healthcare providers, interpreters of the same eth-nic background and gender profile. When receiving care in multiethnic obstetric set-ting.

122 In-depth Individual and focus group interviews using semi-structured and open-ended interviews

Analyzed through the use of qualitative techniques

Participant agreed that communication prob-lems is highest hurdles between patients and healthcare providers. Inadequate communica-tion can lead to some immigrant women being seen as “problematic patient”. All in all, patient and care providers agreed that without language barrier, ethnicity and other barriers are not pronounced. The use of interpreters were seen as neces-sary but can lead to suboptimal care, trauma and distress (the use of family members as in-terpreters) lack of privacy, impractical at times and in an emergency situation,

Briscoe, L. & Lavender, T. 2009

To explore the experiences of maternity care by refu-gees and asylum seeker

Semi structured taped inter-views, fields notes and pho-tographs

Communication between the carer and patient is problematic. There were misunderstanding

Exploring maternity care for asylum seekers and refu-gees

British Journal of Midwifery United Kingdom

Four (4) participants on both sides. Development of partnership be-tween the healthcare worker and the patient is also based on the nonverbal aspect of commu-nication. Such positive development can con-tribute to a more positive partnership.

Castro, I., Llorca, J., Paz-Zulueta, M., Ruiz, M. & San-tibáñez, M. 2015

Factors associated with lack of adherence to antenatal care in African immigrant women in northern Spain: The role of social risk fac-tors in combination with lan-guage proficiency Spain

To examine the relationship between language profi-ciency, social risk factors and lack of adherence to antenatal care in African im-migrant women.

Retrospective cohort study

231 African immigrant women and 627 Spanish women.

This study shows that the lack of Spanish lan-guage proficiency was related to non-adher-ence to maternity care and inadequate antena-tal care. Consequently, these African immi-grant were referred to Social service providers.

Dickerson, S., Kim, W. & Seo, J.

2014

Korean Immigrant Women’s Lived Experience of Child-birth in the United States

JOGNN

To understand the experi-ences of Korean immigrant women using maternity care in the United States

15 Koreans between 29-42 years old and has given birth in the USA for the at least 5 years prior to the start of the research

Phone interview

Patients dealt with many barriers in during their maternity in a foreign and unfamiliar health set-tings including language barriers. Due to lack of English language proficiency, mothers had difficulties attending prenatal visits, they did not have control of information and misunderstand-ings with doctor’s instructions. These Korean mothers were not able to forge good and per-sonal relationships with the care providers due to language barriers.

United States of America However these Korean women actively searched for information through the use of In-ternet and networking

El Ansari, W., Degni, F., Essén, B., Suominen, S. & Vehviläinen-Julkunen, K. 2012

Communication and Cul-tural Issues in Providing Re-productive Health Care to Immigrant Women: Health Care provider’s experiences in meeting Somali women living in Finland

J Immigrant Minority Health Finland

To explore the physicians and nurses/midwives com-munication when providing maternity care for Somalis living in Finland

15 physicians and 17 nurses/midwives Individual and focus group interviews using open ended questions.

The research yielded several findings which can be useful as a reference for future re-searches. The first one is that communication and cultural sensitivity is necessary for provid-ing reproductive and maternity health services. Second one is that the style of communication of the health care provider implicates that the healthcare worker should take active role on in-teraction.

Higginbottom, G., Mumtaz, Z., O’Brien, B., Paton, P., Safipur, J. & Yohani, S. 2015

An ethnographic study of communication challenges in maternity care for immi-grant women in rural Alberta Canada

To identify the communica-tion difficulties in maternity care from the perspectives of heathcare providers, im-migrant women and social services providers in Al-berta, Canada

An ethnography focused study of 31 participants ( IW, HCP, SSP) semi-struc-tured individual interviews

Communication challenges were subdivided: verbal, nonverbal and unshared meaning. Im-migrant women lack of verbal communication ability limited their ability to utilize services available to them, articulate and communicate with health providers. Healthcare providers ex-perienced frustration and time wasting while caring for immigrant women. Lack of interpret-ers increased the likelihood of misunderstand-ing and dissatisfaction. Even if interpreter is available this can lead to fear and anxiety for

the woman. Unshared meaning due to ethno cultural differences led miscommunication, re-jection of care procedure. Nonverbal communi-cation between care provider and immigrant women is greatly impacted by trust.

Kilpatrick, S., Hoang, H.T. & Le, Q. 2009

Having a baby in the new land: A qualitative explora-tion of the experiences of Asian migrants in rural Tas-mania, Australia. Australia

To examine Asian migrant women’s child-birth experi-ences in a rural Australian setting.

10 Asian migrant women resident in rural Tasmania participated in the study us-ing semi-structured inter-views

Language barriers affected Asian migrant women from accessing antenatal classes. Pamphlets were mainly available in English and most women did not receive pamphlet in their languages because they were not aware of the availability.

Iliadi, P., 2008

Refugee Women In Greece: A Qualitative Study Of Their Attitudes And Experiences In Antenatal Care. Greece

Investigate whether refugee women in Greece: receive antenatal care, antenatal visits, and attitude towards antenatal care and highlight any barriers in accessing maternity services.

26 participants interviewed face-to face Semi-structured interviews and tape-rec-orded.

Language barriers negatively affect the refugee women access to maternity care, leading to lack of information, missing appointments and using family members as interpreters which re-sulted in: a source of embarrassment.

Murray, L., Parker, E. & Windsor, C., 2010

Experiences of African Women Giving Birth in Bris-bane, Australia. Australia

To gather and describe the experiences of childbirth of African refugee women in Brisbane. To share the knowledge obtained with stakeholders and commu-nity members

Husserlian phenomenologi-cal framework ( focuses on lived experiences to de-scribe universal phenome-non being studied)

10 Semi-structured inter-views were conducted and recorded

Language insufficiency led to limited knowledge of treatment procedures, hospital policies, patient's right to consent, medication adherence, agreeing to procedure without any knowledge of the procedure. Furthermore, lan-guage barriers lead to some hospital services such as interpreters were unused. Participants experienced fear, mistrust, frustration, distress

and suspicion because of lack of proper com-munication.

Wojnar, D. 2015

Perinatal Experiences of Somali Couples in the United States

JOGNN United States of America

To probe Somali couples’ experiences of care and support in the perinatal pe-riod in the United States

26 Somali couples semi structured interviews, cou-ple interviews, phone inter-views

The results of these interviews showed the conflicting values and traditions of Somali cou-ples and their American hosts when it comes to perinatal care.