The impact of culture on access to and utilisation of maternity care amongst Muslim women: A qualitative systematic review.

The impact of culture on access to and utilisation of maternity care amongst Muslim women: A qualitative systematic review. | Authorea try { document.documentElement.classList.add('js'); } catch (e) { } var _gaq = _gaq || []; _gaq.push(['_setAccount', 'G-8VDV14Y67G']); _gaq.push(['_trackPageview']); (function() { var ga = document.createElement('script'); ga.type = 'text/javascript'; ga.async = true; ga.src = ('https:' == document.location.protocol ? 'https://ssl' : 'http://www') + '.google-analytics.com/ga.js'; var s = document.getElementsByTagName('script')[0]; s.parentNode.insertBefore(ga, s); })(); Skip to main content Preprints Collections Wiley Open Research IET Open Research Ecological Society of Japan All Collections About About Authorea FAQs Contact Us Quick Search anywhere Search for preprint articles, keywords, etc. Search Search ADVANCED SEARCH SCROLL BJOG: An International Journal of Obstetrics and Gynaecology This is a preprint and has not been peer reviewed. Data may be preliminary. 7 February 2025 V1 Latest version Share on The impact of culture on access to and utilisation of maternity care amongst Muslim women: A qualitative systematic review. Authors : Aljawharah Al-Mubarak , Brana Ahilan , Tisha Dasgupta , Sergio Silverio 0000-0001-7177-3471 , Hiten Mistry , Lojain AL-Harbi , Jawza Aldakhail , Stephanie Heys , Peter von Dadelszen 0000-0003-4136-3070 , and Laura Magee 0000-0002-1355-610X [email protected] Authors Info & Affiliations https://doi.org/10.22541/au.173890170.08284862/v1 592 views 300 downloads Contents Abstract Abstract Introduction Methods and study design Data extraction and synthesis Results Supplementary Material References Information & Authors Metrics & Citations View Options References Figures Tables Media Share Abstract Background: Global human migration has highlighted the need to provide culturally-appropriate maternity care, delivered in accordance with the recipient’s beliefs and practices. Objectives: This review aims to examine the impact of culture on access, utilisation, and care delivery of care for Muslim women during pregnancy, and postpartum, through the experiences of women, families, and maternity care-providers. Search Strategy: Six electronic databases were searched for published qualitative and mixed-methods studies, in English (01/January/2003-12/October/2023). Selection criteria: Studies undertaken in high-income countries reporting the experiences of either Muslim women accessing and utilising maternity services, or care-providers delivering those services. Data collection and analysis: Meta-ethnography was used to develop new concepts from included studies. Main results: Of 23,428 articles identified, 24 met inclusion criteria. Four themes were identified: ‘ Religious influences’ , ‘Sociocultural interactions’ , ‘Healthcare as a culture’ , and ‘Disrupted communication’ . Women’s negative experiences highlighted cultural insensitivity, providers’ unconscious bias, inflexible care models (and the conflict between expectations of services and those offered), and cultural stereotyping in addition to indifferent and uniform care. Care-providers’ experiences highlighted challenges with miscommunication and Muslim women’s reliance on information (and sometimes, misinformation) from their communities. Conclusions: Our findings highlight the challenges involved in delivering culturally-sensitive care to Muslim women; issues that extend beyond the confines of culture-specific awareness of religion and ethnicity, to the universal concept of personalisation. This is reflected in the theory, ‘ Recognise our differences, embrace our diversity, and care for me as an individual ’. The impact of culture on access to and utilisation of maternity care amongst Muslim women: A qualitative systematic review. Aljawharah Al-Mubarak, MSc, PhD candidate 1,2 Brana Ahilan, iBSc Student 1 Tisha Dasgupta, MSc, Research Associate and PhD candidate 1 Sergio A. Silverio, MSc, Lecturer in Psychology Medical Psychology & Lifecourse Health 1,3 Hiten D. Mistry, PhD, Senior Research Fellow 1,4 Lojain AL-Harbi, BSc, Emergency Medical Services Specialist 5 Jawza Aldakhail, MSc, Clinical Research Fellow and PhD candidate 6 Stephanie Heys, PhD, Consultant midwife 7 Peter von Dadelszen, DPhil, Professor of Global Women’s Health 1 Laura A. Magee, MD, Professor of Women’s Health 1 Affiliations 1. Department of Women & Children’s Health, School of Life Course & Population Sciences, King’s College London, London, United Kingdom; 2. King Abduallah International Medical Research Centre, Riyadh, Saudi Arabia; 3. Department of Psychology, Institute of Population Health, University of Liverpool, Liverpool, United Kingdom. 4. Department of Health Sciences, University of Leicester, United Kingdom; 5. National Health Emergency Operation Centre, Ministry of Health, Riyadh, Saudi Arabia; 6. Wiliam Harvey Research Institute, Queen Mary University of London, London, United Kingdom; 7. The North West Ambulance Service, Manchester, United Kingdom. Address for correspondence: Professor Laura A. Magee 6 th Floor Addison House, Great Maze Pond King’s College London London, UK SE1 1UL [email protected] Shortened title: Impact of culture on maternity care for Muslim women: systematic review. Key words: Qualitative research, Systematic review, Meta-ethnography, Women, Ethnic minority, Pregnancy, Postpartum, Culture, Muslim. Acknowledgement: This review was conducted with the aid of Ms. Sara Montalti, a Senior Library Assistant (Learning Design & Delivery) at King’s College London. We are grateful for her contribution. Disclosure of interest: The authors have no conflicts of interest relevant to this article to disclose. Contribution to authorship: AA, LM, SH & PvD planned the review including conceptualising the study selection criteria, AA searched the literature and screened eligible articles. BA, LA & JA also screened the articles. AA & BA undertook the data analysis and manuscript draft. AA, LM, SH, PvD, SS, TD & HM contributed to manuscript writing. Ethical approval: Not applicable. Abstract Background: Global human migration has highlighted the need to provide culturally-appropriate maternity care, delivered in accordance with the recipient’s beliefs and practices. Objectives: This review aims to examine the impact of culture on access, utilisation, and care delivery of care for Muslim women during pregnancy, and postpartum, through the experiences of women, families, and maternity care-providers. Search Strategy: Six electronic databases were searched for published qualitative and mixed-methods studies, in English (01/January/2003-12/October/2023). Selection criteria: Studies undertaken in high-income countries reporting the experiences of either Muslim women accessing and utilising maternity services, or care-providers delivering those services. Data collection and analysis: Meta-ethnography was used to develop new concepts from included studies. Main results: Of 23,428 articles identified, 24 met inclusion criteria. Four themes were identified: ‘ Religious influences’ , ‘Sociocultural interactions’ , ‘Healthcare as a culture’ , and ‘Disrupted communication’ . Women’s negative experiences highlighted cultural insensitivity, providers’ unconscious bias, inflexible care models (and the conflict between expectations of services and those offered), and cultural stereotyping in addition to indifferent and uniform care. Care-providers’ experiences highlighted challenges with miscommunication and Muslim women’s reliance on information (and sometimes, misinformation) from their communities. Conclusions: Our findings highlight the challenges involved in delivering culturally-sensitive care to Muslim women; issues that extend beyond the confines of culture-specific awareness of religion and ethnicity, to the universal concept of personalisation. This is reflected in the theory, ‘ Recognise our differences, embrace our diversity, and care for me as an individual ’. Funding: This review is part of a PhD project at King’s College London funded by Kings Saud Bin Abdulaziz University For Health Sciences, Riyadh, Saudi Arabia. Introduction Global migration has necessitated the provision of maternity care to populations of diverse cultures and with varied experiences[1-3]. Yet, studies continue to highlight women from ethnic minority (vs. White) backgrounds experience poorer pregnancy outcomes, including higher maternal morbidity and mortality rates[2-6]. These heightened risks of maternal complications amongst ethnic minority women may be attributed, partly, to delays in accessing maternity care or its under-utilisation[2, 3, 5]. Barriers include transportation difficulties and financial instability[1-7]. A recent qualitative systematic review extends this list of barriers for ethnic minority women from high-income countries (HICs) by adding poor health literacy, prior negative experiences, and cultural insensitivity, which were reported as contributing to delaying initiation of antenatal care (ANC) or failing to complete recommended ANC visits[3]. Cultural insensitivity in healthcare is described in literature as “the inability to be appropriately responsive to the attitudes, feelings, or circumstances of groups of people that share a common and distinctive racial, national, religious, linguistic, or cultural heritage” [8]. This insensitivity stems from differences between the cultures of care-users and care-providers, at the level of individual healthcare professionals (HCPs) and broadly, the healthcare system[5]. . Cultural insensitivity may have a negative impact on care-seeking through mistrust and poor quality of care, especially where implementation of culturally-appropriate maternity care is challenged by linguistic barriers and lack of resources, including staff training[9]. The present systematic review aims to synthesise the qualitative literature focused on Muslim women, and both the receipt and provision of culturally-appropriate maternity care, defined as that which is delivered in accordance with the recipient’s religious or sociocultural beliefs and practices[3, 4, 10, 11]. Methods and study design The review was prospectively registered with the International Prospective Register of Systematic Reviews (PROSPERO, CRD42024499304)[12]. This systematic review was conducted according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines[13]. Eligibility criteria Our search strategy was designed to identify the global literature on the impact of cultural factors on access to, utilisation, and delivery of maternity care. We identified all relevant qualitative studies (i.e., interviews, focus groups, or free text responses in surveys) evaluating the experiences of pregnant women (and their families) receiving maternity care, and those of HCPs providing that care. We defined ‘culture’ as a group’s beliefs and practices that define them, related to issues that include (but are not limited to) language, religion, custom, social norms, and laws[1-7, 9]. Our outcome of interest was the experience of care receipt (by women and families) or provision (by HCPs), evaluated in qualitative study design. To eliminate additional influences, such as economic and conflict issues that may not directly relate to care provision or receipt, studies were only eligible if conducted in HICs (according to the 2023-2024 World Bank index). Searches A preliminary search was conducted to identify all relevant search terms, using keywords and synonyms, based on ‘Population-Exposure-Outcomes’ (PEO) criteria as listed below in Table S1 . Six electronic databases were searched, from January 2003 to 27 November 2023: Clinical Index for Nursing and Allied Health Literature (CINAHL), Medline (Ovid), Global Health (Ovid), Maternity, Infant Care database (MIDIRS, Ovid), Embase (Ovid), and Scopus. PubMed and Google Scholar were used to search citation and references lists. Our search was limited to English publications. A detailed description of the search strategy is shown in Table S2 . Study selection Identified articles were uploaded to Rayyan software [14]. Following removal of duplicates, team members (AA, BA, JA, LA) independently screened the titles and abstracts of identified articles. Abstracts of studies which contained insufficient information were moved to full-text review, undertaken independently by two reviewers (AA, BA) for final article inclusion. The reference lists of included articles were reviewed for additional, potential publications to consider for inclusion. Any conflicts were resolved by discussion. In the event of unresolved conflict, a third reviewer (LAM, PvD, SH) was consulted. Given the broad range of literature identified and the multiple representations of culture, included studies were grouped prior to data extraction, then categorised to either ‘stable’ or ‘migrant’ populations. Articles meeting inclusion criteria which studied stable populations focussed on ethnic/racial minority status, indigenous populations, and sociocultural vulnerabilities (such as homelessness or adolescent pregnancy). Articles focussing on migrant populations focussed on ethnicity, sociocultural vulnerabilities (such as asylum-seekers and undocumented refugees), as well as religion and female genital mutilation (FGM) This study focussed on Muslim women, and included publications focused on participants from the Middle East, where there are predominantly Muslim populations. Two reviewers independently assessed the quality of included studies, using an adaptation of the Walsh and Downe tool for qualitative research appraisal[15]. This tool assesses research quality based on scope and purpose, design, sampling strategy, analysis, interpretation, reflexivity, ethical dimension, and relevance and transferability[15]. To best fit our study, we amended an adaptation of the tool by Yuill et al. , which reduced the number of items in the original Walsh and Downe tool and utilised a numeric scoring system instead of categorical system[16]. The resultant tool consisted of 35 items, each scored from 0-2 (with 0 representing poor, 1 representing moderate, and 2 representing high quality), and the total score ranging from 0-70, with 0-24 as low overall quality, 25-47 as moderate, and 48-70 as high. No studies were excluded based on study quality. Data extraction and synthesis Data from included articles were extracted independently by two reviewers (AA, BA), using a predesigned form in Microsoft Excel ( Table S3 ). Following data extraction, each paper was uploaded to NVivo, a computer-assisted qualitative data analysis software used to assist researchers in managing, organising, visualising, and reporting their data [17]. Participants’ accounts (quotations) from the results sections were highlighted in the uploaded paper, to be coded for an analytic synthesis. Reviewers (AA, BA) undertook a meta-ethnography, as a seven-phase analytic-synthesis technique for qualitative data to explore potential new understandings beyond the findings of the original studies, once papers are amassed and participants’ data from different studies can be pooled[18]. First-order constructs (i.e., quotations, the primary qualitative data) and second-order constructs (i.e., primary authors’ interpretations) were first coded, and then the codes were combined to create a hierarchical cluster of similarities (reciprocal data) and differences (refutational data) across included studies. These clusters were compiled to generate third-order constructs or a ‘line of argument’ the reviewers’ interpretations from a tertiary analysis of first- and second-order constructs. The results were presented as descriptive themes relating to the relevant experiences of patients and HCPs[18]. Results Of 23,528 articles identified, 102 relevant articles met eligibility criteria, of which 24 focused on Muslim women[18-42], and were included in this review ( Figure 1 ). Most studies (n=23) were of high quality with an average score of 61/70[19-41], with one study of moderate quality with a score of 41/70[42] ( Table S4) . Most studies were conducted in Europe (n=14)[19, 20, 23, 25-34, 38-41], with the remaining from North America (n=9)[21, 24, 30, 33, 35-37, 41, 42], or across two settings (Norway and Australia)[22]. Studies were carried out from 2002 to 2018. Most (n=19) undertook interviews for data collection[20-29, 32-37, 40], whilst three studies used focus group discussions[19, 30, 42] and two studies used both[31, 34]. Most studies focused on women’s experiences of receiving maternity care (n=22)[19-21, 23-27, 29-42], while two studies involved partners,[19, 41] and another two studies explored experiences of health care-providers in delivering care[22, 28]. There were 373 participants, of which 293 were women, 45 were maternity HCPs, and 35 were male partners and family members. Most participants were either self-identified as, or were suggested to be, Muslim women[19, 20, 22, 24, 26, 29-34, 38-42]; only eight studies explicitly stated participants’ religion[21, 23, 25, 27, 28, 35-37]. For further details of individual studies, see Table S5 . Meta-ethnography produced four themes (‘Religious influences’, ‘Sociocultural interactions’, ‘Healthcare as a culture’, and ‘Disrupted communication’), and nine sub-themes ( Figure 2 ) . Theme 1: Religious influences This theme reflected experiences of women (n=9)[21, 24, 25, 27, 29, 35-37, 41] and HCPs (n=3)[19, 22, 28], and had two sub-themes: ‘Modesty’ and ‘Religious Practices’ ( Table 1) . Negative experiences of women were heavily influenced by their cultural practices and religious beliefs. Modesty Women’s interactions with HCPs were regulated by their Islamic teachings; this affected care utilisation, as most women preferred female HCPs. Whilst this was especially true when physical examination was required[21, 27, 35-37], women were also embarrassed discussing pregnancy-related matters with male HCPs[21, 27, 29, 39], through male interpreters [24, 39, 40] or whilst attending mixed-gender group prenatal classes[21, 41]. Participants preferred a more private setting[21, 41] to discuss intimate details of their reproductive health[21, 27, 37, 39, 41]. Of note, some Muslim women revealed they simply preferred female HCPs for personal reasons[36, 40]. Failure to respond to Muslim women’s desire to have a female HCP left women feeling upset[21, 27, 35, 41]. Conversely, attempts to accommodate women’s religious needs had a positive impact on their experiences, and when their beliefs were considered, women were more likely to accept care delivered by male providers, if necessary[29, 35-37]. HCPs found that when Muslim women requested treatment by a female provider, this often interfered with care delivery[22, 28]. When a female HCP was not available, pregnant women faced delays in receiving care[22, 28]. Religious practices Muslim maternity care-users considered their religious practices as important, especially during labour[25, 27, 35]. These practices include fasting, praying the Shahadah; a profession of faith prayer, and reciting Quran. Unsupportive attitudes towards these expressions of religion made women reluctant to disclose relevant information (e.g., fasting during pregnancy), potentially having a negative impact on care[25, 27, 35, 36]. In contrast, a few women appreciated providers showing respect for their beliefs and integrating those beliefs into their care, and this improved their care experience[25, 39]. Some HCPs reported finding it difficult to ask if their patient were fasting, due to fear of offending, whilst others expressed the view that even when asked, most Muslim women did not divulge fasting, for fear of being judged[28]. Theme 2: Sociocultural interactions This theme reflected the experiences of women and families (n=11)[24-26, 30, 31, 33, 34, 36, 40-42], and HCPs (n=3)[19, 22, 28], with two sub-themes: ‘Family dynamics’ and ‘Community norms’ ( Table 2) . Family dynamics Muslim women felt family members should be the primary source of information during pregnancy and postpartum[26, 30, 31, 34]. Reliance on familial advice was particularly strong when women did not receive adequate information from their HCPs.[36] Some women felt only new mothers may need to attend antenatal visits or participate in prenatal classes, because knowledge acquired from family members provides them with sufficient guidance[26, 30, 31, 34]. However, other women acknowledged the need to consult maternity HCPs in addition to seeking family advice[42]. . Care-providers described family influences on care access and utilisation[19, 22, 28]. In a cross-country study in Sweden, midwives found the participation of families to be positive, whilst Australian midwives found family influences to hinder care delivery[22]. In both studies, HCPs noted that women’s reliance on family advice often interfered with medical recommendations[19, 22, 28]. Moreover, input from male family members was perceived as a barrier to delivering personalised care as women’s needs may not be properly articulated[19, 22, 28]. Community norms As with family members, women found community members to be a source of support, especially after immigration when no family was present during pregnancy[25, 33, 35]. Some women stated that many women in their communities seek maternity care services only when in labour or there is an emergency[31, 40, 41]. Care-providers noted Muslim women’s dependence on support from other women in the community had contributed to delays in accessing care[22, 28]. As such, some suggested that providing midwives of similar culture to pregnant women might encourage them to use maternity services[28]. Theme 3: Healthcare as a culture This theme reflected the experiences of women and families (n=15)[19-21, 25-27, 29-32, 35-38, 41], and care-providers (n=3)[19, 22, 28], with three sub-themes: ‘Familiarity with healthcare systems’, ‘Expectations of care’ (relevant only to women and families), and ‘Utilising medications and medical interventions’ ( Table 3 ). Familiarity with healthcare systems Several women felt lost and confused trying to navigate healthcare systems different from those in their country of origin; this led to missed opportunities to access appropriate services[20, 21, 26, 32, 35, 39, 41]. . Participants expressed that their experiences with maternity care services could have been better if they had received proper guidance regarding available resources[21, 23, 41]. However, migrant care-users noted that the longer they resided in their host country, the more familiar they became with the healthcare system, and this improved their access and utilisation of maternity care[19, 41]. Care-providers recognised the need to familiarise women with available services, to encourage care access and utilisation. HCPs noted that providing such education was a positive experience[19, 22, 28]. Midwives expressed that women’s lack of familiarity with routine care protocols led to disruption in care[19, 22]. Expectations of care Due to lack of familiarity, multiparous participants expected their care to be similar to previous care, which resulted in dissatisfaction with the care received[21, 25, 29, 30, 32, 37]. Women in Arab countries reported maternity care services to be more flexible and accommodating compared with care in the UK, where unscheduled visits were not felt to be a common practice[23]. Women reported feeling abandoned when their expectation of care was not consistent with the care delivered[23]. Across several studies, Somali women were apprehensive about accessing western maternity care, where Caesarean birth is \RL more common; they regarded medicalised birth as a poor outcome for mothers and their fertility[26, 30, 31, 33, 38, 41]. Utilising medications and medical interventions Both women and HCPs felt that conflicting views on treatment were due, at least in part, to cultural differences between healthcare-user and -provider[19, 22, 28]. Under those circumstances, when the offer of such intervention was declined, this often-made providers worried for women’s health and safety[19, 22, 28]. Australian midwives noted even when informed of available interventions, women often chose healthcare practices familiar to them, such as natural remedies[22]. For prenatal testing for chromosomal abnormalities, some women explained their rejection of testing for fear that this might lead to advice to terminate pregnancy, which they emphasised was against their beliefs[21, 27, 34]; others simply did not want to feel anxious about the potential results[26, 30, 31, 38, 40, 41]. For women who had undergone female genital mutilation (FGM), all aspects of maternity care were affected. Women expressed to their HCPs the need for de-infibulation (re-opening the vaginal opening), to avoid pain and tearing during childbirth; however, women felt that the procedure was rarely provided, due to the lack of familiarity with FGM and its management, leaving women traumatised following childbirth [30]. Care-providers acknowledged their inability to deliver advice or adjust care when they were not knowledgeable about certain cultural practices[19, 22, 28]. Caesareans were reported to have been offered for women with FGM, even when it was not needed, due to their lack of training in de-infibulation procedures[38]. Again, women had positive experiences when providers were culturally-aware, and attentive to their needs[25, 41]. Theme 4: Disrupted communication This theme explores how cultural differences between healthcare-users and -providers may lead to disruptions in communication that have negative consequences on care access, utilisation, and delivery (n=18)[19, 20, 23-27, 29-37, 39, 42]. There were two sub-themes: ‘Provider-patient relationship’ and ‘Decision-making’ (reported only by women) ( Table 4 ). Provider-patient relationship A perceived lack of cultural awareness among care-providers made women fearful of being judged, and hesitant to openly communicate with care teams and specifically, about services offered[19, 30, 31, 33, 40, 42]. Some women chose not to engage with services such as antenatal classes, because they were not adequately informed about them[21, 31]. Women with FGM felt humiliated by providers’ attitudes during physical examination[38, 40]. As a result, there were negative pregnancy experiences[25-27, 29, 39, 42]. However, women who were cared for by providers familiar with their culture reported feeling less isolated[32, 38, 39]. Language proficiency and health literacy affected patient-provider relationships[19, 25, 31, 32, 39]. Women felt that providers should and could be respectful and caring, regardless of language barriers[34]. Providers agreed, and highlighted that there are other forms of effective communication, and highlighted the need for cultural awareness training[19, 22, 28]. A lack of interpretation services often delayed care utilisation[22, 29, 31, 38], and many women felt that using interpreters was ineffective and interfered with patient-provider confidentiality[20, 23, 40]. Similarly, care-providers found language barriers challenging, particularly with regards to building a rapport with women[19, 22, 28]. Decision-making Participants preferred to be informed about their care and to actively participate in decision-making[24, 29, 40, 42], to maintain their autonomy[25, 29, 41]. . Lack of information, miscommunication, misunderstanding, and language barriers all impaired care users’ ability to share in decision-making[19, 24, 37, 38, 40, 41], and made women more sceptical about the medical advice received[31, 33, 39, 41]. They were more inclined to trust and follow medical direction from a provider acquainted with their culture[20, 41]. Of note, however, was that some women felt comfortable leaving decision-making to their care-providers[37]. Those women were used to a patriarch healthcare system and trusted their providers to do what’s best for their care[37]. Discussion Main findings This qualitative systematic review included 24 studies of Muslim women’s views on the receipt of maternity care, as well as HCPs’ views on their provision of said care. The four themes derived focussed on religious influences, sociocultural interactions, the healthcare system as a culture, and disrupted communication. Women’s experiences with maternity care services were positive when communication was open and care was appropriate to the individual and their cultural needs, and negative when these were not the case, which often led to refusal or delayed use of services offered. Women’s negative experiences highlighted cultural insensitivity and stereotyping, providers’ unconscious bias, inflexible care models, and difficulty with language barriers. However, their largely negative experiences were not caused exclusively by culturally-inappropriate care, but also by care that was indifferent, uniform, and not personalised. care user’s past experiences of maternity care in their home countries highlighted how healthcare system culture in host countries impact women’s interaction with maternity care services, a theme that was not highlighted in the included literature. Studies of providers’ perspectives on delivering care to Muslim women were limited to only three studies[19, 22, 28]. There were particular challenges with miscommunication rooted in cultural differences, and a reliance of Muslim women on information from their own communities. Importantly, providers’ experiences varied between women, despite their cultural similarities. Providers acknowledged the need for cultural training to improve women’s experiences and suggested a co-production strategy between women and providers[19, 22, 28]. . Interpretation Our findings highlight the challenges involved in delivering culturally-sensitive care to Muslim women, but also that issues extend beyond the confines of culture-specific awareness of religion and ethnicity, to the universal concept of personalisation. This is reflected in the theory, ‘ Recognise our differences, embrace our diversity, and care for me as an individual ’. Our findings are consistent with global literature on inequalities, including Muslim women. Immigrant women from ethnic minorities have more positive maternity care experiences when they have a better understanding of the language and the setting to the host country where they migrate[2, 3, 6, 10]. The importance of communication has been emphasised repeatedly, as has the negative impact of discriminatory behaviour on care-seeking[43]. Similar to our findings, other research has found that women tend to rely on familial advice as a result of negative experiences with maternity care providers[5, 9, 44]. Other studies presented similar findings to our review regarding the challenges that care-providers face when caring for Muslim women during pregnancy and childbirth, including cultural differences and communication barriers[9, 44-46]. Preconceived ideas about immigrant care-users were apparent amongst the included studies, and impacted the way care was delivered[45]. It is apparent from our findings, consistent with the literature, that ‘culture-clash’ between women and providers remains a barrier to care. Our findings are consistent with the broader healthcare literature on the interaction between personal characteristics and sociocultural factors[47]. Factors such as culture, are indirectly associated with global disparities in utilisation and provision of maternity care, and maternal mortality and morbidity outcomes[47]. Studies have highlighted delays in initiating care due to women lacking information about available services[2, 3, 10, 44, 48-50]. On the other hand, there is an extensive literature on interventions to reduce maternal health inequalities, by educating women, designing services to involve the community, implementing cultural competency training for maternity care-providers, and mobilisation of HCPs with similar backgrounds to care-users[51]. Negative attitudes of HCPs have been highlighted as a deterrent for women to access and utilise maternity care services[3, 4, 7, 10]. Rigid Western healthcare systems have been identified as being largely ill-suited to the individual needs of non-Western and migrant women[49]. In Western high-income settings specifically, a lesser regard for non-Eurocentric communities compounds the impact of these disparities in maternity and other care[51]. Reviews have emphasised that services that involve the community have increased women’s access to maternity care[5, 9, 44]. Mobilised HCPs with similar linguistic and cultural backgrounds, to collaborate with a multi-disciplinary team of midwives, physicians, and psychologists has proved effective in improving patient satisfaction, engagement with maternity care services, and knowledge about pregnancy, birth, and parenthood for Whilst employing care-providers of similar culture to Muslim women may assist in minimising culture-clash between care-users and -providers, it is difficult to envision this as a comprehensive solution, given staffing challenges where Muslim women do not form the predominant culture and diverse needs must be met[9, 45]. Relatedly, our findings also highlighted that personalised women-cantered care is the core for achieving a culturally appropriate care delivery within maternity services. the review showed that women’s representation of their cultural and religious values varied impacting their access and reception of care. That said, there appears to be clear justification for having care-providers skilled at de-infibulation. Strengths and limitations Strengths of our study include a comprehensive literature search that included all stakeholder groups. Although several reviews have discussed the experiences of ethnic minority women with maternity services, we believe that ours is the first to focus specifically on the impact of cultural factors on Muslim women, and to explore the topic from the perspectives of women and maternity care-providers. Also, and uniquely, we have used a meta-ethnography approach that extends the findings of the included studies themselves, by allowing for new interpretations. Limitations of our review are inherent to the primary literature on which the review is based. There are a limited number of published studies exploring care-providers’ experiences of providing care to Muslim women, and those studies do not detail providers’ demographics, ethnicity, and gender, making challenging ascertaining generalisability to the workforce in similar settings. This systematic review has identified considerable scope for improvement in culturally-appropriate maternity care of Muslim women, from care-user and care-provider perspectives. The solutions must consider a personalised way of care to inclusively address culture-specific issues, employing co-production services to ensure a better experience and care delivery. Adopting a lens of ‘cultural safety’ will allow services to acknowledge differences and empower patients’ rights in defining what “safe” care is during an encounter[53]. Although challenging to implement, especially with the directive approach health services use in implementing changes in practice, sharing the process of policy making with participants can reflect better care for women of minority groups. Co-production must therefore be at the heart of future solutions, particularly as some issues raised by Muslim women are common to the maternity care experiences of women more generally.[5, 9, 10, 19, 22, 28, 44] Supplementary Material File (figure 1. prisma flowchart.docx) Download 42.93 KB File (figure 2. a summary of identified themes and sub-themes.docx) Download 66.90 KB File (table 1. religious influences theme, sub-themes, and supportive quotations.docx) Download 16.24 KB File (table 2. social interactions theme, sub-themes, and supportive quotations.docx) Download 15.63 KB File (table 3. healthcare as a culture theme, sub-themes, and supportive quotations.docx) Download 16.70 KB File (table 4. disrupted communication theme, sub-themes, and supportive quotations.docx) Download 15.49 KB References 1. 1. Evans, C., et al., Improving care for women and girls who have undergone female genital mutilation/cutting: qualitative systematic reviews. 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Collection BJOG: An International Journal of Obstetrics and Gynaecology Keywords antenatal care maternal medicine maternity services qualitative research systematic reviews Authors Affiliations Aljawharah Al-Mubarak King's College London School of Life Course & Population Sciences View all articles by this author Brana Ahilan King's College London School of Life Course & Population Sciences View all articles by this author Tisha Dasgupta King's College London School of Life Course & Population Sciences View all articles by this author Sergio Silverio 0000-0001-7177-3471 King's College London School of Life Course & Population Sciences View all articles by this author Hiten Mistry King's College London School of Life Course & Population Sciences View all articles by this author Lojain AL-Harbi Ministry of Health View all articles by this author Jawza Aldakhail Queen Mary University of London William Harvey Research Institute View all articles by this author Stephanie Heys North West Ambulance Service NHS Trust View all articles by this author Peter von Dadelszen 0000-0003-4136-3070 King's College London School of Life Course & Population Sciences View all articles by this author Laura Magee 0000-0002-1355-610X [email protected] King's College London School of Life Course & Population Sciences View all articles by this author Metrics & Citations Metrics Article Usage 592 views 300 downloads .FvxKWukQNSOunydq8rnd { width: 100px; } Citations Download citation Aljawharah Al-Mubarak, Brana Ahilan, Tisha Dasgupta, et al. 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