Perinatal Care Experiences of Somali Women in the United Kingdom: A Scoping Review

Perinatal Care Experiences of Somali Women in the United Kingdom: A Scoping Review | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Perinatal Care Experiences of Somali Women in the United Kingdom: A Scoping Review Ladan Abdirashid Musse This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6068284/v1 This work is licensed under a CC BY 4.0 License Status: Under Revision Version 1 posted 14 You are reading this latest preprint version Abstract Background Perinatal care is a critical component of maternal and child health, encompassing the period shortly before, during, and after childbirth. In the United Kingdom (U.K.), disparities in perinatal outcomes are significant, particularly among ethnic minority groups such as Somali women. Aim This scoping review investigates the perinatal care experiences of Somali women in the U.K., aiming to identify common themes, barriers, and facilitators affecting their access to quality care. Methods A scoping review methodology was employed, including a comprehensive search of databases such as PubMed, CINAHL, Web of Science, and Google Scholar. Studies included were published between 2014 and 2024, focusing on the U.K. context and specifically addressing Somali women's perinatal care experiences. Data extraction and thematic analysis were conducted to synthesise findings from the included studies. Results Sixteen studies met the inclusion criteria. Key themes identified include cultural beliefs and practices, communication barriers, discrimination, psychological and physical impacts of Female Genital Mutilation (FGM), and socio-economic factors. Somali women often face challenges due to traditional practices conflicting with Western medical approaches, language barriers, and negative experiences with healthcare providers, leading to mistrust. However, strong community support networks were identified as significant facilitators. Conclusions Somali women in the U.K. face unique and complex challenges in accessing and receiving perinatal care. Recommendations include implementing culturally competent care practices, providing professional interpreter services, specialised mental health and deinfibulation clinics, and community engagement to improve perinatal care experiences and outcomes. Figures Figure 1 1 INTRODUCTION Antenatal, intrapartum and postpartum care is critical in promoting maternal and neonatal health. Optimal perinatal care eliminates possibilities of maternal and infant mortality besides other adverse long-term effects on the life of both the mother and the child (World Health Organisation [WHO], 2021 ). In the United Kingdom (U.K.), there remain significant inequalities in perinatal outcomes where Black women are four times more likely to die in the perinatal period than White women, and Asian women are two times more at risk (Knight et al., 2019). It is also evident that inequities affect newborns, as babies of Black and Asian mothers have higher perinatal mortality with a stillbirth rate of 7.4 and 6.3 per 1000 live births, respectively, compared to 3.8 per 1,000 births in White infants (MBRRACE-UK, 2022 ). The Somali ethnicity is one of the fastest-growing ethnic minorities in the U.K., and they experience various barriers to accessing perinatal care. The study by Degni et al. (2014) revealed that Somali women face various cultural, linguistic, and socio-economic challenges. Similarly, Dadi et al. ( 2023 ) pointed out that cultural practices around childbearing, combined with experiences of prejudice and exclusion in the healthcare sector, make these women’s challenges more acute. Somali women have negative perceptions of healthcare providers and feel that they are treated with disrespect, which contributes to the mistrust of the health care system and can result in avoidable delays in seeking appropriate care (Lindquist et al., 2014; Brown et al., 2010 ). Despite the growing focus on culturally sensitive care in the last decades, there is still a lack of research investigating the perinatal care delivery to Somali women living in the U.K. The majority of the studies show a tendency to blunt the ethnicity of minority females and, therefore, fail to consider the cultural and systemic issues affecting the Somali female (Lindquist et al., 2014). This lack of research prevents healthcare professionals and policymakers from designing specific prevention and management strategies suitable for this group. The study by Higginbottom et al. (2014) also provides evidence of systemic barriers to care that Somali women and other immigrant women face, like poor interpreter services and culturally unintuitive care leading to poor perinatal experiences. Using the P.C.C. (Population, Concept, Context) approach, this scoping review assesses the perinatal care experience of Somali women in the U.K. context. The subject under study is Somali women. The phenomenon pertains to perinatal care, and the settings are healthcare facilities in the U.K. The overarching research question guiding this review is: What are the experiences of Somali women with regards to perinatal care in the U.K.? This research question enables the investigation of the perinatal care experiences of Somali women and the challenges and enablers that may be observed and experienced in the U.K. The specific objectives of this scoping review are as follows: To identify themes and patterns from the perinatal care experiences of Somali women in the U.K. To investigate factors that enable and hinder Somali women's delivery and receipt of quality perinatal health services. To offer recommendations intended to enhance perinatal care services among Somali women. 2 LITERATURE REVIEW Reviews of the perinatal care experiences of Somali women in many countries reveal that they encounter numerous difficulties, from cultural disparities to linguistic factors in the healthcare systems. Primary care physicians and other general health care providers in the United States are unable to offer any services to Somali women and their companions because of language and cultural differences. According to Wojnar ( 2015 ), there is cultural insensitivity and a shortage of resources in the maternity care encounters of Somali women and their partners. Due to a lack of culturally responsive health care and a lack of spouse participation during prenatal health, Somali women felt neglected, uninformed, and powerless (Wojnar, 2015 ). The quality of primary health care systems received complaints because of cultural and programmatic dissimilarities between Somalis and the American way of delivering health services. In their mixed-method cross-sectional study among Somali women in Maine, Jacoby et al. ( 2015 ) found that Somali women’s perinatal health was determined by their health literacy. The assessment showed that the subjects of the study had poor health literacy and failed to comprehend most of the available treatments targeting females. These literacy deficits place Somali women at a high risk of postnatal depression and emergency caesarean sections (Jacoby et al., 2015 ). This study pointed to the lack of adequate health education and culturally appropriate teaching aids to fill existing knowledge deficits that lead to poor health among Somali immigrant women. In Scandinavia, Somali women’s perinatal care has the same issues as in other parts of the world with minor variance in the hardship. In Norway, Vik et al. ( 2022 ) examined the first encounter with the labour ward among Somali women; the women were characterised by limited health literacy, talking only with care professionals, and anxieties over the use of technology. The women said they required face-to-face consultations and recommendations as most were new to Norwegian healthcare services. The participants noted needing tailored attention and enhanced interpretation to improve their childbirth experience. Wallmo et al. ( 2020 ) also covered similar concerns in a study conducted in Sweden. It was found that Somali women appreciated communication, acknowledgement, and culturally sensitive treatment. However, they often encountered localised practices and a lack of information in Swedish healthcare facilities, especially for women who underwent “female genital mutilation (FGM)”. This study also supported the view that it is vital to provide reproductive care according to Somali culture and that professionals need to consider the cultural context of Somali women. Across these studies, it is evident that barriers to adequate perinatal care among Somali women are minimal communication, misunderstanding and poor health literacy (Wojnar, 2015 ; Vik et al., 2022 ). Although such challenges present themselves differently across the various nations, it is evident that the core problems are still similar. Somali women’s perinatal concerns are shaped more by their cultural background and immigrant status than by the healthcare systems in their host countries. While awareness of these concerns continues to increase, the existing literature lacks information on integrated programs that target the needs of Somali women. Studies predominantly address only minor issues like language differences or comprehension of the language in different healthcare settings without integrating solutions. This scoping review seeks to address this gap by analysing existing research to develop a comprehensive understanding of Somali women’s perinatal care and provide evidence-based recommendations. 3 RESEARCH METHODOLOGY 3.1 Methodological Approach This research has a scoping review approach that provides a comprehensive synthesis of the scientific literature related to the perinatal care experiences of Somali women. The scoping review method is used because it provides a broad assessment of diverse literature, especially in emerging fields where the studies could be diverse in terms of design and objectives (Arksey and O’Malley, 2005 ). Since the experiences of Somali women during the perinatal period have not been researched extensively, this approach enables the consideration of numerical and non-numerical data. As recommended by Tricco et al. ( 2018 ), the review follows the “PRISMA-ScR (Preferred Reporting Items for Systematic Review and Meta-Analysis extension for Scoping review) checklist” which contains 20 essential and two optional items to provide a transparent reporting of the evidence. 3.2 Information Sources An enhanced literature review was carried out using the “PubMed”, “CINAHL”, “Web of Science”, and “Google Scholar” databases. The search strategy was developed using the P.C.C. framework (see Appendix A): Population : Somali women Concept : Perinatal care experiences Context : Healthcare systems in high-income countries Search terms were generated using a combination of relevant keywords such as "Somali women," "perinatal care," "maternal health," and "UK." Boolean operators (AND, OR) and truncation were employed to refine the results. To ensure comprehensiveness, reference lists of included studies were scanned for additional relevant sources. Both published and unpublished literature were considered. 3.3 Eligibility Criteria The following eligibility criteria were applied to ensure the relevance of included studies: Inclusion Criteria : Peer-reviewed studies, studies published in English, those focusing on Somali women’s perinatal care experiences in the U.K., and studies published between 2014 and 2024. Exclusion Criteria : Studies that did not focus on Somali women, studies not in English, grey literature, and studies outside the context of the U.K. The rationale behind these criteria was to capture relevant studies on Somali women’s perinatal care experiences while ensuring the findings were applied to the research context. 3.4 Search The search strategy was documented carefully to ensure replicability. The search terms were refined iteratively, and Boolean operators were employed to maximise relevant results. Given the vast number of studies (15,000) retrieved from Google Scholar, the first 100 studies ranked by relevance were selected for further screening (Table 1 ). This approach is justified by Jacobs et al. (2016), who suggest that the top-ranked results in Google Scholar are often the most relevant. Table 1 Search strategy Database Search Terms Results PubMed "Somali women" AND "perinatal care" AND "U.K." 276 CINAHL "Somali women" AND "maternal health" 14 Web of Science "Somali women" AND "perinatal care" 34 Google Scholar "Somali women" AND "perinatal care" AND "maternal health" AND "U.K." 15,000 (limited to first 100 studies) Search limitations included a restriction to English-language studies and the use of Boolean operators that may have excluded some relevant results. These filters were applied to ensure the feasibility of the review and enhance the quality of included studies. 3.5 Selection of Sources of Evidence The selection process followed a systematic screening procedure. First, titles and abstracts were reviewed to ensure relevance to the study's objectives. Full-text articles were then retrieved for detailed assessment. Due to the nature of the research project, calibration exercises involving multiple reviewers were not possible. Any potential inconsistencies were resolved by re-evaluating the criteria and re-reading the articles to ensure accurate interpretation. 3.6 Data Charting Process A data charting form was developed to extract relevant information from the included studies. The data chart included study characteristics (e.g., author, publication year, study design), participant demographics, key findings, and limitations. As the sole researcher, no calibration exercise was possible, though efforts were made to ensure consistent data extraction by piloting the form on a subset of studies and making iterative revisions. A final version of the charting form is included in Appendix B. 3.7 Data Items Data items extracted included: Study details (e.g., author, year, country of origin) Population characteristics (e.g., sample size, demographics) Study design and methodology (e.g., qualitative, quantitative) Summary of key findings These items identified patterns across studies and contributed to the thematic analysis. The charting form includes clear definitions for each data item to ensure transparency. 3.8 Critical Appraisal of Individual Sources of Evidence As a scoping review, critical appraisal was not a requirement for this project. This decision is aligned with the guidelines for scoping reviews, where the focus is on identifying and mapping the literature rather than assessing the quality of individual studies (Arksey and O'Malley, 2005). The “Critical Appraisal Skills Programme (CASP) checklist” was used to evaluate each of the selected articles (Appendix C). This tool was recommended by Maeda et al. ( 2023 ) because it considers the intelligibility, relevance, sample size, feasibility, ethical concerns, and quality of data and data analysis. 3.9 Synthesis of Results To synthesise the data of the included investigations, thematic synthesis was conducted. The themes were determined prior to data analysis based on objectives, questions and by following the deductive approach, as McGowan et al. ( 2020 ) recommended. Therefore, challenges such as language barriers, cultural considerations in pregnancy, mental health and social determinants, and approaches to improving the perinatal health of Somali women were identified. This led to an assessment of how these aspects were handled in each research study, and the results were grouped. Applying this method helped direct the scoping review to the areas of concern and offered an organised approach to the research analysis. 3.10 Ethics Since scoping reviews do not require critical appraisal, a quality assessment was done to obtain high-quality research. Ethical approval was also unnecessary, as the study used a scoping review method. The ethics declaration form can be observed in Appendix E. 4 RESULTS 4.1 Screening Process for Selection of Sources The study selection process followed the PRISMA (Fig. 1 ) guidelines. The initial search identified 424 records through database searching. Of these, 285 papers were considered for further screening since they related to the research topic. After removing 65 duplicates, 220 records were screened based on the relevance of the issue being addressed in the specific population. Following the screening, 180 articles were excluded for not addressing the issue in the selected population or not presenting the specific outcomes of interest. This left 40 full-text articles, which were further assessed for eligibility. At this stage, 24 studies were excluded due to not meeting the criteria of including measurable outcomes relevant to perinatal care or focusing on a different population. Ultimately, 16 studies were included in the scoping review, each contributing to the thematic analysis and answering the research question. 4.2 Characteristics of Sources of Evidence Data charting provided an overview of the key characteristics of the 16 studies (see Appendix B). The studies included a wide range of designs, populations, and settings, all focusing on Somali women or other migrant women in high-income countries, predominantly in the U.K. Study designs were predominantly qualitative, with some systematic reviews and meta-syntheses, reflecting the need to capture nuanced and in-depth experiences of Somali women in perinatal care. Qualitative designs allowed for exploration of personal and community perspectives, barriers faced in accessing care, and the experiences of healthcare providers. Systematic reviews added to this work by synthesising broader trends across multiple studies. Populations varied but were consistently focused on Somali migrant women or women from similar ethnic and socio-economic backgrounds. Some studies expanded to include healthcare professionals, such as midwives, particularly those involved in perinatal care for women affected by FGM. Different settings included community-based services and obstetric-led units; hence the variation in care context that Somali women encounter. These settings played a crucial role in understanding how institutional practices influenced the women's experiences and the communities' cultural responsiveness and support systems. 4.3 Thematic Analysis Through deductive thematic analysis, four key themes were identified across the 16 studies: Language and Communication Barriers, Cultural Competence and Sensitivity in Care, Mental Health and Socio-economic Challenges, and Strategies to Improve Perinatal Care Outcomes. These themes answer the research question as they explore the main concerns that Somali women encounter during perinatal care and possible solutions. 4.3.1 Language and Communication Barriers The theme of language and communication was the most prominent one, as discussed in 14 out of the 16 studies (88%). The women received poor treatment from the health care providers. They did not understand each other due to language barriers, which left Somali women feeling lonely and receiving inadequate health care services. Moxey and Jones ( 2016 ) underlined that communication is the critical component of antenatal and intrapartum care; however, in many cases, women did not have access to professional interpreting services. This led to the provision of wrong information and continued discomfort when receiving care. Furthermore, professionals voiced concern over the unavailability of health information in Somali and other languages. Zimmerman and Beam ( 2020 ) confirmed that immigrant women had little choice but to obtain information of dubious credibility because credible information is often scarce and available in languages other than the immigrants’ native languages. This made them more susceptible to receiving wrong information and experiencing increased anxiety when pregnant. 4.3.2 Cultural Competence and Sensitivity in Care High awareness of culture and sensitivity in care was evident in 13 studies (81%) under the second theme, Cultural Competence and Sensitivity in Care. The studies highlighted the imperative for the healthcare systems to be culturally competent while treating matters such as FGM. Both Konje and Konje ( 2021 ) and Ahrne et al. ( 2019 ) pointed out that Somali women appreciate the providers who respect their culture, including religion and customs. Regrettably, many women stated that their healthcare providers were not aware of this, and so they faced discrimination and mistrust. In another study carried out by Turkmani et al. ( 2019 ), the authors extended the understanding of the participants’ inherent fear, stigma, and anxiety because of the negligence of cultural knowledge in the maternity service, particularly regarding FGM. The lack of culturally sensitive care also contributed to women feeling out of place in healthcare institutions, making their anxiety towards childbearing and medical practices even worse. 4.3.3 Mental Health and Socio-economic Challenges Psychological problems linked to sociopolitical adversities were found in 11 of the 16 analysed studies (69%), regardless of the type of mental health issues. Most of the Somali women experienced high levels of stress during their perinatal period due to challenges like migration, social isolation and poverty. According to Evans et al. ( 2019 ), women with FGM reported higher levels of mental health problems such as anxiety, depression, and post-traumatic stress disorder (PTSD), primarily due to FGM-related trauma and healthcare-seeking difficulties within developed countries. Lack of mental health care was also identified by Higginbottom et al. (2019) as being common among immigrant women, with reference being made to Somali women. However, socio-economic factors that affected most of these women, like poor housing and joblessness, also affected their mental health. These issues accumulated whereby the women found themselves experiencing intense pressures that affected both their physical and mental health. 4.3.4 Strategies to Improve Perinatal Care Outcomes The last identifiable theme that emerged was Strategies to Improve Perinatal Care Outcomes, identified in 10 studies (63%). Some of the selected studies, such as Kimani et al. ( 2018 ) and Chitongo et al. ( 2022 ), provided suggestions for improving the perinatal care experiences of Somali women. These measures consisted of enhancing the cultural competency training for the healthcare workers and the implementation of the community health centers, as well as anti-racism initiatives. Another approach included peer support programs through which Somali women could access women of similar cultural origins. This form of support by the community addressed the voids in care by providing emotional and informative support while ensuring better women’s interaction with maternity services. Kimani et al. ( 2018 ) also supported the need to enhance training programs in service delivery by including cultural knowledge in training to improve patient care and trust. The study by Musse (2023) underlined the necessity for midwives to receive specialised training to support women with FGM effectively, recommending continuous professional development and integration of FGM education in midwifery training programmes. 5 DISCUSSION This discussion qualitatively synthesises the findings from the above-discussed UK-based studies on Somali women’s perinatal care experiences in other countries. Based on the study's identified research question, this analysis provides information on the difficulties and encounters Somali women face during perinatal care and examines the limitations of the research process and the quality of the selected studies. 5.1 Comparison with Wider Literature While cultural factors are seen as playing a pivotal role in shaping the perinatal care experiences of Somali women in different countries, linguistic factors cannot be ruled out as another influential determinant of the whole process. Some UK-based studies highlighted that the absence of interpreters and limited provision of culturally competent services further harmed Somali women. For example, Obionu et al. ( 2023 ) showed that misunderstandings occurred commonly in conversations between care providers and Somali women due to an overall lack of understanding about the patient’s needs, thus leading to feelings of abandonment. This finding is in concordance with previous findings from other settings. Zhu ( 2023 ) has described the difficulties that Somali women face when it comes to language barriers and their inability to receive proper perinatal care in the U.S. A sample of Somali women stated that they felt unappreciated and misunderstood; some of the women had a poor experience of care because of the inability to discuss certain medical procedures. Similarly, Wojnar ( 2015 ) pointed out that Somali couples married in the U.S. are also facing frustration and confusion due to cultural differences and language barriers; this is supported by the research conducted among partners in the U.K. Dos Santos ( 2023 ) noted that Somali women in Australia are excluded from the health care systems to help them during labour and childbirth due to language barriers and access to interpreters. The needs of these women were that there was no provision of interpreters and relevant information to explain the medical advice given to them. However, certain disparities are evident when comparing the solutions provided. For example, Jacoby et al. ( 2015 ) suggested that by using “historietas”, which is a type of simple educational health pictures, the health literacy of Somali women in the U.S.A. was enhanced. This allowed to eliminate the communication gap. This approach was specific to the U.S., whereas in the U.K., most of the studies proposed providing more interpreter services or teaching healthcare workers culturally appropriate communication techniques (Turkmani et al., 2019 ). Such comparison implies that despite language barriers being inevitable for Somali women in most settings, the responses differ, with some countries providing more creative and context-specific approaches compared to the U.K. Cultural competence was considered a significant factor in Somali women’s perinatal care experiences across various countries. In the U.S., Wandera ( 2018 ) highlighted that the lack of cultural sensitivity and understanding of Somali women’s religious practices resulted in mistrust of healthcare services. The same sentiments were confirmed by Evans et al. ( 2019 ), who advocated for cultural competence to be used to help care for migrant women, especially those who experience FGM. These results are similar to the Swedish study where Wallmo et al. ( 2020 ) described how cultural misconceptions affected the lives of Somali women. The women in this study underlined that they needed to be respected and have their cultural practices valued, especially regarding childbirth. Agbemenu et al. ( 2021 ) also pointed out that cultural respect during the antenatal and intrapartum periods is critical, as Somali women in the U.S. described feeling devalued during childbirth, particularly when their cultural preferences were not considered by healthcare professionals. Aubrey et al. ( 2017 ) also identified the same challenges in Canada, where Somali women reported that their cultural norms, especially concerning gender and religion, were not valued. Such gender disparities as the shortage of female doctors, for instance, made birth even more uncomfortable. These results stress the sustained need for cultural sensitivity to enhance Somali women’s interactions during perinatal care. However, the studies conducted in the U.S. focused on the ethnic-cultural aspect of Somali women in pregnancy and childbirth with emphasis on the role of men in Somali culture, which was less represented in the U.K. studies. According to Wojnar ( 2015 ), Somali men were marginalised from prenatal care in the U.S. while holding influential positions in decisions during pregnancy. This is in contrast to the studies conducted in the U.K., where the main emphasis was on the trial of Somali women without mentioning the male companions. These comparisons show that despite the fact that cultural relevance is an important aspect in all existing settings, certain aspects that culturally define interactions may vary from one country to another, be it the role of the family or gender factors. Mental health issues were seen as a major issue in the U.K. and other literature. Rayment-Jones et al. ( 2019 ) revealed that Somali women in the U.K. are at high risk of depression, postnatal depression in particular, due to social exclusion, poverty and poor access to culturally sensitive mental health services. Such findings aligned with Chitongo et al. ( 2022 ), who pointed out how structural racism and social exclusion influenced the mental health of Somalis in the U.K. Similar mental health concerns were reported by Jacoby et al. ( 2015 ) in the United States, including postpartum depression (P.P.D.). Among the areas of dissatisfaction, the Somali women highlighted perceived inadequate care on mental health problems due to cultural taboo of mental health issues. However, the study did not underscore a general lack of mental health literacy but rather how the “historietas”, an educational tool, can be instrumental in filling the shortcomings in understanding of P.P.D. Vik et al ( 2022 ) studied the Somali women in Norway where they noted that the women were afraid of surgeries like caesarean sections, which contributed to their mental strain during childbirth. This was evident from their ignorance of the structure of the health care system and their distrust of health care practitioners. This result supports the UK-based studies, but the perceived need to extend antenatal education in Norway seems much higher. The findings offer an implication that though there are always mental health concerns in different countries, the factors contributing to it and solutions may also be different. While countries like the U.S.A. and Norway face complex issues such as racism and inequality within Black communities, they place a strong emphasis on improving health literacy through education. Some proposed interventions to improve perinatal care for Somali women include Turkmani et al. ( 2019 ) recommending the use of community centre settings with a cultural lens tailored to minority groups, while Evans et al. ( 2019 ) suggested anti-racial discrimination training for healthcare practitioners. The focus, however, has been on restructuring the U.K.’s NHS to address barriers faced by Somali women, such as racism, poor communication, and inadequate services within healthcare facilities. In Sweden, Wallmo et al. ( 2020 ) advised an increased structure in communication that would require healthcare workers to be specifically taught how to convey clear and culturally appropriate information when a woman is giving birth. Likewise, Vik et al. ( 2022 ) conducted a study in Norway that stressed the significance of face-to-face assessments in early labour to develop a rapport with Somali women and make them comfortable during the perinatal period. On the contrary, the studies carried out in the United States like the one by Jacoby et al. ( 2015 ), put forward more personal recommendations; such as the approach to enhancing health literacy through the use of culturally competent health education aids. This could be seen as a more profound change to the patient’s benefit than the large-scale changes mentioned in the U.K. setting. 5.2 Limitations There are some limitations to the included studies, as follows. Firstly, the use of qualitative data and small samples, which is evident in the research by Wojnar ( 2015 ) and Vik et al. ( 2022 ), limits the external validity of the research results. Furthermore, a considerable number of the studies, especially the cross-sectional ones conducted in the U.K. focused on self-reported data with the likelihood of recall bias. There also lies a restriction in the types of articles in terms of language used, where only articles in English were considered. Additionally, studies conducted in countries with different languages were not examined, and they also could offer more information about Somali women in other settings. Lastly, all the reviewed studies did not provide information relative to intersectionality, for instance, differences in the experiences of immigrant Somali women with reference to their legal immigration status as asylum seekers and other comparatively established statuses. Therefore, future research should seek to understand the root of these differences to have a broader perspective of the various experiences that are present within the Somali community. 6 Conclusion and Recommendations 6.1 Conclusion This study aimed to understand the perinatal care experiences of Somali women in the U.K., comparing these to other high-income countries like the U.S., Sweden, and Norway. Common challenges identified include language barriers, cultural insensitivity, mental health issues, and discrimination. Although these issues are present across countries, the approaches to address them differ due to varying healthcare systems and policies. In the U.K., the focus is on systemic changes to ensure culturally competent care and tackle racism, while in the U.S. and Norway, the focus is more on health literacy and developing culturally appropriate education resources. The reliance on qualitative studies with small sample sizes limits the generalisability of the findings. Nonetheless, it is clear that addressing perinatal care for Somali women requires a systemic approach incorporating cultural understanding, language, and mental health support. 6.2 Recommendations U.K. healthcare services should prioritise creating culturally appropriate care models for Somali women. Research by Vik et al. ( 2022 ) and Wallmo et al. ( 2020 ) highlights the importance of addressing cultural issues in communication and expectations surrounding childbirth. To address this, health systems should provide culturally tailored antenatal care, including workshops and language support, to help Somali women better understand labour and postpartum processes. Moreover, family-centred models should be developed to encourage the inclusion of husbands and male partners, addressing gaps in support during childbirth. Jacoby et al. ( 2015 ) emphasise the need for improving Somali women's health literacy through a comprehensive approach. Health organisations like the NHS should develop culturally sensitive educational resources to address disparities, especially regarding critical medical procedures such as caesarean sections and issues such as postnatal depression. As health literacy is linked to health outcomes, these materials should be frequently updated and evaluated to reduce disparities. Another area for improvement is interpreter services during labour. Vik et al. ( 2022 ) found that the lack of skilled interpreters exacerbates fears and confusion during critical moments. Increasing the availability of well-trained interpreters and making their services more accessible would significantly enhance the care provided to Somali women. Finally, healthcare policymakers should invest in continuous education for healthcare workers to improve cultural competency, particularly for ethnic and immigrant groups. Incorporating this training into continuing professional development (C.P.D.) for maternity and antenatal care providers is essential to better understanding Somali women’s experiences. As Wallmo et al. ( 2020 ) argue, this can reduce discrimination and ensure compassionate, culturally sensitive care. 7 Appendicies 7.1 Appendix A: P.C.C. Framework P.C.C. Element Search Terms and Synonyms Search Strategy String Population Somali women "Somali women", "Somali mothers", "Somali immigrants", "Somali migrants" ("Somali women" OR "Somali mothers" OR "Somali immigrants" OR "Somali migrants") Concept Perinatal care "Perinatal care", "Maternal health", "Maternity services", "Childbirth care" ("Perinatal care" OR "Maternal health" OR "Maternity services" OR "Childbirth care") Context Healthcare in high-income countries "U.K.", "United Kingdom", "Western countries", "High-income countries" ("U.K." OR "United Kingdom" OR "Western countries" OR "High-income countries") 7.2 Appendix B: Data Charting Author(s) and Date Study Size Location Population Setting Method Summary of Findings Moxey and Jones ( 2016 ) 10 women Birmingham, U.K. Somali women with FGM Community centers Qualitative study Somali women with FGM have complex needs and face challenges in antenatal and intrapartum care. Effective communication and culturally sensitive care are essential. Konje and Konje ( 2021 ) 16 paricipants Leicester, U.K. Somali migrant women Various Qualitative study Somali migrant women face significant barriers in accessing maternity care in the U.K., including language barriers and lack of culturally appropriate services. Ahrne et al. ( 2019 ) 60 participants Sweden Somali-born women and their partners Antenatal care settings Qualitative study Somali-born parents and midwives highlighted the need for culturally tailored antenatal care to improve trust and communication. Obionu et al. ( 2023 ) Various studies U.K. Ethnic minority and migrant women Various Systematic review Ethnic minority and migrant women in the U.K. experience disparities in maternity care, including racism, lack of cultural competence among healthcare providers, and systemic barriers to accessing care. Chitongo et al. ( 2022 ) 20 midwives London, UK Midwives caring for ethnic minority women Obstetric led unit Qualitative study Identified barriers to effective perinatal care for ethnic minority women include communication issues, lack of continuity, and social determinants. Suggested solutions include community hubs and anti-racism interventions. MacLellan et al. (2022) 24 studies UK Black, Asian, and minority ethnic women Various Qualitative evidence synthesis Ethnic minority women experience systemic racism and discrimination in maternity services, leading to poorer care and outcomes. Evans et al. ( 2019 ) Various Various Women and girls who have undergone FGM Various Qualitative systematic review Women and girls with FGM face substantial barriers to culturally safe care. Recommended increased training for healthcare providers and the integration of culturally sensitive practices. Kimani et al. ( 2018 ) Various High prevalence settings Nurse-midwives working with FGM Training programs Mixed methods Innovative training approaches for nurse-midwives significantly improved their knowledge and confidence in managing FGM cases. Musse (2023) 9 articles Various Midwives' knowledge and training on FGM Various Systematic review Midwives lack sufficient knowledge and training on FGM, highlighting the need for improved education and evidence-based guidelines to support affected women. Zimmerman and Beam ( 2020 ) 85 women U.S.A. Immigrant and refugee women Survey-based study Survey and interviews Immigrant and refugee women reported significant health information needs and barriers, such as language and cost, leading to reliance on less credible information sources. Rayment-Jones et al. ( 2019 ) Various studies U.K. Women with social risk factors Various Realist synthesis Women with social risk factors experience fragmented and impersonal maternity care. Emphasised the need for continuity of care and tailored support services. Lindquist et al. ( 2015 ) 5,332 women England Women from different socio-economic groups National Maternity Survey Survey Women from lower socio-economic groups reported poorer experiences and outcomes in maternity care. Fair et al. (2020) 51 studies Various European Migrant women Various Systematic review Migrant women face multiple barriers including language, discrimination, and lack of information, affecting their pregnancy, childbirth, and maternity care experiences. Higginbottom et al. (2019) 40 studies U.K. Immigrant women Various Narrative synthesis review Immigrant women in the U.K. experience significant challenges in accessing and utilising maternity care services, including cultural and language barriers, and differing expectations of care. McKnight et al. (2019) 6 studies U.K. Asylum-seeking women Various Systematic review Asylum-seeking women report poor experiences of U.K. maternity care, including lack of respect and inadequate communication. Turkmani et al ( 2019 ) 16 studies High-income countries Migrant women from FGM-practicing countries Various Systematic review and meta-synthesis Migrant women with FGM face fear, stigma, anxiety, and cultural conflicts in high-income countries. Key themes include vulnerability, distrust, and the need for culturally sensitive and women-centred care. 7.3 Appendix C: Quality Assessment Study Year Clear Research Question Appropriate Study Design Robust Data Collection Adequate Sample Size Ethical Considerations Appropriate Recruitment Rigorous Data Analysis Clear Findings Research Valuable Overall Quality Moxey and Jones 2016 Yes Yes Yes No Yes Yes Yes Yes Yes High Konje and Konje 2021 Yes Yes Yes Yes Yes Yes Yes Yes Yes High Ahrne et al. 2019 Yes Yes Yes Yes Yes Yes Yes Yes Yes High Obionu et al. 2023 Yes Yes Yes Yes Yes Yes Yes Yes Yes High Chitongo et al. 2022 Yes Yes Yes Yes Yes Yes Yes Yes Yes High MacLellan et al. 2022 Yes Yes Yes Yes Yes Yes Yes Yes Yes High Evans et al. 2019 Yes Yes Yes Yes Yes Yes Yes Yes Yes High Kimani et al. 2018 Yes Yes Yes Yes Yes Yes Yes Yes Yes High Musse 2023 Yes Yes Yes Yes Yes Yes Yes Yes Yes High Zimmerman and Beam 2020 Yes Yes Yes Yes Yes Yes Yes Yes Yes High Rayment-Jones et al. 2019 Yes Yes Yes Yes Yes Yes Yes Yes Yes High Lindquist et al. 2015 Yes Yes Yes Yes Yes Yes Yes Yes Yes High Fair et al. 2020 Yes Yes Yes Yes Yes Yes Yes Yes Yes High Higginbottom et al. 2019 Yes Yes Yes Yes Yes Yes Yes Yes Yes High McKnight et al. 2019 Yes Yes Yes Yes Yes Yes Yes Yes Yes High Turkmani et al. 2019 Yes Yes Yes Yes Yes Yes Yes Yes Yes High 7.4 Appendix D: Identified Themes Theme Number of Studies Referring to Theme Percentage Language and Communication Barriers 14 87.5% Cultural Competence and Sensitivity in Care 13 81.25% Mental Health and Socio-economic Challenges 11 68.75% Strategies to Improve Perinatal Care Outcomes 10 62.5% Declarations Ethics approval and consent to participate: Not applicable. Consent for publication: Not applicable. Availability of data and materials: The data supporting this study are available within the article. Competing interests: The author declares no competing interests. Funding: This research received no external funding. Authors’ contributions: L.A.M. conceptualized the study, conducted the literature review, analysed the findings, and drafted the manuscript. Authors' Information A Qualified, Registered Nurse Midwife and a Public Health Master's graduate with extensive experience in healthcare and public health within the UK. They have published previous research in the field. Acknowledgements I would like to express my deepest gratitude to my family for their unwavering love, encouragement, and support throughout this journey. Their steadfast support has been invaluable in the completion of this study References Agbemenu K, Banke-Thomas A, Ely G, Johnson-Agbakwu C. Avoiding obstetrical interventions among US-based Somali migrant women: a qualitative study. Ethn Health. 2021;26(7):1082–97. Ahrne M, Schytt E, Andersson E, Small R, Adan A, Essén B, Byrskog U. Antenatal care for Somali-born women in Sweden: Perspectives from mothers, fathers and midwives. Midwifery. 2019;74:107–15. Arksey H, O’Malley L. (2005) ‘Scoping studies: towards a methodological framework’, International Journal of Social Research Methodology, 8(1), pp. 19–32. doi: 10.1080/1364557032000119616. Available at: https://www.tandfonline.com/doi/abs/10.1080/1364557032000119616 [Accessed: 12 July 2024]. Aubrey C, Chari R, Mitchell BP, Mumtaz Z. Gender of provider—barrier to immigrant women's obstetrical care: a narrative review. J Obstet Gynecol Can. 2017;39(7):567–77. Brown E, Carroll J, Fogarty C, Holt C. (2010). They Get a C-Section.. They Gonna Die: Somali Women’s Fears of Obstetrical Interventions in the United States. Journal of Transcultural Nursing, 21(3), pp.220–227. Available at: https://doi.org/10.1177/1043659609358780 [Accessed 1 August 2024]. Chitongo S, Pezaro S, Fyle J, Suthers F, Allan H. 2022. Midwives’ insights in relation to the common barriers in providing effective perinatal care to women from ethnic minority groups with ‘high risk’ pregnancies: A qualitative study. Women and Birth, 35(2), pp.152–159. Available at: https://doi.org/10.1016/j.wombi.2021.05.005 [Accessed 2 August 2024]. Dadi D, Mason S, Areba E. 2023. Why are Somali refugees not utilizing mental healthcare? Identifying barriers impacting mental healthcare utilization among Somali Refugees. Journal of Clinical and Translational Science, 7(Suppl 1), pp.74–75. Available at: https://doi.org/10.1017/cts.2023.310 [Accessed 1 August 2024]. Degni F, Suominen S, Essén B. (2012) ‘Communication and Cultural Issues in Providing Reproductive Health Care to Immigrant Women: Health Care Providers’ Experiences in Meeting Somali Women Living in Finland’, Journal of Immigrant Minority Health, 14, pp. 330–343. 10.1007/s10903-011-9465-6 . Available at: https://link.springer.com/article/10.1007/s10903-011-9465-6 [Accessed: 27 June 2024]. dos Santos EC. (2023). Migrant Mothers' and Health Professionals' Views and Experiences of the Australian Perinatal Health Care System and Its Influence on Their Mental Health (Doctoral dissertation, The Australian National University (Australia)). Evans C, Tweheyo R, McGarry J et al. (2019) ‘Seeking culturally safe care: a qualitative systematic review of the healthcare experiences of women and girls who have undergone female genital mutilation/cutting’, B.M.J. Open, 9, e027452. doi: 10.1136/bmjopen-2018-027452. Available at: https://bmjopen.bmj.com/content/9/4/e027452 [Accessed: 9 July 2024]. Higginbottom GM, Morgan M, Alexandre M et al. (2015) ‘Immigrant women’s experiences of maternity-care services in Canada: a systematic review using a narrative synthesis’, Systematic Reviews, 4, 13. doi: 10.1186/2046-4053-4-13. Available at: https://link.springer.com/article/ 10.1186/2046-4053-4-13 [Accessed: 21 July 2024]. Jacobs JA. Journal rankings in sociology: Using the H Index with Google Scholar. Am Sociologist. 2016;47:192–224. Jacoby SD, Lucarelli M, Musse F, Krishnamurthy A, Salyers V. A mixed-methods study of immigrant Somali women's health literacy and perinatal experiences in Maine. J Midwifery Women's Health. 2015;60(5):593–603. Kimani S, Esho T, Kimani V, Muniu S, Kamau J, Kigondu C, Karanja J, Jaldesa G. (2018) ‘Female Genital Mutilation/Cutting: Innovative Training Approach for Nurse-Midwives in High Prevalent Settings’, Obstetrics and Gynecology International, 5043512. doi: 10.1155/2018/5043512. Available at: https://onlinelibrary.wiley.com/doi/full/10.1155/2018/5043512 [Accessed: 29 July 2024]. Knight M, Bunch K, Tuffnell D, Jayakody H, Shakespeare J, Kotnis R, Kenyon S, Kurinczuk J, editors. (2018) Saving Lives Improving Mothers’ Care - Lessons learned to inform maternity care from the U.K. and Ireland Confidential Enquiries into Maternal Deaths and Morbidity 2014-16. National Perinatal Epidemiology Unit: University of Oxford. Available at: https://www.npeu.ox.ac.uk/assets/downloads/mbrrace-uk/reports/MBRRACE-UK%20Maternal%20Report%202018%20-%20Web%20Version.pdf [Accessed: 20 July 2024]. Konje JK, Konje JC. (2021) ‘Experiences of accessing maternity care in the U.K.: Perspectives from Somali migrant women in Leicester’, European Journal of Midwifery, 5, 56. 10.18332/ejm/143167 . Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8667475/ [Accessed: 11 July 2024]. Lindquist A, Kurinczuk JJ, Redshaw M, Knight M. (2015) ‘Experiences, utilisation and outcomes of maternity care in England among women from different socio-economic groups: findings from the 2010 National Maternity Survey’, BJOG, 122, pp. 1610–1617. 10.1111/1471-0528.13059 . Available at: https://obgyn.onlinelibrary.wiley.com/doi/full/10.1111/1471-0528.13059 [Accessed: 5 August 2024]. Maeda Y, Caskurlu S, Kozan K, Kenney RH. Development of a critical appraisal tool for assessing the reporting quality of qualitative studies: a worked example. Qual Quant. 2023;57(2):1011–31. MBRRACE-UK. (2022) Saving Lives Improving Mothers’ Care . Available at: https://www.npeu.ox.ac.uk/mbrrace-uk/reports [Accessed: 5 July 2024]. McGowan LJ, Powell R, French DP. How can use of the Theoretical Domains Framework be optimized in qualitative research? A rapid systematic review. Br J Health Psychol. 2020;25(3):677–94. Moxey JM, Jones LL. (2016) ‘A qualitative study exploring how Somali women exposed to female genital mutilation experience and perceive antenatal and intrapartum care in England’, B.M.J. Open, 6, e009846. doi: 10.1136/bmjopen-2015-009846. Available at: https://bmjopen.bmj.com/content/6/1/e009846.short [Accessed: 15 July 2024]. Obionu IM, Onyedinma CA, Mielewczyk F, Boyle E. U.K. maternity care experiences of ethnic minority and migrant women: Systematic review. Public Health Nurs. 2023;40(6):846–56. Rayment-Jones H, Harris J, Harden A, Khan Z, Sandall J. (2019) ‘How do women with social risk factors experience United Kingdom maternity care? A realist synthesis’, birth, 46(3), pp. 461–474. doi: 10.1111/birt.12446. Available at: https://onlinelibrary.wiley.com/doi/full/10.1111/birt.12446 [Accessed: 28 July 2024]. Tricco AC, Lillie E, Zarin W, O'Brien KK, Colquhoun H, Levac D, … and, Straus SE. PRISMA extension for scoping reviews (PRISMA-ScR): checklist and explanation. Ann Intern Med. 2018;169(7):467–73. Turkmani S, Homer CSE, Dawson A. (2019) ‘Maternity care experiences and health needs of migrant women from female genital mutilation–practicing countries in high-income contexts: A systematic review and meta-synthesis’, Birth, 46, pp. 3–14. 10.1111/birt.12367 . Available at: https://doi.org/10.1111/birt.12367 [Accessed: 28 July 2024. Vik ES, Hashi RM, Hamud ME, Aasheim V, Kringeland T, Aasekjær K. (2022). Migrant Somali women’s experiences with their first contact with the labor ward prior to admission: A qualitative study. Eur J midwifery, 6. Wallmo S, Allgurin K, Berterö C. The lived experience among Somali women of giving birth in Sweden: an interpretive phenomenological study. B M C pregnancy childbirth. 2020;20:1–12. Wandera A. (2018). Investigating Dropout From Mental Health Care Among Somali Immigrants in the United States. WHO. (2021) WHO recommendations on maternal health: guidelines approved by the WHO Guidelines Review Committee . Available at: https://www.who.int/publications/i/item/9789240012280 [Accessed: 31 July 2024]. Wojnar DM. Perinatal experiences of Somali couples in the United States. J Obstetric Gynecologic Neonatal Nurs. 2015;44(3):358–69. Zhu C. (2023). Barriers and Challenges of Immigrant Women’s Access to and Experience of Optimal Maternity Care. Columbia Univ J Global Health, 13(1). Zimmerman M, Beam H. (2020) ‘Refugee and immigrant health information needs’, International Journal of Migration Health and Social Care, 16(2). doi: 10.1108/IJMHSC-07-2019-0065. Available at: https://www.emerald.com/insight/content/doi/10.1108/IJMHSC-07-2019-0065/full/html [Accessed: 1 August 2024]. APPENDICES. Abbreviations BMC – BioMed Central CINAHL – Cumulative Index to Nursing and Allied Health Literature FGM – Female Genital Mutilation MBRRACE-UK – Mothers and Babies: Reducing Risk through Audits and Confidential Enquiries across the UK NHS – National Health Service PCC – Population, Concept, Context PRISMA-ScR – Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews PTSD – Post-Traumatic Stress Disorder UK – United Kingdom WHO – World Health Organization Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6068284","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":449082811,"identity":"3dd1a7e6-3fa3-4e2b-9a6b-53289c7eb823","order_by":0,"name":"Ladan Abdirashid Musse","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA20lEQVRIiWNgGAWjYNCCAgbGBgbmA0CWhAyRWgxAWtgSQFp4SNHCYwBiEtaiOyP98YcPBnay/bN7Pr+6UWPBw8B++OgGfFrMbuSYSc4wSDaecefsNuucY0CH8aSl3SCghY2Zx4A5seFG7jbjHDagFgkeMwJa0h9//mNQnzj/Rs4z45x/RGlJMJBmMDicuOFGDvPj3DZitJx5YybZY3DceOONNDPm3D4JHjaCfjkODLEfFdWy824kP/6c861Ojp/98DG8WpABmwSYJFY5CDB/IEX1KBgFo2AUjBwAALgoSqb6/G1LAAAAAElFTkSuQmCC","orcid":"","institution":"Brunel University London","correspondingAuthor":true,"prefix":"","firstName":"Ladan","middleName":"Abdirashid","lastName":"Musse","suffix":""}],"badges":[],"createdAt":"2025-02-20 04:08:16","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6068284/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6068284/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":85688744,"identity":"85935681-f199-4a65-bf00-e48f466eb6b2","added_by":"auto","created_at":"2025-06-30 16:27:56","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":12930,"visible":true,"origin":"","legend":"\u003cp\u003ePRISMA flowchart\u003c/p\u003e","description":"","filename":"Onlinefloatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-6068284/v1/f681da27d3fdd01df2c23c30.png"},{"id":85690114,"identity":"57164e76-02d7-4a1b-b5e8-dc7128a448e9","added_by":"auto","created_at":"2025-06-30 16:43:57","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1337854,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6068284/v1/9c48b0d6-45b6-4b94-991d-e9711aaae6cf.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Perinatal Care Experiences of Somali Women in the United Kingdom: A Scoping Review","fulltext":[{"header":"1 INTRODUCTION","content":"\u003cp\u003eAntenatal, intrapartum and postpartum care is critical in promoting maternal and neonatal health. Optimal perinatal care eliminates possibilities of maternal and infant mortality besides other adverse long-term effects on the life of both the mother and the child (World Health Organisation [WHO], \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). In the United Kingdom (U.K.), there remain significant inequalities in perinatal outcomes where Black women are four times more likely to die in the perinatal period than White women, and Asian women are two times more at risk (Knight et al., 2019). It is also evident that inequities affect newborns, as babies of Black and Asian mothers have higher perinatal mortality with a stillbirth rate of 7.4 and 6.3 per 1000 live births, respectively, compared to 3.8 per 1,000 births in White infants (MBRRACE-UK, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e2022\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe Somali ethnicity is one of the fastest-growing ethnic minorities in the U.K., and they experience various barriers to accessing perinatal care. The study by Degni et al. (2014) revealed that Somali women face various cultural, linguistic, and socio-economic challenges. Similarly, Dadi et al. (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2023\u003c/span\u003e) pointed out that cultural practices around childbearing, combined with experiences of prejudice and exclusion in the healthcare sector, make these women\u0026rsquo;s challenges more acute. Somali women have negative perceptions of healthcare providers and feel that they are treated with disrespect, which contributes to the mistrust of the health care system and can result in avoidable delays in seeking appropriate care (Lindquist et al., 2014; Brown et al., \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e2010\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eDespite the growing focus on culturally sensitive care in the last decades, there is still a lack of research investigating the perinatal care delivery to Somali women living in the U.K. The majority of the studies show a tendency to blunt the ethnicity of minority females and, therefore, fail to consider the cultural and systemic issues affecting the Somali female (Lindquist et al., 2014). This lack of research prevents healthcare professionals and policymakers from designing specific prevention and management strategies suitable for this group. The study by Higginbottom et al. (2014) also provides evidence of systemic barriers to care that Somali women and other immigrant women face, like poor interpreter services and culturally unintuitive care leading to poor perinatal experiences.\u003c/p\u003e \u003cp\u003eUsing the P.C.C. (Population, Concept, Context) approach, this scoping review assesses the perinatal care experience of Somali women in the U.K. context. The subject under study is Somali women. The phenomenon pertains to perinatal care, and the settings are healthcare facilities in the U.K. The overarching research question guiding this review is:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003e \u003cem\u003eWhat are the experiences of Somali women with regards to perinatal care in the U.K.?\u003c/em\u003e \u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003eThis research question enables the investigation of the perinatal care experiences of Somali women and the challenges and enablers that may be observed and experienced in the U.K. The specific objectives of this scoping review are as follows:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eTo identify themes and patterns from the perinatal care experiences of Somali women in the U.K.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eTo investigate factors that enable and hinder Somali women's delivery and receipt of quality perinatal health services.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eTo offer recommendations intended to enhance perinatal care services among Somali women.\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e"},{"header":"2 LITERATURE REVIEW","content":"\u003cp\u003eReviews of the perinatal care experiences of Somali women in many countries reveal that they encounter numerous difficulties, from cultural disparities to linguistic factors in the healthcare systems. Primary care physicians and other general health care providers in the United States are unable to offer any services to Somali women and their companions because of language and cultural differences. According to Wojnar (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e2015\u003c/span\u003e), there is cultural insensitivity and a shortage of resources in the maternity care encounters of Somali women and their partners. Due to a lack of culturally responsive health care and a lack of spouse participation during prenatal health, Somali women felt neglected, uninformed, and powerless (Wojnar, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e2015\u003c/span\u003e). The quality of primary health care systems received complaints because of cultural and programmatic dissimilarities between Somalis and the American way of delivering health services.\u003c/p\u003e \u003cp\u003eIn their mixed-method cross-sectional study among Somali women in Maine, Jacoby et al. (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e2015\u003c/span\u003e) found that Somali women\u0026rsquo;s perinatal health was determined by their health literacy. The assessment showed that the subjects of the study had poor health literacy and failed to comprehend most of the available treatments targeting females. These literacy deficits place Somali women at a high risk of postnatal depression and emergency caesarean sections (Jacoby et al., \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e2015\u003c/span\u003e). This study pointed to the lack of adequate health education and culturally appropriate teaching aids to fill existing knowledge deficits that lead to poor health among Somali immigrant women.\u003c/p\u003e \u003cp\u003eIn Scandinavia, Somali women\u0026rsquo;s perinatal care has the same issues as in other parts of the world with minor variance in the hardship. In Norway, Vik et al. (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e2022\u003c/span\u003e) examined the first encounter with the labour ward among Somali women; the women were characterised by limited health literacy, talking only with care professionals, and anxieties over the use of technology. The women said they required face-to-face consultations and recommendations as most were new to Norwegian healthcare services. The participants noted needing tailored attention and enhanced interpretation to improve their childbirth experience. Wallmo et al. (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e2020\u003c/span\u003e) also covered similar concerns in a study conducted in Sweden. It was found that Somali women appreciated communication, acknowledgement, and culturally sensitive treatment. However, they often encountered localised practices and a lack of information in Swedish healthcare facilities, especially for women who underwent \u0026ldquo;female genital mutilation (FGM)\u0026rdquo;. This study also supported the view that it is vital to provide reproductive care according to Somali culture and that professionals need to consider the cultural context of Somali women.\u003c/p\u003e \u003cp\u003eAcross these studies, it is evident that barriers to adequate perinatal care among Somali women are minimal communication, misunderstanding and poor health literacy (Wojnar, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e2015\u003c/span\u003e; Vik et al., \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). Although such challenges present themselves differently across the various nations, it is evident that the core problems are still similar. Somali women\u0026rsquo;s perinatal concerns are shaped more by their cultural background and immigrant status than by the healthcare systems in their host countries. While awareness of these concerns continues to increase, the existing literature lacks information on integrated programs that target the needs of Somali women. Studies predominantly address only minor issues like language differences or comprehension of the language in different healthcare settings without integrating solutions. This scoping review seeks to address this gap by analysing existing research to develop a comprehensive understanding of Somali women\u0026rsquo;s perinatal care and provide evidence-based recommendations.\u003c/p\u003e"},{"header":"3 RESEARCH METHODOLOGY","content":"\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003e3.1 Methodological Approach\u003c/h2\u003e \u003cp\u003eThis research has a scoping review approach that provides a comprehensive synthesis of the scientific literature related to the perinatal care experiences of Somali women. The scoping review method is used because it provides a broad assessment of diverse literature, especially in emerging fields where the studies could be diverse in terms of design and objectives (Arksey and O\u0026rsquo;Malley, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2005\u003c/span\u003e). Since the experiences of Somali women during the perinatal period have not been researched extensively, this approach enables the consideration of numerical and non-numerical data. As recommended by Tricco et al. (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e2018\u003c/span\u003e), the review follows the \u0026ldquo;PRISMA-ScR (Preferred Reporting Items for Systematic Review and Meta-Analysis extension for Scoping review) checklist\u0026rdquo; which contains 20 essential and two optional items to provide a transparent reporting of the evidence.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003e3.2 Information Sources\u003c/h2\u003e \u003cp\u003eAn enhanced literature review was carried out using the \u0026ldquo;PubMed\u0026rdquo;, \u0026ldquo;CINAHL\u0026rdquo;, \u0026ldquo;Web of Science\u0026rdquo;, and \u0026ldquo;Google Scholar\u0026rdquo; databases. The search strategy was developed using the P.C.C. framework (see Appendix A):\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003e \u003cem\u003ePopulation\u003c/em\u003e: Somali women\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e \u003cem\u003eConcept\u003c/em\u003e: Perinatal care experiences\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e \u003cem\u003eContext\u003c/em\u003e: Healthcare systems in high-income countries\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003eSearch terms were generated using a combination of relevant keywords such as \"Somali women,\" \"perinatal care,\" \"maternal health,\" and \"UK.\" Boolean operators (AND, OR) and truncation were employed to refine the results. To ensure comprehensiveness, reference lists of included studies were scanned for additional relevant sources. Both published and unpublished literature were considered.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003e3.3 Eligibility Criteria\u003c/h2\u003e \u003cp\u003eThe following eligibility criteria were applied to ensure the relevance of included studies:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003e \u003cem\u003eInclusion Criteria\u003c/em\u003e: Peer-reviewed studies, studies published in English, those focusing on Somali women\u0026rsquo;s perinatal care experiences in the U.K., and studies published between 2014 and 2024.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e \u003cem\u003eExclusion Criteria\u003c/em\u003e: Studies that did not focus on Somali women, studies not in English, grey literature, and studies outside the context of the U.K.\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003eThe rationale behind these criteria was to capture relevant studies on Somali women\u0026rsquo;s perinatal care experiences while ensuring the findings were applied to the research context.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003e3.4 Search\u003c/h2\u003e \u003cp\u003eThe search strategy was documented carefully to ensure replicability. The search terms were refined iteratively, and Boolean operators were employed to maximise relevant results. Given the vast number of studies (15,000) retrieved from Google Scholar, the first 100 studies ranked by relevance were selected for further screening (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). This approach is justified by Jacobs et al. (2016), who suggest that the top-ranked results in Google Scholar are often the most relevant.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSearch strategy\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDatabase\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSearch Terms\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eResults\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePubMed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\"Somali women\" AND \"perinatal care\" AND \"U.K.\"\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e276\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCINAHL\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\"Somali women\" AND \"maternal health\"\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWeb of Science\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\"Somali women\" AND \"perinatal care\"\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e34\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGoogle Scholar\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\"Somali women\" AND \"perinatal care\" AND \"maternal health\" AND \"U.K.\"\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15,000 (limited to first 100 studies)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eSearch limitations included a restriction to English-language studies and the use of Boolean operators that may have excluded some relevant results. These filters were applied to ensure the feasibility of the review and enhance the quality of included studies.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003e3.5 Selection of Sources of Evidence\u003c/h2\u003e \u003cp\u003eThe selection process followed a systematic screening procedure. First, titles and abstracts were reviewed to ensure relevance to the study's objectives. Full-text articles were then retrieved for detailed assessment. Due to the nature of the research project, calibration exercises involving multiple reviewers were not possible. Any potential inconsistencies were resolved by re-evaluating the criteria and re-reading the articles to ensure accurate interpretation.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003e3.6 Data Charting Process\u003c/h2\u003e \u003cp\u003eA data charting form was developed to extract relevant information from the included studies. The data chart included study characteristics (e.g., author, publication year, study design), participant demographics, key findings, and limitations. As the sole researcher, no calibration exercise was possible, though efforts were made to ensure consistent data extraction by piloting the form on a subset of studies and making iterative revisions. A final version of the charting form is included in Appendix B.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003e3.7 Data Items\u003c/h2\u003e \u003cp\u003eData items extracted included:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eStudy details (e.g., author, year, country of origin)\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003ePopulation characteristics (e.g., sample size, demographics)\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eStudy design and methodology (e.g., qualitative, quantitative)\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eSummary of key findings\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003eThese items identified patterns across studies and contributed to the thematic analysis. The charting form includes clear definitions for each data item to ensure transparency.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003e3.8 Critical Appraisal of Individual Sources of Evidence\u003c/h2\u003e \u003cp\u003eAs a scoping review, critical appraisal was not a requirement for this project. This decision is aligned with the guidelines for scoping reviews, where the focus is on identifying and mapping the literature rather than assessing the quality of individual studies (Arksey and O'Malley, 2005). The \u0026ldquo;Critical Appraisal Skills Programme (CASP) checklist\u0026rdquo; was used to evaluate each of the selected articles (Appendix C). This tool was recommended by Maeda et al. (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e2023\u003c/span\u003e) because it considers the intelligibility, relevance, sample size, feasibility, ethical concerns, and quality of data and data analysis.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003e3.9 Synthesis of Results\u003c/h2\u003e \u003cp\u003eTo synthesise the data of the included investigations, thematic synthesis was conducted. The themes were determined prior to data analysis based on objectives, questions and by following the deductive approach, as McGowan et al. (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e2020\u003c/span\u003e) recommended. Therefore, challenges such as language barriers, cultural considerations in pregnancy, mental health and social determinants, and approaches to improving the perinatal health of Somali women were identified. This led to an assessment of how these aspects were handled in each research study, and the results were grouped. Applying this method helped direct the scoping review to the areas of concern and offered an organised approach to the research analysis.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003e3.10 Ethics\u003c/h2\u003e \u003cp\u003eSince scoping reviews do not require critical appraisal, a quality assessment was done to obtain high-quality research. Ethical approval was also unnecessary, as the study used a scoping review method. The ethics declaration form can be observed in Appendix E.\u003c/p\u003e \u003c/div\u003e"},{"header":"4 RESULTS","content":"\u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003e4.1 Screening Process for Selection of Sources\u003c/h2\u003e \u003cp\u003eThe study selection process followed the PRISMA (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e) guidelines. The initial search identified 424 records through database searching. Of these, 285 papers were considered for further screening since they related to the research topic. After removing 65 duplicates, 220 records were screened based on the relevance of the issue being addressed in the specific population. Following the screening, 180 articles were excluded for not addressing the issue in the selected population or not presenting the specific outcomes of interest. This left 40 full-text articles, which were further assessed for eligibility. At this stage, 24 studies were excluded due to not meeting the criteria of including measurable outcomes relevant to perinatal care or focusing on a different population. Ultimately, 16 studies were included in the scoping review, each contributing to the thematic analysis and answering the research question.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003e4.2 Characteristics of Sources of Evidence\u003c/h2\u003e \u003cp\u003eData charting provided an overview of the key characteristics of the 16 studies (see Appendix B). The studies included a wide range of designs, populations, and settings, all focusing on Somali women or other migrant women in high-income countries, predominantly in the U.K. Study designs were predominantly qualitative, with some systematic reviews and meta-syntheses, reflecting the need to capture nuanced and in-depth experiences of Somali women in perinatal care. Qualitative designs allowed for exploration of personal and community perspectives, barriers faced in accessing care, and the experiences of healthcare providers. Systematic reviews added to this work by synthesising broader trends across multiple studies.\u003c/p\u003e \u003cp\u003ePopulations varied but were consistently focused on Somali migrant women or women from similar ethnic and socio-economic backgrounds. Some studies expanded to include healthcare professionals, such as midwives, particularly those involved in perinatal care for women affected by FGM. Different settings included community-based services and obstetric-led units; hence the variation in care context that Somali women encounter. These settings played a crucial role in understanding how institutional practices influenced the women's experiences and the communities' cultural responsiveness and support systems.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003e4.3 Thematic Analysis\u003c/h2\u003e \u003cp\u003eThrough deductive thematic analysis, four key themes were identified across the 16 studies: Language and Communication Barriers, Cultural Competence and Sensitivity in Care, Mental Health and Socio-economic Challenges, and Strategies to Improve Perinatal Care Outcomes. These themes answer the research question as they explore the main concerns that Somali women encounter during perinatal care and possible solutions.\u003c/p\u003e \u003cdiv id=\"Sec18\" class=\"Section3\"\u003e \u003ch2\u003e4.3.1 Language and Communication Barriers\u003c/h2\u003e \u003cp\u003eThe theme of language and communication was the most prominent one, as discussed in 14 out of the 16 studies (88%). The women received poor treatment from the health care providers. They did not understand each other due to language barriers, which left Somali women feeling lonely and receiving inadequate health care services. Moxey and Jones (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e2016\u003c/span\u003e) underlined that communication is the critical component of antenatal and intrapartum care; however, in many cases, women did not have access to professional interpreting services. This led to the provision of wrong information and continued discomfort when receiving care. Furthermore, professionals voiced concern over the unavailability of health information in Somali and other languages. Zimmerman and Beam (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e2020\u003c/span\u003e) confirmed that immigrant women had little choice but to obtain information of dubious credibility because credible information is often scarce and available in languages other than the immigrants\u0026rsquo; native languages. This made them more susceptible to receiving wrong information and experiencing increased anxiety when pregnant.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec19\" class=\"Section3\"\u003e \u003ch2\u003e4.3.2 Cultural Competence and Sensitivity in Care\u003c/h2\u003e \u003cp\u003eHigh awareness of culture and sensitivity in care was evident in 13 studies (81%) under the second theme, Cultural Competence and Sensitivity in Care. The studies highlighted the imperative for the healthcare systems to be culturally competent while treating matters such as FGM. Both Konje and Konje (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e2021\u003c/span\u003e) and Ahrne et al. (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2019\u003c/span\u003e) pointed out that Somali women appreciate the providers who respect their culture, including religion and customs. Regrettably, many women stated that their healthcare providers were not aware of this, and so they faced discrimination and mistrust. In another study carried out by Turkmani et al. (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e2019\u003c/span\u003e), the authors extended the understanding of the participants\u0026rsquo; inherent fear, stigma, and anxiety because of the negligence of cultural knowledge in the maternity service, particularly regarding FGM. The lack of culturally sensitive care also contributed to women feeling out of place in healthcare institutions, making their anxiety towards childbearing and medical practices even worse.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec20\" class=\"Section3\"\u003e \u003ch2\u003e4.3.3 Mental Health and Socio-economic Challenges\u003c/h2\u003e \u003cp\u003ePsychological problems linked to sociopolitical adversities were found in 11 of the 16 analysed studies (69%), regardless of the type of mental health issues. Most of the Somali women experienced high levels of stress during their perinatal period due to challenges like migration, social isolation and poverty. According to Evans et al. (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e2019\u003c/span\u003e), women with FGM reported higher levels of mental health problems such as anxiety, depression, and post-traumatic stress disorder (PTSD), primarily due to FGM-related trauma and healthcare-seeking difficulties within developed countries. Lack of mental health care was also identified by Higginbottom et al. (2019) as being common among immigrant women, with reference being made to Somali women. However, socio-economic factors that affected most of these women, like poor housing and joblessness, also affected their mental health. These issues accumulated whereby the women found themselves experiencing intense pressures that affected both their physical and mental health.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec21\" class=\"Section3\"\u003e \u003ch2\u003e4.3.4 Strategies to Improve Perinatal Care Outcomes\u003c/h2\u003e \u003cp\u003eThe last identifiable theme that emerged was Strategies to Improve Perinatal Care Outcomes, identified in 10 studies (63%). Some of the selected studies, such as Kimani et al. (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e2018\u003c/span\u003e) and Chitongo et al. (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e2022\u003c/span\u003e), provided suggestions for improving the perinatal care experiences of Somali women. These measures consisted of enhancing the cultural competency training for the healthcare workers and the implementation of the community health centers, as well as anti-racism initiatives. Another approach included peer support programs through which Somali women could access women of similar cultural origins. This form of support by the community addressed the voids in care by providing emotional and informative support while ensuring better women\u0026rsquo;s interaction with maternity services. Kimani et al. (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e2018\u003c/span\u003e) also supported the need to enhance training programs in service delivery by including cultural knowledge in training to improve patient care and trust. The study by Musse (2023) underlined the necessity for midwives to receive specialised training to support women with FGM effectively, recommending continuous professional development and integration of FGM education in midwifery training programmes.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"5 DISCUSSION","content":"\u003cp\u003eThis discussion qualitatively synthesises the findings from the above-discussed UK-based studies on Somali women\u0026rsquo;s perinatal care experiences in other countries. Based on the study's identified research question, this analysis provides information on the difficulties and encounters Somali women face during perinatal care and examines the limitations of the research process and the quality of the selected studies.\u003c/p\u003e \u003cdiv id=\"Sec23\" class=\"Section2\"\u003e \u003ch2\u003e5.1 Comparison with Wider Literature\u003c/h2\u003e \u003cp\u003eWhile cultural factors are seen as playing a pivotal role in shaping the perinatal care experiences of Somali women in different countries, linguistic factors cannot be ruled out as another influential determinant of the whole process. Some UK-based studies highlighted that the absence of interpreters and limited provision of culturally competent services further harmed Somali women. For example, Obionu et al. (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e2023\u003c/span\u003e) showed that misunderstandings occurred commonly in conversations between care providers and Somali women due to an overall lack of understanding about the patient\u0026rsquo;s needs, thus leading to feelings of abandonment. This finding is in concordance with previous findings from other settings. Zhu (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e2023\u003c/span\u003e) has described the difficulties that Somali women face when it comes to language barriers and their inability to receive proper perinatal care in the U.S. A sample of Somali women stated that they felt unappreciated and misunderstood; some of the women had a poor experience of care because of the inability to discuss certain medical procedures. Similarly, Wojnar (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e2015\u003c/span\u003e) pointed out that Somali couples married in the U.S. are also facing frustration and confusion due to cultural differences and language barriers; this is supported by the research conducted among partners in the U.K.\u003c/p\u003e \u003cp\u003eDos Santos (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2023\u003c/span\u003e) noted that Somali women in Australia are excluded from the health care systems to help them during labour and childbirth due to language barriers and access to interpreters. The needs of these women were that there was no provision of interpreters and relevant information to explain the medical advice given to them. However, certain disparities are evident when comparing the solutions provided. For example, Jacoby et al. (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e2015\u003c/span\u003e) suggested that by using \u0026ldquo;historietas\u0026rdquo;, which is a type of simple educational health pictures, the health literacy of Somali women in the U.S.A. was enhanced. This allowed to eliminate the communication gap. This approach was specific to the U.S., whereas in the U.K., most of the studies proposed providing more interpreter services or teaching healthcare workers culturally appropriate communication techniques (Turkmani et al., \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e2019\u003c/span\u003e). Such comparison implies that despite language barriers being inevitable for Somali women in most settings, the responses differ, with some countries providing more creative and context-specific approaches compared to the U.K.\u003c/p\u003e \u003cp\u003eCultural competence was considered a significant factor in Somali women\u0026rsquo;s perinatal care experiences across various countries. In the U.S., Wandera (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e2018\u003c/span\u003e) highlighted that the lack of cultural sensitivity and understanding of Somali women\u0026rsquo;s religious practices resulted in mistrust of healthcare services. The same sentiments were confirmed by Evans et al. (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e2019\u003c/span\u003e), who advocated for cultural competence to be used to help care for migrant women, especially those who experience FGM. These results are similar to the Swedish study where Wallmo et al. (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e2020\u003c/span\u003e) described how cultural misconceptions affected the lives of Somali women. The women in this study underlined that they needed to be respected and have their cultural practices valued, especially regarding childbirth. Agbemenu et al. (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e2021\u003c/span\u003e) also pointed out that cultural respect during the antenatal and intrapartum periods is critical, as Somali women in the U.S. described feeling devalued during childbirth, particularly when their cultural preferences were not considered by healthcare professionals.\u003c/p\u003e \u003cp\u003eAubrey et al. (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e2017\u003c/span\u003e) also identified the same challenges in Canada, where Somali women reported that their cultural norms, especially concerning gender and religion, were not valued. Such gender disparities as the shortage of female doctors, for instance, made birth even more uncomfortable. These results stress the sustained need for cultural sensitivity to enhance Somali women\u0026rsquo;s interactions during perinatal care.\u003c/p\u003e \u003cp\u003eHowever, the studies conducted in the U.S. focused on the ethnic-cultural aspect of Somali women in pregnancy and childbirth with emphasis on the role of men in Somali culture, which was less represented in the U.K. studies. According to Wojnar (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e2015\u003c/span\u003e), Somali men were marginalised from prenatal care in the U.S. while holding influential positions in decisions during pregnancy. This is in contrast to the studies conducted in the U.K., where the main emphasis was on the trial of Somali women without mentioning the male companions. These comparisons show that despite the fact that cultural relevance is an important aspect in all existing settings, certain aspects that culturally define interactions may vary from one country to another, be it the role of the family or gender factors.\u003c/p\u003e \u003cp\u003eMental health issues were seen as a major issue in the U.K. and other literature. Rayment-Jones et al. (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e2019\u003c/span\u003e) revealed that Somali women in the U.K. are at high risk of depression, postnatal depression in particular, due to social exclusion, poverty and poor access to culturally sensitive mental health services. Such findings aligned with Chitongo et al. (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e2022\u003c/span\u003e), who pointed out how structural racism and social exclusion influenced the mental health of Somalis in the U.K. Similar mental health concerns were reported by Jacoby et al. (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e2015\u003c/span\u003e) in the United States, including postpartum depression (P.P.D.). Among the areas of dissatisfaction, the Somali women highlighted perceived inadequate care on mental health problems due to cultural taboo of mental health issues. However, the study did not underscore a general lack of mental health literacy but rather how the \u0026ldquo;historietas\u0026rdquo;, an educational tool, can be instrumental in filling the shortcomings in understanding of P.P.D.\u003c/p\u003e \u003cp\u003eVik et al (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e2022\u003c/span\u003e) studied the Somali women in Norway where they noted that the women were afraid of surgeries like caesarean sections, which contributed to their mental strain during childbirth. This was evident from their ignorance of the structure of the health care system and their distrust of health care practitioners. This result supports the UK-based studies, but the perceived need to extend antenatal education in Norway seems much higher. The findings offer an implication that though there are always mental health concerns in different countries, the factors contributing to it and solutions may also be different. While countries like the U.S.A. and Norway face complex issues such as racism and inequality within Black communities, they place a strong emphasis on improving health literacy through education.\u003c/p\u003e \u003cp\u003eSome proposed interventions to improve perinatal care for Somali women include Turkmani et al. (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e2019\u003c/span\u003e) recommending the use of community centre settings with a cultural lens tailored to minority groups, while Evans et al. (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e2019\u003c/span\u003e) suggested anti-racial discrimination training for healthcare practitioners. The focus, however, has been on restructuring the U.K.\u0026rsquo;s NHS to address barriers faced by Somali women, such as racism, poor communication, and inadequate services within healthcare facilities. In Sweden, Wallmo et al. (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e2020\u003c/span\u003e) advised an increased structure in communication that would require healthcare workers to be specifically taught how to convey clear and culturally appropriate information when a woman is giving birth. Likewise, Vik et al. (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e2022\u003c/span\u003e) conducted a study in Norway that stressed the significance of face-to-face assessments in early labour to develop a rapport with Somali women and make them comfortable during the perinatal period. On the contrary, the studies carried out in the United States like the one by Jacoby et al. (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e2015\u003c/span\u003e), put forward more personal recommendations; such as the approach to enhancing health literacy through the use of culturally competent health education aids. This could be seen as a more profound change to the patient\u0026rsquo;s benefit than the large-scale changes mentioned in the U.K. setting.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec24\" class=\"Section2\"\u003e \u003ch2\u003e5.2 Limitations\u003c/h2\u003e \u003cp\u003eThere are some limitations to the included studies, as follows. Firstly, the use of qualitative data and small samples, which is evident in the research by Wojnar (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e2015\u003c/span\u003e) and Vik et al. (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e2022\u003c/span\u003e), limits the external validity of the research results. Furthermore, a considerable number of the studies, especially the cross-sectional ones conducted in the U.K. focused on self-reported data with the likelihood of recall bias. There also lies a restriction in the types of articles in terms of language used, where only articles in English were considered. Additionally, studies conducted in countries with different languages were not examined, and they also could offer more information about Somali women in other settings. Lastly, all the reviewed studies did not provide information relative to intersectionality, for instance, differences in the experiences of immigrant Somali women with reference to their legal immigration status as asylum seekers and other comparatively established statuses. Therefore, future research should seek to understand the root of these differences to have a broader perspective of the various experiences that are present within the Somali community.\u003c/p\u003e \u003c/div\u003e"},{"header":"6 Conclusion and Recommendations","content":"\u003cdiv id=\"Sec26\" class=\"Section2\"\u003e \u003ch2\u003e6.1 Conclusion\u003c/h2\u003e \u003cp\u003eThis study aimed to understand the perinatal care experiences of Somali women in the U.K., comparing these to other high-income countries like the U.S., Sweden, and Norway. Common challenges identified include language barriers, cultural insensitivity, mental health issues, and discrimination. Although these issues are present across countries, the approaches to address them differ due to varying healthcare systems and policies. In the U.K., the focus is on systemic changes to ensure culturally competent care and tackle racism, while in the U.S. and Norway, the focus is more on health literacy and developing culturally appropriate education resources. The reliance on qualitative studies with small sample sizes limits the generalisability of the findings. Nonetheless, it is clear that addressing perinatal care for Somali women requires a systemic approach incorporating cultural understanding, language, and mental health support.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec27\" class=\"Section2\"\u003e \u003ch2\u003e6.2 Recommendations\u003c/h2\u003e \u003cp\u003eU.K. healthcare services should prioritise creating culturally appropriate care models for Somali women. Research by Vik et al. (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e2022\u003c/span\u003e) and Wallmo et al. (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e2020\u003c/span\u003e) highlights the importance of addressing cultural issues in communication and expectations surrounding childbirth. To address this, health systems should provide culturally tailored antenatal care, including workshops and language support, to help Somali women better understand labour and postpartum processes. Moreover, family-centred models should be developed to encourage the inclusion of husbands and male partners, addressing gaps in support during childbirth.\u003c/p\u003e \u003cp\u003eJacoby et al. (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e2015\u003c/span\u003e) emphasise the need for improving Somali women's health literacy through a comprehensive approach. Health organisations like the NHS should develop culturally sensitive educational resources to address disparities, especially regarding critical medical procedures such as caesarean sections and issues such as postnatal depression. As health literacy is linked to health outcomes, these materials should be frequently updated and evaluated to reduce disparities.\u003c/p\u003e \u003cp\u003eAnother area for improvement is interpreter services during labour. Vik et al. (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e2022\u003c/span\u003e) found that the lack of skilled interpreters exacerbates fears and confusion during critical moments. Increasing the availability of well-trained interpreters and making their services more accessible would significantly enhance the care provided to Somali women. Finally, healthcare policymakers should invest in continuous education for healthcare workers to improve cultural competency, particularly for ethnic and immigrant groups. Incorporating this training into continuing professional development (C.P.D.) for maternity and antenatal care providers is essential to better understanding Somali women\u0026rsquo;s experiences. As Wallmo et al. (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e2020\u003c/span\u003e) argue, this can reduce discrimination and ensure compassionate, culturally sensitive care.\u003c/p\u003e \u003c/div\u003e"},{"header":"7 Appendicies","content":"\n\u003ch3\u003e7.1 Appendix A: P.C.C. Framework\u003c/h3\u003e\n\u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"No\" id=\"Taba\" border=\"1\"\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eP.C.C. Element\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSearch Terms and Synonyms\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSearch Strategy String\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePopulation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSomali women\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\"Somali women\", \"Somali mothers\", \"Somali immigrants\", \"Somali migrants\"\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e(\"Somali women\" OR \"Somali mothers\" OR \"Somali immigrants\" OR \"Somali migrants\")\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eConcept\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePerinatal care\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\"Perinatal care\", \"Maternal health\", \"Maternity services\", \"Childbirth care\"\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e(\"Perinatal care\" OR \"Maternal health\" OR \"Maternity services\" OR \"Childbirth care\")\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eContext\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHealthcare in high-income countries\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\"U.K.\", \"United Kingdom\", \"Western countries\", \"High-income countries\"\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e(\"U.K.\" OR \"United Kingdom\" OR \"Western countries\" OR \"High-income countries\")\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e\n\u003ch3\u003e7.2 Appendix B: Data Charting\u003c/h3\u003e\n\u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"No\" id=\"Tabb\" border=\"1\"\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAuthor(s) and Date\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eStudy Size\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eLocation\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePopulation\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eSetting\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eMethod\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eSummary of Findings\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMoxey and Jones (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e2016\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10 women\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eBirmingham, U.K.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSomali women with FGM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eCommunity centers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eQualitative study\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eSomali women with FGM have complex needs and face challenges in antenatal and intrapartum care. Effective communication and culturally sensitive care are essential.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eKonje and Konje (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e2021\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16 paricipants\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eLeicester, U.K.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSomali migrant women\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eVarious\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eQualitative study\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eSomali migrant women face significant barriers in accessing maternity care in the U.K., including language barriers and lack of culturally appropriate services.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAhrne et al. (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2019\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e60 participants\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSweden\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSomali-born women and their partners\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eAntenatal care settings\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eQualitative study\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eSomali-born parents and midwives highlighted the need for culturally tailored antenatal care to improve trust and communication.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eObionu et al. (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e2023\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eVarious studies\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eU.K.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eEthnic minority and migrant women\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eVarious\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eSystematic review\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eEthnic minority and migrant women in the U.K. experience disparities in maternity care, including racism, lack of cultural competence among healthcare providers, and systemic barriers to accessing care.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChitongo et al. (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e2022\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e20 midwives\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eLondon, UK\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMidwives caring for ethnic minority women\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eObstetric led unit\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eQualitative study\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eIdentified barriers to effective perinatal care for ethnic minority women include communication issues, lack of continuity, and social determinants. Suggested solutions include community hubs and anti-racism interventions.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMacLellan et al. (2022)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e24 studies\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eUK\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eBlack, Asian, and minority ethnic women\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eVarious\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eQualitative evidence synthesis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eEthnic minority women experience systemic racism and discrimination in maternity services, leading to poorer care and outcomes.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEvans et al. (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e2019\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eVarious\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eVarious\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eWomen and girls who have undergone FGM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eVarious\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eQualitative systematic review\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eWomen and girls with FGM face substantial barriers to culturally safe care. Recommended increased training for healthcare providers and the integration of culturally sensitive practices.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eKimani et al. (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e2018\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eVarious\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eHigh prevalence settings\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNurse-midwives working with FGM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eTraining programs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eMixed methods\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eInnovative training approaches for nurse-midwives significantly improved their knowledge and confidence in managing FGM cases.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMusse (2023)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9 articles\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eVarious\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMidwives' knowledge and training on FGM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eVarious\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eSystematic review\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eMidwives lack sufficient knowledge and training on FGM, highlighting the need for improved education and evidence-based guidelines to support affected women.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eZimmerman and Beam (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e2020\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e85 women\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eU.S.A.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eImmigrant and refugee women\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eSurvey-based study\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eSurvey and interviews\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eImmigrant and refugee women reported significant health information needs and barriers, such as language and cost, leading to reliance on less credible information sources.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRayment-Jones et al. (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e2019\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eVarious studies\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eU.K.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eWomen with social risk factors\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eVarious\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eRealist synthesis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eWomen with social risk factors experience fragmented and impersonal maternity care. Emphasised the need for continuity of care and tailored support services.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLindquist et al. (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e2015\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5,332 women\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eEngland\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eWomen from different socio-economic groups\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNational Maternity Survey\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eSurvey\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eWomen from lower socio-economic groups reported poorer experiences and outcomes in maternity care.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFair et al. (2020)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e51 studies\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eVarious European\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMigrant women\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eVarious\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eSystematic review\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eMigrant women face multiple barriers including language, discrimination, and lack of information, affecting their pregnancy, childbirth, and maternity care experiences.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHigginbottom et al. (2019)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e40 studies\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eU.K.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eImmigrant women\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eVarious\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNarrative synthesis review\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eImmigrant women in the U.K. experience significant challenges in accessing and utilising maternity care services, including cultural and language barriers, and differing expectations of care.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMcKnight et al. (2019)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6 studies\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eU.K.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eAsylum-seeking women\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eVarious\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eSystematic review\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eAsylum-seeking women report poor experiences of U.K. maternity care, including lack of respect and inadequate communication.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTurkmani et al (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e2019\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16 studies\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eHigh-income countries\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMigrant women from FGM-practicing countries\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eVarious\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eSystematic review and meta-synthesis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eMigrant women with FGM face fear, stigma, anxiety, and cultural conflicts in high-income countries. Key themes include vulnerability, distrust, and the need for culturally sensitive and women-centred care.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e\n\u003ch3\u003e7.3 Appendix C: Quality Assessment\u003c/h3\u003e\n\u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"No\" id=\"Tabc\" border=\"1\"\u003e \u003ccolgroup cols=\"12\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c11\" colnum=\"11\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c12\" colnum=\"12\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStudy\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYear\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eClear Research Question\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eAppropriate Study Design\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eRobust Data Collection\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eAdequate Sample Size\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eEthical Considerations\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003eAppropriate Recruitment\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e \u003cp\u003eRigorous Data Analysis\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c10\"\u003e \u003cp\u003eClear Findings\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c11\"\u003e \u003cp\u003eResearch Valuable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c12\"\u003e \u003cp\u003eOverall Quality\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMoxey and Jones\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2016\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003eHigh\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eKonje and Konje\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2021\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003eHigh\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAhrne et al.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2019\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003eHigh\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eObionu et al.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2023\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003eHigh\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChitongo et al.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2022\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003eHigh\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMacLellan et al.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2022\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003eHigh\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEvans et al.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2019\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003eHigh\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eKimani et al.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2018\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003eHigh\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMusse\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2023\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003eHigh\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eZimmerman and Beam\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2020\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003eHigh\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRayment-Jones et al.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2019\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003eHigh\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLindquist et al.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2015\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003eHigh\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFair et al.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2020\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003eHigh\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHigginbottom et al.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2019\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003eHigh\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMcKnight et al.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2019\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003eHigh\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTurkmani et al.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2019\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003eHigh\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e\n\u003ch3\u003e7.4 Appendix D: Identified Themes\u003c/h3\u003e\n\u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"No\" id=\"Tabd\" border=\"1\"\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTheme\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNumber of Studies Referring to Theme\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePercentage\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLanguage and Communication Barriers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e87.5%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCultural Competence and Sensitivity in Care\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e81.25%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMental Health and Socio-economic Challenges\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e68.75%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStrategies to Improve Perinatal Care Outcomes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e62.5%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate:\u003c/strong\u003e Not applicable.\u003cbr\u003e\u0026nbsp;\u003cstrong\u003eConsent for publication:\u003c/strong\u003e Not applicable.\u003cbr\u003e\u0026nbsp;\u003cstrong\u003eAvailability of data and materials:\u003c/strong\u003e The data supporting this study are available within the article.\u003cbr\u003e\u0026nbsp;\u003cstrong\u003eCompeting interests:\u003c/strong\u003e The author declares no competing interests.\u003cbr\u003e\u0026nbsp;\u003cstrong\u003eFunding:\u003c/strong\u003e This research received no external funding.\u003cbr\u003e\u0026nbsp;\u003cstrong\u003eAuthors\u0026rsquo; contributions:\u003c/strong\u003e L.A.M. conceptualized the study, conducted the literature review, analysed the findings, and drafted the manuscript.\u003c/p\u003e\n\n\u003ch2\u003e\u003cstrong\u003eAuthors\u0026apos; Information\u003c/strong\u003e\u003c/h2\u003e\n\u003cp\u003eA Qualified,\u0026nbsp;\u003cstrong\u003eRegistered Nurse Midwife\u003c/strong\u003e and a\u0026nbsp;\u003cstrong\u003ePublic Health Master\u0026apos;s graduate\u003c/strong\u003e with extensive experience in healthcare and public health within the UK. They have published previous research in the field.\u003c/p\u003e\n\u003ch2\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/h2\u003e\n \u003cp\u003eI would like to express my deepest gratitude to my family for their unwavering love, encouragement, and support throughout this journey. Their steadfast support has been invaluable in the completion of this study\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eAgbemenu K, Banke-Thomas A, Ely G, Johnson-Agbakwu C. Avoiding obstetrical interventions among US-based Somali migrant women: a qualitative study. Ethn Health. 2021;26(7):1082\u0026ndash;97.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAhrne M, Schytt E, Andersson E, Small R, Adan A, Ess\u0026eacute;n B, Byrskog U. Antenatal care for Somali-born women in Sweden: Perspectives from mothers, fathers and midwives. 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(2019) \u0026lsquo;How do women with social risk factors experience United Kingdom maternity care? A realist synthesis\u0026rsquo;, birth, 46(3), pp. 461\u0026ndash;474. doi: 10.1111/birt.12446. Available at: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://onlinelibrary.wiley.com/doi/full/10.1111/birt.12446\u003c/span\u003e\u003cspan address=\"https://onlinelibrary.wiley.com/doi/full/10.1111/birt.12446\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e [Accessed: 28 July 2024].\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTricco AC, Lillie E, Zarin W, O'Brien KK, Colquhoun H, Levac D, \u0026hellip; and, Straus SE. PRISMA extension for scoping reviews (PRISMA-ScR): checklist and explanation. Ann Intern Med. 2018;169(7):467\u0026ndash;73.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTurkmani S, Homer CSE, Dawson A. 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Perinatal experiences of Somali couples in the United States. J Obstetric Gynecologic Neonatal Nurs. 2015;44(3):358\u0026ndash;69.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZhu C. (2023). Barriers and Challenges of Immigrant Women\u0026rsquo;s Access to and Experience of Optimal Maternity Care. Columbia Univ J Global Health, 13(1).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZimmerman M, Beam H. (2020) \u0026lsquo;Refugee and immigrant health information needs\u0026rsquo;, International Journal of Migration Health and Social Care, 16(2). doi: 10.1108/IJMHSC-07-2019-0065. Available at: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.emerald.com/insight/content/doi/10.1108/IJMHSC-07-2019-0065/full/html\u003c/span\u003e\u003cspan address=\"https://www.emerald.com/insight/content/doi/10.1108/IJMHSC-07-2019-0065/full/html\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e [Accessed: 1 August 2024].\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAPPENDICES.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Abbreviations","content":"\u003cp\u003e\u003cstrong\u003eBMC\u003c/strong\u003e \u0026ndash; BioMed Central\u003cbr\u003e\u003cstrong\u003eCINAHL\u003c/strong\u003e \u0026ndash; Cumulative Index to Nursing and Allied Health Literature\u003cbr\u003e\u003cstrong\u003eFGM\u003c/strong\u003e \u0026ndash; Female Genital Mutilation\u003cbr\u003e\u003cstrong\u003eMBRRACE-UK\u003c/strong\u003e \u0026ndash; Mothers and Babies: Reducing Risk through Audits and Confidential Enquiries across the UK\u003cbr\u003e\u003cstrong\u003eNHS\u003c/strong\u003e \u0026ndash; National Health Service\u003cbr\u003e\u003cstrong\u003ePCC\u003c/strong\u003e \u0026ndash; Population, Concept, Context\u003cbr\u003e\u003cstrong\u003ePRISMA-ScR\u0026nbsp;\u003c/strong\u003e\u0026ndash; Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews\u003cbr\u003e\u003cstrong\u003ePTSD\u003c/strong\u003e \u0026ndash; Post-Traumatic Stress Disorder\u003cbr\u003e\u003cstrong\u003eUK\u003c/strong\u003e \u0026ndash; United Kingdom\u003cbr\u003e\u003cstrong\u003eWHO\u003c/strong\u003e \u0026ndash; World Health Organization\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-pregnancy-and-childbirth","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"prch","sideBox":"Learn more about [BMC Pregnancy and Childbirth](http://bmcpregnancychildbirth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/prch/default.aspx","title":"BMC Pregnancy and Childbirth","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-6068284/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6068284/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003ePerinatal care is a critical component of maternal and child health, encompassing the period shortly before, during, and after childbirth. In the United Kingdom (U.K.), disparities in perinatal outcomes are significant, particularly among ethnic minority groups such as Somali women.\u003c/p\u003e\u003ch2\u003eAim\u003c/h2\u003e \u003cp\u003eThis scoping review investigates the perinatal care experiences of Somali women in the U.K., aiming to identify common themes, barriers, and facilitators affecting their access to quality care.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA scoping review methodology was employed, including a comprehensive search of databases such as PubMed, CINAHL, Web of Science, and Google Scholar. Studies included were published between 2014 and 2024, focusing on the U.K. context and specifically addressing Somali women's perinatal care experiences. Data extraction and thematic analysis were conducted to synthesise findings from the included studies.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eSixteen studies met the inclusion criteria. Key themes identified include cultural beliefs and practices, communication barriers, discrimination, psychological and physical impacts of Female Genital Mutilation (FGM), and socio-economic factors. Somali women often face challenges due to traditional practices conflicting with Western medical approaches, language barriers, and negative experiences with healthcare providers, leading to mistrust. However, strong community support networks were identified as significant facilitators.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eSomali women in the U.K. face unique and complex challenges in accessing and receiving perinatal care. Recommendations include implementing culturally competent care practices, providing professional interpreter services, specialised mental health and deinfibulation clinics, and community engagement to improve perinatal care experiences and outcomes.\u003c/p\u003e","manuscriptTitle":"Perinatal Care Experiences of Somali Women in the United Kingdom: A Scoping Review","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-06-30 16:27:52","doi":"10.21203/rs.3.rs-6068284/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-04-10T18:32:09+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-09-07T20:49:51+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-04-15T16:01:15+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-04-07T13:23:10+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"161265091754832377909876269720807410114","date":"2025-04-06T16:21:19+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-04-03T17:42:55+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"235633247543805075662462525711005813518","date":"2025-04-03T17:27:17+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"211243655076842256702975741708629015084","date":"2025-03-28T10:19:40+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"170216515568537352339250612210821986134","date":"2025-03-24T11:56:25+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-03-19T11:59:07+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-02-27T14:35:06+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-02-25T23:56:18+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-02-25T23:56:11+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Pregnancy and Childbirth","date":"2025-02-20T04:00:46+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-pregnancy-and-childbirth","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"prch","sideBox":"Learn more about [BMC Pregnancy and Childbirth](http://bmcpregnancychildbirth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/prch/default.aspx","title":"BMC Pregnancy and Childbirth","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"2167546c-fc68-45e8-9c4e-76a1ace262b4","owner":[],"postedDate":"June 30th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"in-revision","subjectAreas":[],"tags":[],"updatedAt":"2026-04-10T18:39:57+00:00","versionOfRecord":[],"versionCreatedAt":"2025-06-30 16:27:52","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6068284","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6068284","identity":"rs-6068284","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}