Exploring Women’s Views and Experiences of Language Barriers in High Income Maternity Care Settings: A Qualitative Systematic Review and Thematic Synthesis

Exploring Women’s Views and Experiences of Language Barriers in High Income Maternity Care Settings: A Qualitative Systematic Review and Thematic Synthesis | 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 Systematic Review Exploring Women’s Views and Experiences of Language Barriers in High Income Maternity Care Settings: A Qualitative Systematic Review and Thematic Synthesis Eleanor Molloy, Sophie-Anna Dann, Fiona Cross-Sudworth, Amy Delicate, and 5 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9645588/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted You are reading this latest preprint version Abstract Background In high-income countries (HIC), an increasing number of women giving birth require support to communicate in the host-country language. Interpreter services and translated resources should be provided for all who require them in healthcare settings. However, interpreter and translation provision in maternity services remain inconsistent. Language barriers are associated with poorer birth outcomes and contribute to maternal morbidity and mortality. This qualitative systematic review and synthesis explored women’s experiences of language barriers in high-income maternity settings. Methods Systematic searches across six electronic databases yielded 2652 results between January 2023 and November 2025. Two reviewers independently screened titles, abstracts, and full text against eligibility criteria, resolving discrepancies through discussion with team members. Data were analysed using interpretive thematic synthesis and reported and interpreted against the Socio-Ecological Model framework. Results Eighty-four studies (86 articles) encompassing 1,801 women’s voices from 22 HICs were included. Themes were integrated into a model describing outcomes for women based on interactions with maternity services and interpreting provision in the context of language barriers. Women’s experiences of maternity services in the context of a language barrier were mediated by two key factors: 1) interactions with professional interpreters and 2) ‘Work arounds’ in the absence of a professional interpreter. Women frequently reported inadequate or lack of interpreter and translation provision, inconsistent communication and system-level failures to recognise and address linguistic needs. These experiences contributed to disengagement, isolation and reduced trust in services, while increasing perceived and actual risk for women and infants. The model illustrates how structural and organisational constraints perpetuate inequalities in maternity care. Conclusion This synthesis highlights the inconsistency in provision of professional interpreting services and how this perpetuates disparities in care in high-income maternity settings. Institutional and individual level understanding of language barriers may contribute to perpetuating lack of access to safe care for women. System and personal changes are required to improve equity, understanding, and safety in maternity care. Appropriate, effective, 24/7 interpreter services and enhanced cultural awareness among healthcare providers are essential. Failure to address language barriers negatively impacts women’s maternity experiences leading to disengagement and isolation of women, increasing risks to safety. Registration: This review was prospectively registered on PROSPERO (CRD42023416095). pregnant women pregnancy language barriers interpreter services translation maternity care qualitative evidence synthesis high income settings communication systematic review Figures Figure 1 Figure 2 Figure 3 INTRODUCTION Language and communication barriers within healthcare interactions are increasing, reflecting substantial growth in global migration, which doubled between 1990 and 2020 1 , and contributing to an era of superdiversity 2 . Speaking a different language to your country of residence’s first language does not always equate to needing additional communication support. For example, in the United States (US), over a fifth (22%) of the population does not identify English as their first language; with Spanish and Chinese being the most commonly spoken languages at home, and 61%, and 48% respectively, reporting speaking English well. 2 However, differences in language proficiency between patients and healthcare providers (HCP) are associated with reduced access to and engagement with healthcare services, 3 increased adverse events, 4–6 experiences of discrimination, 7 and greater frustration and dissatisfaction among both groups. 8 Globally in maternity care and other patient-healthcare interactions the number of women who require language support varies and may be as high as 25%, 2,9–11 although reliable data remain limited. Some of these increases may be due to economic and political upheaval, for example displacement due to war and conflict 12 , 13 . The United Kingdom (UK) Government 14 and National Institute for Health and Care Excellence (NICE) 4 guidance details that professional interpreter services should use a ‘variety of means to communicate’ including translated written resources, alongside verbal support and should be provided free of cost. Language barriers are key determinants of maternal health 15 , 16 , and have been identified as a particular risk for adverse outcomes 11 . 17 – 19 Women who experience language barriers in maternity care are at increased risk of poor birth outcomes. 20 Language barriers, alongside ethnicity and other structural factors, have also been identified as contributing to maternal mortality 21 , 22 . UK data suggests that between 2020 and 2022, Black women had a threefold higher risk of mortality, and Asian women a twofold higher risk compared to white women 23 . Mothers and Babies: Reducing Risk through Audits and Confidential Enquiries (MBRRACE-UK) have consistently reported that migrant women and their infants are overrepresented in UK and Irish perinatal mortality figures. 18 , 19 , 24 , 25 A case review of maternal and fetal morbidity and mortality in the Netherlands identified language barriers to be associated with safety risks from miscommunication 26 . A UK study into non-English speaking women who died in pregnancy identified none received appropriate interpreter provision. 27 Language barriers have been described as associated with difficulties understanding maternity healthcare systems 28 , 29 and timely registering for services, thus potentially delaying access to care, and increasing risks to safety for both mothers and their infants. 9 , 19 , 30 , 31 Effective communication between women and their HCP is essential to ensure needs are understood, informed consent can be obtained, and risk factors that can negatively affect outcomes, are identified and managed appropriately. 11 , 32 , 33 Maternity services must find ways to address language barriers to reduce disparities in experience and outcomes. The World Health Organisation (WHO) recommendations for Intrapartum Care 34 , alongside the compendium for respectful maternity care 35 , identifies that for women to experience childbirth as a positive event, services should ensure that all women have access to effective communication and respect. As far as the authors are aware, there has not been a qualitative systematic review and interpretative thematic synthesis 36 solely focussed on women’s experiences of language and communication barriers in high-income maternity settings. Our aim was therefore to systematically explore and synthesise the experiences and views of women navigating a language barrier, in high income maternity settings to inform recommendations for policy and practice. METHODS A qualitative systematic review and interpretive thematic synthesis was undertaken to integrate primary qualitative research from multiple perspectives, enabling the generation of new cumulative knowledge. 37 The review is reported against the Enhancing Transparency in Reporting the synthesis of Qualitative research (ENTREQ) framework 38 (Additional File 1). Search strategy and eligibility criteria. The SPIDER (Sample, Phenomenon of Interest, Data, Evaluation, Research Type) tool 39 , 40 was used to support the development of the research question, search strategy, (see Appendix 1) and review eligibility criteria (see Table 1 ). The search was limited to January 2013 to November 2025, to reflect current maternity care in high income countries (HIC). Electronic database searches were developed using scoping searches of the existing relevant literature, supported by the SPIDER tool. The searches were adapted to each of the following six databases and conducted in November 2025: MEDLINE, CINAHL, EMBASE, Web of Science, PsychInfo and ProQuest. Example search terms are described in Additional File 2. Table 1 Study eligibility criteria. Time-frame Inclusion Criteria Exclusion Criteria Published between 2013–2025, to capture data that reflects contemporary maternal care Language Published in English, limiting to countries that are comparable to UK in language and setting Publication type Peer reviewed journal articles Primary research Commentaries, conference abstracts, reviews, opinion piece, editorials, letter to editor, protocols, systematic reviews Secondary research/analysis Setting High income country (according to the World Bank List 2025 41,42 ) maternity care, for transferability of review to UK services Low-middle income countries Methodology All qualitative, mixed methods and multi method study designs Include primary quotes Quantitative data, systematic reviews Primary quotes and experiences of different groups cannot be disaggregated (e.g. voices of healthcare providers, women and family members) Grey literature Study topic Includes focus on women with limited host country language proficiency and their views and experiences of maternity care in that country. Communicating with a language barrier Availability and use of interpreter services: in-person, over the phone or remote/virtual Use of app / online platform for translation which does not involve physical interpreter. Translation of written information Screening Database search results were imported into Covidence 43 for screening, with duplicates removed automatically. All screening was completed by at least two independent reviewers against the eligibility criteria, to increase rigour and consistency of criteria application. 44 Disagreements were resolved through discussion with wider review team members (SK, LJ, AD, SB). Screening process and results are illustrated in the PRISMA diagram (see Fig. 1 ). Data extraction and quality appraisal Data extraction was conducted at three levels: (1) contextual data extraction and analysis, (2) quality appraisal of studies, and (3) qualitative analysis of study findings and conclusions. Study characteristics including contextual variables, e.g., study setting, data collection and analysis methods, and participant demographics were recorded for each study in an Excel database (see Additional File 3). Quality appraisal was performed using, the Critical Appraisal Skills Programme (CASP) 45 qualitative studies checklist. The outcome of the quality assessment did not impact a studies inclusion in the review. 46 Data from the results and discussion sections of each included study, including primary participant quotations, identified themes and subthemes, and authors’ interpretations were recorded in a Microsoft Word document for each study and then imported into NVivo 14 47 software to support data organisation and management. Data analysis and synthesis Interpretive thematic synthesis 49 following Thomas and Harden 36 was chosen as it allows analysis to be inductively led by women’s voices instead of a predetermined framework and also allows for the interpretation of both ‘thin’ and ‘thick’ data. 50 Thick data can be described as that which includes context of social, cultural and historical positioning of participants alongside insight into participant experiences, reflections and thoughts and feelings, allowing more in-depth analysis than thinner data which may be lacking in some or all the above. This differs from ‘rich’ data which has high levels of conceptual detail 51 . Thomas and Harden’s thematic synthesis follows a three-stage process 36 in which data are coded line-by-line, descriptive themes are developed from this coding, and subsequently analytical themes are developed and refined in the final synthesis. Contextual data were extracted from all studies by AG, FCS, EM and SD. Studies were assessed as being contextually thick or thin 50 . Studies were coded to generate an initial set of codes, beginning with those assessed as being thicker. More codes were created as needed, guided by coding of thinner studies. After initial coding, articles were reviewed again to ensure consistent application of the coding framework. These codes were organised into clusters to create descriptive themes, discussed with other reviewers (SD and AD) which were developed into analytical themes and supported the generation of an illustrative conceptual model (Fig. 3 ). Conceptual richness of each study was then assessed 50 . The analytical themes and model were discussed and refined with all review team members. Grade CERQual (Confidence in the Evidence from Reviews of Qualitative research) was undertaken following the refinement of the final conceptual model to increase transparency and confidence in review findings. 52 Ethics No ethical approval was required for this review. All data used is published and available in the public domain. Patient and Public Involvement The design, analysis and interpretation of findings were discussed with public contributors from the National Institute for Health and Care Research Applied Research Collaboration (West Midlands) patient advisory group. Reflexivity statement Qualitative research aims to reveal personal experiential truths within data 53 – 55 ; however, it is inherently intertwined with researcher interpretation and therefore potential subjectivity 56 – 58 . Reporting of women’s experiences linked to language barriers, and race and immigration status could be emotive 58 , 59 . Author reflexivity and researcher triangulation was necessary to limit the potential bias that can be created in the analytical and synthesis processes 60 – 62 . All co-authors and the wider PPIE contributors identify as women, are predominantly white and well educated. Some have had their own children or share caring responsibilities, at least one team member has had experience of accessing women’s healthcare while resident in another country, without the use of an interpreter, but none have experience of birth outside of their home country. The ability of the multidisciplinary team, including the invaluable expertise of the public and patient participants, to reflect together whilst conducting analysis adds rigour to our approach and final interpretations. RESULTS Database searches yielded 2,652 results. After removal of duplicates, 1,889 were title and abstract, and 233 were full text screened, respectively. 84 studies (86 articles) met eligibility criteria and were included in this review (see Fig. 1 ). 63 – 147 Study characteristics Study characteristics are summarised in Additional File 3. A total of 1801 women’s voices are included across the studies, ranging from four 114 to 193 participants 136 (median average of 21 voices per study). The geographic spread of the papers is shown in Fig. 2 . Most studies aimed to explore general perinatal and intrapartum experiences and needs of refugee or migrant women 64 , 68 , 71 , 85 , 87 – 93 , 95 , 98 – 101 , 104 , 105 , 107 , 108 , 111 – 116 , 119 , 122 , 124 , 127 – 129 , 132 , 133 , 135 , 136 , 140 – 142 , 144 , 146 , 148 – 150 Other studies looked at specific populations in a host country, for example, Chinese women in Switzerland 76 , 77 , Japanese women in New Zealand 84 , Polish women in Iceland 145 , Ukrainian women in Portugal 134 , Afghan women in USA and Australia 143 , 147 . Marshallese mothers 67 migrant Arab Muslim 69 , 79 and African immigrant women 66 in the US, and the Roma community in England 82 and in Ireland 86 . Further studies looked at specific elements of care, for example, Somali migrant women’s understanding of self-monitoring of foetal movements in Sweden 65 and maternity care in Norway 110 , 138 . Experiences and expectations of women and their husbands regarding shared decision making in maternity care in Suadi Arabia 151 , exploration of assessing women’s satisfaction with care in New Zealand 121 and the acceptability of interpreters for women with social risk factors in England 123 . Two studies looked at the use of online or smartphone apps: one around healthier lifestyle behaviours in pregnant migrant women 130 and one around Arabic speaking women’s experiences of communication using an app 73 , in Sweden. Australian studies explored the needs of indigenous pregnant women with rheumatic heart disease 70 , and how conversations about stillbirth prevention with migrant families 72 , trauma informed care 125 and group antenatal education for Karen women 126 and gestational diabetes care for Chinese women 139 were experienced and understood. US studies explored Spanish speaking parents understanding of newborn immunisations 74 , support with breastfeeding and lactation education 75 , education around post-partum bleeding 83 , electronic health records 97 , and interactions with medical interpreters 120 . Other studies looked at care following a prenatal diagnosis of congenital heart defect 78 ; the childbirth experiences of international marriage migrant women marrying Korean men in South Korea 80 ; experiences and access to perinatal mental health support 81 , 103 . Experiences and needs around communication about Interpersonal Violence in antenatal care 94 . Two studies looked at perinatal care for migrant and refugee women during Covid-19 106,152 . Across studies, data was gathered using ethnographic methods 90 , 101 , 140 , online or in-person workshops 82 , 86 , World Cafe methodology 122 , photo-elicitation workshops 135 , and observations 75 or video recordings of interactions on wards 83 or in individual consultations 120 . Two utilised questionnaires, one followed by interviews. 87 and another with four open questions. 136 All other studies used interviews and focus groups. Methodology was reported variably; 14 studies used content analysis 65 , 71 , 73 , 74 , 78 , 81 , 92 , 97 , 100 , 115 , 116 , 130 , 137 , 143 Including two which took a phenomenological approach to content analysis 92 , 115 ; most other studies (n = 50) reported using a thematic analysis approach 66 – 68 , 72 , 75 – 77 , 82 – 86 , 88 – 91 , 93 – 95 , 98 , 99 , 104 , 106 , 107 , 109 , 111 – 114 , 117 , 119 , 122 , 125 – 129 , 131 , 132 , 134 , 135 , 139 , 141 , 142 , 147 , 148 , 150 , 151 , 153 , 154 , using varied frameworks and approaches. Others described using narrative analysis 133 interpretive phenomenological analysis 69 , discourse analysis 120 , and various framework approaches, 70,87,105 Colaizzi’s data analysis method 80 Roper and Shapira’s principles of ethnographic research analysis 101 , constant comparison and grounded theory, 108 text consolidation 110 , and analysis based on theories of behaviour and behaviour change. 103 , 144 Two described used general qualitative analysis coding data into themes 96 , 118 and one did not report their analysis approach. 136 Although most studies reported duration since participants accessed maternity care, the timeframe was unclear in 16 studies 67 , 71 , 88 , 89 , 92 , 111 , 112 , 115 , 118 , 119 , 122 , 127 , 131 , 132 , 134 , 136 . Quality appraisal Quality appraisal results are shown in Additional File 4. All studies demonstrated clear aims and appropriate qualitative methodologies, including suitable research designs, recruitment strategies, and data collection methods. 26 studies reported reflexivity 63 , 65 , 66 , 76 , 81 , 85 , 90 , 93 , 95 , 104 , 107 , 119 , 125 , 127 , 129 , 130 , 132 , 133 , 135 , 139 , 143 – 145 , 148 , 150 and 44 were assessed as containing thick contextual descriptions. 69 – 71 , 75 – 79 , 81 – 83 , 86 – 88 , 94 , 97 , 99 , 101 , 104 , 107 , 113 , 117 , 118 , 125 , 126 , 128 – 130 , 133 – 135 , 137 , 138 , 140 , 142 – 146 , 150 – 153 , 155 Analysis was generally well reported, in six studies it was unclear or difficult to tell how data had been analysed 84 , 118 , 121 , 136 , 147 , 155 , and nine did not show evidence of ethical approval. 69 , 74 , 92 , 107 , 118 , 134 , 136 , 146 , 155 Thematic Analysis, Interpretation and Synthesis The following sections describe our interpretation and synthesis of the qualitative data from studies included in this review. We begin with a table identifying the terms we use in the reporting of the results and discussion (Table 2 ). Table 2 Definitions of terms used in reporting and discussion of findings in this review. Term Definition within this review Benefits (of positive engagement or experiences of host country maternity and healthcare) Ways in which having positive experiences and engagements in maternity interactions supports physical and emotional well-being of migrant women Consequences (of negative engagement or experiences of host country maternity and healthcare) How negative or poor experiences and interactions with maternity healthcare negatively influences both physical and emotional well-being and safety of migrant women and their infants ‘Home’ language Describes the women’s mother tongue, or the language she speaks with her family and/or within her country of birth. ‘Host’ country/language Describes the HIC in which the mother is now residing and the language in which the health, and maternity services are run. Mediators of experiences An element of a woman’s experience which influences how women experience navigating a language barrier between themselves and their HCPs and/or maternity systems. (E.g., a professional interpreter). Associated factors Factors which contribute to the overarching mediator, e.g., the availability of professional interpreters; the suitability of professional interpreters. Professional interpreter Describes a person who is paid for their time as a trained interpreter, and is accessed through, or provided by the health or social care system in the host country. We describe and identify two over-arching mediators of impact and experiences of women’s engagement with maternity care, interpreted from the included studies. These have been integrated into the Conceptual Model (Fig. 3 ), with factors we interpreted as associated with each mediator, and the consequences and benefits these result in for women. Table 3 summarises each mediator and their associated factors alongside illustrative quotations. In the section ‘Mediators of Impact and Experience’, we describe each mediator, and their associated factors. The section ‘Consequences and Benefits of Experiences, Engagement and Interactions’ describes our interpretations of consequences and benefits to women (Table 4 ), illustrated by excerpts and quotations from the included article. Where quotations are used, italics indicate article author interpretation and bold italics indicate women’s voices . The results section concludes with an interpretation of how women’s needs in the context of language barriers, can be supported to overcome structural barriers which perpetuating barriers in care access. These needs are framed in reference to the WHO recommendations on respectful maternity care. 35 An assessment of confidence in review findings was undertaken using the GRADE-CERQual assessment tool 52 , 156 and is indicated in brief alongside each review finding (mediator associated factors, consequence, benefit) and summarised at the end of the results (see Additional File 5 for the full Confidence in Review Findings Table). The two mediators, their associated factors, and the resultant consequences and benefits for women described in Fig. 3 , follow a pathway from language barriers through mediators of interaction and experiences to psychological and behavioural responses, and ultimately to care engagement and safety outcomes. Within the conceptual model, larger, darker coloured ‘bubbles’ indicate the strength of evidence from included studies, reflecting greater representation of each theme in the analysis. Interpreted themes: Mediators of impact and experiences Pregnant women in a host country experienced interactions with maternity services and care along a continuum from positive to negative. This review found that women’s experiences were centred around two key mediators: the provision of professional interpreter offering and ‘ work arounds’ in their absence . These mediators consisted of various associated factors. Table 3 describes a summary of the themes created through this analysis and interpretation. Table 3 Themes interpreted as mediators of impact and experiences of interactions with maternity services. Mediator of impact and experience Associated factors Illustrative quotation from included article(s) 1. Interactions with professional interpreters 1.1 Access to suitable professional interpreters “ The greatest challenge I have experienced is the following: If you are incapable of understanding anything [they say], then no one can help you…I was not offered an interpreter, and I never got the help I needed” 138 “ He was a Dari speaker, and I was [a] Hazaragi speaker and this difference of the language made it difficult for me to understand everything that he said . ” [Afghan woman, participant 8] 147 1.2 Positive experiences and interactions with interpreters ‘All interviewed groups, but most of all the migrant women, found that “interpreting services were indispensable ” to achieving appropriate maternity care.’ 102 1.3 Use of telephone and/or other interpreting medium “ I think it’s more useful [in person services], you have the person just next to you, you can see, you can talk, and it just inspires more security and trust, than the telephone line . ” 23 2. ‘Work arounds’ in the absence of professional interpreters 2.1 Language support from non-professional alternatives and specialist services “ The doctor is American, but she speaks a little Spanish. I bring my children with me so they can translate. And otherwise, I’ll ask one of the women there… But they don’t give me an interpreter or anything .” 97 2.2 Use of alternative communication strategies and good communication styles “They spoke to us with friendliness and smiles and love. They measured us and measured our blood pressure and everything, they did it all with kindness, so I was happy about that.” (Recent mother) 72 ‘…women appreciated the fact that the Health Centre midwife recognised the need to speak slower, and allowed time for them to ask questions to ensure they had understood correctly , ‘‘she told me about pregnancy, about baby very carefully, and very slowly talk with me because my English not very strong, but I understand everything ’’’ (woman 4). 148 In the context of language barriers, the central mediators and influencing factors (1.1–1.3; 2.1–2.2), were distinct but interrelated, with areas of overlap between them. Each mediator, and their associated, affected how women experienced their interactions with and engagement in maternity services. These experiences, in turn, shaped women’s psychological and behavioural responses to maternity care. The nature of these experiences and responses led to different outcomes for women and their infants and families, with potentially beneficial or adverse implications for maternal and infant clinical and psychological safety. The five factors associated with each mediator (Table 3 ) resulted in positive or negative experiences and engagement with maternity systems. These experiences and engagements were interpreted as having either negative consequences (C) or positive benefits (B) for women and their families, identified in Table 4 . Each factor is numbered, i.e., Ci, Cii, Bi, and these are described in sections 3.1 and 3.2. Table 4 Consequences and Benefits of Interactions with Maternity Care Mediated by Language Barriers Consequences of negative experiences and/or interactions with maternity services Benefits of positive experiences and/or interactions with maternity services (Ci) Lack of understanding of host healthcare system and medical terminology (Bi) Improved host language and healthcare system fluency, and community integration (Cii) Reduced access to and disengagement from maternity care services (Bii) Positive, culturally safe birth experiences (Ciii) Isolation from wider community and negative self-perception, helplessness and dependence on others (Biii) Supportive relationships with providers developed through continuity of care (Civ) Risk to safety for mother and/or baby (Cv) Lack of informed consent (Cvi) Perceptions of discrimination and racism (Cvii) Accessing care outside of formal host health systems Benefits and consequences were not experienced by women in isolation nor were women’s perinatal journeys wholly positive or negative. Rather, positive and negative experiences often co-occurred, integrating with and influencing one another, leading to positive or negative outcomes. In the following sections, each mediator and its associated factors are described, and links to the resultant consequences (C) or benefits (B) are highlighted. In a later section (3. Consequences and Benefits), the consequences (3.1 Ci-Cvii) and benefits (3.2 Bi-Biii) experienced by women are described in more detail in which interactions and overlaps between different consequences and/or benefits, and their associations to mediating factors are highlighted. Interactions with professional interpreters Most women expressed a need for an effective, appropriate, culturally competent and safe interpreter to support their interactions with maternity services in their host country. However, many women reported a lack of consistent provision of such support. Even when an interpreter was provided (whether professional or non-professional) there were concerns regarding trust, accuracy (including issues related to language proficiency and dialect), confidentiality, disclosure of sensitive issues, the gender of the interpreter, and disrespectful and unprofessional behaviour by interpreters. Across the included studies, most women reported being offered access to some form of interpreting service at some point during their perinatal journey. These included maternity specific interpreting teams or programmes, professional interpreters, and telephone interpreting services. Access to an appropriate professional interpreter Confidence in Review Finding: high confidence In-person, professional interpretation services were not available for all appointments: women across 48 studies 67 , 68 , 70 , 72 – 75 , 79 , 83 , 85 – 89 , 92 , 94 , 95 , 97 , 98 , 101 , 104 – 108 , 110 , 111 , 116 , 118 – 120 , 123 , 125 – 127 , 129 , 132 , 136 , 140 , 141 , 143 , 145 , 147 – 150 , 153 , 155 described a lack of, or inconsistent provision. Inconsistency included expectations from HCP that spouses, family, or community members would be availability for interpretation in emergency appointments, 105 during labour/night-time 101 or during blood test and scan appointments 147 where professional interpreter services were not provided outside of what were considered ‘routine’ maternity appointments. Some women reported being unaware that there was an interpreter service. 579, 95 , 98 , 101 , 112 , 125 , 134 , 144 This inconsistent offering and availability of professional interpreters increased communication barriers and reduced opportunities for effective communication (Cii: reduced access to and disengagement from services; Ciii: isolation and negative self-perception). Women with some fluency in the host language sometimes reported finding it difficult to express themselves in the context of medical terminology around pregnancy, and during periods of increased physiological stress (i.e., during labour) 84 , 106 , 122 . Women described that when HCP considered them proficient in the host language, interpreters were not always involved in supporting their care 84 , 122 . It is unclear from the data if women declined or were not offered interpreting based on a perceived lack of need by the HCPs caring for them. (Ci: lack of understanding of host healthcare system and medical terminology; Cii: reduced access to maternity services; Cv: lack of informed consent). The availability of professional interpreters either supported or hindered access to care throughout the perinatal journey (Cii: reduced access or disengagement from maternity services; Ciii: isolation and negative self-perception). When available, access to professional interpreters also supported women’s understanding of their care and rationale for ongoing antenatal and intrapartum clinical decision making 110 , 150 . Positive and negative impacts of interactions with professional interpreters was highlighted throughout women’s perinatal journeys. Some studies highlighted that even competent professional interpreters could create a barrier to sensitive communication and relationship building between a woman and her healthcare professionals, e.g., where women felt it challenging to have communication across several people 68 , 74 , 75 , 111 , where they felt that the interpreter was translating their words, but not their worries or emotions 153 . Professional interpreters were sometimes refused by women, reportedly because of a lack of trust in the interpreter or a lack of trust or understanding about interpreter service provision (e.g.., fear of cost), as well as the impact of having a third-party present for confidential and sensitive conversations 88 , 129 , 143 . One study suggested that HCPs and interpreter did not always work well together 126 , with too much information from HCP, and little checking by interpreters that women understood it 83,125,155 (Civ: risk to safety; Cv: lack of informed consent). Some women who used professional interpreter services had concerns about potential breaches of confidentiality. 68,101,108,110,119,123,141,144 This was especially relevant for women from smaller ethnic communities who were concerned that sensitive information, such as mental health issues, would be shared with their community locally, or in their home country 68 , 77 , 108 , 147 . The worry was that this could reflect badly on them within their communities, or increase perceived risks to themselves or their families, particularly where there were concerns about surveillance by authorities in their home country 68 , 73 . Some studies discussed the perceived lack of confidentiality as an issue effecting truthfulness in consultations; women felt embarrassment answering questions about more taboo topics, such as abuse or violence, and were more hesitant to answer openly 94 , 108 , 125 , 147 . Studies suggested this could be ameliorated where interpreters had appropriate experience or training, or some self-completion of forms by parents could provide additional confidentiality between a woman and her care provider. 94 , 125 , 141 There appeared to be little choice reported in the data in relation to who the interpreter was 68 , 123 although in one study when there was concern about ineffective interpreting, two women reported that their midwives changed the interpreter. 125 Women expressed frustration when they perceived interpreters were changing their words or were not reliable in their interpretations, leading to a reluctance of repeating the experience, and questioned their interpreter’s abilities or willingness to translate accurately. 73 , 110 , 111 , 123 , 129 , 143 One study 73 described that the interpreter had an inadequate knowledge of maternity terminology and felt that this could impact on their safety (Civ: risk to safety). Women also raised the issue of unprofessional behaviour among a small number of interpreters, including rudeness, ignoring women, and providing unsolicited advice or directing women’s responses 68 , 73 , 100 , 110 , 111 , 120 , 123 , 125 , 143 . Such behaviours were perceived as undermining respectful and safe care. Some studies described that the interpretation services provided were not always understandable to women. 73 , 91 , 107 , 116 , 123 , 125 , 138 , 151 , 153 , 155 This included situations in which interpreters or family members explained procedures (see also mediator 2.1 – language support from non-professional alternatives and specialist services), yet women still did not fully understand what was communicated, particularly when they were new to the country 66 , 79 , 86 , 89 , 108 , 140 , 147 , 153 . Differences in dialect influenced understanding of interpretation. 68 , 73 , 107 , 123 , 147 For example, dialects differed between Arab countries, and across different regions within countries, meaning that women and interpreters did not always share the same linguist nuances and words can carry different cultural meanings when used by individuals from different countries, and non-verbal gestures accompanying speech could also vary leading to misunderstandings 68 , 72 , 73 , 107 , 122 , 129 , 147 , 153 (Ci: lack of understanding of host healthcare system and medical terminology; Cii: reduced access to care and disengagement from services; Civ: risk to safety; Cv: lack of informed consent; Cvii: accessing care outside of health systems). Similarly, women were not always able to choose their interpreter in relation to preferred gender, with several studies 68 , 73 , 119 , 123 , 125 , 143 , 147 , 155 reporting that having a male interpreter often made women uncomfortable and reluctant to discuss sensitive or culturally taboo topics. This made women less likely to voice concerns, and limited information exchange with HCPs regarding their feelings, clinical history, and situations 68 , 73 , 86 , 92 , 147 , 153 , 155 (Cii: reduced access to and disengagement from maternity services; Civ: risk to safety). There was a concern that HCPs may not recognise women’s discomfort, and that the presence of a male interpreter could limit a woman’s ability to maintain culturally appropriate norms of modesty, particularly during childbirth 143 , 147 . However, it is important to highlight that not all women expressed concern at having a male interpreter on the basis of having a professional and effective language support 125 , 149 (Bii: supportive relationships developed with providers). Women with language barriers had additional financial and psychological pressures compared to those without 67 , 68 , 87 , 101 , 103 , 118 , 122 , 142 , 149 . Some were hesitant to try to access interpreters as they were uncertain about potential costs. 125 , 126 , 128 , 131 One woman reported refusing interpreter services which required payment. 105 A few women further reported being asked to return for appointments if interpreters were not available, wasting both time and effort and potentially having increased transport cost implications. 108 , 125 , 127 These wasted/return journeys may also contribute to barriers to accessing and/or continuing maternity care (Cii: reduced access to and disengagement from maternity care; Civ: increasing risk to maternal and infant safety). Positive relationships and interactions with professional interpreters. Confidence in Review Finding: moderate confidence (minor concerns regarding adequacy, because of limited data within the included studies, and how much the included studies focused on research questions, which are specific to this review finding.) A smaller number of studies reported that women appreciated and had positive working relationships with the professional interpreting services they were offered. 69,75,77,106,111,150 For many, these professional interpreters were able to maintain confidentiality, interpret accurately, and foster feelings of respect, safety and security among women accessing maternity care. The interpreter's role was multidimensional and at times complex 68 , 69 , 126 , 148 ; in some cases, women built important relationships with interpreters who acted as advocates; playing an important role in emotionally supporting and providing companionship as well as perceived effective interpretation 69 (Bii: supportive relationships developed through continuity of care). Use of telephone interpreting and other translation or interpreter medium. Confidence in Review Finding: high confidence Across the included studies, preferences regarding the mode of interpretation were mixed. One study reported no clear preference regarding the medium used 91 (online, telephone, in-person interpretation). In contrast, another study described the specific benefits of in-person interpretation, suggesting it facilitated effective communication and rapport. 123 In-person interpreters allowed for more comprehensive understanding and relationship building resulting in more effective communication. The addition of body language and their presence helped to build trust, and greater understanding of a woman’s emotional condition, as opposed to interpretation over telephone, or video where the emotional state of a woman may not come across as clearly. 65,123 Women expressed concern about using the telephone to book, be informed of appointments or seek help. 79 , 123 This impacts women’s access to both standard care, and care in an emergency, (Cii: reduced access to or disengagement from maternity services). Women expressed a need for written information in their own language. 65 , 69 , 70 , 72 , 77 , 79 , 84 , 91 , 93 , 108 , 110 , 135 , 136 , 144 , 153 In some settings, non-‘Westernised’ accents were highlighted as a unique barrier to accessing care, impacting on women’s feeling of a lack of respectful care from the healthcare system 106 (Cvi). Perceptions of discrimination and racism). Some women expressed frustrations around the lack of translated materials or the extra effort it took to understand information which was only provided in the host language 65 , 71 , 72 , 86 , 135 , 138 , 153 . More broadly, several studies indicated a preference for direct, personal explanation over alternative formats such as videos, mobile app or written leaflets. 65 , 73 , 110 , 115 , 144 One study did note that ‘providing information in two ways enhanced understanding’ , 73 indicating that a combined approach might be beneficial. There were contrasting experiences within and between studies, with a few women reporting that some clinics had provided them with satisfactory information in their preferred language 65 , 110 as well as through mobile apps and websites 73 , 81 , 82 , 116 , 130 . Pictures and images were described as helpful ways of increasing understanding 73 , 78 , 79 , 150 usually when used as complementary to each other 73 (see also 2.2: Work-arounds - Use of alternative communication strategies and good communication styles). ‘Work arounds’ in the absence of professional interpreter Where language and communication barriers remained, either due to lack of professional or non-professional interpreters, or due to a mismatch between the required language/dialect and that provided by the interpreter, women and their HCPs often worked in different and creative ways to overcome these barriers. In Fig. 3 and Table 3 these “Workarounds” were synthesised as language support from non-professional alternatives and specialist services (2.1) and the use of alternative communication strategies and good communication styles (2.2). 2.1 Language support from non-professional alternatives and specialist services. Confidence in Review Finding: high confidence Several studies reported that women actively sought care from HCPs who spoke their language or shared similar cultural backgrounds. 68 , 77 , 79 , 123 This was a strategy described to circumvent the need for professional interpreters or to avoid relying on family members for interpretation. The development of trusting relationships was closely linked to cultural and linguistic congruence between women and either interpreters or HCPs 77 , 104 , 153 . Continuity of care further supported these relationships, enabling greater familiarity, improved communication, and increased comfort over time 72 , 77 , 91 , 123 , 148 (Bii: supportive relationships with providers developed through continuity of care). A further workaround reported across studies was the use of bilingual staff when professional interpreters were unavailable. 68 , 77 , 79 , 100 , 140 , 143 , 155 In these instances, HCPS who spoke relevant languages were called upon to facilitate communication. While this approach was sometimes welcomed, it was typically limited to commonly spoken local languages and therefore not universally accessible. The ability of HCPs to speak more than one language was thus positioned as both a pragmatic response to gaps in interpreter provision and, in some cases, a facilitator of culturally safe care. However, while linguistic and cultural concordance could contribute to more positive maternity experiences, (Bii: positive culturally safe birth experiences) this was not the experience or opinion of all women and may add additional burden on some staff in an already stretched maternity care ecosystem. While many women described the challenge of accessing suitable interpreters 149 (1.1) two specialist services for refugee women reported always having access to interpreters 85 , 131 . Some women preferred to take their own ‘trusted’ interpreter, often family or friends, with them to appointments or when giving birth. 93 , 110 , 112 , 123 , 132 , 143 Those who preferred friends and family to act as interpreters highlighted the importance of having someone they trusted with them in potentially vulnerable situations. Some women perceived a general expectation from HCPs that they should provide their own interpreter 79 , 98 , and a few recounted being specifically asked to bring someone to interpret 79 , 86 , 100 , 147 or having their partners asked to interpret 80 , 126 , 140 , 148 Whether women chose to bring a trusted person or were pressured into providing their own interpreter, having the use of non-professional interpreters raised many issues. These included inaccurate interpretation due to limited language fluency and insufficient understanding of medical terminology, as well as difficulties in interpreting impartially, such as withholding information or inserting personal opinions 69 , 84 . In addition, some non-professional interpreters lacked a clear understanding of the issues being discussed. Some women were unhappy about having non-professional interpreters for a variety of practical and ethical reasons 79 , 100 , 108 , 123 , 132 , 141 , 147 . Ethical concerns included reduced participation in decision-making and compromised informed consent (Cv), as well as the appropriateness and effectiveness of interpretation. Similar issues were identified across both professional and non-professional interpreters (see 2.1, language support from non-professionals; including Cii: reduced access to and disengagement from maternity care services; Civ: isolation and negative self-perception; Cv: lack of informed consent; Civ: risk to safety for mother and baby). Another issue was the imbalance of power and control when partners agreed, offered or insisted on interpreting for their partner or that they should manage without professional services 123 . Some women felt this increased dependency within relationships 65 , 72 , 80 , 147 , 148 and could be a form of, or contribute to coercive control (Ciii: isolation and negative self-perception Civ: risk to safety Cv: lack of informed consent). Some studies referenced the impracticalities of women bringing friends or family 79 , 80 , 108 or that non-professional alternatives were as likely to be someone the woman would not have preferred due to concerns about confidentiality and discomfort in revealing personal information 87 , 108 , 141 , 147 . Four studies described children acting as interpreters 97 , 100 , 143 , 144 , including one case in which a woman’s 15-year-old daughter interpreted for her during childbirth, an experience that was emotionally challenging for them both. 100 2.2 Use of alternative communication strategies and good communication styles Confidence in Review Finding: high confidence When there were language barriers, alternative non-verbal ways of communicating and building rapport were sometimes used to good effect. This included gestures, images, facial expressions, body language, touch, and laughter, 77,79,80,118,132 . This was most effective when used alongside some level of verbal language interpretation or shared language, as on its own it limited information sharing. Non-verbal cues and expressions could be frightening when used to display negative emotions especially when there was no other communication. The actions and attitudes of professional interpreters and HCPs in navigating a language barrier mediated women’s experience of healthcare encounters. Women reported that some HCPs communicated effectively by listening and providing attentive care, despite the language barrier, while some professional interpreters offered both emotional support and facilitated effective communication 117 , 132 , 139 , 141 , 142 , 147 , 148 . When there was no interpreter, or when interpretation has been declined, women described feeling grateful to HCPs who spoke slowly and simply and checked their understanding, highlighting the importance of tailoring care 77 , 79 , 81 , 150 . However, this was not universal, and compassionate care was seen as key to bridging cultural gaps and building rapport between women and HCPs. 113 Consequences and benefits of experiences, engagement and interactions The five factors associated with each mediator (Table 3 , Fig. 3 ) shaped women’s experiences and engagement with maternity systems by influencing psychological and behavioural responses which had either negative consequences (3.1; C) or positive benefits (3.2; B) for women and their families (see Table 4 ). These resulting consequences and benefits are described in more detail in which interactions are highlighted. Illustrative quotations from included studies are used, in which women’s voices are in bold italics and author interpretation and reporting is in italic . 3.1 Consequences of women’s negative experiences of and interactions with maternity staff in host countries Ci. Lack of understanding of host healthcare system and medical terminology Confidence in Review Finding: high confidence Women who were new to a country or had a language barrier frequently reported difficulty understanding, 77,98,100,105,106,110,124,125,128,134,138,144 or accessing, 65,68,98,106,108,110,111,127,128,133,134,148 , host healthcare systems. They also reported limited ability to find sufficient information on, or engage with varied aspects of care, e.g., antenatal classes. 67 , 68 , 79 , 80 , 91 , 92 , 94 , 98 , 100 , 101 , 108 , 110 , 114 , 124 , 127 , 133 , 134 , 140 , 144 , 147 , 148 Women were uncertain where to seek help and, and as a result, missed antenatal care 157 – 161 . They reported that when access relied on an initial telephone call or booking appointments via telephone, language barriers were especially problematic (mediator 1.3 – telephone and other translated media). 79 , 106 , 123 Medical jargon was identified as a key barrier, including among those with good host language fluency, 67–70,73,75,77–79,84,92,99,101,114,141,144 reflecting a gap in familiarity with medical terminology compared to everyday conversational language (see also 2.1, non-professional alternatives). Similarly, some women who were otherwise proficient in the host language reported being unable to effectively use this ability at times of increased stress and anxiety 84 . ‘A woman who had lived in New Zealand for 20 years, since entering a university, commented on the language barrier, especially about understanding the more technical terms. A few of the women experienced some difficulties using English, particularly during their labour . “ I became not able to speak in English [during the labour] ... English never came out. "’ (Participant 8) 84 This lack of familiarity with medical terminology was also linked to issues relating to the accessibility and appropriateness of interpreters, including both the ability of professional interpreter’s to accurately convey meaning in complex situations and the reliance on non-professional alternatives (2.1). Some women identified this lack of understanding as a gap they wished to address and reported that it contributed to increased fear about childbirth and uncertainty about what to expect from the healthcare system 65 , 92 , 113 , 138 (Ci: lack of understanding, Cii: reduced access to care, Ciii: isolation and negative self-perception). ‘One participant said that she would like more to be offered, “ Because we can always learn more. ” Another respondent agreed, in response to the same question , “the most important thing is education. ” Education was seen as a key to driving out the fear they experienced. As one woman noted, “ I sometimes wish they would ask me more questions—What worries you or what are you thinking about? Ask me questions, not just check my blood pressure. Sit down with me and talk . ”’ 92 The combined inconsistencies in professional and non-professional interpreting provision together with limited understanding of the healthcare system resulted in reduced access to and disengagement from maternity services (Cii) as well as increased isolation and negative self-perception (Ciii). Cii Reduced access to, & lack of confidence in care. Disengagement from maternity care services Confidence in Review Finding: high confidence Studies reported that limited understanding of care across the antenatal, intrapartum and postnatal periods, particularly regarding screening tests and pain relief, sometimes resulted in women missing out on options available to them 67 , 77 , 91 . Women with previous negative experiences described a reluctance to seek further care, leading to subsequent disengagement from maternity services. 67,70,77,79,91,101,106,110,114,121,125,144,148,150 ‘Limited fluency in English sometimes prevented an IW [immigrant woman] from participating in prenatal classes; an IW FGI [focus group interview] participant stated, “ I didn’t quite understand because it’s in English and so I only attended I think two times and then I just quit because I didn’t quite understand . ”’ 144 Ciii. Isolation and negative self-perception Confidence in Review Finding: high confidence Women reported a lack of agency in clinical decision making, with decisions often made on their behalf without their involvement, which was interpreted here as negative self-perception. Women expressed frustration, shame, inferiority and embarrassment when, in the absence of interpretation they were unable to respond to or make requests of their healthcare providers. 68 , 79 , 80 , 92 , 95 , 107 , 108 , 118 , 123 , 125 , 131 , 140 Difficulties communicating within healthcare settings were often compounded by increased social isolation during the perinatal period. Women from migrant communities described challenges associated with parenting without established support networks and reported that language barriers further limited their ability to engage with both local and co-cultural communities increasing reliance on smaller, more limited dependent on limited social circles and reducing independence 68 , 69 , 71 , 73 , 75 , 84 , 86 – 88 , 95 , 111 , 115 , 127 , 128 , 133 , 137 , 138 , 140 , 149 , 150 , 153 , 155 . Some explicitly described their perceived isolation: “ […] just greet “Hello hello” ... I sit my own for lunch and breakfast ...I sit alone . ” (SP1_I1) […] Establishing desired social support networks was also perceived as challenging by participants resulting from factors such as the multitude of nationalities and the language barriers : “.. .because in (city) people from Afghanistan, Macedonia they don’t speak English. . .only languages. .. Some people speak German. . .language. So very difficult to contact, yeah. Very little people have. . .can contact. It’s very difficult . ” (SP8_I1) 95 Several women also highlighted a desire to form friendships and build a supportive network with other parents in their local host community 79 , 88 , 100 , 107 , 137 , 140 , 148 . Civ. Risk to safety of mother and/or baby Confidence in Review Finding: high confidence Language barriers were frequently associated with miscommunication or misunderstandings, 68,73,77,79,101,105,106,110,115,125,127,132,143,155 including instances occurring despite the use of both professional and ad hoc interpreters 79 , 83 , 84 , 100 , 115 , 135 , 138 , 149 , 153 . Women described multiple factors that compromised the safety of their care. This included misunderstanding of clinical information, or inadequate interpretation, and uncertainty about when to seek help for abnormal symptoms or concerns. Medication use was identified as a key area of risk 73 , 79 , 100 , 108 , 155 , as women were reliant on HCPs ability to accurately convey appropriate medication use, as well as appropriate prescribing. “The smallest misinterpretation can lead to misunderstandings and wrong treatment” (8) - (App use 5 times, 3 years of residence, understands and speaks Swedish quite well). 73 Limited understanding contributed to avoidance of medications, incorrect administration, and instances of inappropriate prescribing (e.g., three women 79 reported being inappropriately prescribed Naproxen during pregnancy). Both inappropriate prescribing and women’s lack of understanding of how to use medication, and potential side-effects increased the risk of adverse drug events, while also limiting women’s health literacy and their capacity to advocate for themselves and/or their children 65 – 68 , 73 , 79 , 84 , 86 , 92 , 118 , 123 , 129 , 133 , 138 , 140 , 147 – 149 . “ In Syria, I used to read the leaflet to understand everything including side effects. If I took a medicine and something happened, I could check if this medicine is causing the side effect, but here in Belgium I can't do this . ” (W8) 79 Cv. Lack of informed consent Confidence in Review Finding: high confidence Many women reported disempowerment, helplessness and dependence on others due to language. barriers 70 , 76 , 77 , 80 , 88 , 92 , 100 , 101 , 107 , 111 , 118 , 121 , 123 , 125 , 127 , 140 , 143 , 144 , 155 . Inconsistencies in professional and non-professional interpreting provision, combined with limited understanding of medical terminology in the host language contributed to a lack of informed consent 66 , 67 , 75 – 77 , 79 , 82 – 84 , 86 – 88 , 91 , 99 – 101 , 107 , 108 , 112 , 113 , 115 , 118 , 122 , 125 , 127 , 133 , 135 , 138 , 143 – 146 , 149 – 151 , 155 . Experiences of disempowerment and poor treatment sometimes led to women disengaging from care (Cii: reduced access to and disengagement from care) 70 , 77 , 91 , 125 , 150 . Women felt dependent on HCPs, fuelling a ‘culture of compliance’ 91 and found it challenging to explain their experiences and concerns, or advocate for themselves during pregnancy and birth. Some studies described a ‘happy migrant effect’ 149 , whereby behaviours such as nodding, smiling and agreement reflected coping strategies (e.g., ‘fawning’) or resignation, to sub-standard care, rather than genuine understanding or informed agreement to care or treatment options. Women reported that ineffective communication limited their ability to feel heard and to participate in decision-making 68 , 92 , 110 , 144 , 150 , 153 . These imbalanced communication dynamics reduced women’s agency in influencing decisions at crucial points during pregnancy and labour and made them less likely to question HCPs actions or raise concerns (Cii: reduced access to care and disengagement from services; Civ: risk to safety of mother or baby). “ It was critical for me and the baby. They had to do something. I didn’t understand anything […] I just signed blindly. I did not know what happened to me, what happened to the baby. Is my baby still alive or has it died? I had no idea what help I should get, I was scared, I started to cry. ” (Albanian woman) 150 Women frequently described not understanding the reasons for medical interventions, local maternity care and clinical processes 66 , 68 , 82 , 84 , 88 , 100 , 107 , 108 , 116 , 118 , 125 , 127 , 129 , 132 , 135 , 143 , 145 , 150 , 153 . Issues relating to informed consent were particularly evident in relation to screening tests and during labour, often causing distress. Studies reported women feeling uncomfortable, fearful, worried and/or anxious due to poorly understood communication, and in some cases, the attitude of HCPs 80 , 84 , 92 , 100 , 101 , 106 , 108 , 118 , 125 , 127 , 131 – 133 , 138 , 140 , 144 , 147 , 150 , 155 (Cvi: perceptions of discrimination and racism). This lack of understanding led to ‘blind’ agreement in some cases, where women accepted interventions without full awareness of the context or detail, while in others it resulted in refusal of care due to uncertainty 144 (also increasing Civ: risk to safety, from a wider public health perspective). Lack of shared meaning was the biggest issue between the immigrants presenting for maternity care and their HCPs . P55 : Nurse ask me, ‘You know about that HPV test?’ So I said, ‘I don’t know.’ She said to me, ‘You suggest yes or no?’ So I said no because I can’t understand so that’s why I said no . ” 101 Cvi. Perceptions of discrimination and racism Confidence in Review Finding: high confidence Women without interpreter support to overcome language barriers frequently experienced maternity care, and interactions with some healthcare professionals as disrespectful, stigmatising, and discriminatory 66 , 68 , 69 , 72 , 77 , 82 , 86 – 88 , 90 – 92 , 106 , 110 , 111 , 117 , 118 , 122 , 127 , 129 , 136 , 137 , 143 , 144 , 149 , 150 . Language barriers, together with perceived discrimination, further amplified existing power imbalances and the dominance of HCPs within care interactions. 70 , 150 Women were less likely to communicate openly or make decisions in their own best interests and, in some cases, became increasingly dependent on family members or friends to interpret on their behalf 68 , 69 , 71 , 75 , 77 , 79 , 80 , 88 , 153 (mediator 2.1 alternatives to professionals; resulting in Ciii: isolation and negative self-perception, Cv: lack of informed consent, Cii: reduced access to and disengagement form services; Civ: risk to safety of mother and/or baby). Women reported experiences of discrimination associated with a lack of respect, absences of shared language, and different cultural frames of reference, 88,91,92,106,110,125,127,136,137,140,144,150 and for some, racism was also involved where HCPs were perceived as behaving in unkind or disrespectful ways. One woman noted, “It’s awful because I personally feel discriminated against...” Another participant discouragingly shared that she has been made fun of by nurses, and continued I don’t really speak the language, so I just keep quiet, but it really bothers me because sometimes you go with an emergency or a pain or something and they are really angry. They aren’t nice in some clinic. It’s awful because I personally feel discriminated against because if someone goes in with an emergency with pain and they have an angry face when they are with you. I don’t like it. You know, I understand a little, and they are laughing and talking, and I know because they say, “Spanish,” and I ask why are they like that? But oh well, I have to ignore it. But it is sad . ” 92 Women also felt stereotyped and ‘othered’ when HCPs assumed they could not speak the local language based on visible characteristics such as skin colour or traditional clothing (e.g., hijabs) 110 , 150 . Discrimination was also reported in accent bias with women from one study sharing feeling that their care was deprioritised when contacting services by phone due to their non-British accent. 106 Additional findings, while not always explicitly labelled as discrimination by study participants, were interpreted as such, including perceptions of negative stereotyping from staff ‘“ When she (the midwife) was talking to me, I felt like there wasn't a great deal of respect. I felt as though she was thinking “you stupid Somali mothers”. ’ (Fatima) 110 Conversely, other participants described positive and respectful care experiences, mediated by staff who were able to 2. Work around communication barriers . The associated factor of (2b) alternative communication practices led to women experiencing effective communication (Bi); positive, culturally safe birth experiences (Bii) and supportive relationships with providers developed through continuity of care (Biii). Cvii. Accessing care outside of health systems. Confidence in Review Finding: high confidence Women with limited proficiency in the host country’s language sought support in their preferred language and medium outside the formal host healthcare systems and structures (Cvii), through two primary pathways. These were either through accessing healthcare information from their country of origin or in their native language. The second was reliance on locally available community networks composed of individuals sharing similar linguistic and cultural backgrounds. When women had questions or concerns and were unable to obtain relevant information from their HCPs, some turned to the internet or to contacts in their country of origin 65 , 66 , 68 , 69 , 76 , 80 , 84 , 100 , 106 , 130 , 134 , 139 , 143 , 145 , 146 , 153 , where information was not always evidence based, for example, ‘using unproven folk remedies from their home countries’ 80 thus potentially increasing risk to safety (Civ). Women accessed care outside formalised health care systems in their host country sometimes also sought advice directly from HCPs in their country of origin 68 , 69 , 100 , 106 , 146 . For some, this provided reassurance, improved health literacy, and encouraged engagement with healthcare in their host country. ‘Women have formed transnational networks, which also contributed to their access to health care. By receiving vital information about pregnancy, delivery, and childcare from female relatives in their countries of origin, they compensated for information gaps and were able to perceive needs for health care, seek health-care providers, and utilize health-care services. As shown in this study, one of the participants decided to seek health care only after calling her mother in Syria, who alerted her to the urgency of the situation.’ 100 When women were not provided with enough information or appropriate translated leaflets from HCPs, they reported turning to other available sources including the internet, apps, and books 65 , 66 , 77 , 79 , 80 , 100 , 130 , 134 , 153 . These sources were perceived to meet their information needs and addressed their concerns. The second pathway involved support accessed through local community networks in their host country. Women sought information and social support from local networks of friends, family, connections and/or doulas in a language they understood 73 , 74 , 76 , 77 , 79 , 80 , 86 , 92 , 100 , 107 , 112 , 117 , 125 , 127 , 130 , 135 , 138 , 139 , 145 , 148 , 153 . However, this sometimes led to the circulation of inaccurate information, increasing fear 138 when combined with limited understanding of, and trust in, healthcare professionals. further contributed to negative experiences when engaging with unfamiliar maternity systems (Civ: risk to safety of mother and/or baby). (Ci: lack of understanding of host healthcare system and medical terminology). “The misinformation on the negative effects of caesarean section came from other Somali mothers. Other concerns learnt from Somali mothers included a risk of becoming disabled after interventions or that an epidural could possibly prolong labor or hinder labor progress. This kind of information made the women worried, and some said they therefore refused interventions or help with labor pain during labor. One parous woman explained it in the following way: ‘ I was afraid they would put a needle in my back. I had heard from other Somali women that the needle was bad for me, and that the procedure can leave you paralyzed [for life]. ’” (Interview 7) 138 The absence of wider familial support networks typically available in women’s countries of origin contributed to experiences of isolation 68 , 69 , 77 , 80 , 81 , 86 , 91 , 92 , 107 , 144 , 153 , (Ciii: isolation and negative self-perception), although local community members from similar background were sometimes able to partially fulfil this role 76 , 77 , 79 , 80 , 100 , 112 , 125 , 139 , 148 . 3.2 Benefits of women’s positive experiences and interactions with maternity staff in host countries Bi. Improved host language and healthcare system fluency, and community integration Confidence in Review Finding: moderate confidence (minor concerns regarding adequacy, because of limited data within the included studies, and how much the included studies focused on research questions, which are specific to this review finding.) For many women, supportive relationships with the same HCPs were integral to positive maternity care and childbirth experiences 84 , 100 , 112 , 142 , 145 , 150 . For women with language barriers continuity of care supported the development of trust and relationships (Biii), and in some cases enhanced language confidence and fluency 104 , 137 , 140 , 145 with the potential to negate or reduce experiences of isolation and helplessness observed in other immigrant women 148 . Women in multiple studies expressed a desire to improve their language proficiency 88 , 107 , 137 , 140 to better navigate and support their own and their family’s healthcare needs, as well as to facilitate integration into the host society, which was often perceived as a safer environment to raise their families 140 . Supportive positive care experiences therefore functioned not only to improve language and healthcare system fluency but also encourages women’s motivation to further develop language skills and integrated into the host country. 137 , 140 “ Learning Norwegian as a part of the Introductory Programme was very important to all the participants. They wished to improve their language skills and have an opportunity to practise the language. “ I have a positive opinion of the municipality. I obtained all the information I needed about pregnancy and delivery. I also had the opportunity to learn Norwegian and earn money by attending “The Introductory Programme.”” (P6)” 137 Bii. Positive, culturally safe birth experiences Confidence in Review Finding: moderate confidence (minor concerns regarding adequacy, because of limited data within the included studies, and how much the included studies focused on research questions, which are specific to this review finding.) Women valued opportunities to access information and connect with other mothers in in prenatal classes where interpreters or language-specific classes were provided 100 , 107 , 112 , 126 , 150 . The ability to communicate effectively and develop positive relationships with HCPs further contribute to improved and more culturally safe birth experiences 69 , 76 , 80 , 83 – 85 , 91 , 103 , 104 , 107 , 108 , 112 , 118 , 126 , 135 , 142 , 145 , 151 . “Women revealed how care experiences made them feel understood, culturally safe and heard. […] Many women felt ‘ heard and understood’ by their midwives, in contrast to standard hospital care, where they struggled to communicate, be heard, and have their needs met. This is a known strength of caseload midwifery models, where women and midwives build strong relationships, helping midwives understand women better .” 85 Biii. Continuity of care supports trusting therapeutic relationship development Confidence in Review Finding: moderate confidence (minor concerns regarding adequacy, because of limited data within the included studies, and how much the included studies focused on research questions, which are specific to this review finding.) Women with language barriers reported valuing the development of trusting relationships with HCPs which were strengthened over time through continuity of care 65 , 71 , 72 , 77 , 79 , 85 , 88 , 91 , 94 , 100 , 104 , 110 , 117 , 120 , 123 , 125 – 127 , 131 , 132 , 142 , 145 , 146 , 148 , 150 , 153 . For some there was a perception of receiving more individualised and responsive care, even with limited interpretation 65 , 72 , 76 , 91 , 123 , 126 , 127 , 142 , 145 . These trusted relationships were associated with increased increase safety for both mother and baby and facilitated more accurate and open information sharing, 110,127,131,148 in contrast to experiences of discriminatory care (Cvi) which were linked to increased risk of mother and baby (Civ) through reduced engagement and diminished trust in services (Cii). ‘The women expressed how trusting the caregiver afforded them the opportunity to share matters of an intimate nature, or ask questions they might never have had the courage to ask. One woman with four children was especially grateful for her midwife, who made her feel welcome at any time “I would rather go to a midwife than a doctor (…) The midwife takes her time, gives me good advice and asks me how I’m doing (…) The doctor asks me more basic things. (…) I like talking to my midwife (…) The midwife always had time to talk to me (…) She made me feel welcome and that she genuinely cared about me.” ’ (Fatima) 110 Supportive relationships with HCPs and interpreters, particularly those who demonstrated time, patience and understanding of the additional complexities faced by migrant women, enhanced women’s confidence in navigating the host healthcare system and contributed to improving their language skills 79 , 88 , 100 , 107 , 115 , 137 , 140 , 148 . ‘…women point out they needed the cooperation of their providers to make communication effective. Providers can help by slowing down when speaking, taking time to explain unusual words and answer questions, and by listening carefully. Participant A said, “ It’s important for doctors to have an open mind and be flexible because there is more than one way to do things. It’s so helpful to listen to what is important for the patient.” ’ 115 Confidence in Review Findings Most of the 15 review findings were assessed as high confidence (Additional File 5). We had moderate confidence in three findings (Bi. ii, iii) due to minor concerns regarding data adequacy, reflecting limited data within the included studies specific to these findings. For one finding (1.2) we had moderate confidence due to data adequacy and relevant, including, and limited data within the included studies, and the extent to which these studies address the specific review finding. Overcoming structural barriers According to the WHO Quality of Care framework 34 , 35 , “effective communication” and “experience of care” are core domains of quality, aligning with the provision of universal healthcare which is safe , effective and person centred . 34 Table 5 outlines the information and support needs of women with language barriers to address gaps in, and consequences of, inconsistent interpreter provision identified in this review. These needs are framed in reference to the WHO recommendations on intrapartum care, 35 which aim to address mistreatment and abuse of women and babies in maternity systems, and the FIGO statement of respectful maternity care which emphasises that healthcare practitioners should provide respectful and dignified care, ensure clear communication and informed decision-making, and support collaborative care involving women, their families, and healthcare providers. 162 These domains provide a framework through which the findings of this review can be operationalised into practice. 10 Respectful maternity care 163 Organised and delivered in a way that maintains dignity, privacy, and confidentiality; ensures freedom from harm and mistreatment; and enables informed choice and continuous support during labour and childbirth. Companion of choice during labour and childbirth The presence of a companion of choice is recommended for all women throughout labour and childbirth. Effective communication Communication between maternity care providers and women should be clear, accessible, and delivered using simple and culturally appropriate methods. Table 5 Key domain(s) of gaps in access framed within Respectful Maternity Care framework 162 . Safe, respectful maternity care Description Suggestions to improve access and care Safe and respectful maternity care is a fundamental right for all women giving birth. All women are entitled to make informed choices about their care and that of their unborn child or infant. For safety, trauma-informed care, and the provision of informed consent, it is essential that parents understand both the choices available to them and what is happening to themselves and/or their baby. • Families should be provided with clear information on how maternity services and healthcare access operate within their local area. • Healthcare professionals (e.g., doctors, midwives, and nurses) should clearly indicate which services are free and which may incur additional costs, for example prescription medications, additional testing or screening, or the use of private interpreting services outside formal healthcare provision. • All parents, including those new to the host country or with limited host-language proficiency, should be encouraged to provide feedback on their care experiences. This is important for capturing data on underrepresented groups, including the availability and appropriateness of interpreting services. • Women should be encouraged to ask questions without fear of judgement or discrimination, particularly where they do not understand information provided by healthcare professionals. This may relate to their clinical situation, medication use, or decisions regarding screening or vaccination. • For all interventions, women should be offered additional appointments with appropriate interpreter support and supported to ask questions until they have a clear understanding, thereby enabling informed consent. • Parents should be encouraged to highlight both positive and negative aspects of their care experiences. • Healthcare providers should be informed of areas for improvement, to strengthen service delivery, while also recognising and reinforcing examples of good practice. Companion of choice during labour and childbirth Description Suggestions to improve access and care “Each health care practitioner that a woman sees during the childbirth continuum should […] communicate health knowledge and information in a culturally safe and sensitive manner, and in a language that the woman and her family understand. 162 ” • A companion of choice may include an appropriate interpreter selected by the woman. • The use of non-professional interpreters is complex and context dependent. Systems should ensure that no woman is required to rely on family members for interpretation unless this is her explicit preference. • Some women may prefer a known and trusted individual to act as both companion and interpreter , particularly during intimate or stressful situations such as labour and birth. However, this must be considered within safeguarding frameworks, including risks of coercive control or intimate partner violence. • The relationship between the woman, healthcare professional, and interpreter is nuanced and multi-faceted. • Strong existing relationships between healthcare professionals and interpreters may, in some cases, influence the woman’s ability to develop a direct therapeutic relationship with her provider. - Continuity between the woman, her healthcare professional, and an appropriate interpreter can support sustained engagement with services. - Women should be provided with opportunities to give feedback on interpreter experiences, and to request continuity or change of interpreter for future appointments. Effective communication Description Suggestions to improve access and care Midwives should be encouraged to discuss women’s communication preferences to enable and support effective communication . This may include literacy in spoken languages, other languages women might read and or speak, and needs and preferences for online or paper/written communications. 8Health and language literacy and alternative or preferred communication methods • Women whose primary language differs from the host language should be routinely offered interpreter support. This should be part of standard care and made available at all stages, including where women and their families appear fluent in the host language. Conversational fluency does not necessarily equate to understanding medical terminology or navigating unfamiliar healthcare systems. • Women should be supported to enquire about the availability of interpreter services at each appointment. • Where awareness is limited, healthcare professionals should proactively provide this information, beginning at the initial booking appointment. • Where healthcare professionals identify gaps in understanding, they should utilise interpreter support or translated materials to facilitate communication. • Developing a central repository of multilingual information resources may support access to information. • Women may be encouraged to share externally sourced language resources with their midwife. These resources can be reviewed to: • ensure the information is safe and accurate, including consultation with professional interpreting services where needed. • assess relevance to local care pathways, intervention availability, and alignment with health policies and maternity practices in the host country. • Where resources are deemed appropriate, they may be incorporated into central repositories and shared with other parents as appropriate. • Access to local support groups with shared linguistic or cultural backgrounds should be promoted; peer support is highly valued by parents. • Engagement with diverse groups, including those involving host-country parents, may also support social integration and language development. • Women’s communication preferences should be regularly reviewed and updated throughout the perinatal period, particularly during discussions regarding birth options. Discussion This review examined women’s experiences of accessing maternity care in the context of language barriers, framed against the navigation of complex, unfamiliar healthcare systems. Women’s access to and understanding of health and maternity care were shaped by the presence or absence of a shared language. Their ability to engage with maternity care was mediated not only by the availability of professional interpreting services, but also by how accessible, trustworthy, and appropriate these services were perceived to be. Women facing inconsistencies in availability and suitability of professional interpreters sometimes described examples of HCPs working to overcome language barriers, whereas other interactions contributed to feelings of ‘othering’ and experiences of discrimination. Respectful maternity care has been identified as a global area for improvement within the inequality agenda 164 . One recent synthesis of 12 respectful midwifery care frameworks proposes ‘an approach to maternity care that honours the dignity, personhood, autonomy, and interests of birthing people; prevents disrespect, mistreatment, or abuse toward individuals who are using maternal care services; and provides a practical paradigm for the delivery and receipt of peripartum care through a rights- and reproductive justice–based framework’. 163 Within this context, women may decline interpreting services due to concerns about cost, confidentiality, or a preference for a trusted non-professional interpreter 165 . HCPs may face additional challenges in accurately assessing the need for interpretation as medical staff often overestimate how much patients understand 166 , 167 , while conversational fluency may not extend to understanding obstetric or medical terminology 124 , 168 , 169 . Interpreter needs are often recorded at the start of pregnancy; however, regular review throughout the perinatal period, particularly during periods of increased complexity or stress, may be necessary to ensure appropriate support. These findings must be understood within the broader context of women’s pre-existing social, cultural, and structural positions. Women enter pregnancy with diverse social, cultural and health-related characteristics that shape their prior experiences, including those within their home countries. Disparities in maternity outcomes are already well documented among underserved populations within countries. 7 , 25 , 27 Women who migrate to a host country, whether through either choice, economic migration, or as refugees or asylum seekers, are frequently at higher risk of poorer maternal and infant outcomes 21 , 102 , 170 – 172 . These communities often experience socio-economic disadvantage and may experience social discrimination and prejudice due to their ethnicity, positioning them amount the most vulnerable groups globally 31 , 173 . These intersecting characteristics contribute to compounding forms of disadvantage, amplifying both vulnerability and risk 173 – 176 . Healthcare systems in host countries are typically structured around population-level models of care, whether publicly funded or insurance-based, and often operate as ‘one-size-fits-all’ systems. As a result, structural inequities embedded within service design and resource allocation may persist, contributing to and exacerbating disparities in access, care, and outcomes 150 , 177 – 179 . Within clinical encounters language barriers result in disrupted shared decision making and person-centred communication between women and their HCPs, where informed consent, understanding and emotional safety all rely on shared language and meaning 180 – 184 . Drawing on cultural safety frameworks, safety is understood not only as physical but also relational and psychological, requiring both clinicians and institutions to reflect on power, bias and trust within communication. 7 , 180 , 185 Interpreting these findings through a socio-ecological lens suggests that language inequities are reinforced across multiple layers of the maternity care system 186 – 191 . Women’s accounts highlight not only gaps in individual communication but also the broader structural conditions that allow these gaps to persist. Addressing these gaps requires coordinated action across each level, from individual encounters to policy development, implementation, and system level reform 188 – 192 . Individual At the individual level, efforts should focus on strengthening both women’s and clinicians’ capacity for meaningful communication 193 , 194 . For women, this may include improved awareness of their right to request professional interpreters and support for language confidence where appropriate (see overcoming structural barriers Table 5 ). For clinicians, reflective practice is essential, —recognising assumptions about ‘good’ communication, developing awareness of power dynamics, and adopting clear, inclusive language, alongside training on communication practices and their downstream impact on clinical interactions and outcomes 195 – 197 . Interpersonal At the interpersonal level, the quality of the care relationship is pivotal. Trust and mutual respect may mitigate vulnerabilities arising from language barriers, whereas reliance on, or removal of, family members as interpreters may intensify these vulnerabilities 31 , 198 , 199 . Continuity of care, across relationships between women, HCPS, and interpreters, alongside attentive listening, and validation of women’s voices, is central to enabling shared decision-making and respectful care 200 – 203 . Community At the community level, social networks and local organisations play a key role in shaping access. Community advocates and migrant women’s groups often fill informational gaps left by formal systems 148 , 204 ; involving these actors in maternity outreach may strengthen engagement and ensure resources are culturally and linguistically appropriate. However, reliance on community interpretation and translation alone risks entrenching inequity if institutional responsibility is not maintained 119 , 183 , 205 – 207 . A lack of trust in, and understanding of, host healthcare systems may lead to over reliance on community and peer support. Local community organisations can function as conduits for information exchange and support integration into the host community. These often third sector organisations may alleviate pressure on statutory systems; however, they frequently operate within unstable funding structure and fragile networks, leaving them financially and politically vulnerable. At times, local peer support may also contribute to circulation of inaccurate or non-contextualised health information. This disconnect between host and home maternity care, shaped by differing cultural understandings and experiences, may further isolate communities and perpetuate divisions in access to care 6 , 195 , 208 – 212 . Institutional At the institutional level, these findings underscore the need for consistent, high-quality interpreter provision as a core component of safe maternity care. Safe care encompasses not only physical but also psychological dimensions, therefore culturally competent interpreters with a nuanced understanding of trauma informed practice should be available and accessible to all women experiencing language barriers 208 , 213 . Such provision supports women’s ability to engage with care, provide informed consent, and experience culturally safe care 214 , 215 . This requires resourcing interpreter services on a continuous basis, embedding language access into clinical governance, and collecting data on interpreter use across the maternity pathway. Interpreter provision should be recognised as a patient safety measure, equivalent in importance to infection control or emergency readiness. Policy At the policy level, aligning national standards in each country, with the WHO Quality of Care framework 34 would formalise and embed communication as a dimension of care quality and equity 188 , 189 , 192 . Routine monitoring, accountability mechanisms, and investment in interpreter training would help close the gap between policy intent and women’s direct experiences 215 . Taken together, these levels illustrate how structural inequities and interpersonal power imbalances intersect to shape maternity experiences 216 .. Addressing language barriers requires coordinated action across all levels of the system, not as a peripheral concern, but as a central condition of safe, respectful and equitable care. 35 , 216 This review synthesised women’s experiences of accessing maternity care in the context of language barriers within complex and unfamiliar healthcare systems. Women’s access to and understanding of health and maternity care were shaped by the presence or absence of a shared language, with consequences for their ability to engage with services. Engagement with maternity care was mediated not only by the availability of professional interpreting services, but also by how accessible, trustworthy, and appropriate these services were perceived to be. Inconsistent provision and perceived appropriateness of interpreting services contributed to variable experiences, with some healthcare professionals working to overcome communication barriers, while other interactions reinforced feelings of ‘othering’ and discrimination. Strengths and limitations As far as the authors are aware, this is the first qualitative systematic review and synthesis focussing on women’s experiences on language barriers in high income maternity care. The findings build on and extend the existing evidence base. A key strength of this review is the methodological rigour applied throughout. The literature search was developed with the input of specialist librarians, and search terms were iteratively refined to ensure sufficient sensitivity and breadth to capture relevant studies, although grey literature was excluded due to volume of studies identified, which may have limited the inclusion of additional relevant evidence. A second reviewer was involved in screening, study selection, data extraction and thematic synthesis. The themes and conceptual model were discussed as a team in which FCS, SD, SK have a midwifery background, some of whom have worked with interpreters, which may have influenced interpretation of the data. However, the inclusion of other team members (EM, LLJ, VM, AD) with expertise in qualitative analysis, synthesis, and women’s health strengthened the analytical process and overall rigour of the findings. The heterogeneity of the included studies provided a wider range of data and experiences, which presented challenges for coherent synthesis given the volume and richness of the data. The breadth of the included studies may limit transferability, as differences in healthcare systems across countries influence service delivery and experiences of language barriers. Women’s experiences are shaped by cultural norms, as well as individual differences in language proficiency, attitudes, education, and prior experiences, in addition to country context. Nevertheless, all included studies were conducted in high-income settings, and no substantial differences in reported experiences were identified across contexts. Overall, these strengths support confidence in the findings, while limitations should be considered when interpreting transferability. Conclusion This synthesis reveals that language barriers in maternity care are not isolated communication breakdowns but expressions of deeper structural inequities. When women cannot participate fully in their own care, safety, dignity, and respect are compromised. While respectful care is presumed in high-income settings, women’s accounts of exclusion and misunderstanding demonstrate that it is inconsistent and must be actively enacted. These findings highlight that inequitable communication reflects systemic priorities rather than inevitability. Recognising language access as fundamental to both clinical quality and human rights reframe interpreter provision from a logistical concern to an ethical imperative. A multi-level response is required. Aligning with the WHO Quality of Care framework 34 , 35 , effective communication, respect, and experience of care must be prioritised across all levels of the system. The Socio-Ecological Model highlights meaningful change must occur across individual, interpersonal, community, institutional and policy levels, supported by training for HCPS to meet the complex needs of women experiencing language barriers. Professional interpreting services remain inconsistently available and, at times, inappropriate. This reflects and reinforces inequities within maternity systems. Ultimately, ensuring that women are understood, and able to understand, is not an adjunct to care, but a fundamental condition of safe, equitable, and respectful maternity services. Abbreviations Enhancing transparency in Reporting the synthesis of qualitative research (ENTREQ); Health care provider (HCP); Mothers and babies: reducing risk through audits and confidential enquiries across the UK (MBRRACE-UK); Maternal mortality rate (MMR); National institute for health and care excellence (NICE); NHS (National Health Service – UK) systematic review (SR); United Kingdom (UK); United States of America (USA); World Health Organisation (WHO) Declarations Ethics approval Human research ethical approval was not required as we have synthesised published literature available. Patient consent for publication Not applicable. Data availability statement As a systematic review and qualitative thematic evidence synthesis all data is available from published works. Competing interests None declared. Funding This work was funded by the National Institute for Health Research (NIHR) grant 970014 through the Applied Research Collaborative (ARC) West Midlands (Maternity Theme) programme. The views expressed are those of the authors and not necessarily of the NIHR or the Department of Health and Social Care. Author contributions: SK had the original idea for the review, which was refined with LJ. AT wrote the original proposal and protocol and submitted the protocol to PROSPERO as part of an intercalation project supervised by LJ, FCS and SK. AT and FCS, with support from LJ and SK, led the original review process and with SD identified and screened and undertook preliminary analysis of the findings and creation of the original conceptual model. LJ led on the methodology with contributions from EM. EM, SD, AD and SB undertook further screening and analysis of the included articles, updated searches, and additional refinement of the conceptual model. EM and AD undertook assessment of all included findings using GRADE-Cerqual. All authors contributed to the interpretation of the analysis and the writing of the manuscript. All authors actively participated in the final version for submission. LJ is responsible for the overall content as the guarantor. Acknowledgements Many thanks to James Barnett, specialist librarian and the library services team for their help and encouragement while conducting this review. Many thanks also to the wider ARC team within University of Birmingham, and specifically the West-Midlands ARC PPIE members for their valuable contributions to this piece of work. References Al Shamsi H, Almutairi AG, Al Mashrafi S, Al Kalbani T. Implications of Language Barriers for Healthcare: A Systematic Review. Oman Med J. 2020;35(2):e122. 10.5001/OMJ.2020.40 . Vertovec S. Super-diversity and its implications. Ethn Racial Stud. 2007;30(6):1024–54. 10.1080/01419870701599465 . Language interpreting and translation: migrant health guide - GOV.UK. Accessed April 2. 2026. https://www.gov.uk/guidance/language-interpretation-migrant-health-guide Overview. | Pregnancy and complex social factors: a model for service provision for pregnant women with complex social factors | Guidance | NICE. Grant AP. Multilingual Capital: The Languages of London’s Schoolchildren and Their Relevance to Economic, Social and Educational Policies (review). Lang (Baltim). 2002;78(4):814–5. 10.1353/LAN.2003.0031 . van Rosse F, de Bruijne M, Suurmond J, Essink-Bot ML, Wagner C. Language barriers and patient safety risks in hospital care. A mixed methods study. Int J Nurs Stud. 2016;54:45–53. 10.1016/j.ijnurstu.2015.03.012 . Suurmond J, Ulters E, De Bruljne MNC, Stronks K, Essink-Bot ML. Explaining ethnic disparities in patient safety: a qualitative analysis. Am J Public Health. 2010;100(Suppl 1). 10.2105/AJPH.2009.167064 . Wasserman M, Renfrew MR, Green AR, et al. Identifying and preventing medical errors in patients with limited English proficiency: key findings and tools for the field. J Healthc Qual. 2014;36(3):5–16. 10.1111/JHQ.12065 . Sentell T, Chang A, Ahn HJ, Miyamura J. Maternal language and adverse birth outcomes in a statewide analysis. Women Health. 2016;56(3):257–80. 10.1080/03630242.2015.1088114 . Diamond L, Izquierdo K, Canfield D, Matsoukas K, Gany F. A Systematic Review of the Impact of Patient-Physician Non-English Language Concordance on Quality of Care and Outcomes. J Gen Intern Med. 2019;34(8):1591–606. 10.1007/S11606-019-04847-5 . Phillimore J. Migrant maternity in an era of superdiversity: New migrants’ access to, and experience of, antenatal care in the West Midlands, UK. Soc Sci Med. 2016;148:152–9. 10.1016/J.SOCSCIMED.2015.11.030 . Abubakar I, Aldridge RW, Devakumar D, et al. The UCL–Lancet Commission on Migration and Health: the health of a world on the move. Lancet. 2018;392(10164):2606–54. 10.1016/S0140-6736(18)32114-7 . Gagnon AJ, Dougherty G, Wahoush O, et al. International migration to Canada: The post-birth health of mothers and infants by immigration class. Soc Sci Med. 2013;76(1):197–207. 10.1016/j.socscimed.2012.11.001 . Language interpreting and translation: migrant health guide - GOV.UK. Accessed April 30. 2026. https://www.gov.uk/guidance/language-interpretation-migrant-health-guide Divi C, Koss RG, Schmaltz SP, Loeb JM. Language proficiency and adverse events in US hospitals: a pilot study. Int J Qual Health Care. 2007;19(2):60–7. 10.1093/INTQHC/MZL069 . Cull J, Anwar N, Brooks E, Cunningham J, Forman J, Hall D. Why does the inequity in outcomes remain? Hot Topic. Knight M, Bunch K, Vousden N, et al. A national cohort study and confidential enquiry to investigate ethnic disparities in maternal mortality. EClinicalMedicine. 2021;43:101237. 10.1016/J.ECLINM.2021.101237 . Accessed Mmortality. October 7, 2025. https://www.npeu.ox.ac.uk/mbrrace-uk/data-brief/maternal-mortality-2020-2022 Saving Lives I, Mothers. ’ Care 2020 - Lessons learned to inform maternity care from the UK and Ireland Confidential Enquiries in Maternal Death and Morbidity 2016-18 | MBRRACE-UK | NPEU. Accessed October 8, 2025. https://www.npeu.ox.ac.uk/mbrrace-uk/reports/maternal-reports/maternal-report-2016-2018 Providing feedback and comment on HSIB reports. Published online 2021. Accessed October 7. 2025. Cosstick E, Nirmal R, Cross-Sudworth F, Knight M, Kenyon S. The role of social risk factors and engagement with maternity services in ethnic disparities in maternal mortality: A retrospective case note review. EClinicalMedicine. 2022;52. 10.1016/j.eclinm.2022.101587 . Heath M, Hvass AMF, Wejse CM. Interpreter services and effect on healthcare - a systematic review of the impact of different types of interpreters on patient outcome. J Migr Health. 2023;7. 10.1016/j.jmh.2023.100162 . Rayment-Jones H, Harris J, Harden A, Khan Z, Sandall J. How do women with social risk factors experience United Kingdom maternity care? A realist synthesis. Birth. 2019;46(3):461–74. 10.1111/BIRT.12446 . Perinatal Confidential Enquiry: The care of recent migrant women with language barriers who have experienced a stillbirth or neonatal death | MBRRACE-UK | NPEU. Accessed April 29. 2026. https://www.npeu.ox.ac.uk/mbrrace-uk/reports/perinatal-mortality-and-morbidity-confidential-enquiries/perinatal-ce-migrant-women Knight M, Bunch K, Vousden N, et al. A national cohort study and confidential enquiry to investigate ethnic disparities in maternal mortality. EClinicalMedicine. 2022;43:101237. 10.1016/j.eclinm.2021.101237 . Martijn L, Jacobs A, Amelink-Verburg M, Wentzel R, Buitendijk S, Wensing M. Adverse outcomes in maternity care for women with a low risk profile in The Netherlands: a case series analysis. BMC Pregnancy Childbirth. 2013;13:219. 10.1186/1471-2393-13-219 . Cosstick E, Nirmal R, Cross-Sudworth F, Knight M, Kenyon S. The role of social risk factors and engagement with maternity services in ethnic disparities in maternal mortality: A retrospective case note review. EClinicalMedicine. 2022;52. 10.1016/j.eclinm.2022.101587 . McKnight P, Goodwin L, Kenyon S. A systematic review of asylum-seeking women’s views and experiences of UK maternity care. Midwifery. 2019;77:16–23. 10.1016/j.midw.2019.06.007 . Higginbottom GMA, Evans C, Morgan M, Bharj KK, Eldridge J, Hussain B. Experience of and access to maternity care in the UK by immigrant women: a narrative synthesis systematic review. BMJ Open. 2019;9(12). 10.1136/BMJOPEN-2019-029478 . Billett H, Vazquez Corona M, Bohren MA. Women from migrant and refugee backgrounds’ perceptions and experiences of the continuum of maternity care in Australia: A qualitative evidence synthesis. Women Birth. 2022;35(4):327–39. 10.1016/j.wombi.2021.08.005 . Heys S, Downe S, Thomson G. I know my place’; a meta-ethnographic synthesis of disadvantaged and vulnerable women’s negative experiences of maternity care in high-income countries. Midwifery. 2021;103. 10.1016/j.midw.2021.103123 . Lyberg A, Viken B, Haruna M, Severinsson E. Diversity and challenges in the management of maternity care for migrant women. J Nurs Manag. 2012;20(2):287–95. 10.1111/J.1365-2834.2011.01364.X . Phillimore J. Delivering maternity services in an era of superdiversity: the challenges of novelty and newness. Ethn Racial Stud. 2015;38(4):568–82. 10.1080/01419870.2015.980288 . World Health Organization. WHO recommendations. Intrapartum care for a positive childbirth experience. Published online 200AD:200. WHO. Compendium on respectful maternal and newborn care. Published online 2025. Accessed October 7. 2025. https://iris.who.int/ Thomas J, Harden A. Methods for the thematic synthesis of qualitative research in systematic reviews. BMC Med Res Methodol. 2008;8(1):1–10. 10.1186/1471-2288-8-45/FIGURES/2 . Flemming K, Booth A, Garside R, Tunçalp Ö, Noyes J. Qualitative evidence synthesis for complex interventions and guideline development: clarification of the purpose, designs and relevant methods. BMJ Glob Health. 2019;4(Suppl 1):e000882. 10.1136/BMJGH-2018-000882 . Tong A, Flemming K, McInnes E, Oliver S, Craig J. Enhancing transparency in reporting the synthesis of qualitative research: ENTREQ. BMC Med Res Methodol. 2012;12. 10.1186/1471-2288-12-181 . Methley AM, Campbell S, Chew-Graham C, McNally R, Cheraghi-Sohi S, PICO. PICOS and SPIDER: a comparison study of specificity and sensitivity in three search tools for qualitative systematic reviews. BMC Health Serv Res. 2014;14(1):579. 10.1186/S12913-014-0579-0 . Cooke A, Smith D, Booth A, Beyond PICO. the SPIDER tool for qualitative evidence synthesis. Qual Health Res. 2012;22(10):1435–43. 10.1177/1049732312452938 . New World Bank country classifications by income level: 2022–2023. Accessed April 2. 2026. https://blogs.worldbank.org/en/opendata/new-world-bank-country-classifications-income-level-2022-2023 World Bank Country and Lending Groups – World Bank Data Help Desk. Accessed April 2. 2026. https://datahelpdesk.worldbank.org/knowledgebase/articles/906519-world-bank-country-and-lending-groups Covidence - Better systematic review management. Accessed October 8. 2025. https://www.covidence.org/ Waffenschmidt S, Knelangen M, Sieben W, Bühn S, Pieper D. Single screening versus conventional double screening for study selection in systematic reviews: a methodological systematic review. BMC Med Res Methodol. 2019;19(1). 10.1186/S12874-019-0782-0 . Qualitative Studies Checklist - CASP, Accessed. April 2, 2026. https://casp-uk.net/casp-tools-checklists/qualitative-studies-checklist/ Garside R. Should we appraise the quality of qualitative research reports for systematic reviews, and if so, how? Innovation: Eur J Social Sci Res. 2014;27(1):67–79. 10.1080/13511610.2013.777270 . NVivo. by Lumivero | Qualitative data analysis (QDA) software. Accessed April 2, 2026. https://lumivero.com/products/nvivo/ Moher D, Liberati A, Tetzlaff J, Altman DG. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. BMJ. 2009;339(7716):b2535. 10.1136/bmj.b2535 . Barnett-Page E, Thomas J. Methods for the synthesis of qualitative research: a critical review. BMC Med Res Methodol. 2009;9(1). 10.1186/1471-2288-9-59 . Hong A, Baker L, Curiel RP, et al. Reconciling big data and thick data to advance the new urban science and smart city governance. Published online. 2022. 10.1080/07352166.2021.2021085 . Flemming K. The synthesis of qualitative research and evidence-based nursing. Evid Based Nurs. 2007;10(3):68–71. 10.1136/EBN.10.3.68 . Lewin S, Booth A, Glenton C, et al. Applying GRADE-CERQual to qualitative evidence synthesis findings: Introduction to the series. Implement Sci. 2018;13(1):1–10. 10.1186/S13012-017-0688-3/TABLES/4 . Britten N. Qualitative interviews in medical research. BMJ. 1995;311(6999):251. 10.1136/BMJ.311.6999.251 . VARIETIES OF QUALITATIVE. RESEARCH METHODS: selected contextual. Published online 2023. Pope C, Mays N. Qualitative Research: Reaching The parts other methods cannot reach: An introduction to qualitative methods in health and health services research. BMJ. 1995;311(6996):42. 10.1136/BMJ.311.6996.42 . Polit DF, Beck CT. Generalization in quantitative and qualitative research: Myths and strategies. Int J Nurs Stud. 2010;47(11):1451–8. 10.1016/J.IJNURSTU.2010.06.004 . Mauthner NS, Doucet A. Reflexive Accounts and Accounts of Reflexivity in Qualitative Data Analysis . Vol 37. 2003. Silverio SA, Sheen KS, Bramante A, et al. Sensitive, Challenging, and Difficult Topics: Experiences and Practical Considerations for Qualitative Researchers. Regul Article Int J Qualitative Methods. 2023;21:1–16. 10.1177/16094069221124739 . Dempsey L, Dowling M, Larkin P, Murphy K. Sensitive Interviewing in Qualitative Research. Res Nurs Health. 2016;39(6):480–90. 10. 1002/NUR.21743;ISSUE:ISSUE:DOI. Dodgson JE. Reflexivity in Qualitative Research. J Hum Lactation. 2019;35(2):220–2. 10.1177/0890334419830990 . Carter N, Bryant-Lukosius D, Dicenso A, Blythe J, Neville AJ. The use of triangulation in qualitative research. Oncol Nurs Forum. 2014;41(5):545–7. 10.1188/14.ONF.545-547 . Mays N, Pope C. Rigour and qualitative research. BMJ. 1995;311(6997):109–12. 10.1136/bmj.311.6997.109 . Alruwaili TA, Fooladi E, Crawford K. Women and husbands’ experiences and expectations of shared decision-making during pregnancy and childbirth in Saudi Arabia: A qualitative study. Midwifery. 2025;148:104533. 10.1016/J.MIDW.2025.104533 . Alsamman S, Tadesse RT, Sarferaz K, Mohamed AS, Mody SK. Barriers to postpartum health and opinions on a postpartum peer navigator program amongst refugee women resettled in California. BMC Pregnancy and Childbirth 2025 25:1 . 2025;25(1):372-. 10.1186/S12884-025-07479-2 Andrén A, Akselsson A, Rådestad I, et al. Miscommunication influences how women act when fetal movements decrease an interview study with Swedish Somali migrant women. Midwifery. 2023;126. 10.1016/j.midw.2023.103796 . Appiah-Kubi R, Kim YH, Attanasio LB. African Immigrant Women’s Experiences of Maternity Care in the United States. MCN Am J Matern Child Nurs. 2024;49(6):341–7. 10.1097/NMC.0000000000001043 . Ayers BL, Purvis RS, Bing WI, et al. Structural and Socio-cultural Barriers to Prenatal Care in a US Marshallese Community. Matern Child Health J. 2018;22(7):1067–76. 10.1007/s10995-018-2490-5 . Bains S, Skråning S, Sundby J, Vangen S, Sørbye IK, Lindskog BV. Challenges and barriers to optimal maternity care for recently migrated women - a mixed-method study in Norway. BMC Pregnancy Childbirth. 2021;21(1). 10.1186/s12884-021-04131-7 . Bawadi H, Al-Hamdan Z, Ahmad MM. Needs of Migrant Arab Muslim Childbearing Women in the United Kingdom. J Transcult Nurs. 2020;31(6):591–7. 10.1177/1043659620921219 . Belton S, Kruske S, Jackson Pulver L, et al. Rheumatic heart disease in pregnancy: How can health services adapt to the needs of Indigenous women? A qualitative study. Aust N Z J Obstet Gynaecol. 2018;58(4):425–31. 10.1111/ajo.12744 . Benzaken T, Siracusa F, D’souza M, et al. Supporting infants and parents in the perinatal period (SIPP): Co-creating an improved journey. Published online. 2025. 10.1371/journal.pone.0305786 . Biggs LJ, Yelland J, Due C, et al. Conversations about stillbirth prevention during pregnancy care from the perspectives of recent parents of refugee and migrant backgrounds, health professionals, and interpreters: A qualitative study. Women’s Health. 2025;21. 10.1177/17455057251365726 . Bitar D, Oscarsson M. Arabic-speaking women’s experiences of communication at antenatal care in Sweden using a tablet application—Part of development and feasibility study. Midwifery. 2020;84. 10.1016/j.midw.2020.102660 . Felek Boyvat S, Hinderstein S, Aragona E, Loyal J. Perspectives of Spanish-Speaking Families on RSV Immunoprophylaxis for Healthy Newborns. Journal of Immigrant and Minority Health 2025 27:6 . 2025;27(6):1009–1017. 10.1007/s10903-025-01742-6 Brown-Johnson CG, Kling SMR, Saliba-Gustafsson EA, et al. Hispanic Birthing Parents’ Experiences With Lactation Support Received In-Hospital: A Quality Improvement Needs Assessment. J Hum Lactation. 2025;41(2):207–19. 10.1177/08903344251321777 . Cai D, Villanueva P, Lu H, Zimmermann B, Horsch A. What matters to migrant women during labor and birth: Chinese mothers’ experiences in Switzerland. BMC Pregnancy Childbirth. 2024;24(1). 10.1186/s12884-024-06271-y . Cai D, Villanueva P, Stuijfzand S, Lu H, Zimmermann B, Horsch A. The pregnancy experiences and antenatal care services of Chinese migrants in Switzerland: a qualitative study. BMC Pregnancy Childbirth. 2022;22(1). 10.1186/s12884-022-04444-1 . Carlsson T, Marttala UM, Mattsson E, Ringnér A. Experiences and preferences of care among Swedish immigrants following a prenatal diagnosis of congenital heart defect in the fetus: A qualitative interview study. BMC Pregnancy Childbirth. 2016;16(1). 10.1186/s12884-016-0912-1 . Ceulemans M, Chaar R, Van Calsteren K, Allegaert K, Foulon V. Arabic-speaking pregnant women with a migration background: A vulnerable target group for prenatal counseling on medicines. Res Social Administrative Pharm. 2020;16(3):377–82. 10.1016/j.sapharm.2019.06.004 . Chu MS, Park M, Kim JA. First childbirth experience of international marriage migrant women in South Korea. Women Birth. 2017;30(4):e198–206. 10.1016/j.wombi.2017.01.001 . Claerbout A, Steppe J, Joni G, van kelst L. Challenges and facilitators to perinatal mental healthcare among first-generation migrant women: A qualitative ethnographic study in Flanders, Belgium. Eur J Midwifery. 2024;8(December):1–10. 10.18332/ejm/194682 . Claisse C, Durrant AC, Lie M. Understanding Antenatal Care Needs through Co-Creation with Roma Women to Inform the Design of mHealth Technologies. Conference on Human Factors in Computing Systems - Proceedings . Published online May 11, 2024. 10.1145/3613904.3642584 Darivemula SM, Massengale KEC, Montiel C, Stuebe AM, Tully KP. Postpartum menstrual equity: Video and audio analysis of vaginal bleeding counseling during postpartum inpatient care at a southeastern US tertiary hospital. Women’s Health. 2024;20. 10.1177/17455057241274897 . Doering RMKA, Patterson RMJB, Griffiths RMCB, Corresponding Author A. Experience of the New Zealand maternity care system by a group of Japanese women in one centre ABSTRACT. New Z Coll Midwives J. 2015;(51). Dube M, Ireland S, Bromley A, Steel M, Gao Y, Kildea S. It’s all about cultural understanding: A reflexive thematic analysis of women’s experiences at a dedicated refugee midwifery group practice service. Women Birth. 2024;37(2):410–8. 10.1016/j.wombi.2023.12.006 . Dullat JK, McDonnell T, Hendrick L, et al. Understanding a Minority Group’s (Roma) Experiences of Access and Quality in Maternity Services. Health Expect. 2025;28(4):e70389. 10. 1111/HEX.70389;WGROUP:STRING:PUBLICATION. Engelhardt M, Gaudion M, Mohr E et al. Exclusion and Othering in maternity care for forced migrant women: a qualitative study with forced migrant mothers and health care professionals in Germany. Published online 2025. 10.1016/j.ssmqr.2025.100614 Evans M, Plows J, McCarthy R, McConville B, Haith-Cooper M. What refugee women want from maternity care: a qualitative study. Br J Midwifery. 2022;30. Furness A, Salmon A, Fair F, Soltani H. Exploring research and healthcare priorities in maternal health: A qualitative ethnographic study with mothers from ethnic minority backgrounds in the UK. Eur J Midwifery. 2025;9(September):1–9. 10.18332/ejm/209195 . Fair F, Furness A, Higginbottom G, Oddie S, Soltani H. Parent’s experiences of the impact of ethnicity and skin pigmentation on perinatal care. Ethn Health. 2025;30(5):581–601. 10.1080/13557858.2025.2488893 . Filby A, Robertson W, Afonso E. A service evaluation of a specialist migrant maternity service from the user’s perspective. Br J Midwifery. 2020;(9). Fitzgerald EM, Cronin SN, Boccella SH. Anguish, Yearning, and Identity: Toward a Better Understanding of the Pregnant Hispanic Woman’s Prenatal Care Experience. J Transcult Nurs. 2016;27(5):464–70. 10.1177/1043659615578718 . Gallimore A, Irshad T, Cooper M, Cameron S. Influence of culture, religion and experience on the decision of Pakistani women in Lothian, Scotland to use postnatal contraception: a qualitative study. BMJ Sex Reprod Health. 2020;47(1):43–8. 10.1136/bmjsrh-2019-200497 . Garnweidner-Holme LM, Lukasse M, Solheim M, Henriksen L. Talking about intimate partner violence in multi-cultural antenatal care: A qualitative study of pregnant women’s advice for better communication in South-East Norway. BMC Pregnancy Childbirth. 2017;17(1). 10.1186/s12884-017-1308-6 . Gewalt SC, Berger S, Ziegler S, Szecsenyi J, Bozorgmehr K. Psychosocial health of asylum seeking women living in state-provided accommodation in Germany during pregnancy and early motherhood: A case study exploring the role of social determinants of health. PLoS ONE. 2018;13(12). 10.1371/journal.pone.0208007 . Gardner A, Oduola S, Teague B. Culturally Sensitive Perinatal Mental Health Care: Experiences of Women From Minority Ethnic Groups. Health Expect. 2024;27(4). 10.1111/HEX.14160 . Guo Y, Hildebrand J, Rousseau J, Brown B, Pimentel P, Olshansky E. Underserved pregnant and postpartum women’s access and use of their health records. MCN Am J Maternal/Child Nurs. 2018;43(3):164–70. 10.1097/NMC.0000000000000432 . Hatherall B, Morris J, Jamal F, et al. Timing of the initiation of antenatal care: An exploratory qualitative study of women and service providers in East London. Midwifery. 2016;36:1–7. 10.1016/j.midw.2016.02.017 . Jose Henrique A, Rodney P, Hall W, Thorne S, Joolaee S. Women’s autonomy for managing labour pain in a relational context: An interpretive description study. J Clin Nurs. 2023;32(19–20):7390–401. 10.1111/jocn.16780 . Henry J, Beruf C, Fischer T. Access to Health Care for Pregnant Arabic-Speaking Refugee Women and Mothers in Germany. Qual Health Res. 2020;30(3):437–47. 10.1177/1049732319873620 . Higginbottom GMA, Safipour J, Yohani S, O’Brien B, Mumtaz Z, Paton P. An ethnographic study of communication challenges in maternity care for immigrant women in rural Alberta. Midwifery. 2015;31(2):297–304. 10.1016/j.midw.2014.09.009 . Origlia Ikhilor P, Hasenberg G, Kurth E, Asefaw F, Pehlke-Milde J, Cignacco E. Communication barriers in maternity care of allophone migrants: Experiences of women, healthcare professionals, and intercultural interpreters. J Adv Nurs. 2019;75(10):2200–10. 10.1111/JAN.14093 . Iturralde E, Hsiao CA, Nkemere L, et al. Engagement in perinatal depression treatment: a qualitative study of barriers across and within racial/ethnic groups. BMC Pregnancy Childbirth. 2021;21(1). 10.1186/s12884-021-03969-1 . Johansson M, Kaminsky E, Ström I, Volgsten H. Migrant women with cultural doula support during pregnancy and after childbirth as a complement to midwifery care in Sweden – An interview study. Midwifery. 2025;146:104420. 10.1016/J.MIDW.2025.104420 . Johnsen H, Christensen U, Juhl M, Villadsen SF. Organisational barriers to implementing the MAMAACT intervention to improve maternity care for non-Western immigrant women: A qualitative evaluation. Int J Nurs Stud. 2020;111. 10.1016/j.ijnurstu.2020.103742 . John JR, Curry G, Cunningham-Burley S. Exploring ethnic minority women’s experiences of maternity care during the SARS-CoV-2 pandemic: A qualitative study. BMJ Open. 2021;11(9). 10.1136/bmjopen-2021-050666 . Kirkendall A, Dutt A. Refugee women’s pregnancy and childbirth experiences in the US: Examining context through a reproductive justice framework. Fem Psychol. 2023;33(4):529–49. 10.1177/09593535221149166 . Konje JK, Konje JC. Experiences of accessing maternity care in the UK: Perspectives from Somali migrant women in Leicester. Eur J Midwifery. 2021;5:1–10. 10.18332/EJM/143167 . Li L. The vicious circle: how systemic barriers perpetuate maternity interpreting service inadequacies for migrant women in the UK. Front Glob Womens Health. 2025;6:1638434. 10.3389/fgwh.2025.1638434 . Utne R, Antrobus-Johannessen CL, Aasheim V, Aaseskjær K, Vik ES. Somali women’s experiences of antenatal care: A qualitative interview study. Midwifery. 2020;83. 10.1016/j.midw.2020.102656 . Lindsay AC, De Oliveira MG, Wallington SF, et al. Access and utilization of healthcare services in Massachusetts, United States: A qualitative study of the perspectives and experiences of Brazilian-born immigrant women. BMC Health Serv Res. 2016;16(1). 10.1186/s12913-016-1723-9 . Liu R, Chao MT, Jostad-Laswell A, Duncan LG. Does CenteringPregnancy Group Prenatal Care Affect the Birth Experience of Underserved Women? A Mixed Methods Analysis. J Immigr Minor Health. 2017;19(2):415–22. 10.1007/s10903-016-0371-9 . Lukasse M, Akhmedova F, Oommen H. Ukrainian refugee women’s experience with maternity care in Norway: A qualitative study. Eur J Midwifery. 2025;9(February):1–8. 10.18332/ejm/200613 . Malmström N, Lydell M, Carlsson IM. Womanhood, a shared experience of participating in a lifestyle intervention with a focus on integration and physical activity to promote health among pregnant women: perspectives from pregnant women, midwives, and cultural interpreter doulas. Int J Qual Stud Health Well-being. 2022;17(1). 10.1080/17482631.2022.2043527 . McClellan C, Madler B. Lived Experiences of Mongolian Immigrant Women Seeking Perinatal Care in the United States. J Transcult Nurs. 2022;33(5):594–602. 10.1177/10436596221091689 . McEvoy B, Watson K, Farrant K, Stacey TT, Heazell AEP, Haith-Cooper M. Evaluation of a co-designed digital animation in service improvement (DAISI) sharing messages around modifiable behaviours to reduce the risk of stillbirth. Midwifery. 2025;148(8):104517. 10.1016/j.midw.2025.104517 . Nagesh N, Hoi C, Ip L et al. South Asian women’s views on and experiences of maternity care services in Hong Kong: A qualitative study. Published online 2024. 10.1016/j.wombi.2024.101806 Niner S, Kokanovic R, Cuthbert D. Displaced Mothers: Birth and Resettlement, Gratitude and Complaint. Med Anthropology: Cross Cult Stud Health Illn. 2013;32(6):535–51. 10.1080/01459740.2013.769103 . Nithianandan N, Gibson-Helm M, McBride J, et al. Factors affecting implementation of perinatal mental health screening in women of refugee background. Implement Sci. 2016;11(1). 10.1186/s13012-016-0515-2 . Pope C. The comparison of shared decision making in monolingual and bilingual health encounters. Commun Med. 2018;2(5):206–21. Pullon S, Pullon MPHCS, Gray FRNZCGPB, Steinmetz Midwifery MB. Molineux MBChB C. VOLUME 6 • NUMBER 4 • DECEMBER . Vol 319. 2014. Rambaldini-Gooding D, Olcoń K. Molloy | Luke. et al Health Expect Published online. 2024. 10.1111/hex.70106 . Rayment-Jones H, Harris J, Harden A, Silverio SA, Turienzo CF, Sandall J. Project20: interpreter services for pregnant women with social risk factors in England: what works, for whom, in what circumstances, and how? Int J Equity Health. 2021;20(1). 10.1186/s12939-021-01570-8 . Reid CN, Fryer K, Cabral N, Marshall J. Health care system barriers and facilitators to early prenatal care among diverse women in Florida. Birth. 2021;48(3):416–27. 10.1111/birt.12551 . Toke S, Correa-Velez I, Riggs E. Exploring Trauma- and Violence-Informed Pregnancy Care for Karen Women of Refugee Background: A Community-Based Participatory Study. Int J Environ Res Public Health. 2024;21(3). 10.3390/ijerph21030254 . Riggs E, Muyeen S, Brown S, et al. Cultural safety and belonging for refugee background women attending group pregnancy care: An Australian qualitative study. Birth. 2017;44(2):145–52. 10.1111/birt.12272 . Rowe A, Bhardwaj M, McCauley M. Maternal multimorbidity - experiences of women seeking asylum during pregnancy and after childbirth: a qualitative study. BMC Pregnancy Childbirth. 2023;23(1). 10.1186/s12884-023-06054-x . Sami J, Lötscher KCQ, Eperon I, et al. Giving birth in Switzerland: A qualitative study exploring migrant women’s experiences during pregnancy and childbirth in Geneva and Zurich using focus groups. Reprod Health. 2019;16(1). 10.1186/s12978-019-0771-0 . Smith DC, Thumm EB, Tien NC, Kissler K. Respectful maternity care experiences of South Asian refugees in the US: a qualitative study. Front Public Health. 2025;13:1613249. 10.3389/fpubh.2025.1613249 . Söderström E, Alexandrou C, Bressanutti S, Sandborg J, Lindqvist AK, Löf M. Adapting a pregnancy app (HealthyMoms) to support healthy habits in migrant women—a qualitative study on women’s preferences and perceived needs to support health behaviors during pregnancy. Digit Health. 2024;10. 10.1177/20552076241304045 . Stapleton H, Murphy R, Correa-Velez I, Steel M, Kildea S. Women from refugee backgrounds and their experiences of attending a specialist antenatal clinic. Narratives from an Australian setting. Women Birth. 2013;26:260–6. Ternström E, Small R, Lindgren H. Migrant women’s experiences of an individual language-assisted information and support visit to the labor ward before giving birth – A qualitative study from Sweden. Sex Reproductive Healthc. 2023;38. 10.1016/j.srhc.2023.100915 . Tobin C, Murphy-Lawless J, Beck CT. Childbirth in exile: Asylum seeking women’s experience of childbirth in Ireland. Midwifery. 2014;30(7):831–8. 10.1016/j.midw.2013.07.012 . Topa JB, Nogueira CO, Neves SA. Maternal health services: an equal or framed territory? Int J Hum Rights Healthc. 2017;10(2):110–22. 10.1108/IJHRH-11-2015-0039 . Vazquez Corona M, Hazfiarini A, Cao J, et al. Migrant Mums and Maternity Care: A Qualitative Participatory Health Research Study. BJOG. 2025;132(13):2121–30. 10.1111/1471-0528.18249 . Velemínský M, Průchová D, Vránová V, et al. Medical and salutogenic approaches and their integration in taking prenatal and postnatal care of immigrants. Neuroendocrinol Lett. 2014;35:67–79. www.nel.edu. Viken B, Lyberg A, Severinsson E. Maternal Health Coping Strategies of Migrant Women in Norway. Nurs Res Pract. 2015;2015:1–11. 10.1155/2015/878040 . Vik ES, Hashi RMA, Hamud ME, Aasheim V, Kringeland T, Aasekjær K. Migrant Somali women’s experiences with their first contact with the labor ward prior to admission: A qualitative study. Eur J Midwifery. 2022;6(July). 10.18332/EJM/150584 . Wan CS, Nankervis A, Teede H, Aroni R. Priorities to improve woman-centred gestational diabetes mellitus care: A qualitative study to compare views between clinical and consumer end-users. J Hum Nutr Dietetics. 2023;36(5):1636–48. 10.1111/jhn.13191 . Wikberg A, Eriksson K, Bondas T. Immigrant New Mothers in Finnish Maternity Care: An Ethnographic Study of Caring. Int J Childbirth. 2014;4(2):86–102. 10.1891/2156-5287.4.2.86 . Willey SM, Blackmore RP, Gibson-Helm ME, et al. If you don’t ask … you don’t tell:Refugee women’s perspectives on perinatal mental health screening. Women and Birth . 2020;33(5):e429-e437. doi:10.1016/j.wombi.2019.10.003. Wiseman O, McCourt C, Mehay A, et al. Involving women with limited English proficiency in group antenatal care: Findings from the integrated process evaluation of the Pregnancy Circles pilot trial. Midwifery. 2024;139:104197. 10.1016/J.MIDW.2024.104197 . Worabo HJ, Safi F, Gill SL, Farokhi M. It’s different here Afghan refugee maternal health experiences in the United States. BMC Pregnancy Childbirth. 2024;24(1). 10.1186/s12884-024-06678-7 . Higginbottom GM, Safipour J, Yohani S, et al. An ethnographic investigation of the maternity healthcare experience of immigrants in rural and urban Alberta, Canada. BMC Pregnancy Childbirth. 2016;16(1). 10.1186/s12884-015-0773-z . Guðmundsdóttir EÝ, Nieuwenhuijze M, Rúdólfsdóttir AG, Gottfreðsdóttir H. Fostering empowerment through communication: The needs, expectations, and experience of maternity care among polish migrant women in Iceland. Sex Reproductive Healthc. 2025;44(4):101087. 10.1016/j.srhc.2025.101087 . Pařízková A, Glajchová A. Trust in maternity care: challenges for healthcare professionals and migrant women. http://kont.zsf.jcu.cz/doi/1032725/kont2024027.html . 2024;26(2):126–132. 10.32725/kont.2024.027 Yelland J, Riggs E, Szwarc J, et al. Compromised communication: A qualitative study exploring Afghan families and health professionals’ experience of interpreting support in Australian maternity care. BMJ Qual Saf. 2016;25(4):e1. 10.1136/bmjqs-2014-003837 . Owens C, Dandy J, Hancock P. Perceptions of pregnancy experiences when using a community-based antenatal service: A qualitative study of refugee and migrant women in Perth, Western Australia. Women Birth. 2016;29(2):128–37. 10.1016/j.wombi.2015.09.003 . Li L. The vicious circle: how systemic barriers perpetuate maternity interpreting service inadequacies for migrant women in the UK. Front Glob Womens Health. 2025;6:1638434. 10.3389/FGWH.2025.1638434/BIBTEX . Origlia Ikhilor P, Hasenberg G, Kurth E, Asefaw F, Pehlke-Milde J, Cignacco E. Communication barriers in maternity care of allophone migrants: Experiences of women, healthcare professionals, and intercultural interpreters. J Adv Nurs. 2019;75(10):2200–10. 10.1111/jan.14093 . Alruwaili TA, Fooladi E, Crawford K. Women and husbands’ experiences and expectations of shared decision-making during pregnancy and childbirth in Saudi Arabia: A qualitative study. Midwifery. 2025;148(7):104533. 10.1016/j.midw.2025.104533 . Gardner A, Oduola S, Teague B. Culturally Sensitive Perinatal Mental Health Care: Experiences of Women From Minority Ethnic Groups. Health Expect. 2024;27(4):e14160. 10.1111. /HEX.14160;SUBPAGE:STRING:FULL. Alsamman S, Tadesse RT, Sarferaz K, Mohamed AS, Mody SK. Barriers to postpartum health and opinions on a postpartum peer navigator program amongst refugee women resettled in California. BMC Pregnancy and Childbirth 2025 25:1 . 2025;25(1):372-. 10.1186/s12884-025-07479-2 Guðmundsdóttir EÝ, Nieuwenhuijze M, Rúdólfsdóttir AG, Gottfreðsdóttir H. Fostering empowerment through communication: The needs, expectations, and experience of maternity care among polish migrant women in Iceland. Sex Reproductive Healthc. 2025;44:101087. 10.1016/J.SRHC.2025.101087 . Granada S, Quinteros Baumgart C, Rupley D. Birthing Experiences of Spanish Speakers During the COVID-19 Pandemic in NYC. J Immigr Minor Health. 2022;24(4):1013–9. 10.1007/s10903-022-01331-x . Wainwright M. The Epistemonikos Foundation MWC and the NI of PH for the GCerqPG. Interactive Summary of Qualitative Findings. Norwegian Institute of Public Health . Preprint posted online March 9, 2026:1.0. Accessed March 9, 2026. https://isoq.epistemonikos.org/#/ Sami J, Quack Lötscher KC, Eperon I, et al. Giving birth in Switzerland: a qualitative study exploring migrant women’s experiences during pregnancy and childbirth in Geneva and Zurich using focus groups. Reprod Health. 2019;16(1):112. 10.1186/s12978-019-0771-0 . Reid CN, Fryer K, Cabral N, Marshall J. Health care system barriers and facilitators to early prenatal care among diverse women in Florida. Birth. 2021;48(3):416–27. https://doi.org/10.1111/birt.12551 . Cai D, Villanueva P, Stuijfzand S, Lu H, Zimmermann B, Horsch A. The pregnancy experiences and antenatal care services of Chinese migrants in Switzerland: a qualitative study. BMC Pregnancy Childbirth. 2022;22(1):148. 10.1186/s12884-022-04444-1 . Utne R, Antrobus-Johannessen CL, Aasheim V, Aasekjær K, Vik ES. Somali women’s experiences of antenatal care: A qualitative interview study. Midwifery. 2020;83:102656. https://doi.org/10.1016/j.midw.2020.102656 . Crowther S, Lau A. Migrant Polish women overcoming communication challenges in Scottish maternity services: A qualitative descriptive study. Midwifery. 2019;72:30–8. https://doi.org/10.1016/j.midw.2019.02.004 . FIGO. Ethical Framework for Respectful Maternity Care During Pregnancy and Childbirth | Figo. 2025. Accessed October 7, 2025. https://www.figo.org/resources/figo-statements/ethical-framework-respectful-maternity-care-during-pregnancy-and-childbirth Cantor AG, Jungbauer RM, Skelly AC, et al. Respectful Maternity Care A Systematic Review. Ann Intern Med. 2024;177(1):50–64. 10.7326/M23-2676 . Goal 10: Reduce inequality within and among countries - United Nations Sustainable Development. Accessed May 7. 2026. https://www.un.org/sustainabledevelopment/inequality/ Haith-Cooper M, Bradshaw G. Meeting the health and social care needs of pregnant asylum seekers. Nurse Educ Today. 2013;33(9):1045–50. 10.1016/j.nedt.2012.04.016 . Arya AN, Hyman I, Holland T, et al. Medical Interpreting Services for Refugees in Canada: Current State of Practice and Considerations in Promoting this Essential Human Right for All. Int J Environ Res Public Health. 2024;21(5). 10.3390/IJERPH21050588 . Bridle L, Bassett S, Silverio SA. We couldn’t talk to her: a qualitative exploration of the experiences of UK midwives when navigating women’s care without language. Int J Hum Rights Healthc. 2021;14(4):359–73. 10.1108/IJHRH-10-2020-0089 . Flores G, Abreu M, Barone CP, Bachur R, Lin H. Errors of medical interpretation and their potential clinical consequences: A comparison of professional versus ad hoc versus no interpreters. Ann Emerg Med. 2012;60(5):545–53. 10.1016/j.annemergmed.2012.01.025 . Samkange-Zeeb F, Samerski S, Doos L, Humphris R, Padilla B, Bradby H. It’s the First Barrier – Lack of Common Language a Major Obstacle When Accessing/Providing Healthcare Services Across Europe. Front Sociol. 2020;5:557563. 10.3389/FSOC.2020.557563/BIBTEX . Hayes I, Enohumah K, McCaul C. Care of the migrant obstetric population. Int J Obstet Anesth. 2011;20(4):321–9. 10.1016/j.ijoa.2011.06.008 . El Arab RA, Urbanavice R, Jakavonyte-Akstiniene A, et al. We want our freedom back, that’s our only need: a qualitative study of health and social needs among asylum seekers and undocumented migrants crossing the borders from Belarus to Lithuania. Front Public Health. 2024;12. 10.3389/fpubh.2024.1371119 . Pérez-Sánchez M, Immordino P, Romano G, Giordano A, García-Gil C, Morales F. Access of migrant women to sexual and reproductive health services: A systematic review. Midwifery. 2024;139. 10.1016/j.midw.2024.104167 . Dixon-Woods M, Cavers D, Agarwal S, et al. Conducting a critical interpretive synthesis of the literature on access to healthcare by vulnerable groups. BMC Med Res Methodol. 2006;6. 10.1186/1471-2288-6-35 . Bowleg L. The problem with the phrase women and minorities: Intersectionality-an important theoretical framework for public health. Am J Public Health. 2012;102(7):1267–73. 10.2105/AJPH.2012.300750 . MacLellan J, Collins S, Myatt M, Pope C, Knighton W, Rai T, Black. Asian and minority ethnic women’s experiences of maternity services in the UK: A qualitative evidence synthesis. J Adv Nurs. 2022;78(7):2175–90. 10.1111/JAN.15233 . Silverio SA, Varman N, Barry Z, et al. Inside the ‘imperfect mosaic’: Minority ethnic women’s qualitative experiences of race and ethnicity during pregnancy, childbirth, and maternity care in the United Kingdom. BMC Public Health. 2023;23(1). 10.1186/s12889-023-17505-7 . Mangrio E, Sjögren Forss K. Refugees’ experiences of healthcare in the host country: a scoping review. BMC Health Serv Res. 2017;17(1):814. 10.1186/S12913-017-2731-0/TABLES/2 . Floyd A, Sakellariou D. Healthcare access for refugee women with limited literacy: Layers of disadvantage. Int J Equity Health. 2017;16(1):1–10. 10.1186/S12939-017-0694-8/TABLES/1 . Mukhopadhyay S, Mahmood T. Healthcare inequalities in antenatal care in the European Region: EBCOG Scientific review. Eur J Obstet Gynecol Reproductive Biology. 2022;272:55–7. 10.1016/j.ejogrb.2022.03.010 . Binder P, Borné Y, Johnsdotter S, Essén B. Shared language is essential: communication in a multiethnic obstetric care setting. J Health Commun. 2012;17(10):1171–86. 10.1080/10810730.2012.665421 . Decision making and consent Professional standards Decision making and consent Professional standards: More detailed guidance. Accessed October 8. 2025. Lee JS, Pérez-Stable EJ, Gregorich SE, et al. Increased Access to Professional Interpreters in the Hospital Improves Informed Consent for Patients with Limited English Proficiency. J Gen Intern Med. 2017;32(8):863–70. 10.1007/s11606-017-3983-4 . Patterson J, Susam-Saraeva Ş. Translating informed consent in Scottish maternity services: perspectives from providers and researchers of both maternity care and translation/interpreting services. Lang Health. 2024;2(2):100023. 10.1016/J.LAHEAL.2024.06.001 . Morrice L, Tip LK, Collyer M, Brown R. You can’t have a good integration when you don’t have a good communication’: English language learning among resettled refugees in the UK. J Refug Stud. 2021;34(1):681–99. 10.1093/JRS/FEZ023 . Schouten BC, Meeuwesen L. Cultural differences in medical communication: A review of the literature. Patient Educ Couns. 2006;64(1–3):21–34. 10.1016/j.pec.2005.11.014 . Yau SY, Zheng T. Socio-ecological Lens Towards Health Behaviours. Published online 2026:1–35. 10.1007/978-981-97-1788-0_22-1 Kilanowski JF. Breadth of the Socio-Ecological Model. J Agromedicine. 2017;22(4):295–7. 10.1080/1059924X.2017.1358971 . Taylor J, Novoa C, Hamm K, Phadke S. Eliminating Racial Disparities in Maternal and Infant Mortality A Comprehensive Policy Blueprint . 2019. Chalmers I. Trying to do more good than harm in policy and practice: the role of rigorous, transparent and up-to-date evaluations. Ann Am Acad Pol Soc Sci. 2003;589:22–40. 10.1177/0002716203254762 . Ferrie JE. Evidence and policy: Mind the gap. Int J Epidemiol. 2015;44(1):1–7. 10.1093/IJE/DYV002 . Stevenson K, Edwards S, Ogunlana K, et al. Public health, policy, and clinical interventions to improve perinatal care for migrant women and infants in high-income countries: a systematic review. EClinicalMedicine. 2024;78:102938. 10.1016/j.eclinm.2024.102938 . Barnish MS, Tan SY, Robinson S, Taeihagh A, Melendez-Torres GJ. A realist synthesis to develop an explanatory model of how policy instruments impact child and maternal health outcomes. Soc Sci Med. 2023;339:116402. 10.1016/J.SOCSCIMED.2023.116402 . Hamwi S, Lorthe E, Severo M, Barros H. Migrant and native women’s perceptions of prenatal care communication quality: the role of host-country language proficiency. BMC Public Health. 2023;23(1):1–12. 10.1186/S12889-023-15154-4/TABLES/2 . Schinkel S, Schouten BC, Kerpiclik F, Van Den Putte B, Van Weert JCM. Perceptions of Barriers to Patient Participation: Are They Due to Language, Culture, or Discrimination? Health Commun. 2019;34(12):1469–81. 10.1080/10410236.2018.1500431 . Shim JK. Cultural health capital: A theoretical approach to understanding health care interactions and the dynamics of unequal treatment. J Health Soc Behav. 2010;51(1):1–15. 10.1177/0022146509361185 . Williams DR, Rucker TD. Understanding and Addressing Racial Disparities in Health Care. Health Care Financ Rev. 2000;21(4):75–91. Drewniak D, Krones T, Wild V. Do attitudes and behavior of health care professionals exacerbate health care disparities among immigrant and ethnic minority groups? An integrative literature review. Int J Nurs Stud. 2017;70:89–98. 10.1016/j.ijnurstu.2017.02.015 . Rogers W, Ballantyne A. Gender and Trust in Medicine: Vulnerabilities, Abuses, and Remedies . Vol 1. Spring; 2008. Dixon-Woods M, Cavers D, Agarwal S, et al. Conducting a critical interpretative synthesis of the literature on access to healthcare by vulnerable groups. BMC Med Res Methodol. 2006;6:35. 10.1186/1471-2288-6-35 . Perriman N, Davis DL, Ferguson S. What women value in the midwifery continuity of care model: A systematic review with meta-synthesis. Midwifery. 2018;62:220–9. 10.1016/J.MIDW.2018.04.011 . Sandall J, Soltani H, Gates S, Shennan A, Devane D. Midwife-led continuity models versus other models of care for childbearing women. Cochrane Database Syst Reviews. 2016;2016(4). 10.1002/14651858.CD004667.PUB5 . Hsu C, Liss DT, Frosch DL, Westbrook EO, Arterburn D. Exploring provider reactions to decision aid distribution and shared decision making: Lessons from two specialties. Med Decis Making. 2017;37(1):113–26. 10.1177/0272989X16671933 . Joosten EAG, DeFuentes-Merillas L, De Weert GH, Sensky T, Van Der Staak CPF, De Jong CAJ. Systematic review of the effects of shared decision-making on patient satisfaction, treatment adherence and health status. Psychother Psychosom. 2008;77(4):219–26. 10.1159/000126073 . Flanagan SM, Hancock B. Reaching the hard to reach - lessons learned from the VCS (voluntary and community Sector). A qualitative study. BMC Health Serv Res. 2010;10:92. 10.1186/1472-6963-10-92 . Sobande F. Lecture on Racism Institutional Racism & Workplace Cultures: Addressing Intersecting Oppression and Demystifying Data . 2020. Adegoke TM, Pinder LF, Ndiwane N, Parker SE, Vragovic O, Yarrington CD. Inequities in Adverse Maternal and Perinatal Outcomes: The Effect of Maternal Race and Nativity. Matern Child Health J. 2022;26(4):823–33. 10.1007/s10995-021-03225-0 . Interpretation and Translation Services Framework Agreement | SBS10519. Accessed April 2. 2026. https://www.sbs.nhs.uk/services/framework-agreements/interpretation-and-translation-services/ Boakye PN, Prendergast N. There is nothing to protect us from dying: Black women’s perceived sense of safety accessing pregnancy and intrapartum care. Nurs Inq. 2024;31(3). 10.1111/NIN.12638 . Behruzi R. Understanding childbirth practices as an organizational cultural phenomenon: a conceptual framework. BMC Pregnancy Childbirth. 2013;13(205):1–10. Thomas PE, Beckmann M, Gibbons K. The effect of cultural and linguistic diversity on pregnancy outcome. Aust N Z J Obstet Gynaecol. 2010;50(5):419–22. 10.1111/J.1479-828X.2010.01210.X . Team V, Vasey K, Manderson L. CULTURAL DIMENSIONS OF PREGNANCY, BIRTH AND POST-NATAL CARE . 2009. MacLellan J, McNiven A, Kenyon S. Provision of interpreting support for cross-cultural communication in UK maternity services: A Freedom of Information request. Int J Nurs Stud Adv. 2024;6:100162. 10.1016/J.IJNSA.2023.100162 . Hwang SS, Rybin DV, Kerr SM, Heeren TC, Colson ER, Corwin MJ. Predictors of Maternal Trust in Doctors About Advice on Infant Care Practices: The SAFE Study. Acad Pediatr. 2017;17(7):762–9. 10.1016/j.acap.2017.03.005 . Tamene M, MicelandcKenzie-Sampson S, Ahern J, Bradshaw PT, Carmichael SL, Mujahid MS. Structural racism and perinatal mental health – The role of racialized economic segregation. Soc Sci Med. 2025;381:118296. 10.1016/J.SOCSCIMED.2025.118296 . Sadler M, Santos MJ, Ruiz-Berdún D, et al. Moving beyond disrespect and abuse: addressing the structural dimensions of obstetric violence. Reprod Health Matters. 2016;24(47):47–55. 10.1016/j.rhm.2016.04.002 . Jolly Y, Aminu M, Mgawadere F, Van Den Broek. N. we are the ones who should make the decision - Knowledge and understanding of the rights-based approach to maternity care among women and healthcare providers. BMC Pregnancy Childbirth. 2019;19(1). 10.1186/s12884-019-2189-7 . Tong A, Flemming K, McInnes E, Oliver S, Craig J. Enhancing transparency in reporting the synthesis of qualitative research: ENTREQ. BMC Med Res Methodol. 2012;12(1):1–8. 10.1186/1471-2288-12-181/TABLES . Additional Declarations No competing interests reported. Supplementary Files AdditionalFilesSupplementaryInformation.docx Cite Share Download PDF Status: Under Review Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. 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-9645588","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Systematic Review","associatedPublications":[],"authors":[{"id":636955396,"identity":"b06dc0bb-dca3-4680-ae89-6f6a4cf5bda6","order_by":0,"name":"Eleanor Molloy","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA1klEQVRIiWNgGAWjYLCCBwUMDPwSPDAuGxFaEgwYGCRnkKzF4AaxWvgZuBMfJBjYJG6+3Xvw0w0GO3kGibQEvFokG3g3GyQYpCVuu3MuWTqHIdmwQSLtAF4tBgd4t0kkGBxO3HYjxwCohTmBQSK9Aa8We5iWzTNyjH/nMNQT1mLAANWyQSLHDGjLYaAWAg6TOAzxi/GMO2fMrHMMjhu28TxLwKuFv71344MPFTay/bN7jG/nVFTL87OnGeDVwsAMoRwboO4kKiLBwJ5YhaNgFIyCUTACAQD5uUB54EnQJwAAAABJRU5ErkJggg==","orcid":"","institution":"University of Birmingham","correspondingAuthor":true,"prefix":"","firstName":"Eleanor","middleName":"","lastName":"Molloy","suffix":""},{"id":636955397,"identity":"146a02f0-68cd-48ed-9988-3c54eaddda4e","order_by":1,"name":"Sophie-Anna Dann","email":"","orcid":"","institution":"University of Birmingham","correspondingAuthor":false,"prefix":"","firstName":"Sophie-Anna","middleName":"","lastName":"Dann","suffix":""},{"id":636955398,"identity":"47ebc601-a47f-49c8-9c0a-e133db7caf93","order_by":2,"name":"Fiona Cross-Sudworth","email":"","orcid":"","institution":"University of Warwick","correspondingAuthor":false,"prefix":"","firstName":"Fiona","middleName":"","lastName":"Cross-Sudworth","suffix":""},{"id":636955399,"identity":"dc5cf8c9-bcc8-4998-922a-b53763c20c23","order_by":3,"name":"Amy Delicate","email":"","orcid":"","institution":"University of Birmingham","correspondingAuthor":false,"prefix":"","firstName":"Amy","middleName":"","lastName":"Delicate","suffix":""},{"id":636955400,"identity":"ffc2e3bc-9da6-4711-bdac-fe0ebaa1348e","order_by":4,"name":"Agiya Tadros","email":"","orcid":"","institution":"Sandwell \u0026 West Birmingham Hospitals NHS Trust","correspondingAuthor":false,"prefix":"","firstName":"Agiya","middleName":"","lastName":"Tadros","suffix":""},{"id":636955401,"identity":"1a5cd7a6-e035-40f4-b12b-a40c53055f4b","order_by":5,"name":"Sarah Bicknell","email":"","orcid":"","institution":"University of Birmingham","correspondingAuthor":false,"prefix":"","firstName":"Sarah","middleName":"","lastName":"Bicknell","suffix":""},{"id":636955402,"identity":"6716427a-e448-4b42-a248-9bd6d0906204","order_by":6,"name":"Victoria Hodgetts-Morton","email":"","orcid":"","institution":"University of Birmingham","correspondingAuthor":false,"prefix":"","firstName":"Victoria","middleName":"","lastName":"Hodgetts-Morton","suffix":""},{"id":636955403,"identity":"3bf3d0f6-28db-4522-8e4e-60e7182c0989","order_by":7,"name":"Sara Kenyon","email":"","orcid":"","institution":"University of Birmingham","correspondingAuthor":false,"prefix":"","firstName":"Sara","middleName":"","lastName":"Kenyon","suffix":""},{"id":636955404,"identity":"832a080f-ba13-4637-9160-06eaf121cc69","order_by":8,"name":"Laura Jones","email":"","orcid":"","institution":"University of Birmingham","correspondingAuthor":false,"prefix":"","firstName":"Laura","middleName":"","lastName":"Jones","suffix":""}],"badges":[],"createdAt":"2026-05-07 17:24:17","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-9645588/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9645588/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":109452433,"identity":"71cdbfa1-063f-45ef-8681-7fe8958e0b7f","added_by":"auto","created_at":"2026-05-18 09:14:00","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":44293,"visible":true,"origin":"","legend":"\u003cp\u003ePRISMA\u003csup\u003e48\u003c/sup\u003e diagram of study screening for inclusion\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-9645588/v1/5e9085a39cf0e115fab9996c.png"},{"id":109759835,"identity":"c3fadf09-f322-46bc-88b1-29a76789da4b","added_by":"auto","created_at":"2026-05-22 07:27:49","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":50721,"visible":true,"origin":"","legend":"\u003cp\u003eGeographic representation of countries the studies were conducted in.\u003c/p\u003e","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-9645588/v1/ddd8d69ad159ecaa4eb68159.png"},{"id":109452436,"identity":"536ed662-7b94-4182-bc9a-dd8d402bedba","added_by":"auto","created_at":"2026-05-18 09:14:00","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":215529,"visible":true,"origin":"","legend":"\u003cp\u003eConceptual Model\u003c/p\u003e","description":"","filename":"floatimage3.png","url":"https://assets-eu.researchsquare.com/files/rs-9645588/v1/7499ea068afea5ef6960518e.png"},{"id":109906380,"identity":"ce0e9a3e-ae28-4e3e-851e-4fb4e89704a4","added_by":"auto","created_at":"2026-05-25 06:40:04","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1074242,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9645588/v1/f899c6c7-c563-42de-8282-36fecc7f3ad2.pdf"},{"id":109759683,"identity":"d61e24db-0666-4eb9-ae77-7628f45b26a2","added_by":"auto","created_at":"2026-05-22 07:27:32","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":132315,"visible":true,"origin":"","legend":"","description":"","filename":"AdditionalFilesSupplementaryInformation.docx","url":"https://assets-eu.researchsquare.com/files/rs-9645588/v1/a4ba35e7fc0351c02415ee7f.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Exploring Women’s Views and Experiences of Language Barriers in High Income Maternity Care Settings: A Qualitative Systematic Review and Thematic Synthesis","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eLanguage and communication barriers within healthcare interactions are increasing, reflecting substantial growth in global migration, which doubled between 1990 and 2020\u003csup\u003e1\u003c/sup\u003e, and contributing to an era of superdiversity\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e. Speaking a different language to your country of residence\u0026rsquo;s first language does not always equate to needing additional communication support. For example, in the United States (US), over a fifth (22%) of the population does not identify English as their first language; with Spanish and Chinese being the most commonly spoken languages at home, and 61%, and 48% respectively, reporting speaking English well.\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e However, differences in language proficiency between patients and healthcare providers (HCP) are associated with reduced access to and engagement with healthcare services,\u003csup\u003e3\u003c/sup\u003e increased adverse events,\u003csup\u003e4\u0026ndash;6\u003c/sup\u003e experiences of discrimination,\u003csup\u003e7\u003c/sup\u003e and greater frustration and dissatisfaction among both groups.\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eGlobally in maternity care and other patient-healthcare interactions the number of women who require language support varies and may be as high as 25%,\u003csup\u003e2,9\u0026ndash;11\u003c/sup\u003e although reliable data remain limited. Some of these increases may be due to economic and political upheaval, for example displacement due to war and conflict\u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e,\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eThe United Kingdom (UK) Government\u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e and National Institute for Health and Care Excellence (NICE)\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e guidance details that professional interpreter services should use a \u0026lsquo;variety of means to communicate\u0026rsquo; including translated written resources, alongside verbal support and should be provided free of cost.\u003c/p\u003e \u003cp\u003eLanguage barriers are key determinants of maternal health\u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e,\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e, and have been identified as a particular risk for adverse outcomes\u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e.\u003csup\u003e\u003cspan additionalcitationids=\"CR18\" citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e Women who experience language barriers in maternity care are at increased risk of poor birth outcomes.\u003csup\u003e\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u003c/sup\u003e Language barriers, alongside ethnicity and other structural factors, have also been identified as contributing to maternal mortality\u003csup\u003e\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e,\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u003c/sup\u003e. UK data suggests that between 2020 and 2022, Black women had a threefold higher risk of mortality, and Asian women a twofold higher risk compared to white women\u003csup\u003e\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u003c/sup\u003e. Mothers and Babies: Reducing Risk through Audits and Confidential Enquiries (MBRRACE-UK) have consistently reported that migrant women and their infants are overrepresented in UK and Irish perinatal mortality figures.\u003csup\u003e\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e,\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e,\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e,\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u003c/sup\u003e A case review of maternal and fetal morbidity and mortality in the Netherlands identified language barriers to be associated with safety risks from miscommunication\u003csup\u003e\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u003c/sup\u003e. A UK study into non-English speaking women who died in pregnancy identified none received appropriate interpreter provision.\u003csup\u003e\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u003c/sup\u003e Language barriers have been described as associated with difficulties understanding maternity healthcare systems\u003csup\u003e\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e,\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e\u003c/sup\u003e and timely registering for services, thus potentially delaying access to care, and increasing risks to safety for both mothers and their infants.\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e,\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e,\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e,\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eEffective communication between women and their HCP is essential to ensure needs are understood, informed consent can be obtained, and risk factors that can negatively affect outcomes, are identified and managed appropriately.\u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e,\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e,\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e\u003c/sup\u003e Maternity services must find ways to address language barriers to reduce disparities in experience and outcomes. The World Health Organisation (WHO) recommendations for Intrapartum Care\u003csup\u003e\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e\u003c/sup\u003e, alongside the compendium for respectful maternity care\u003csup\u003e\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e\u003c/sup\u003e, identifies that for women to experience childbirth as a positive event, services should ensure that all women have access to effective communication and respect.\u003c/p\u003e \u003cp\u003eAs far as the authors are aware, there has not been a qualitative systematic review and interpretative thematic synthesis\u003csup\u003e\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e\u003c/sup\u003e solely focussed on women\u0026rsquo;s experiences of language and communication barriers in high-income maternity settings. Our aim was therefore to systematically explore and synthesise the experiences and views of women navigating a language barrier, in high income maternity settings to inform recommendations for policy and practice.\u003c/p\u003e"},{"header":"METHODS","content":"\u003cp\u003eA qualitative systematic review and interpretive thematic synthesis was undertaken to integrate primary qualitative research from multiple perspectives, enabling the generation of new cumulative knowledge.\u003csup\u003e\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e\u003c/sup\u003e The review is reported against the Enhancing Transparency in Reporting the synthesis of Qualitative research (ENTREQ) framework\u003csup\u003e\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e\u003c/sup\u003e (Additional File 1).\u003c/p\u003e \u003cp\u003e \u003cb\u003eSearch strategy and eligibility criteria.\u003c/b\u003e \u003c/p\u003e \u003cp\u003eThe SPIDER (Sample, Phenomenon of Interest, Data, Evaluation, Research Type) tool\u003csup\u003e\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e,\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e\u003c/sup\u003e was used to support the development of the research question, search strategy, (see Appendix 1) and review eligibility criteria (see Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). The search was limited to January 2013 to November 2025, to reflect current maternity care in high income countries (HIC). Electronic database searches were developed using scoping searches of the existing relevant literature, supported by the SPIDER tool. The searches were adapted to each of the following six databases and conducted in November 2025: MEDLINE, CINAHL, EMBASE, Web of Science, PsychInfo and ProQuest. Example search terms are described in Additional File 2.\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\u003eStudy eligibility criteria.\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\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eTime-frame\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eInclusion Criteria\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eExclusion Criteria\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePublished between 2013\u0026ndash;2025, to capture data that reflects contemporary maternal care\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLanguage\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePublished in English, limiting to countries that are comparable to UK in language and setting\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePublication type\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePeer reviewed journal articles\u003c/p\u003e \u003cp\u003ePrimary research\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCommentaries, conference abstracts, reviews, opinion piece, editorials, letter to editor, protocols, systematic reviews\u003c/p\u003e \u003cp\u003eSecondary research/analysis\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSetting\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHigh income country (according to the World Bank List 2025\u003csup\u003e41,42\u003c/sup\u003e) maternity care, for transferability of review to UK services\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eLow-middle income countries\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMethodology\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAll qualitative, mixed methods and multi method study designs\u003c/p\u003e \u003cp\u003eInclude primary quotes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eQuantitative data, systematic reviews\u003c/p\u003e \u003cp\u003ePrimary quotes and experiences of different groups cannot be disaggregated (e.g. voices of healthcare providers, women and family members)\u003c/p\u003e \u003cp\u003eGrey literature\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStudy topic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIncludes focus on women with limited host country language proficiency and their views and experiences of maternity care in that country.\u003c/p\u003e \u003cp\u003eCommunicating with a language barrier\u003c/p\u003e \u003cp\u003eAvailability and use of interpreter services: in-person, over the phone or remote/virtual\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eUse of app / online platform for translation which does not involve physical interpreter.\u003c/p\u003e \u003cp\u003eTranslation of written information\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eScreening\u003c/h2\u003e \u003cp\u003eDatabase search results were imported into Covidence\u003csup\u003e\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e\u003c/sup\u003e for screening, with duplicates removed automatically. All screening was completed by at least two independent reviewers against the eligibility criteria, to increase rigour and consistency of criteria application.\u003csup\u003e\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e\u003c/sup\u003e Disagreements were resolved through discussion with wider review team members (SK, LJ, AD, SB). Screening process and results are illustrated in the PRISMA diagram (see Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eData extraction and quality appraisal\u003c/h3\u003e\n\u003cp\u003eData extraction was conducted at three levels: (1) contextual data extraction and analysis, (2) quality appraisal of studies, and (3) qualitative analysis of study findings and conclusions. Study characteristics including contextual variables, e.g., study setting, data collection and analysis methods, and participant demographics were recorded for each study in an Excel database (see Additional File 3). Quality appraisal was performed using, the Critical Appraisal Skills Programme (CASP)\u003csup\u003e\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e\u003c/sup\u003e qualitative studies checklist. The outcome of the quality assessment did not impact a studies inclusion in the review.\u003csup\u003e\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e\u003c/sup\u003e Data from the results and discussion sections of each included study, including primary participant quotations, identified themes and subthemes, and authors\u0026rsquo; interpretations were recorded in a Microsoft Word document for each study and then imported into NVivo 14\u003csup\u003e47\u003c/sup\u003e software to support data organisation and management.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e\n\u003ch3\u003eData analysis and synthesis\u003c/h3\u003e\n\u003cp\u003eInterpretive thematic synthesis\u003csup\u003e\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e\u003c/sup\u003e following Thomas and Harden\u003csup\u003e\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e\u003c/sup\u003e was chosen as it allows analysis to be inductively led by women\u0026rsquo;s voices instead of a predetermined framework and also allows for the interpretation of both \u0026lsquo;thin\u0026rsquo; and \u0026lsquo;thick\u0026rsquo; data.\u003csup\u003e\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e\u003c/sup\u003e Thick data can be described as that which includes context of social, cultural and historical positioning of participants alongside insight into participant experiences, reflections and thoughts and feelings, allowing more in-depth analysis than thinner data which may be lacking in some or all the above. This differs from \u0026lsquo;rich\u0026rsquo; data which has high levels of conceptual detail\u003csup\u003e\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e\u003c/sup\u003e. Thomas and Harden\u0026rsquo;s thematic synthesis follows a three-stage process\u003csup\u003e\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e\u003c/sup\u003e in which data are coded line-by-line, descriptive themes are developed from this coding, and subsequently analytical themes are developed and refined in the final synthesis.\u003c/p\u003e \u003cp\u003eContextual data were extracted from all studies by AG, FCS, EM and SD. Studies were assessed as being contextually thick or thin\u003csup\u003e\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e\u003c/sup\u003e. Studies were coded to generate an initial set of codes, beginning with those assessed as being thicker. More codes were created as needed, guided by coding of thinner studies. After initial coding, articles were reviewed again to ensure consistent application of the coding framework. These codes were organised into clusters to create descriptive themes, discussed with other reviewers (SD and AD) which were developed into analytical themes and supported the generation of an illustrative conceptual model (Fig.\u0026nbsp;\u003cspan refid=\"Fig6\" class=\"InternalRef\"\u003e3\u003c/span\u003e). Conceptual richness of each study was then assessed\u003csup\u003e\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e\u003c/sup\u003e. The analytical themes and model were discussed and refined with all review team members. Grade CERQual (Confidence in the Evidence from Reviews of Qualitative research) was undertaken following the refinement of the final conceptual model to increase transparency and confidence in review findings.\u003csup\u003e\u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003e \u003c/p\u003e\n\u003ch3\u003eEthics\u003c/h3\u003e\n\u003cp\u003e No ethical approval was required for this review. All data used is published and available in the public domain.\u003c/p\u003e\n\u003ch3\u003ePatient and Public Involvement\u003c/h3\u003e\n\u003cp\u003eThe design, analysis and interpretation of findings were discussed with public contributors from the National Institute for Health and Care Research Applied Research Collaboration (West Midlands) patient advisory group.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eReflexivity statement\u003c/h2\u003e \u003cp\u003eQualitative research aims to reveal personal experiential truths within data\u003csup\u003e\u003cspan additionalcitationids=\"CR54\" citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e\u003c/sup\u003e; however, it is inherently intertwined with researcher interpretation and therefore potential subjectivity\u003csup\u003e\u003cspan additionalcitationids=\"CR57\" citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e58\u003c/span\u003e\u003c/sup\u003e. Reporting of women\u0026rsquo;s experiences linked to language barriers, and race and immigration status could be emotive\u003csup\u003e\u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e58\u003c/span\u003e,\u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e59\u003c/span\u003e\u003c/sup\u003e. Author reflexivity and researcher triangulation was necessary to limit the potential bias that can be created in the analytical and synthesis processes\u003csup\u003e\u003cspan additionalcitationids=\"CR61\" citationid=\"CR60\" class=\"CitationRef\"\u003e60\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR62\" class=\"CitationRef\"\u003e62\u003c/span\u003e\u003c/sup\u003e. All co-authors and the wider PPIE contributors identify as women, are predominantly white and well educated. Some have had their own children or share caring responsibilities, at least one team member has had experience of accessing women\u0026rsquo;s healthcare while resident in another country, without the use of an interpreter, but none have experience of birth outside of their home country. The ability of the multidisciplinary team, including the invaluable expertise of the public and patient participants, to reflect together whilst conducting analysis adds rigour to our approach and final interpretations.\u003c/p\u003e \u003c/div\u003e"},{"header":"RESULTS","content":"\u003cp\u003eDatabase searches yielded 2,652 results. After removal of duplicates, 1,889 were title and abstract, and 233 were full text screened, respectively. 84 studies (86 articles) met eligibility criteria and were included in this review (see Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003csup\u003e\u003cspan additionalcitationids=\"CR64 CR65 CR66 CR67 CR68 CR69 CR70 CR71 CR72 CR73 CR74 CR75 CR76 CR77 CR78 CR79 CR80 CR81 CR82 CR83 CR84 CR85 CR86 CR87 CR88 CR89 CR90 CR91 CR92 CR93 CR94 CR95 CR96 CR97 CR98 CR99 CR100 CR101 CR102 CR103 CR104 CR105 CR106 CR107 CR108 CR109 CR110 CR111 CR112 CR113 CR114 CR115 CR116 CR117 CR118 CR119 CR120 CR121 CR122 CR123 CR124 CR125 CR126 CR127 CR128 CR129 CR130 CR131 CR132 CR133 CR134 CR135 CR136 CR137 CR138 CR139 CR140 CR141 CR142 CR143 CR144 CR145 CR146\" citationid=\"CR63\" class=\"CitationRef\"\u003e63\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR147\" class=\"CitationRef\"\u003e147\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\n\u003ch3\u003eStudy characteristics\u003c/h3\u003e\n\u003cp\u003eStudy characteristics are summarised in Additional File 3. A total of 1801 women\u0026rsquo;s voices are included across the studies, ranging from four\u003csup\u003e\u003cspan citationid=\"CR114\" class=\"CitationRef\"\u003e114\u003c/span\u003e\u003c/sup\u003e to 193 participants\u003csup\u003e\u003cspan citationid=\"CR136\" class=\"CitationRef\"\u003e136\u003c/span\u003e\u003c/sup\u003e (median average of 21 voices per study).\u003c/p\u003e \u003cp\u003eThe geographic spread of the papers is shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eMost studies aimed to explore general perinatal and intrapartum experiences and needs of refugee or migrant women\u003csup\u003e\u003cspan citationid=\"CR64\" class=\"CitationRef\"\u003e64\u003c/span\u003e,\u003cspan citationid=\"CR68\" class=\"CitationRef\"\u003e68\u003c/span\u003e,\u003cspan citationid=\"CR71\" class=\"CitationRef\"\u003e71\u003c/span\u003e,\u003cspan citationid=\"CR85\" class=\"CitationRef\"\u003e85\u003c/span\u003e,\u003cspan additionalcitationids=\"CR88 CR89 CR90 CR91 CR92\" citationid=\"CR87\" class=\"CitationRef\"\u003e87\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR93\" class=\"CitationRef\"\u003e93\u003c/span\u003e,\u003cspan citationid=\"CR95\" class=\"CitationRef\"\u003e95\u003c/span\u003e,\u003cspan additionalcitationids=\"CR99 CR100\" citationid=\"CR98\" class=\"CitationRef\"\u003e98\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR101\" class=\"CitationRef\"\u003e101\u003c/span\u003e,\u003cspan citationid=\"CR104\" class=\"CitationRef\"\u003e104\u003c/span\u003e,\u003cspan citationid=\"CR105\" class=\"CitationRef\"\u003e105\u003c/span\u003e,\u003cspan citationid=\"CR107\" class=\"CitationRef\"\u003e107\u003c/span\u003e,\u003cspan citationid=\"CR108\" class=\"CitationRef\"\u003e108\u003c/span\u003e,\u003cspan additionalcitationids=\"CR112 CR113 CR114 CR115\" citationid=\"CR111\" class=\"CitationRef\"\u003e111\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR116\" class=\"CitationRef\"\u003e116\u003c/span\u003e,\u003cspan citationid=\"CR119\" class=\"CitationRef\"\u003e119\u003c/span\u003e,\u003cspan citationid=\"CR122\" class=\"CitationRef\"\u003e122\u003c/span\u003e,\u003cspan citationid=\"CR124\" class=\"CitationRef\"\u003e124\u003c/span\u003e,\u003cspan additionalcitationids=\"CR128\" citationid=\"CR127\" class=\"CitationRef\"\u003e127\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR129\" class=\"CitationRef\"\u003e129\u003c/span\u003e,\u003cspan citationid=\"CR132\" class=\"CitationRef\"\u003e132\u003c/span\u003e,\u003cspan citationid=\"CR133\" class=\"CitationRef\"\u003e133\u003c/span\u003e,\u003cspan citationid=\"CR135\" class=\"CitationRef\"\u003e135\u003c/span\u003e,\u003cspan citationid=\"CR136\" class=\"CitationRef\"\u003e136\u003c/span\u003e,\u003cspan additionalcitationids=\"CR141\" citationid=\"CR140\" class=\"CitationRef\"\u003e140\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR142\" class=\"CitationRef\"\u003e142\u003c/span\u003e,\u003cspan citationid=\"CR144\" class=\"CitationRef\"\u003e144\u003c/span\u003e,\u003cspan citationid=\"CR146\" class=\"CitationRef\"\u003e146\u003c/span\u003e,\u003cspan additionalcitationids=\"CR149\" citationid=\"CR148\" class=\"CitationRef\"\u003e148\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR150\" class=\"CitationRef\"\u003e150\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eOther studies looked at specific populations in a host country, for example, Chinese women in Switzerland\u003csup\u003e\u003cspan citationid=\"CR76\" class=\"CitationRef\"\u003e76\u003c/span\u003e,\u003cspan citationid=\"CR77\" class=\"CitationRef\"\u003e77\u003c/span\u003e\u003c/sup\u003e, Japanese women in New Zealand\u003csup\u003e\u003cspan citationid=\"CR84\" class=\"CitationRef\"\u003e84\u003c/span\u003e\u003c/sup\u003e, Polish women in Iceland\u003csup\u003e\u003cspan citationid=\"CR145\" class=\"CitationRef\"\u003e145\u003c/span\u003e\u003c/sup\u003e, Ukrainian women in Portugal\u003csup\u003e\u003cspan citationid=\"CR134\" class=\"CitationRef\"\u003e134\u003c/span\u003e\u003c/sup\u003e, Afghan women in USA and Australia\u003csup\u003e\u003cspan citationid=\"CR143\" class=\"CitationRef\"\u003e143\u003c/span\u003e,\u003cspan citationid=\"CR147\" class=\"CitationRef\"\u003e147\u003c/span\u003e\u003c/sup\u003e. Marshallese mothers \u003csup\u003e\u003cspan citationid=\"CR67\" class=\"CitationRef\"\u003e67\u003c/span\u003e\u003c/sup\u003e migrant Arab Muslim\u003csup\u003e\u003cspan citationid=\"CR69\" class=\"CitationRef\"\u003e69\u003c/span\u003e,\u003cspan citationid=\"CR79\" class=\"CitationRef\"\u003e79\u003c/span\u003e\u003c/sup\u003e and African immigrant women\u003csup\u003e\u003cspan citationid=\"CR66\" class=\"CitationRef\"\u003e66\u003c/span\u003e\u003c/sup\u003e in the US, and the Roma community in England\u003csup\u003e\u003cspan citationid=\"CR82\" class=\"CitationRef\"\u003e82\u003c/span\u003e\u003c/sup\u003e and in Ireland\u003csup\u003e\u003cspan citationid=\"CR86\" class=\"CitationRef\"\u003e86\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eFurther studies looked at specific elements of care, for example, Somali migrant women\u0026rsquo;s understanding of self-monitoring of foetal movements in Sweden\u003csup\u003e\u003cspan citationid=\"CR65\" class=\"CitationRef\"\u003e65\u003c/span\u003e\u003c/sup\u003e and maternity care in Norway\u003csup\u003e\u003cspan citationid=\"CR110\" class=\"CitationRef\"\u003e110\u003c/span\u003e,\u003cspan citationid=\"CR138\" class=\"CitationRef\"\u003e138\u003c/span\u003e\u003c/sup\u003e. Experiences and expectations of women and their husbands regarding shared decision making in maternity care in Suadi Arabia\u003csup\u003e\u003cspan citationid=\"CR151\" class=\"CitationRef\"\u003e151\u003c/span\u003e\u003c/sup\u003e, exploration of assessing women\u0026rsquo;s satisfaction with care in New Zealand\u003csup\u003e\u003cspan citationid=\"CR121\" class=\"CitationRef\"\u003e121\u003c/span\u003e\u003c/sup\u003e and the acceptability of interpreters for women with social risk factors in England\u003csup\u003e\u003cspan citationid=\"CR123\" class=\"CitationRef\"\u003e123\u003c/span\u003e\u003c/sup\u003e. Two studies looked at the use of online or smartphone apps: one around healthier lifestyle behaviours in pregnant migrant women\u003csup\u003e\u003cspan citationid=\"CR130\" class=\"CitationRef\"\u003e130\u003c/span\u003e\u003c/sup\u003e and one around Arabic speaking women\u0026rsquo;s experiences of communication using an app\u003csup\u003e\u003cspan citationid=\"CR73\" class=\"CitationRef\"\u003e73\u003c/span\u003e\u003c/sup\u003e, in Sweden.\u003c/p\u003e \u003cp\u003eAustralian studies explored the needs of indigenous pregnant women with rheumatic heart disease\u003csup\u003e\u003cspan citationid=\"CR70\" class=\"CitationRef\"\u003e70\u003c/span\u003e\u003c/sup\u003e, and how conversations about stillbirth prevention with migrant families\u003csup\u003e\u003cspan citationid=\"CR72\" class=\"CitationRef\"\u003e72\u003c/span\u003e\u003c/sup\u003e, trauma informed care\u003csup\u003e\u003cspan citationid=\"CR125\" class=\"CitationRef\"\u003e125\u003c/span\u003e\u003c/sup\u003e and group antenatal education for Karen women\u003csup\u003e\u003cspan citationid=\"CR126\" class=\"CitationRef\"\u003e126\u003c/span\u003e\u003c/sup\u003e and gestational diabetes care for Chinese women\u003csup\u003e\u003cspan citationid=\"CR139\" class=\"CitationRef\"\u003e139\u003c/span\u003e\u003c/sup\u003e were experienced and understood.\u003c/p\u003e \u003cp\u003eUS studies explored Spanish speaking parents understanding of newborn immunisations\u003csup\u003e\u003cspan citationid=\"CR74\" class=\"CitationRef\"\u003e74\u003c/span\u003e\u003c/sup\u003e, support with breastfeeding and lactation education\u003csup\u003e\u003cspan citationid=\"CR75\" class=\"CitationRef\"\u003e75\u003c/span\u003e\u003c/sup\u003e, education around post-partum bleeding\u003csup\u003e\u003cspan citationid=\"CR83\" class=\"CitationRef\"\u003e83\u003c/span\u003e\u003c/sup\u003e, electronic health records\u003csup\u003e\u003cspan citationid=\"CR97\" class=\"CitationRef\"\u003e97\u003c/span\u003e\u003c/sup\u003e, and interactions with medical interpreters\u003csup\u003e\u003cspan citationid=\"CR120\" class=\"CitationRef\"\u003e120\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eOther studies looked at care following a prenatal diagnosis of congenital heart defect\u003csup\u003e\u003cspan citationid=\"CR78\" class=\"CitationRef\"\u003e78\u003c/span\u003e\u003c/sup\u003e; the childbirth experiences of international marriage migrant women marrying Korean men in South Korea\u003csup\u003e\u003cspan citationid=\"CR80\" class=\"CitationRef\"\u003e80\u003c/span\u003e\u003c/sup\u003e; experiences and access to perinatal mental health support\u003csup\u003e\u003cspan citationid=\"CR81\" class=\"CitationRef\"\u003e81\u003c/span\u003e,\u003cspan citationid=\"CR103\" class=\"CitationRef\"\u003e103\u003c/span\u003e\u003c/sup\u003e. Experiences and needs around communication about Interpersonal Violence in antenatal care\u003csup\u003e\u003cspan citationid=\"CR94\" class=\"CitationRef\"\u003e94\u003c/span\u003e\u003c/sup\u003e. Two studies looked at perinatal care for migrant and refugee women during Covid-19\u003csup\u003e106,152\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eAcross studies, data was gathered using ethnographic methods\u003csup\u003e\u003cspan citationid=\"CR90\" class=\"CitationRef\"\u003e90\u003c/span\u003e,\u003cspan citationid=\"CR101\" class=\"CitationRef\"\u003e101\u003c/span\u003e,\u003cspan citationid=\"CR140\" class=\"CitationRef\"\u003e140\u003c/span\u003e\u003c/sup\u003e, online or in-person workshops\u003csup\u003e\u003cspan citationid=\"CR82\" class=\"CitationRef\"\u003e82\u003c/span\u003e,\u003cspan citationid=\"CR86\" class=\"CitationRef\"\u003e86\u003c/span\u003e\u003c/sup\u003e, World Cafe methodology\u003csup\u003e\u003cspan citationid=\"CR122\" class=\"CitationRef\"\u003e122\u003c/span\u003e\u003c/sup\u003e, photo-elicitation workshops\u003csup\u003e\u003cspan citationid=\"CR135\" class=\"CitationRef\"\u003e135\u003c/span\u003e\u003c/sup\u003e, and observations\u003csup\u003e\u003cspan citationid=\"CR75\" class=\"CitationRef\"\u003e75\u003c/span\u003e\u003c/sup\u003e or video recordings of interactions on wards\u003csup\u003e\u003cspan citationid=\"CR83\" class=\"CitationRef\"\u003e83\u003c/span\u003e\u003c/sup\u003e or in individual consultations\u003csup\u003e\u003cspan citationid=\"CR120\" class=\"CitationRef\"\u003e120\u003c/span\u003e\u003c/sup\u003e. Two utilised questionnaires, one followed by interviews.\u003csup\u003e\u003cspan citationid=\"CR87\" class=\"CitationRef\"\u003e87\u003c/span\u003e\u003c/sup\u003e and another with four open questions.\u003csup\u003e\u003cspan citationid=\"CR136\" class=\"CitationRef\"\u003e136\u003c/span\u003e\u003c/sup\u003e All other studies used interviews and focus groups.\u003c/p\u003e \u003cp\u003eMethodology was reported variably; 14 studies used content analysis\u003csup\u003e\u003cspan citationid=\"CR65\" class=\"CitationRef\"\u003e65\u003c/span\u003e,\u003cspan citationid=\"CR71\" class=\"CitationRef\"\u003e71\u003c/span\u003e,\u003cspan citationid=\"CR73\" class=\"CitationRef\"\u003e73\u003c/span\u003e,\u003cspan citationid=\"CR74\" class=\"CitationRef\"\u003e74\u003c/span\u003e,\u003cspan citationid=\"CR78\" class=\"CitationRef\"\u003e78\u003c/span\u003e,\u003cspan citationid=\"CR81\" class=\"CitationRef\"\u003e81\u003c/span\u003e,\u003cspan citationid=\"CR92\" class=\"CitationRef\"\u003e92\u003c/span\u003e,\u003cspan citationid=\"CR97\" class=\"CitationRef\"\u003e97\u003c/span\u003e,\u003cspan citationid=\"CR100\" class=\"CitationRef\"\u003e100\u003c/span\u003e,\u003cspan citationid=\"CR115\" class=\"CitationRef\"\u003e115\u003c/span\u003e,\u003cspan citationid=\"CR116\" class=\"CitationRef\"\u003e116\u003c/span\u003e,\u003cspan citationid=\"CR130\" class=\"CitationRef\"\u003e130\u003c/span\u003e,\u003cspan citationid=\"CR137\" class=\"CitationRef\"\u003e137\u003c/span\u003e,\u003cspan citationid=\"CR143\" class=\"CitationRef\"\u003e143\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eIncluding two which took a phenomenological approach to content analysis\u003csup\u003e\u003cspan citationid=\"CR92\" class=\"CitationRef\"\u003e92\u003c/span\u003e,\u003cspan citationid=\"CR115\" class=\"CitationRef\"\u003e115\u003c/span\u003e\u003c/sup\u003e ; most other studies (n\u0026thinsp;=\u0026thinsp;50) reported using a thematic analysis approach\u003csup\u003e\u003cspan additionalcitationids=\"CR67\" citationid=\"CR66\" class=\"CitationRef\"\u003e66\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR68\" class=\"CitationRef\"\u003e68\u003c/span\u003e,\u003cspan citationid=\"CR72\" class=\"CitationRef\"\u003e72\u003c/span\u003e,\u003cspan additionalcitationids=\"CR76\" citationid=\"CR75\" class=\"CitationRef\"\u003e75\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR77\" class=\"CitationRef\"\u003e77\u003c/span\u003e,\u003cspan additionalcitationids=\"CR83 CR84 CR85\" citationid=\"CR82\" class=\"CitationRef\"\u003e82\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR86\" class=\"CitationRef\"\u003e86\u003c/span\u003e,\u003cspan additionalcitationids=\"CR89 CR90\" citationid=\"CR88\" class=\"CitationRef\"\u003e88\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR91\" class=\"CitationRef\"\u003e91\u003c/span\u003e,\u003cspan additionalcitationids=\"CR94\" citationid=\"CR93\" class=\"CitationRef\"\u003e93\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR95\" class=\"CitationRef\"\u003e95\u003c/span\u003e,\u003cspan citationid=\"CR98\" class=\"CitationRef\"\u003e98\u003c/span\u003e,\u003cspan citationid=\"CR99\" class=\"CitationRef\"\u003e99\u003c/span\u003e,\u003cspan citationid=\"CR104\" class=\"CitationRef\"\u003e104\u003c/span\u003e,\u003cspan citationid=\"CR106\" class=\"CitationRef\"\u003e106\u003c/span\u003e,\u003cspan citationid=\"CR107\" class=\"CitationRef\"\u003e107\u003c/span\u003e,\u003cspan citationid=\"CR109\" class=\"CitationRef\"\u003e109\u003c/span\u003e,\u003cspan additionalcitationids=\"CR112 CR113\" citationid=\"CR111\" class=\"CitationRef\"\u003e111\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR114\" class=\"CitationRef\"\u003e114\u003c/span\u003e,\u003cspan citationid=\"CR117\" class=\"CitationRef\"\u003e117\u003c/span\u003e,\u003cspan citationid=\"CR119\" class=\"CitationRef\"\u003e119\u003c/span\u003e,\u003cspan citationid=\"CR122\" class=\"CitationRef\"\u003e122\u003c/span\u003e,\u003cspan additionalcitationids=\"CR126 CR127 CR128\" citationid=\"CR125\" class=\"CitationRef\"\u003e125\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR129\" class=\"CitationRef\"\u003e129\u003c/span\u003e,\u003cspan citationid=\"CR131\" class=\"CitationRef\"\u003e131\u003c/span\u003e,\u003cspan citationid=\"CR132\" class=\"CitationRef\"\u003e132\u003c/span\u003e,\u003cspan citationid=\"CR134\" class=\"CitationRef\"\u003e134\u003c/span\u003e,\u003cspan citationid=\"CR135\" class=\"CitationRef\"\u003e135\u003c/span\u003e,\u003cspan citationid=\"CR139\" class=\"CitationRef\"\u003e139\u003c/span\u003e,\u003cspan citationid=\"CR141\" class=\"CitationRef\"\u003e141\u003c/span\u003e,\u003cspan citationid=\"CR142\" class=\"CitationRef\"\u003e142\u003c/span\u003e,\u003cspan citationid=\"CR147\" class=\"CitationRef\"\u003e147\u003c/span\u003e,\u003cspan citationid=\"CR148\" class=\"CitationRef\"\u003e148\u003c/span\u003e,\u003cspan citationid=\"CR150\" class=\"CitationRef\"\u003e150\u003c/span\u003e,\u003cspan citationid=\"CR151\" class=\"CitationRef\"\u003e151\u003c/span\u003e,\u003cspan citationid=\"CR153\" class=\"CitationRef\"\u003e153\u003c/span\u003e,\u003cspan citationid=\"CR154\" class=\"CitationRef\"\u003e154\u003c/span\u003e\u003c/sup\u003e, using varied frameworks and approaches. Others described using narrative analysis\u003csup\u003e\u003cspan citationid=\"CR133\" class=\"CitationRef\"\u003e133\u003c/span\u003e\u003c/sup\u003e interpretive phenomenological analysis\u003csup\u003e\u003cspan citationid=\"CR69\" class=\"CitationRef\"\u003e69\u003c/span\u003e\u003c/sup\u003e, discourse analysis\u003csup\u003e\u003cspan citationid=\"CR120\" class=\"CitationRef\"\u003e120\u003c/span\u003e\u003c/sup\u003e, and various framework approaches,\u003csup\u003e70,87,105\u003c/sup\u003e Colaizzi\u0026rsquo;s data analysis method\u003csup\u003e\u003cspan citationid=\"CR80\" class=\"CitationRef\"\u003e80\u003c/span\u003e\u003c/sup\u003e Roper and Shapira\u0026rsquo;s principles of ethnographic research analysis\u003csup\u003e\u003cspan citationid=\"CR101\" class=\"CitationRef\"\u003e101\u003c/span\u003e\u003c/sup\u003e, constant comparison and grounded theory,\u003csup\u003e108\u003c/sup\u003e text consolidation\u003csup\u003e\u003cspan citationid=\"CR110\" class=\"CitationRef\"\u003e110\u003c/span\u003e\u003c/sup\u003e, and analysis based on theories of behaviour and behaviour change.\u003csup\u003e\u003cspan citationid=\"CR103\" class=\"CitationRef\"\u003e103\u003c/span\u003e,\u003cspan citationid=\"CR144\" class=\"CitationRef\"\u003e144\u003c/span\u003e\u003c/sup\u003e Two described used general qualitative analysis coding data into themes\u003csup\u003e\u003cspan citationid=\"CR96\" class=\"CitationRef\"\u003e96\u003c/span\u003e,\u003cspan citationid=\"CR118\" class=\"CitationRef\"\u003e118\u003c/span\u003e\u003c/sup\u003e and one did not report their analysis approach.\u003csup\u003e\u003cspan citationid=\"CR136\" class=\"CitationRef\"\u003e136\u003c/span\u003e\u003c/sup\u003e Although most studies reported duration since participants accessed maternity care, the timeframe was unclear in 16 studies\u003csup\u003e\u003cspan citationid=\"CR67\" class=\"CitationRef\"\u003e67\u003c/span\u003e,\u003cspan citationid=\"CR71\" class=\"CitationRef\"\u003e71\u003c/span\u003e,\u003cspan citationid=\"CR88\" class=\"CitationRef\"\u003e88\u003c/span\u003e,\u003cspan citationid=\"CR89\" class=\"CitationRef\"\u003e89\u003c/span\u003e,\u003cspan citationid=\"CR92\" class=\"CitationRef\"\u003e92\u003c/span\u003e,\u003cspan citationid=\"CR111\" class=\"CitationRef\"\u003e111\u003c/span\u003e,\u003cspan citationid=\"CR112\" class=\"CitationRef\"\u003e112\u003c/span\u003e,\u003cspan citationid=\"CR115\" class=\"CitationRef\"\u003e115\u003c/span\u003e,\u003cspan citationid=\"CR118\" class=\"CitationRef\"\u003e118\u003c/span\u003e,\u003cspan citationid=\"CR119\" class=\"CitationRef\"\u003e119\u003c/span\u003e,\u003cspan citationid=\"CR122\" class=\"CitationRef\"\u003e122\u003c/span\u003e,\u003cspan citationid=\"CR127\" class=\"CitationRef\"\u003e127\u003c/span\u003e,\u003cspan citationid=\"CR131\" class=\"CitationRef\"\u003e131\u003c/span\u003e,\u003cspan citationid=\"CR132\" class=\"CitationRef\"\u003e132\u003c/span\u003e,\u003cspan citationid=\"CR134\" class=\"CitationRef\"\u003e134\u003c/span\u003e,\u003cspan citationid=\"CR136\" class=\"CitationRef\"\u003e136\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eQuality appraisal\u003c/h2\u003e \u003cp\u003eQuality appraisal results are shown in Additional File 4. All studies demonstrated clear aims and appropriate qualitative methodologies, including suitable research designs, recruitment strategies, and data collection methods. 26 studies reported reflexivity\u003csup\u003e\u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e63\u003c/span\u003e,\u003cspan citationid=\"CR65\" class=\"CitationRef\"\u003e65\u003c/span\u003e,\u003cspan citationid=\"CR66\" class=\"CitationRef\"\u003e66\u003c/span\u003e,\u003cspan citationid=\"CR76\" class=\"CitationRef\"\u003e76\u003c/span\u003e,\u003cspan citationid=\"CR81\" class=\"CitationRef\"\u003e81\u003c/span\u003e,\u003cspan citationid=\"CR85\" class=\"CitationRef\"\u003e85\u003c/span\u003e,\u003cspan citationid=\"CR90\" class=\"CitationRef\"\u003e90\u003c/span\u003e,\u003cspan citationid=\"CR93\" class=\"CitationRef\"\u003e93\u003c/span\u003e,\u003cspan citationid=\"CR95\" class=\"CitationRef\"\u003e95\u003c/span\u003e,\u003cspan citationid=\"CR104\" class=\"CitationRef\"\u003e104\u003c/span\u003e,\u003cspan citationid=\"CR107\" class=\"CitationRef\"\u003e107\u003c/span\u003e,\u003cspan citationid=\"CR119\" class=\"CitationRef\"\u003e119\u003c/span\u003e,\u003cspan citationid=\"CR125\" class=\"CitationRef\"\u003e125\u003c/span\u003e,\u003cspan citationid=\"CR127\" class=\"CitationRef\"\u003e127\u003c/span\u003e,\u003cspan citationid=\"CR129\" class=\"CitationRef\"\u003e129\u003c/span\u003e,\u003cspan citationid=\"CR130\" class=\"CitationRef\"\u003e130\u003c/span\u003e,\u003cspan citationid=\"CR132\" class=\"CitationRef\"\u003e132\u003c/span\u003e,\u003cspan citationid=\"CR133\" class=\"CitationRef\"\u003e133\u003c/span\u003e,\u003cspan citationid=\"CR135\" class=\"CitationRef\"\u003e135\u003c/span\u003e,\u003cspan citationid=\"CR139\" class=\"CitationRef\"\u003e139\u003c/span\u003e,\u003cspan additionalcitationids=\"CR144\" citationid=\"CR143\" class=\"CitationRef\"\u003e143\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR145\" class=\"CitationRef\"\u003e145\u003c/span\u003e,\u003cspan citationid=\"CR148\" class=\"CitationRef\"\u003e148\u003c/span\u003e,\u003cspan citationid=\"CR150\" class=\"CitationRef\"\u003e150\u003c/span\u003e\u003c/sup\u003e and 44 were assessed as containing thick contextual descriptions.\u003csup\u003e\u003cspan additionalcitationids=\"CR70\" citationid=\"CR69\" class=\"CitationRef\"\u003e69\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR71\" class=\"CitationRef\"\u003e71\u003c/span\u003e,\u003cspan additionalcitationids=\"CR76 CR77 CR78\" citationid=\"CR75\" class=\"CitationRef\"\u003e75\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR79\" class=\"CitationRef\"\u003e79\u003c/span\u003e,\u003cspan additionalcitationids=\"CR82\" citationid=\"CR81\" class=\"CitationRef\"\u003e81\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR83\" class=\"CitationRef\"\u003e83\u003c/span\u003e,\u003cspan additionalcitationids=\"CR87\" citationid=\"CR86\" class=\"CitationRef\"\u003e86\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR88\" class=\"CitationRef\"\u003e88\u003c/span\u003e,\u003cspan citationid=\"CR94\" class=\"CitationRef\"\u003e94\u003c/span\u003e,\u003cspan citationid=\"CR97\" class=\"CitationRef\"\u003e97\u003c/span\u003e,\u003cspan citationid=\"CR99\" class=\"CitationRef\"\u003e99\u003c/span\u003e,\u003cspan citationid=\"CR101\" class=\"CitationRef\"\u003e101\u003c/span\u003e,\u003cspan citationid=\"CR104\" class=\"CitationRef\"\u003e104\u003c/span\u003e,\u003cspan citationid=\"CR107\" class=\"CitationRef\"\u003e107\u003c/span\u003e,\u003cspan citationid=\"CR113\" class=\"CitationRef\"\u003e113\u003c/span\u003e,\u003cspan citationid=\"CR117\" class=\"CitationRef\"\u003e117\u003c/span\u003e,\u003cspan citationid=\"CR118\" class=\"CitationRef\"\u003e118\u003c/span\u003e,\u003cspan citationid=\"CR125\" class=\"CitationRef\"\u003e125\u003c/span\u003e,\u003cspan citationid=\"CR126\" class=\"CitationRef\"\u003e126\u003c/span\u003e,\u003cspan additionalcitationids=\"CR129\" citationid=\"CR128\" class=\"CitationRef\"\u003e128\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR130\" class=\"CitationRef\"\u003e130\u003c/span\u003e,\u003cspan additionalcitationids=\"CR134\" citationid=\"CR133\" class=\"CitationRef\"\u003e133\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR135\" class=\"CitationRef\"\u003e135\u003c/span\u003e,\u003cspan citationid=\"CR137\" class=\"CitationRef\"\u003e137\u003c/span\u003e,\u003cspan citationid=\"CR138\" class=\"CitationRef\"\u003e138\u003c/span\u003e,\u003cspan citationid=\"CR140\" class=\"CitationRef\"\u003e140\u003c/span\u003e,\u003cspan additionalcitationids=\"CR143 CR144 CR145\" citationid=\"CR142\" class=\"CitationRef\"\u003e142\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR146\" class=\"CitationRef\"\u003e146\u003c/span\u003e,\u003cspan additionalcitationids=\"CR151 CR152\" citationid=\"CR150\" class=\"CitationRef\"\u003e150\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR153\" class=\"CitationRef\"\u003e153\u003c/span\u003e,\u003cspan citationid=\"CR155\" class=\"CitationRef\"\u003e155\u003c/span\u003e\u003c/sup\u003e Analysis was generally well reported, in six studies it was unclear or difficult to tell how data had been analysed\u003csup\u003e\u003cspan citationid=\"CR84\" class=\"CitationRef\"\u003e84\u003c/span\u003e,\u003cspan citationid=\"CR118\" class=\"CitationRef\"\u003e118\u003c/span\u003e,\u003cspan citationid=\"CR121\" class=\"CitationRef\"\u003e121\u003c/span\u003e,\u003cspan citationid=\"CR136\" class=\"CitationRef\"\u003e136\u003c/span\u003e,\u003cspan citationid=\"CR147\" class=\"CitationRef\"\u003e147\u003c/span\u003e,\u003cspan citationid=\"CR155\" class=\"CitationRef\"\u003e155\u003c/span\u003e\u003c/sup\u003e, and nine did not show evidence of ethical approval.\u003csup\u003e\u003cspan citationid=\"CR69\" class=\"CitationRef\"\u003e69\u003c/span\u003e,\u003cspan citationid=\"CR74\" class=\"CitationRef\"\u003e74\u003c/span\u003e,\u003cspan citationid=\"CR92\" class=\"CitationRef\"\u003e92\u003c/span\u003e,\u003cspan citationid=\"CR107\" class=\"CitationRef\"\u003e107\u003c/span\u003e,\u003cspan citationid=\"CR118\" class=\"CitationRef\"\u003e118\u003c/span\u003e,\u003cspan citationid=\"CR134\" class=\"CitationRef\"\u003e134\u003c/span\u003e,\u003cspan citationid=\"CR136\" class=\"CitationRef\"\u003e136\u003c/span\u003e,\u003cspan citationid=\"CR146\" class=\"CitationRef\"\u003e146\u003c/span\u003e,\u003cspan citationid=\"CR155\" class=\"CitationRef\"\u003e155\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eThematic Analysis, Interpretation and Synthesis\u003c/h2\u003e \u003cp\u003eThe following sections describe our interpretation and synthesis of the qualitative data from studies included in this review. We begin with a table identifying the terms we use in the reporting of the results and discussion (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDefinitions of terms used in reporting and discussion of findings in this review.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\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 \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTerm\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDefinition within this review\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBenefits (of positive engagement or experiences of host country maternity and healthcare)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWays in which having positive experiences and engagements in maternity interactions supports physical and emotional well-being of migrant women\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eConsequences (of negative engagement or experiences of host country maternity and healthcare)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHow negative or poor experiences and interactions with maternity healthcare negatively influences both physical and emotional well-being and safety of migrant women and their infants\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026lsquo;Home\u0026rsquo; language\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDescribes the women\u0026rsquo;s mother tongue, or the language she speaks with her family and/or within her country of birth.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026lsquo;Host\u0026rsquo; country/language\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDescribes the HIC in which the mother is now residing and the language in which the health, and maternity services are run.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMediators of experiences\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAn element of a woman\u0026rsquo;s experience which influences how women experience navigating a language barrier between themselves and their HCPs and/or maternity systems. (E.g., a professional interpreter).\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAssociated factors\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFactors which contribute to the overarching mediator, e.g., the availability of professional interpreters; the suitability of professional interpreters.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eProfessional interpreter\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDescribes a person who is paid for their time as a trained interpreter, and is accessed through, or provided by the health or social care system in the host country.\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\u003eWe describe and identify two over-arching mediators of impact and experiences of women\u0026rsquo;s engagement with maternity care, interpreted from the included studies. These have been integrated into the Conceptual Model (Fig.\u0026nbsp;\u003cspan refid=\"Fig6\" class=\"InternalRef\"\u003e3\u003c/span\u003e), with factors we interpreted as associated with each mediator, and the consequences and benefits these result in for women.\u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e summarises each mediator and their associated factors alongside illustrative quotations. In the section \u0026lsquo;Mediators of Impact and Experience\u0026rsquo;, we describe each mediator, and their associated factors. The section \u0026lsquo;Consequences and Benefits of Experiences, Engagement and Interactions\u0026rsquo; describes our interpretations of consequences and benefits to women (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e), illustrated by excerpts and quotations from the included article. Where quotations are used, \u003cem\u003eitalics\u003c/em\u003e indicate \u003cem\u003earticle author interpretation\u003c/em\u003e and \u003cb\u003ebold italics\u003c/b\u003e indicate \u003cb\u003ewomen\u0026rsquo;s voices\u003c/b\u003e.\u003c/p\u003e \u003cp\u003eThe results section concludes with an interpretation of how women\u0026rsquo;s needs in the context of language barriers, can be supported to overcome structural barriers which perpetuating barriers in care access. These needs are framed in reference to the WHO recommendations on respectful maternity care. \u003csup\u003e35\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eAn assessment of confidence in review findings was undertaken using the GRADE-CERQual assessment tool\u003csup\u003e\u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e,\u003cspan citationid=\"CR156\" class=\"CitationRef\"\u003e156\u003c/span\u003e\u003c/sup\u003e and is indicated in brief alongside each review finding (mediator associated factors, consequence, benefit) and summarised at the end of the results (see Additional File 5 for the full Confidence in Review Findings Table).\u003c/p\u003e \u003cp\u003eThe two mediators, their associated factors, and the resultant consequences and benefits for women described in Fig.\u0026nbsp;\u003cspan refid=\"Fig6\" class=\"InternalRef\"\u003e3\u003c/span\u003e, follow a pathway from language barriers through mediators of interaction and experiences to psychological and behavioural responses, and ultimately to care engagement and safety outcomes. Within the conceptual model, larger, darker coloured \u0026lsquo;bubbles\u0026rsquo; indicate the strength of evidence from included studies, reflecting greater representation of each theme in the analysis.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eInterpreted themes: Mediators of impact and experiences\u003c/h2\u003e \u003cp\u003ePregnant women in a host country experienced interactions with maternity services and care along a continuum from positive to negative. This review found that women\u0026rsquo;s experiences were centred around two key mediators: the provision of \u003cb\u003eprofessional interpreter offering\u003c/b\u003e and \u0026lsquo;\u003cb\u003ework arounds\u0026rsquo; in their absence\u003c/b\u003e. These mediators consisted of various associated factors. Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e describes a summary of the themes created through this analysis and interpretation.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eThemes interpreted as mediators of impact and experiences of interactions with maternity services.\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\u003eMediator of impact and experience\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAssociated factors\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eIllustrative quotation from included article(s)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e1. Interactions with professional interpreters\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.1 Access to suitable professional interpreters\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026ldquo;\u003cb\u003eThe greatest challenge I have experienced is the following: If you are incapable of understanding anything [they say], then no one can help you\u0026hellip;I was not offered an interpreter, and I never got the help I needed\u0026rdquo;\u003c/b\u003e \u003csup\u003e\u003cb\u003e138\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003e\u003cem\u003e\u0026ldquo;\u003c/em\u003e\u003cb\u003eHe was a Dari speaker, and I was [a] Hazaragi speaker and this difference of the language made it difficult for me to understand everything that he said\u003c/b\u003e.\u003cem\u003e\u0026rdquo; [Afghan woman, participant 8]\u003c/em\u003e\u003csup\u003e\u003cem\u003e147\u003c/em\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.2 Positive experiences and interactions with interpreters\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003e\u0026lsquo;All interviewed groups, but most of all the migrant women, found that\u003c/em\u003e \u003cb\u003e\u0026ldquo;interpreting services were indispensable\u003c/b\u003e\u003cem\u003e\u0026rdquo; to achieving appropriate maternity care.\u0026rsquo;\u003c/em\u003e \u003csup\u003e\u003cem\u003e102\u003c/em\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.3 Use of telephone and/or other interpreting medium\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003e\u0026ldquo;\u003c/em\u003e\u003cb\u003eI think it\u0026rsquo;s more useful\u003c/b\u003e [in person services], \u003cb\u003eyou have the person just next to you, you can see, you can talk, and it just inspires more security and trust, than the telephone line\u003c/b\u003e.\u003cem\u003e\u0026rdquo;\u003c/em\u003e\u003csup\u003e\u003cem\u003e23\u003c/em\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e2. \u0026lsquo;Work arounds\u0026rsquo; in the absence of professional interpreters\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.1 Language support from non-professional alternatives and specialist services\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003e\u0026ldquo;\u003c/em\u003e\u003cb\u003eThe doctor is American, but she speaks a little Spanish. I bring my children with me so they can translate. And otherwise, I\u0026rsquo;ll ask one of the women there\u0026hellip; But they don\u0026rsquo;t give me an interpreter or anything\u003c/b\u003e.\u0026rdquo; \u003csup\u003e97\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e2.2 Use of alternative communication strategies and good communication styles\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e\u0026ldquo;They spoke to us with friendliness and smiles and love. They measured us and measured our blood pressure and everything, they did it all with kindness, so I was happy about that.\u0026rdquo;\u003c/b\u003e \u003cem\u003e(Recent mother)\u003c/em\u003e \u003csup\u003e\u003cem\u003e\u003cspan citationid=\"CR72\" class=\"CitationRef\"\u003e72\u003c/span\u003e\u003c/em\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003e\u0026lsquo;\u0026hellip;women appreciated the fact that the Health Centre midwife recognised the need to speak slower, and allowed time for them to ask questions to ensure they had understood correctly\u003c/em\u003e, \u003cb\u003e\u0026lsquo;\u0026lsquo;she told me about pregnancy, about baby very carefully, and very slowly talk with me because my English not very strong, but I understand everything\u003c/b\u003e\u003cem\u003e\u0026rsquo;\u0026rsquo;\u0026rsquo;\u003c/em\u003e (woman 4). \u003csup\u003e148\u003c/sup\u003e\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\u003eIn the context of language barriers, the central mediators and influencing factors (1.1\u0026ndash;1.3; 2.1\u0026ndash;2.2), were distinct but interrelated, with areas of overlap between them. Each mediator, and their associated, affected how women experienced their interactions with and engagement in maternity services. These experiences, in turn, shaped women\u0026rsquo;s psychological and behavioural responses to maternity care. The nature of these experiences and responses led to different outcomes for women and their infants and families, with potentially beneficial or adverse implications for maternal and infant clinical and psychological safety.\u003c/p\u003e \u003cp\u003eThe five factors associated with each mediator (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e) resulted in positive or negative experiences and engagement with maternity systems. These experiences and engagements were interpreted as having either negative consequences (C) or positive benefits (B) for women and their families, identified in Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e. Each factor is numbered, i.e., Ci, Cii, Bi, and these are described in sections 3.1 and 3.2.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eConsequences and Benefits of Interactions with Maternity Care Mediated by Language Barriers\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\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 \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eConsequences of negative experiences and/or interactions with maternity services\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBenefits of positive experiences and/or interactions with maternity services\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e(Ci) Lack of understanding of host healthcare system and medical terminology\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e(Bi) Improved host language and healthcare system fluency, and community integration\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e(Cii) Reduced access to and disengagement from maternity care services\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e(Bii) Positive, culturally safe birth experiences\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e(Ciii) Isolation from wider community and negative self-perception, helplessness and dependence on others\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e(Biii) Supportive relationships with providers developed through continuity of care\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e(Civ) Risk to safety for mother and/or baby\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e(Cv) Lack of informed consent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e(Cvi) Perceptions of discrimination and racism\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e(Cvii) \u003cem\u003eAccessing care outside of formal host health systems\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eBenefits and consequences were not experienced by women in isolation nor were women\u0026rsquo;s perinatal journeys wholly positive or negative. Rather, positive and negative experiences often co-occurred, integrating with and influencing one another, leading to positive or negative outcomes. In the following sections, each mediator and its associated factors are described, and links to the resultant consequences (C) or benefits (B) are highlighted. In a later section (3. Consequences and Benefits), the consequences (3.1 Ci-Cvii) and benefits (3.2 Bi-Biii) experienced by women are described in more detail in which interactions and overlaps between different consequences and/or benefits, and their associations to mediating factors are highlighted.\u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003e \u003cb\u003eInteractions with professional interpreters\u003c/b\u003e \u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e \u003cp\u003eMost women expressed a need for an effective, appropriate, culturally competent and safe interpreter to support their interactions with maternity services in their host country. However, many women reported a lack of consistent provision of such support. Even when an interpreter was provided (whether professional or non-professional) there were concerns regarding trust, accuracy (including issues related to language proficiency and dialect), confidentiality, disclosure of sensitive issues, the gender of the interpreter, and disrespectful and unprofessional behaviour by interpreters. Across the included studies, most women reported being offered access to some form of interpreting service at some point during their perinatal journey. These included maternity specific interpreting teams or programmes, professional interpreters, and telephone interpreting services.\u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eAccess to an appropriate professional interpreter\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e \u003cp\u003eConfidence in Review Finding: high confidence\u003c/p\u003e \u003cp\u003eIn-person, professional interpretation services were not available for all appointments: women across 48 studies\u003csup\u003e\u003cspan citationid=\"CR67\" class=\"CitationRef\"\u003e67\u003c/span\u003e,\u003cspan citationid=\"CR68\" class=\"CitationRef\"\u003e68\u003c/span\u003e,\u003cspan citationid=\"CR70\" class=\"CitationRef\"\u003e70\u003c/span\u003e,\u003cspan additionalcitationids=\"CR73 CR74\" citationid=\"CR72\" class=\"CitationRef\"\u003e72\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR75\" class=\"CitationRef\"\u003e75\u003c/span\u003e,\u003cspan citationid=\"CR79\" class=\"CitationRef\"\u003e79\u003c/span\u003e,\u003cspan citationid=\"CR83\" class=\"CitationRef\"\u003e83\u003c/span\u003e,\u003cspan additionalcitationids=\"CR86 CR87 CR88\" citationid=\"CR85\" class=\"CitationRef\"\u003e85\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR89\" class=\"CitationRef\"\u003e89\u003c/span\u003e,\u003cspan citationid=\"CR92\" class=\"CitationRef\"\u003e92\u003c/span\u003e,\u003cspan citationid=\"CR94\" class=\"CitationRef\"\u003e94\u003c/span\u003e,\u003cspan citationid=\"CR95\" class=\"CitationRef\"\u003e95\u003c/span\u003e,\u003cspan citationid=\"CR97\" class=\"CitationRef\"\u003e97\u003c/span\u003e,\u003cspan citationid=\"CR98\" class=\"CitationRef\"\u003e98\u003c/span\u003e,\u003cspan citationid=\"CR101\" class=\"CitationRef\"\u003e101\u003c/span\u003e,\u003cspan additionalcitationids=\"CR105 CR106 CR107\" citationid=\"CR104\" class=\"CitationRef\"\u003e104\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR108\" class=\"CitationRef\"\u003e108\u003c/span\u003e,\u003cspan citationid=\"CR110\" class=\"CitationRef\"\u003e110\u003c/span\u003e,\u003cspan citationid=\"CR111\" class=\"CitationRef\"\u003e111\u003c/span\u003e,\u003cspan citationid=\"CR116\" class=\"CitationRef\"\u003e116\u003c/span\u003e,\u003cspan additionalcitationids=\"CR119\" citationid=\"CR118\" class=\"CitationRef\"\u003e118\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR120\" class=\"CitationRef\"\u003e120\u003c/span\u003e,\u003cspan citationid=\"CR123\" class=\"CitationRef\"\u003e123\u003c/span\u003e,\u003cspan additionalcitationids=\"CR126\" citationid=\"CR125\" class=\"CitationRef\"\u003e125\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR127\" class=\"CitationRef\"\u003e127\u003c/span\u003e,\u003cspan citationid=\"CR129\" class=\"CitationRef\"\u003e129\u003c/span\u003e,\u003cspan citationid=\"CR132\" class=\"CitationRef\"\u003e132\u003c/span\u003e,\u003cspan citationid=\"CR136\" class=\"CitationRef\"\u003e136\u003c/span\u003e,\u003cspan citationid=\"CR140\" class=\"CitationRef\"\u003e140\u003c/span\u003e,\u003cspan citationid=\"CR141\" class=\"CitationRef\"\u003e141\u003c/span\u003e,\u003cspan citationid=\"CR143\" class=\"CitationRef\"\u003e143\u003c/span\u003e,\u003cspan citationid=\"CR145\" class=\"CitationRef\"\u003e145\u003c/span\u003e,\u003cspan additionalcitationids=\"CR148 CR149\" citationid=\"CR147\" class=\"CitationRef\"\u003e147\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR150\" class=\"CitationRef\"\u003e150\u003c/span\u003e,\u003cspan citationid=\"CR153\" class=\"CitationRef\"\u003e153\u003c/span\u003e,\u003cspan citationid=\"CR155\" class=\"CitationRef\"\u003e155\u003c/span\u003e\u003c/sup\u003e described a lack of, or inconsistent provision. Inconsistency included expectations from HCP that spouses, family, or community members would be availability for interpretation in emergency appointments,\u003csup\u003e105\u003c/sup\u003e during labour/night-time\u003csup\u003e101\u003c/sup\u003e or during blood test and scan appointments\u003csup\u003e\u003cspan citationid=\"CR147\" class=\"CitationRef\"\u003e147\u003c/span\u003e\u003c/sup\u003e where professional interpreter services were not provided outside of what were considered \u0026lsquo;routine\u0026rsquo; maternity appointments. Some women reported being unaware that there was an interpreter service.\u003csup\u003e579,\u003cspan citationid=\"CR95\" class=\"CitationRef\"\u003e95\u003c/span\u003e,\u003cspan citationid=\"CR98\" class=\"CitationRef\"\u003e98\u003c/span\u003e,\u003cspan citationid=\"CR101\" class=\"CitationRef\"\u003e101\u003c/span\u003e,\u003cspan citationid=\"CR112\" class=\"CitationRef\"\u003e112\u003c/span\u003e,\u003cspan citationid=\"CR125\" class=\"CitationRef\"\u003e125\u003c/span\u003e,\u003cspan citationid=\"CR134\" class=\"CitationRef\"\u003e134\u003c/span\u003e,\u003cspan citationid=\"CR144\" class=\"CitationRef\"\u003e144\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eThis inconsistent offering and availability of professional interpreters increased communication barriers and reduced opportunities for effective communication (Cii: reduced access to and disengagement from services; Ciii: isolation and negative self-perception).\u003c/p\u003e \u003cp\u003eWomen with some fluency in the host language sometimes reported finding it difficult to express themselves in the context of medical terminology around pregnancy, and during periods of increased physiological stress (i.e., during labour)\u003csup\u003e\u003cspan citationid=\"CR84\" class=\"CitationRef\"\u003e84\u003c/span\u003e,\u003cspan citationid=\"CR106\" class=\"CitationRef\"\u003e106\u003c/span\u003e,\u003cspan citationid=\"CR122\" class=\"CitationRef\"\u003e122\u003c/span\u003e\u003c/sup\u003e. Women described that when HCP considered them proficient in the host language, interpreters were not always involved in supporting their care\u003csup\u003e\u003cspan citationid=\"CR84\" class=\"CitationRef\"\u003e84\u003c/span\u003e,\u003cspan citationid=\"CR122\" class=\"CitationRef\"\u003e122\u003c/span\u003e\u003c/sup\u003e. It is unclear from the data if women declined or were not offered interpreting based on a perceived lack of need by the HCPs caring for them. (Ci: lack of understanding of host healthcare system and medical terminology; Cii: reduced access to maternity services; Cv: lack of informed consent).\u003c/p\u003e \u003cp\u003eThe availability of professional interpreters either supported or hindered access to care throughout the perinatal journey (Cii: reduced access or disengagement from maternity services; Ciii: isolation and negative self-perception). When available, access to professional interpreters also supported women\u0026rsquo;s understanding of their care and rationale for ongoing antenatal and intrapartum clinical decision making\u003csup\u003e\u003cspan citationid=\"CR110\" class=\"CitationRef\"\u003e110\u003c/span\u003e,\u003cspan citationid=\"CR150\" class=\"CitationRef\"\u003e150\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003ePositive and negative impacts of interactions with professional interpreters was highlighted throughout women\u0026rsquo;s perinatal journeys. Some studies highlighted that even competent professional interpreters could create a barrier to sensitive communication and relationship building between a woman and her healthcare professionals, e.g., where women felt it challenging to have communication across several people\u003csup\u003e\u003cspan citationid=\"CR68\" class=\"CitationRef\"\u003e68\u003c/span\u003e,\u003cspan citationid=\"CR74\" class=\"CitationRef\"\u003e74\u003c/span\u003e,\u003cspan citationid=\"CR75\" class=\"CitationRef\"\u003e75\u003c/span\u003e,\u003cspan citationid=\"CR111\" class=\"CitationRef\"\u003e111\u003c/span\u003e\u003c/sup\u003e, where they felt that the interpreter was translating their words, but not their worries or emotions\u003csup\u003e\u003cspan citationid=\"CR153\" class=\"CitationRef\"\u003e153\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eProfessional interpreters were sometimes refused by women, reportedly because of a lack of trust in the interpreter or a lack of trust or understanding about interpreter service provision (e.g.., fear of cost), as well as the impact of having a third-party present for confidential and sensitive conversations\u003csup\u003e\u003cspan citationid=\"CR88\" class=\"CitationRef\"\u003e88\u003c/span\u003e,\u003cspan citationid=\"CR129\" class=\"CitationRef\"\u003e129\u003c/span\u003e,\u003cspan citationid=\"CR143\" class=\"CitationRef\"\u003e143\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eOne study suggested that HCPs and interpreter did not always work well together\u003csup\u003e\u003cspan citationid=\"CR126\" class=\"CitationRef\"\u003e126\u003c/span\u003e\u003c/sup\u003e, with too much information from HCP, and little checking by interpreters that women understood it\u003csup\u003e83,125,155\u003c/sup\u003e (Civ: risk to safety; Cv: lack of informed consent).\u003c/p\u003e \u003cp\u003eSome women who used professional interpreter services had concerns about potential breaches of confidentiality. \u003csup\u003e68,101,108,110,119,123,141,144\u003c/sup\u003eThis was especially relevant for women from smaller ethnic communities who were concerned that sensitive information, such as mental health issues, would be shared with their community locally, or in their home country\u003csup\u003e\u003cspan citationid=\"CR68\" class=\"CitationRef\"\u003e68\u003c/span\u003e,\u003cspan citationid=\"CR77\" class=\"CitationRef\"\u003e77\u003c/span\u003e,\u003cspan citationid=\"CR108\" class=\"CitationRef\"\u003e108\u003c/span\u003e,\u003cspan citationid=\"CR147\" class=\"CitationRef\"\u003e147\u003c/span\u003e\u003c/sup\u003e. The worry was that this could reflect badly on them within their communities, or increase perceived risks to themselves or their families, particularly where there were concerns about surveillance by authorities in their home country\u003csup\u003e\u003cspan citationid=\"CR68\" class=\"CitationRef\"\u003e68\u003c/span\u003e,\u003cspan citationid=\"CR73\" class=\"CitationRef\"\u003e73\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eSome studies discussed the perceived lack of confidentiality as an issue effecting truthfulness in consultations; women felt embarrassment answering questions about more taboo topics, such as abuse or violence, and were more hesitant to answer openly\u003csup\u003e\u003cspan citationid=\"CR94\" class=\"CitationRef\"\u003e94\u003c/span\u003e,\u003cspan citationid=\"CR108\" class=\"CitationRef\"\u003e108\u003c/span\u003e,\u003cspan citationid=\"CR125\" class=\"CitationRef\"\u003e125\u003c/span\u003e,\u003cspan citationid=\"CR147\" class=\"CitationRef\"\u003e147\u003c/span\u003e\u003c/sup\u003e. Studies suggested this could be ameliorated where interpreters had appropriate experience or training, or some self-completion of forms by parents could provide additional confidentiality between a woman and her care provider.\u003csup\u003e\u003cspan citationid=\"CR94\" class=\"CitationRef\"\u003e94\u003c/span\u003e,\u003cspan citationid=\"CR125\" class=\"CitationRef\"\u003e125\u003c/span\u003e,\u003cspan citationid=\"CR141\" class=\"CitationRef\"\u003e141\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eThere appeared to be little choice reported in the data in relation to who the interpreter was\u003csup\u003e\u003cspan citationid=\"CR68\" class=\"CitationRef\"\u003e68\u003c/span\u003e,\u003cspan citationid=\"CR123\" class=\"CitationRef\"\u003e123\u003c/span\u003e\u003c/sup\u003e although in one study when there was concern about ineffective interpreting, two women reported that their midwives changed the interpreter.\u003csup\u003e\u003cspan citationid=\"CR125\" class=\"CitationRef\"\u003e125\u003c/span\u003e\u003c/sup\u003e Women expressed frustration when they perceived interpreters were changing their words or were not reliable in their interpretations, leading to a reluctance of repeating the experience, and questioned their interpreter\u0026rsquo;s abilities or willingness to translate accurately.\u003csup\u003e\u003cspan citationid=\"CR73\" class=\"CitationRef\"\u003e73\u003c/span\u003e,\u003cspan citationid=\"CR110\" class=\"CitationRef\"\u003e110\u003c/span\u003e,\u003cspan citationid=\"CR111\" class=\"CitationRef\"\u003e111\u003c/span\u003e,\u003cspan citationid=\"CR123\" class=\"CitationRef\"\u003e123\u003c/span\u003e,\u003cspan citationid=\"CR129\" class=\"CitationRef\"\u003e129\u003c/span\u003e,\u003cspan citationid=\"CR143\" class=\"CitationRef\"\u003e143\u003c/span\u003e\u003c/sup\u003e One study\u003csup\u003e\u003cspan citationid=\"CR73\" class=\"CitationRef\"\u003e73\u003c/span\u003e\u003c/sup\u003e described that the interpreter had an inadequate knowledge of maternity terminology and felt that this could impact on their safety (Civ: risk to safety). Women also raised the issue of unprofessional behaviour among a small number of interpreters, including rudeness, ignoring women, and providing unsolicited advice or directing women\u0026rsquo;s responses\u003csup\u003e\u003cspan citationid=\"CR68\" class=\"CitationRef\"\u003e68\u003c/span\u003e,\u003cspan citationid=\"CR73\" class=\"CitationRef\"\u003e73\u003c/span\u003e,\u003cspan citationid=\"CR100\" class=\"CitationRef\"\u003e100\u003c/span\u003e,\u003cspan citationid=\"CR110\" class=\"CitationRef\"\u003e110\u003c/span\u003e,\u003cspan citationid=\"CR111\" class=\"CitationRef\"\u003e111\u003c/span\u003e,\u003cspan citationid=\"CR120\" class=\"CitationRef\"\u003e120\u003c/span\u003e,\u003cspan citationid=\"CR123\" class=\"CitationRef\"\u003e123\u003c/span\u003e,\u003cspan citationid=\"CR125\" class=\"CitationRef\"\u003e125\u003c/span\u003e,\u003cspan citationid=\"CR143\" class=\"CitationRef\"\u003e143\u003c/span\u003e\u003c/sup\u003e. Such behaviours were perceived as undermining respectful and safe care.\u003c/p\u003e \u003cp\u003eSome studies described that the interpretation services provided were not always understandable to women.\u003csup\u003e\u003cspan citationid=\"CR73\" class=\"CitationRef\"\u003e73\u003c/span\u003e,\u003cspan citationid=\"CR91\" class=\"CitationRef\"\u003e91\u003c/span\u003e,\u003cspan citationid=\"CR107\" class=\"CitationRef\"\u003e107\u003c/span\u003e,\u003cspan citationid=\"CR116\" class=\"CitationRef\"\u003e116\u003c/span\u003e,\u003cspan citationid=\"CR123\" class=\"CitationRef\"\u003e123\u003c/span\u003e,\u003cspan citationid=\"CR125\" class=\"CitationRef\"\u003e125\u003c/span\u003e,\u003cspan citationid=\"CR138\" class=\"CitationRef\"\u003e138\u003c/span\u003e,\u003cspan citationid=\"CR151\" class=\"CitationRef\"\u003e151\u003c/span\u003e,\u003cspan citationid=\"CR153\" class=\"CitationRef\"\u003e153\u003c/span\u003e,\u003cspan citationid=\"CR155\" class=\"CitationRef\"\u003e155\u003c/span\u003e\u003c/sup\u003e This included situations in which interpreters or family members explained procedures (see also mediator 2.1 \u0026ndash; language support from non-professional alternatives and specialist services), yet women still did not fully understand what was communicated, particularly when they were new to the country\u003csup\u003e\u003cspan citationid=\"CR66\" class=\"CitationRef\"\u003e66\u003c/span\u003e,\u003cspan citationid=\"CR79\" class=\"CitationRef\"\u003e79\u003c/span\u003e,\u003cspan citationid=\"CR86\" class=\"CitationRef\"\u003e86\u003c/span\u003e,\u003cspan citationid=\"CR89\" class=\"CitationRef\"\u003e89\u003c/span\u003e,\u003cspan citationid=\"CR108\" class=\"CitationRef\"\u003e108\u003c/span\u003e,\u003cspan citationid=\"CR140\" class=\"CitationRef\"\u003e140\u003c/span\u003e,\u003cspan citationid=\"CR147\" class=\"CitationRef\"\u003e147\u003c/span\u003e,\u003cspan citationid=\"CR153\" class=\"CitationRef\"\u003e153\u003c/span\u003e\u003c/sup\u003e. Differences in dialect influenced understanding of interpretation.\u003csup\u003e\u003cspan citationid=\"CR68\" class=\"CitationRef\"\u003e68\u003c/span\u003e,\u003cspan citationid=\"CR73\" class=\"CitationRef\"\u003e73\u003c/span\u003e,\u003cspan citationid=\"CR107\" class=\"CitationRef\"\u003e107\u003c/span\u003e,\u003cspan citationid=\"CR123\" class=\"CitationRef\"\u003e123\u003c/span\u003e,\u003cspan citationid=\"CR147\" class=\"CitationRef\"\u003e147\u003c/span\u003e\u003c/sup\u003e For example, dialects differed between Arab countries, and across different regions within countries, meaning that women and interpreters did not always share the same linguist nuances and words can carry different cultural meanings when used by individuals from different countries, and non-verbal gestures accompanying speech could also vary leading to misunderstandings\u003csup\u003e\u003cspan citationid=\"CR68\" class=\"CitationRef\"\u003e68\u003c/span\u003e,\u003cspan citationid=\"CR72\" class=\"CitationRef\"\u003e72\u003c/span\u003e,\u003cspan citationid=\"CR73\" class=\"CitationRef\"\u003e73\u003c/span\u003e,\u003cspan citationid=\"CR107\" class=\"CitationRef\"\u003e107\u003c/span\u003e,\u003cspan citationid=\"CR122\" class=\"CitationRef\"\u003e122\u003c/span\u003e,\u003cspan citationid=\"CR129\" class=\"CitationRef\"\u003e129\u003c/span\u003e,\u003cspan citationid=\"CR147\" class=\"CitationRef\"\u003e147\u003c/span\u003e,\u003cspan citationid=\"CR153\" class=\"CitationRef\"\u003e153\u003c/span\u003e\u003c/sup\u003e (Ci: lack of understanding of host healthcare system and medical terminology; Cii: reduced access to care and disengagement from services; Civ: risk to safety; Cv: lack of informed consent; Cvii: accessing care outside of health systems).\u003c/p\u003e \u003cp\u003eSimilarly, women were not always able to choose their interpreter in relation to preferred gender, with several studies\u003csup\u003e\u003cspan citationid=\"CR68\" class=\"CitationRef\"\u003e68\u003c/span\u003e,\u003cspan citationid=\"CR73\" class=\"CitationRef\"\u003e73\u003c/span\u003e,\u003cspan citationid=\"CR119\" class=\"CitationRef\"\u003e119\u003c/span\u003e,\u003cspan citationid=\"CR123\" class=\"CitationRef\"\u003e123\u003c/span\u003e,\u003cspan citationid=\"CR125\" class=\"CitationRef\"\u003e125\u003c/span\u003e,\u003cspan citationid=\"CR143\" class=\"CitationRef\"\u003e143\u003c/span\u003e,\u003cspan citationid=\"CR147\" class=\"CitationRef\"\u003e147\u003c/span\u003e,\u003cspan citationid=\"CR155\" class=\"CitationRef\"\u003e155\u003c/span\u003e\u003c/sup\u003e reporting that having a male interpreter often made women uncomfortable and reluctant to discuss sensitive or culturally taboo topics. This made women less likely to voice concerns, and limited information exchange with HCPs regarding their feelings, clinical history, and situations\u003csup\u003e\u003cspan citationid=\"CR68\" class=\"CitationRef\"\u003e68\u003c/span\u003e,\u003cspan citationid=\"CR73\" class=\"CitationRef\"\u003e73\u003c/span\u003e,\u003cspan citationid=\"CR86\" class=\"CitationRef\"\u003e86\u003c/span\u003e,\u003cspan citationid=\"CR92\" class=\"CitationRef\"\u003e92\u003c/span\u003e,\u003cspan citationid=\"CR147\" class=\"CitationRef\"\u003e147\u003c/span\u003e,\u003cspan citationid=\"CR153\" class=\"CitationRef\"\u003e153\u003c/span\u003e,\u003cspan citationid=\"CR155\" class=\"CitationRef\"\u003e155\u003c/span\u003e\u003c/sup\u003e (Cii: reduced access to and disengagement from maternity services; Civ: risk to safety). There was a concern that HCPs may not recognise women\u0026rsquo;s discomfort, and that the presence of a male interpreter could limit a woman\u0026rsquo;s ability to maintain culturally appropriate norms of modesty, particularly during childbirth\u003csup\u003e\u003cspan citationid=\"CR143\" class=\"CitationRef\"\u003e143\u003c/span\u003e,\u003cspan citationid=\"CR147\" class=\"CitationRef\"\u003e147\u003c/span\u003e\u003c/sup\u003e. However, it is important to highlight that not all women expressed concern at having a male interpreter on the basis of having a professional and effective language support\u003csup\u003e\u003cspan citationid=\"CR125\" class=\"CitationRef\"\u003e125\u003c/span\u003e,\u003cspan citationid=\"CR149\" class=\"CitationRef\"\u003e149\u003c/span\u003e\u003c/sup\u003e (Bii: supportive relationships developed with providers).\u003c/p\u003e \u003cp\u003eWomen with language barriers had additional financial and psychological pressures compared to those without\u003csup\u003e\u003cspan citationid=\"CR67\" class=\"CitationRef\"\u003e67\u003c/span\u003e,\u003cspan citationid=\"CR68\" class=\"CitationRef\"\u003e68\u003c/span\u003e,\u003cspan citationid=\"CR87\" class=\"CitationRef\"\u003e87\u003c/span\u003e,\u003cspan citationid=\"CR101\" class=\"CitationRef\"\u003e101\u003c/span\u003e,\u003cspan citationid=\"CR103\" class=\"CitationRef\"\u003e103\u003c/span\u003e,\u003cspan citationid=\"CR118\" class=\"CitationRef\"\u003e118\u003c/span\u003e,\u003cspan citationid=\"CR122\" class=\"CitationRef\"\u003e122\u003c/span\u003e,\u003cspan citationid=\"CR142\" class=\"CitationRef\"\u003e142\u003c/span\u003e,\u003cspan citationid=\"CR149\" class=\"CitationRef\"\u003e149\u003c/span\u003e\u003c/sup\u003e. Some were hesitant to try to access interpreters as they were uncertain about potential costs.\u003csup\u003e\u003cspan citationid=\"CR125\" class=\"CitationRef\"\u003e125\u003c/span\u003e,\u003cspan citationid=\"CR126\" class=\"CitationRef\"\u003e126\u003c/span\u003e,\u003cspan citationid=\"CR128\" class=\"CitationRef\"\u003e128\u003c/span\u003e,\u003cspan citationid=\"CR131\" class=\"CitationRef\"\u003e131\u003c/span\u003e\u003c/sup\u003e One woman reported refusing interpreter services which required payment.\u003csup\u003e\u003cspan citationid=\"CR105\" class=\"CitationRef\"\u003e105\u003c/span\u003e\u003c/sup\u003e A few women further reported being asked to return for appointments if interpreters were not available, wasting both time and effort and potentially having increased transport cost implications.\u003csup\u003e\u003cspan citationid=\"CR108\" class=\"CitationRef\"\u003e108\u003c/span\u003e,\u003cspan citationid=\"CR125\" class=\"CitationRef\"\u003e125\u003c/span\u003e,\u003cspan citationid=\"CR127\" class=\"CitationRef\"\u003e127\u003c/span\u003e\u003c/sup\u003e These wasted/return journeys may also contribute to barriers to accessing and/or continuing maternity care (Cii: reduced access to and disengagement from maternity care; Civ: increasing risk to maternal and infant safety).\u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003e \u003cb\u003ePositive relationships and interactions with professional interpreters.\u003c/b\u003e \u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e \u003cp\u003eConfidence in Review Finding: moderate confidence (minor concerns regarding adequacy, because of limited data within the included studies, and how much the included studies focused on research questions, which are specific to this review finding.)\u003c/p\u003e \u003cp\u003eA smaller number of studies reported that women appreciated and had positive working relationships with the professional interpreting services they were offered. \u003csup\u003e69,75,77,106,111,150\u003c/sup\u003eFor many, these professional interpreters were able to maintain confidentiality, interpret accurately, and foster feelings of respect, safety and security among women accessing maternity care.\u003c/p\u003e \u003cp\u003eThe interpreter's role was multidimensional and at times complex\u003csup\u003e\u003cspan citationid=\"CR68\" class=\"CitationRef\"\u003e68\u003c/span\u003e,\u003cspan citationid=\"CR69\" class=\"CitationRef\"\u003e69\u003c/span\u003e,\u003cspan citationid=\"CR126\" class=\"CitationRef\"\u003e126\u003c/span\u003e,\u003cspan citationid=\"CR148\" class=\"CitationRef\"\u003e148\u003c/span\u003e\u003c/sup\u003e; in some cases, women built important relationships with interpreters who acted as advocates; playing an important role in emotionally supporting and providing companionship as well as perceived effective interpretation\u003csup\u003e\u003cspan citationid=\"CR69\" class=\"CitationRef\"\u003e69\u003c/span\u003e\u003c/sup\u003e (Bii: supportive relationships developed through continuity of care).\u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003e \u003cb\u003eUse of telephone interpreting and other translation or interpreter medium.\u003c/b\u003e \u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e \u003cp\u003eConfidence in Review Finding: high confidence\u003c/p\u003e \u003cp\u003eAcross the included studies, preferences regarding the mode of interpretation were mixed. One study reported no clear preference regarding the medium used\u003csup\u003e\u003cspan citationid=\"CR91\" class=\"CitationRef\"\u003e91\u003c/span\u003e\u003c/sup\u003e (online, telephone, in-person interpretation). In contrast, another study described the specific benefits of in-person interpretation, suggesting it facilitated effective communication and rapport.\u003csup\u003e\u003cspan citationid=\"CR123\" class=\"CitationRef\"\u003e123\u003c/span\u003e\u003c/sup\u003e In-person interpreters allowed for more comprehensive understanding and relationship building resulting in more effective communication. The addition of body language and their presence helped to build trust, and greater understanding of a woman\u0026rsquo;s emotional condition, as opposed to interpretation over telephone, or video where the emotional state of a woman may not come across as clearly. \u003csup\u003e65,123\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eWomen expressed concern about using the telephone to book, be informed of appointments or seek help.\u003csup\u003e\u003cspan citationid=\"CR79\" class=\"CitationRef\"\u003e79\u003c/span\u003e,\u003cspan citationid=\"CR123\" class=\"CitationRef\"\u003e123\u003c/span\u003e\u003c/sup\u003e This impacts women\u0026rsquo;s access to both standard care, and care in an emergency, (Cii: reduced access to or disengagement from maternity services). Women expressed a need for written information in their own language.\u003csup\u003e\u003cspan citationid=\"CR65\" class=\"CitationRef\"\u003e65\u003c/span\u003e,\u003cspan citationid=\"CR69\" class=\"CitationRef\"\u003e69\u003c/span\u003e,\u003cspan citationid=\"CR70\" class=\"CitationRef\"\u003e70\u003c/span\u003e,\u003cspan citationid=\"CR72\" class=\"CitationRef\"\u003e72\u003c/span\u003e,\u003cspan citationid=\"CR77\" class=\"CitationRef\"\u003e77\u003c/span\u003e,\u003cspan citationid=\"CR79\" class=\"CitationRef\"\u003e79\u003c/span\u003e,\u003cspan citationid=\"CR84\" class=\"CitationRef\"\u003e84\u003c/span\u003e,\u003cspan citationid=\"CR91\" class=\"CitationRef\"\u003e91\u003c/span\u003e,\u003cspan citationid=\"CR93\" class=\"CitationRef\"\u003e93\u003c/span\u003e,\u003cspan citationid=\"CR108\" class=\"CitationRef\"\u003e108\u003c/span\u003e,\u003cspan citationid=\"CR110\" class=\"CitationRef\"\u003e110\u003c/span\u003e,\u003cspan citationid=\"CR135\" class=\"CitationRef\"\u003e135\u003c/span\u003e,\u003cspan citationid=\"CR136\" class=\"CitationRef\"\u003e136\u003c/span\u003e,\u003cspan citationid=\"CR144\" class=\"CitationRef\"\u003e144\u003c/span\u003e,\u003cspan citationid=\"CR153\" class=\"CitationRef\"\u003e153\u003c/span\u003e\u003c/sup\u003e In some settings, non-\u0026lsquo;Westernised\u0026rsquo; accents were highlighted as a unique barrier to accessing care, impacting on women\u0026rsquo;s feeling of a lack of respectful care from the healthcare system\u003csup\u003e\u003cspan citationid=\"CR106\" class=\"CitationRef\"\u003e106\u003c/span\u003e\u003c/sup\u003e (Cvi). Perceptions of discrimination and racism). Some women expressed frustrations around the lack of translated materials or the extra effort it took to understand information which was only provided in the host language\u003csup\u003e\u003cspan citationid=\"CR65\" class=\"CitationRef\"\u003e65\u003c/span\u003e,\u003cspan citationid=\"CR71\" class=\"CitationRef\"\u003e71\u003c/span\u003e,\u003cspan citationid=\"CR72\" class=\"CitationRef\"\u003e72\u003c/span\u003e,\u003cspan citationid=\"CR86\" class=\"CitationRef\"\u003e86\u003c/span\u003e,\u003cspan citationid=\"CR135\" class=\"CitationRef\"\u003e135\u003c/span\u003e,\u003cspan citationid=\"CR138\" class=\"CitationRef\"\u003e138\u003c/span\u003e,\u003cspan citationid=\"CR153\" class=\"CitationRef\"\u003e153\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eMore broadly, several studies indicated a preference for direct, personal explanation over alternative formats such as videos, mobile app or written leaflets.\u003csup\u003e\u003cspan citationid=\"CR65\" class=\"CitationRef\"\u003e65\u003c/span\u003e,\u003cspan citationid=\"CR73\" class=\"CitationRef\"\u003e73\u003c/span\u003e,\u003cspan citationid=\"CR110\" class=\"CitationRef\"\u003e110\u003c/span\u003e,\u003cspan citationid=\"CR115\" class=\"CitationRef\"\u003e115\u003c/span\u003e,\u003cspan citationid=\"CR144\" class=\"CitationRef\"\u003e144\u003c/span\u003e\u003c/sup\u003e One study did note that \u003cem\u003e\u0026lsquo;providing information in two ways enhanced understanding\u0026rsquo;\u003c/em\u003e,\u003csup\u003e\u003cem\u003e73\u003c/em\u003e\u003c/sup\u003e indicating that a combined approach might be beneficial. There were contrasting experiences within and between studies, with a few women reporting that some clinics had provided them with satisfactory information in their preferred language\u003csup\u003e\u003cspan citationid=\"CR65\" class=\"CitationRef\"\u003e65\u003c/span\u003e,\u003cspan citationid=\"CR110\" class=\"CitationRef\"\u003e110\u003c/span\u003e\u003c/sup\u003e as well as through mobile apps and websites\u003csup\u003e\u003cspan citationid=\"CR73\" class=\"CitationRef\"\u003e73\u003c/span\u003e,\u003cspan citationid=\"CR81\" class=\"CitationRef\"\u003e81\u003c/span\u003e,\u003cspan citationid=\"CR82\" class=\"CitationRef\"\u003e82\u003c/span\u003e,\u003cspan citationid=\"CR116\" class=\"CitationRef\"\u003e116\u003c/span\u003e,\u003cspan citationid=\"CR130\" class=\"CitationRef\"\u003e130\u003c/span\u003e\u003c/sup\u003e. Pictures and images were described as helpful ways of increasing understanding\u003csup\u003e\u003cspan citationid=\"CR73\" class=\"CitationRef\"\u003e73\u003c/span\u003e,\u003cspan citationid=\"CR78\" class=\"CitationRef\"\u003e78\u003c/span\u003e,\u003cspan citationid=\"CR79\" class=\"CitationRef\"\u003e79\u003c/span\u003e,\u003cspan citationid=\"CR150\" class=\"CitationRef\"\u003e150\u003c/span\u003e\u003c/sup\u003e usually when used as complementary to each other\u003csup\u003e\u003cspan citationid=\"CR73\" class=\"CitationRef\"\u003e73\u003c/span\u003e\u003c/sup\u003e (see also 2.2: Work-arounds - Use of alternative communication strategies and good communication styles).\u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003e \u003cb\u003e\u0026lsquo;Work arounds\u0026rsquo; in the absence of professional interpreter\u003c/b\u003e \u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e \u003cp\u003eWhere language and communication barriers remained, either due to lack of professional or non-professional interpreters, or due to a mismatch between the required language/dialect and that provided by the interpreter, women and their HCPs often worked in different and creative ways to overcome these barriers. In Fig.\u0026nbsp;\u003cspan refid=\"Fig6\" class=\"InternalRef\"\u003e3\u003c/span\u003e and Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e these \u0026ldquo;Workarounds\u0026rdquo; were synthesised as language support from non-professional alternatives and specialist services (2.1) and the use of alternative communication strategies and good communication styles (2.2).\u003c/p\u003e \u003cp\u003e \u003cb\u003e2.1 Language support from non-professional alternatives and specialist services.\u003c/b\u003e \u003c/p\u003e \u003cp\u003eConfidence in Review Finding: high confidence\u003c/p\u003e \u003cp\u003eSeveral studies reported that women actively sought care from HCPs who spoke their language or shared similar cultural backgrounds.\u003csup\u003e\u003cspan citationid=\"CR68\" class=\"CitationRef\"\u003e68\u003c/span\u003e,\u003cspan citationid=\"CR77\" class=\"CitationRef\"\u003e77\u003c/span\u003e,\u003cspan citationid=\"CR79\" class=\"CitationRef\"\u003e79\u003c/span\u003e,\u003cspan citationid=\"CR123\" class=\"CitationRef\"\u003e123\u003c/span\u003e\u003c/sup\u003e This was a strategy described to circumvent the need for professional interpreters or to avoid relying on family members for interpretation. The development of trusting relationships was closely linked to cultural and linguistic congruence between women and either interpreters or HCPs\u003csup\u003e\u003cspan citationid=\"CR77\" class=\"CitationRef\"\u003e77\u003c/span\u003e,\u003cspan citationid=\"CR104\" class=\"CitationRef\"\u003e104\u003c/span\u003e,\u003cspan citationid=\"CR153\" class=\"CitationRef\"\u003e153\u003c/span\u003e\u003c/sup\u003e. Continuity of care further supported these relationships, enabling greater familiarity, improved communication, and increased comfort over time\u003csup\u003e\u003cspan citationid=\"CR72\" class=\"CitationRef\"\u003e72\u003c/span\u003e,\u003cspan citationid=\"CR77\" class=\"CitationRef\"\u003e77\u003c/span\u003e,\u003cspan citationid=\"CR91\" class=\"CitationRef\"\u003e91\u003c/span\u003e,\u003cspan citationid=\"CR123\" class=\"CitationRef\"\u003e123\u003c/span\u003e,\u003cspan citationid=\"CR148\" class=\"CitationRef\"\u003e148\u003c/span\u003e\u003c/sup\u003e (Bii: supportive relationships with providers developed through continuity of care).\u003c/p\u003e \u003cp\u003eA further workaround reported across studies was the use of bilingual staff when professional interpreters were unavailable.\u003csup\u003e\u003cspan citationid=\"CR68\" class=\"CitationRef\"\u003e68\u003c/span\u003e,\u003cspan citationid=\"CR77\" class=\"CitationRef\"\u003e77\u003c/span\u003e,\u003cspan citationid=\"CR79\" class=\"CitationRef\"\u003e79\u003c/span\u003e,\u003cspan citationid=\"CR100\" class=\"CitationRef\"\u003e100\u003c/span\u003e,\u003cspan citationid=\"CR140\" class=\"CitationRef\"\u003e140\u003c/span\u003e,\u003cspan citationid=\"CR143\" class=\"CitationRef\"\u003e143\u003c/span\u003e,\u003cspan citationid=\"CR155\" class=\"CitationRef\"\u003e155\u003c/span\u003e\u003c/sup\u003e In these instances, HCPS who spoke relevant languages were called upon to facilitate communication. While this approach was sometimes welcomed, it was typically limited to commonly spoken local languages and therefore not universally accessible. The ability of HCPs to speak more than one language was thus positioned as both a pragmatic response to gaps in interpreter provision and, in some cases, a facilitator of culturally safe care. However, while linguistic and cultural concordance could contribute to more positive maternity experiences, (Bii: positive culturally safe birth experiences) this was not the experience or opinion of all women and may add additional burden on some staff in an already stretched maternity care ecosystem.\u003c/p\u003e \u003cp\u003eWhile many women described the challenge of accessing suitable interpreters\u003csup\u003e\u003cspan citationid=\"CR149\" class=\"CitationRef\"\u003e149\u003c/span\u003e\u003c/sup\u003e (1.1) two specialist services for refugee women reported always having access to interpreters\u003csup\u003e\u003cspan citationid=\"CR85\" class=\"CitationRef\"\u003e85\u003c/span\u003e,\u003cspan citationid=\"CR131\" class=\"CitationRef\"\u003e131\u003c/span\u003e\u003c/sup\u003e. Some women preferred to take their own \u0026lsquo;trusted\u0026rsquo; interpreter, often family or friends, with them to appointments or when giving birth.\u003csup\u003e\u003cspan citationid=\"CR93\" class=\"CitationRef\"\u003e93\u003c/span\u003e,\u003cspan citationid=\"CR110\" class=\"CitationRef\"\u003e110\u003c/span\u003e,\u003cspan citationid=\"CR112\" class=\"CitationRef\"\u003e112\u003c/span\u003e,\u003cspan citationid=\"CR123\" class=\"CitationRef\"\u003e123\u003c/span\u003e,\u003cspan citationid=\"CR132\" class=\"CitationRef\"\u003e132\u003c/span\u003e,\u003cspan citationid=\"CR143\" class=\"CitationRef\"\u003e143\u003c/span\u003e\u003c/sup\u003e Those who preferred friends and family to act as interpreters highlighted the importance of having someone they trusted with them in potentially vulnerable situations. Some women perceived a general expectation from HCPs that they should provide their own interpreter\u003csup\u003e\u003cspan citationid=\"CR79\" class=\"CitationRef\"\u003e79\u003c/span\u003e,\u003cspan citationid=\"CR98\" class=\"CitationRef\"\u003e98\u003c/span\u003e\u003c/sup\u003e, and a few recounted being specifically asked to bring someone to interpret\u003csup\u003e\u003cspan citationid=\"CR79\" class=\"CitationRef\"\u003e79\u003c/span\u003e,\u003cspan citationid=\"CR86\" class=\"CitationRef\"\u003e86\u003c/span\u003e,\u003cspan citationid=\"CR100\" class=\"CitationRef\"\u003e100\u003c/span\u003e,\u003cspan citationid=\"CR147\" class=\"CitationRef\"\u003e147\u003c/span\u003e\u003c/sup\u003e or having their partners asked to interpret\u003csup\u003e\u003cspan citationid=\"CR80\" class=\"CitationRef\"\u003e80\u003c/span\u003e,\u003cspan citationid=\"CR126\" class=\"CitationRef\"\u003e126\u003c/span\u003e,\u003cspan citationid=\"CR140\" class=\"CitationRef\"\u003e140\u003c/span\u003e,\u003cspan citationid=\"CR148\" class=\"CitationRef\"\u003e148\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eWhether women chose to bring a trusted person or were pressured into providing their own interpreter, having the use of non-professional interpreters raised many issues. These included inaccurate interpretation due to limited language fluency and insufficient understanding of medical terminology, as well as difficulties in interpreting impartially, such as withholding information or inserting personal opinions\u003csup\u003e\u003cspan citationid=\"CR69\" class=\"CitationRef\"\u003e69\u003c/span\u003e,\u003cspan citationid=\"CR84\" class=\"CitationRef\"\u003e84\u003c/span\u003e\u003c/sup\u003e. In addition, some non-professional interpreters lacked a clear understanding of the issues being discussed. Some women were unhappy about having non-professional interpreters for a variety of practical and ethical reasons\u003csup\u003e\u003cspan citationid=\"CR79\" class=\"CitationRef\"\u003e79\u003c/span\u003e,\u003cspan citationid=\"CR100\" class=\"CitationRef\"\u003e100\u003c/span\u003e,\u003cspan citationid=\"CR108\" class=\"CitationRef\"\u003e108\u003c/span\u003e,\u003cspan citationid=\"CR123\" class=\"CitationRef\"\u003e123\u003c/span\u003e,\u003cspan citationid=\"CR132\" class=\"CitationRef\"\u003e132\u003c/span\u003e,\u003cspan citationid=\"CR141\" class=\"CitationRef\"\u003e141\u003c/span\u003e,\u003cspan citationid=\"CR147\" class=\"CitationRef\"\u003e147\u003c/span\u003e\u003c/sup\u003e. Ethical concerns included reduced participation in decision-making and compromised informed consent (Cv), as well as the appropriateness and effectiveness of interpretation. Similar issues were identified across both professional and non-professional interpreters (see 2.1, language support from non-professionals; including Cii: reduced access to and disengagement from maternity care services; Civ: isolation and negative self-perception; Cv: lack of informed consent; Civ: risk to safety for mother and baby).\u003c/p\u003e \u003cp\u003eAnother issue was the imbalance of power and control when partners agreed, offered or insisted on interpreting for their partner or that they should manage without professional services\u003csup\u003e\u003cspan citationid=\"CR123\" class=\"CitationRef\"\u003e123\u003c/span\u003e\u003c/sup\u003e. Some women felt this increased dependency within relationships\u003csup\u003e\u003cspan citationid=\"CR65\" class=\"CitationRef\"\u003e65\u003c/span\u003e,\u003cspan citationid=\"CR72\" class=\"CitationRef\"\u003e72\u003c/span\u003e,\u003cspan citationid=\"CR80\" class=\"CitationRef\"\u003e80\u003c/span\u003e,\u003cspan citationid=\"CR147\" class=\"CitationRef\"\u003e147\u003c/span\u003e,\u003cspan citationid=\"CR148\" class=\"CitationRef\"\u003e148\u003c/span\u003e\u003c/sup\u003e and could be a form of, or contribute to coercive control (Ciii: isolation and negative self-perception Civ: risk to safety Cv: lack of informed consent).\u003c/p\u003e \u003cp\u003eSome studies referenced the impracticalities of women bringing friends or family\u003csup\u003e\u003cspan citationid=\"CR79\" class=\"CitationRef\"\u003e79\u003c/span\u003e,\u003cspan citationid=\"CR80\" class=\"CitationRef\"\u003e80\u003c/span\u003e,\u003cspan citationid=\"CR108\" class=\"CitationRef\"\u003e108\u003c/span\u003e\u003c/sup\u003e or that non-professional alternatives were as likely to be someone the woman would not have preferred due to concerns about confidentiality and discomfort in revealing personal information\u003csup\u003e\u003cspan citationid=\"CR87\" class=\"CitationRef\"\u003e87\u003c/span\u003e,\u003cspan citationid=\"CR108\" class=\"CitationRef\"\u003e108\u003c/span\u003e,\u003cspan citationid=\"CR141\" class=\"CitationRef\"\u003e141\u003c/span\u003e,\u003cspan citationid=\"CR147\" class=\"CitationRef\"\u003e147\u003c/span\u003e\u003c/sup\u003e. Four studies described children acting as interpreters\u003csup\u003e\u003cspan citationid=\"CR97\" class=\"CitationRef\"\u003e97\u003c/span\u003e,\u003cspan citationid=\"CR100\" class=\"CitationRef\"\u003e100\u003c/span\u003e,\u003cspan citationid=\"CR143\" class=\"CitationRef\"\u003e143\u003c/span\u003e,\u003cspan citationid=\"CR144\" class=\"CitationRef\"\u003e144\u003c/span\u003e\u003c/sup\u003e, including one case in which a woman\u0026rsquo;s 15-year-old daughter interpreted for her during childbirth, an experience that was emotionally challenging for them both.\u003csup\u003e\u003cspan citationid=\"CR100\" class=\"CitationRef\"\u003e100\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003e \u003cb\u003e2.2 Use of alternative communication strategies and good communication styles\u003c/b\u003e \u003c/p\u003e \u003cp\u003eConfidence in Review Finding: high confidence\u003c/p\u003e \u003cp\u003e When there were language barriers, alternative non-verbal ways of communicating and building rapport were sometimes used to good effect. This included gestures, images, facial expressions, body language, touch, and laughter,\u003csup\u003e77,79,80,118,132\u003c/sup\u003e. This was most effective when used alongside some level of verbal language interpretation or shared language, as on its own it limited information sharing. Non-verbal cues and expressions could be frightening when used to display negative emotions especially when there was no other communication.\u003c/p\u003e \u003cp\u003eThe actions and attitudes of professional interpreters and HCPs in navigating a language barrier mediated women\u0026rsquo;s experience of healthcare encounters. Women reported that some HCPs communicated effectively by listening and providing attentive care, despite the language barrier, while some professional interpreters offered both emotional support and facilitated effective communication\u003csup\u003e\u003cspan citationid=\"CR117\" class=\"CitationRef\"\u003e117\u003c/span\u003e,\u003cspan citationid=\"CR132\" class=\"CitationRef\"\u003e132\u003c/span\u003e,\u003cspan citationid=\"CR139\" class=\"CitationRef\"\u003e139\u003c/span\u003e,\u003cspan citationid=\"CR141\" class=\"CitationRef\"\u003e141\u003c/span\u003e,\u003cspan citationid=\"CR142\" class=\"CitationRef\"\u003e142\u003c/span\u003e,\u003cspan citationid=\"CR147\" class=\"CitationRef\"\u003e147\u003c/span\u003e,\u003cspan citationid=\"CR148\" class=\"CitationRef\"\u003e148\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eWhen there was no interpreter, or when interpretation has been declined, women described feeling grateful to HCPs who spoke slowly and simply and checked their understanding, highlighting the importance of tailoring care\u003csup\u003e\u003cspan citationid=\"CR77\" class=\"CitationRef\"\u003e77\u003c/span\u003e,\u003cspan citationid=\"CR79\" class=\"CitationRef\"\u003e79\u003c/span\u003e,\u003cspan citationid=\"CR81\" class=\"CitationRef\"\u003e81\u003c/span\u003e,\u003cspan citationid=\"CR150\" class=\"CitationRef\"\u003e150\u003c/span\u003e\u003c/sup\u003e. However, this was not universal, and compassionate care was seen as key to bridging cultural gaps and building rapport between women and HCPs.\u003csup\u003e\u003cspan citationid=\"CR113\" class=\"CitationRef\"\u003e113\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003e \u003cb\u003eConsequences and benefits of experiences, engagement and interactions\u003c/b\u003e \u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e \u003cp\u003eThe five factors associated with each mediator (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e, Fig.\u0026nbsp;\u003cspan refid=\"Fig6\" class=\"InternalRef\"\u003e3\u003c/span\u003e) shaped women\u0026rsquo;s experiences and engagement with maternity systems by influencing psychological and behavioural responses which had either negative consequences (3.1; C) or positive benefits (3.2; B) for women and their families (see Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). These resulting consequences and benefits are described in more detail in which interactions are highlighted. Illustrative quotations from included studies are used, in which \u003cb\u003ewomen\u0026rsquo;s voices are in bold italics\u003c/b\u003e and \u003cem\u003eauthor interpretation and reporting is in italic\u003c/em\u003e.\u003c/p\u003e \u003cp\u003e \u003cb\u003e3.1 Consequences of women\u0026rsquo;s negative experiences of and interactions with maternity staff in host countries\u003c/b\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eCi. Lack of understanding of host healthcare system and medical terminology\u003c/h2\u003e \u003cp\u003eConfidence in Review Finding: high confidence\u003c/p\u003e \u003cp\u003eWomen who were new to a country or had a language barrier frequently reported difficulty understanding,\u003csup\u003e77,98,100,105,106,110,124,125,128,134,138,144\u003c/sup\u003e or accessing,\u003csup\u003e65,68,98,106,108,110,111,127,128,133,134,148\u003c/sup\u003e, host healthcare systems. They also reported limited ability to find sufficient information on, or engage with varied aspects of care, e.g., antenatal classes.\u003csup\u003e\u003cspan citationid=\"CR67\" class=\"CitationRef\"\u003e67\u003c/span\u003e,\u003cspan citationid=\"CR68\" class=\"CitationRef\"\u003e68\u003c/span\u003e,\u003cspan citationid=\"CR79\" class=\"CitationRef\"\u003e79\u003c/span\u003e,\u003cspan citationid=\"CR80\" class=\"CitationRef\"\u003e80\u003c/span\u003e,\u003cspan citationid=\"CR91\" class=\"CitationRef\"\u003e91\u003c/span\u003e,\u003cspan citationid=\"CR92\" class=\"CitationRef\"\u003e92\u003c/span\u003e,\u003cspan citationid=\"CR94\" class=\"CitationRef\"\u003e94\u003c/span\u003e,\u003cspan citationid=\"CR98\" class=\"CitationRef\"\u003e98\u003c/span\u003e,\u003cspan citationid=\"CR100\" class=\"CitationRef\"\u003e100\u003c/span\u003e,\u003cspan citationid=\"CR101\" class=\"CitationRef\"\u003e101\u003c/span\u003e,\u003cspan citationid=\"CR108\" class=\"CitationRef\"\u003e108\u003c/span\u003e,\u003cspan citationid=\"CR110\" class=\"CitationRef\"\u003e110\u003c/span\u003e,\u003cspan citationid=\"CR114\" class=\"CitationRef\"\u003e114\u003c/span\u003e,\u003cspan citationid=\"CR124\" class=\"CitationRef\"\u003e124\u003c/span\u003e,\u003cspan citationid=\"CR127\" class=\"CitationRef\"\u003e127\u003c/span\u003e,\u003cspan citationid=\"CR133\" class=\"CitationRef\"\u003e133\u003c/span\u003e,\u003cspan citationid=\"CR134\" class=\"CitationRef\"\u003e134\u003c/span\u003e,\u003cspan citationid=\"CR140\" class=\"CitationRef\"\u003e140\u003c/span\u003e,\u003cspan citationid=\"CR144\" class=\"CitationRef\"\u003e144\u003c/span\u003e,\u003cspan citationid=\"CR147\" class=\"CitationRef\"\u003e147\u003c/span\u003e,\u003cspan citationid=\"CR148\" class=\"CitationRef\"\u003e148\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eWomen were uncertain where to seek help and, and as a result, missed antenatal care\u003csup\u003e\u003cspan additionalcitationids=\"CR158 CR159 CR160\" citationid=\"CR157\" class=\"CitationRef\"\u003e157\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR161\" class=\"CitationRef\"\u003e161\u003c/span\u003e\u003c/sup\u003e. They reported that when access relied on an initial telephone call or booking appointments via telephone, language barriers were especially problematic (mediator 1.3 \u0026ndash; telephone and other translated media).\u003csup\u003e\u003cspan citationid=\"CR79\" class=\"CitationRef\"\u003e79\u003c/span\u003e,\u003cspan citationid=\"CR106\" class=\"CitationRef\"\u003e106\u003c/span\u003e,\u003cspan citationid=\"CR123\" class=\"CitationRef\"\u003e123\u003c/span\u003e\u003c/sup\u003e Medical jargon was identified as a key barrier, including among those with good host language fluency,\u003csup\u003e67\u0026ndash;70,73,75,77\u0026ndash;79,84,92,99,101,114,141,144\u003c/sup\u003e reflecting a gap in familiarity with medical terminology compared to everyday conversational language (see also 2.1, non-professional alternatives). Similarly, some women who were otherwise proficient in the host language reported being unable to effectively use this ability at times of increased stress and anxiety\u003csup\u003e\u003cspan citationid=\"CR84\" class=\"CitationRef\"\u003e84\u003c/span\u003e\u003c/sup\u003e.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026lsquo;A woman who had lived in New Zealand for 20 years, since entering a university, commented on the language barrier, especially about understanding the more technical terms. A few of the women experienced some difficulties using English, particularly during their labour\u003c/em\u003e. \u003cem\u003e\u0026ldquo;\u003c/em\u003e\u003cb\u003eI became not able to speak in English [during the labour] ... English never came out.\u003c/b\u003e\u003cem\u003e\"\u0026rsquo; (Participant 8)\u003c/em\u003e\u003csup\u003e\u003cem\u003e84\u003c/em\u003e\u003c/sup\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eThis lack of familiarity with medical terminology was also linked to issues relating to the accessibility and appropriateness of interpreters, including both the ability of professional interpreter\u0026rsquo;s to accurately convey meaning in complex situations and the reliance on non-professional alternatives (2.1). Some women identified this lack of understanding as a gap they wished to address and reported that it contributed to increased fear about childbirth and uncertainty about what to expect from the healthcare system\u003csup\u003e\u003cspan citationid=\"CR65\" class=\"CitationRef\"\u003e65\u003c/span\u003e,\u003cspan citationid=\"CR92\" class=\"CitationRef\"\u003e92\u003c/span\u003e,\u003cspan citationid=\"CR113\" class=\"CitationRef\"\u003e113\u003c/span\u003e,\u003cspan citationid=\"CR138\" class=\"CitationRef\"\u003e138\u003c/span\u003e\u003c/sup\u003e (Ci: lack of understanding, Cii: reduced access to care, Ciii: isolation and negative self-perception).\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026lsquo;One participant said that she would like more to be offered, \u0026ldquo;\u003c/em\u003e \u003cb\u003eBecause we can always learn more.\u003c/b\u003e \u003cem\u003e\u0026rdquo; Another respondent agreed, in response to the same question\u003c/em\u003e, \u003cb\u003e\u0026ldquo;the most important thing is education.\u003c/b\u003e\u003cem\u003e\u0026rdquo; Education was seen as a key to driving out the fear they experienced. As one woman noted, \u0026ldquo;\u003c/em\u003e\u003cb\u003eI sometimes wish they would ask me more questions\u0026mdash;What worries you or what are you thinking about? Ask me questions, not just check my blood pressure. Sit down with me and talk\u003c/b\u003e.\u003cem\u003e\u0026rdquo;\u0026rsquo;\u003c/em\u003e\u003csup\u003e92\u003c/sup\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eThe combined inconsistencies in professional and non-professional interpreting provision together with limited understanding of the healthcare system resulted in reduced access to and disengagement from maternity services (Cii) as well as increased isolation and negative self-perception (Ciii).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eCii Reduced access to, \u0026amp; lack of confidence in care. Disengagement from maternity care services\u003c/h2\u003e \u003cp\u003eConfidence in Review Finding: high confidence\u003c/p\u003e \u003cp\u003eStudies reported that limited understanding of care across the antenatal, intrapartum and postnatal periods, particularly regarding screening tests and pain relief, sometimes resulted in women missing out on options available to them\u003csup\u003e\u003cspan citationid=\"CR67\" class=\"CitationRef\"\u003e67\u003c/span\u003e,\u003cspan citationid=\"CR77\" class=\"CitationRef\"\u003e77\u003c/span\u003e,\u003cspan citationid=\"CR91\" class=\"CitationRef\"\u003e91\u003c/span\u003e\u003c/sup\u003e. Women with previous negative experiences described a reluctance to seek further care, leading to subsequent disengagement from maternity services. \u003csup\u003e67,70,77,79,91,101,106,110,114,121,125,144,148,150\u003c/sup\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026lsquo;Limited fluency in English sometimes prevented an IW [immigrant woman] from participating in prenatal classes; an IW FGI [focus group interview] participant stated, \u0026ldquo;\u003c/em\u003e \u003cb\u003eI didn\u0026rsquo;t quite understand because it\u0026rsquo;s in English and so I only attended I think two times and then I just quit because I didn\u0026rsquo;t quite understand\u003c/b\u003e.\u003cem\u003e\u0026rdquo;\u0026rsquo;\u003c/em\u003e \u003csup\u003e144\u003c/sup\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eCiii. Isolation and negative self-perception\u003c/h2\u003e \u003cp\u003eConfidence in Review Finding: high confidence\u003c/p\u003e \u003cp\u003eWomen reported a lack of agency in clinical decision making, with decisions often made on their behalf without their involvement, which was interpreted here as negative self-perception. Women expressed frustration, shame, inferiority and embarrassment when, in the absence of interpretation they were unable to respond to or make requests of their healthcare providers.\u003csup\u003e\u003cspan citationid=\"CR68\" class=\"CitationRef\"\u003e68\u003c/span\u003e,\u003cspan citationid=\"CR79\" class=\"CitationRef\"\u003e79\u003c/span\u003e,\u003cspan citationid=\"CR80\" class=\"CitationRef\"\u003e80\u003c/span\u003e,\u003cspan citationid=\"CR92\" class=\"CitationRef\"\u003e92\u003c/span\u003e,\u003cspan citationid=\"CR95\" class=\"CitationRef\"\u003e95\u003c/span\u003e,\u003cspan citationid=\"CR107\" class=\"CitationRef\"\u003e107\u003c/span\u003e,\u003cspan citationid=\"CR108\" class=\"CitationRef\"\u003e108\u003c/span\u003e,\u003cspan citationid=\"CR118\" class=\"CitationRef\"\u003e118\u003c/span\u003e,\u003cspan citationid=\"CR123\" class=\"CitationRef\"\u003e123\u003c/span\u003e,\u003cspan citationid=\"CR125\" class=\"CitationRef\"\u003e125\u003c/span\u003e,\u003cspan citationid=\"CR131\" class=\"CitationRef\"\u003e131\u003c/span\u003e,\u003cspan citationid=\"CR140\" class=\"CitationRef\"\u003e140\u003c/span\u003e\u003c/sup\u003e Difficulties communicating within healthcare settings were often compounded by increased social isolation during the perinatal period. Women from migrant communities described challenges associated with parenting without established support networks and reported that language barriers further limited their ability to engage with both local and co-cultural communities increasing reliance on smaller, more limited dependent on limited social circles and reducing independence\u003csup\u003e\u003cspan citationid=\"CR68\" class=\"CitationRef\"\u003e68\u003c/span\u003e,\u003cspan citationid=\"CR69\" class=\"CitationRef\"\u003e69\u003c/span\u003e,\u003cspan citationid=\"CR71\" class=\"CitationRef\"\u003e71\u003c/span\u003e,\u003cspan citationid=\"CR73\" class=\"CitationRef\"\u003e73\u003c/span\u003e,\u003cspan citationid=\"CR75\" class=\"CitationRef\"\u003e75\u003c/span\u003e,\u003cspan citationid=\"CR84\" class=\"CitationRef\"\u003e84\u003c/span\u003e,\u003cspan additionalcitationids=\"CR87\" citationid=\"CR86\" class=\"CitationRef\"\u003e86\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR88\" class=\"CitationRef\"\u003e88\u003c/span\u003e,\u003cspan citationid=\"CR95\" class=\"CitationRef\"\u003e95\u003c/span\u003e,\u003cspan citationid=\"CR111\" class=\"CitationRef\"\u003e111\u003c/span\u003e,\u003cspan citationid=\"CR115\" class=\"CitationRef\"\u003e115\u003c/span\u003e,\u003cspan citationid=\"CR127\" class=\"CitationRef\"\u003e127\u003c/span\u003e,\u003cspan citationid=\"CR128\" class=\"CitationRef\"\u003e128\u003c/span\u003e,\u003cspan citationid=\"CR133\" class=\"CitationRef\"\u003e133\u003c/span\u003e,\u003cspan citationid=\"CR137\" class=\"CitationRef\"\u003e137\u003c/span\u003e,\u003cspan citationid=\"CR138\" class=\"CitationRef\"\u003e138\u003c/span\u003e,\u003cspan citationid=\"CR140\" class=\"CitationRef\"\u003e140\u003c/span\u003e,\u003cspan citationid=\"CR149\" class=\"CitationRef\"\u003e149\u003c/span\u003e,\u003cspan citationid=\"CR150\" class=\"CitationRef\"\u003e150\u003c/span\u003e,\u003cspan citationid=\"CR153\" class=\"CitationRef\"\u003e153\u003c/span\u003e,\u003cspan citationid=\"CR155\" class=\"CitationRef\"\u003e155\u003c/span\u003e\u003c/sup\u003e.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003eSome explicitly described their perceived isolation: \u0026ldquo;\u003c/em\u003e \u003cb\u003e[\u0026hellip;] just greet \u0026ldquo;Hello hello\u0026rdquo; ... I sit my own for lunch and breakfast ...I sit alone\u003c/b\u003e.\u003cem\u003e\u0026rdquo; (SP1_I1) [\u0026hellip;] Establishing desired social support networks was also perceived as challenging by participants resulting from factors such as the multitude of nationalities and the language barriers\u003c/em\u003e: \u003cb\u003e\u0026ldquo;.. .because in (city) people from Afghanistan, Macedonia they don\u0026rsquo;t speak English. . .only languages. .. Some people speak German. . .language. So very difficult to contact, yeah. Very little people have. . .can contact. It\u0026rsquo;s very difficult\u003c/b\u003e.\u003cem\u003e\u0026rdquo; (SP8_I1)\u003c/em\u003e \u003csup\u003e\u003cem\u003e\u003cspan citationid=\"CR95\" class=\"CitationRef\"\u003e95\u003c/span\u003e\u003c/em\u003e\u003c/sup\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eSeveral women also highlighted a desire to form friendships and build a supportive network with other parents in their local host community\u003csup\u003e\u003cspan citationid=\"CR79\" class=\"CitationRef\"\u003e79\u003c/span\u003e,\u003cspan citationid=\"CR88\" class=\"CitationRef\"\u003e88\u003c/span\u003e,\u003cspan citationid=\"CR100\" class=\"CitationRef\"\u003e100\u003c/span\u003e,\u003cspan citationid=\"CR107\" class=\"CitationRef\"\u003e107\u003c/span\u003e,\u003cspan citationid=\"CR137\" class=\"CitationRef\"\u003e137\u003c/span\u003e,\u003cspan citationid=\"CR140\" class=\"CitationRef\"\u003e140\u003c/span\u003e,\u003cspan citationid=\"CR148\" class=\"CitationRef\"\u003e148\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eCiv. Risk to safety of mother and/or baby\u003c/h2\u003e \u003cp\u003eConfidence in Review Finding: high confidence\u003c/p\u003e \u003cp\u003eLanguage barriers were frequently associated with miscommunication or misunderstandings,\u003csup\u003e68,73,77,79,101,105,106,110,115,125,127,132,143,155\u003c/sup\u003e including instances occurring despite the use of both professional and ad hoc interpreters \u003csup\u003e\u003cspan citationid=\"CR79\" class=\"CitationRef\"\u003e79\u003c/span\u003e,\u003cspan citationid=\"CR83\" class=\"CitationRef\"\u003e83\u003c/span\u003e,\u003cspan citationid=\"CR84\" class=\"CitationRef\"\u003e84\u003c/span\u003e,\u003cspan citationid=\"CR100\" class=\"CitationRef\"\u003e100\u003c/span\u003e,\u003cspan citationid=\"CR115\" class=\"CitationRef\"\u003e115\u003c/span\u003e,\u003cspan citationid=\"CR135\" class=\"CitationRef\"\u003e135\u003c/span\u003e,\u003cspan citationid=\"CR138\" class=\"CitationRef\"\u003e138\u003c/span\u003e,\u003cspan citationid=\"CR149\" class=\"CitationRef\"\u003e149\u003c/span\u003e,\u003cspan citationid=\"CR153\" class=\"CitationRef\"\u003e153\u003c/span\u003e\u003c/sup\u003e. Women described multiple factors that compromised the safety of their care. This included misunderstanding of clinical information, or inadequate interpretation, and uncertainty about when to seek help for abnormal symptoms or concerns. Medication use was identified as a key area of risk\u003csup\u003e\u003cspan citationid=\"CR73\" class=\"CitationRef\"\u003e73\u003c/span\u003e,\u003cspan citationid=\"CR79\" class=\"CitationRef\"\u003e79\u003c/span\u003e,\u003cspan citationid=\"CR100\" class=\"CitationRef\"\u003e100\u003c/span\u003e,\u003cspan citationid=\"CR108\" class=\"CitationRef\"\u003e108\u003c/span\u003e,\u003cspan citationid=\"CR155\" class=\"CitationRef\"\u003e155\u003c/span\u003e\u003c/sup\u003e, as women were reliant on HCPs ability to accurately convey appropriate medication use, as well as appropriate prescribing.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cb\u003e\u0026ldquo;The smallest misinterpretation can lead to misunderstandings and wrong treatment\u0026rdquo;\u003c/b\u003e \u003cem\u003e(8) - (App use 5 times, 3 years of residence, understands and speaks Swedish quite well).\u003c/em\u003e \u003csup\u003e\u003cem\u003e73\u003c/em\u003e\u003c/sup\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eLimited understanding contributed to avoidance of medications, incorrect administration, and instances of inappropriate prescribing (e.g., three women\u003csup\u003e\u003cspan citationid=\"CR79\" class=\"CitationRef\"\u003e79\u003c/span\u003e\u003c/sup\u003e reported being inappropriately prescribed Naproxen during pregnancy). Both inappropriate prescribing and women\u0026rsquo;s lack of understanding of how to use medication, and potential side-effects increased the risk of adverse drug events, while also limiting women\u0026rsquo;s health literacy and their capacity to advocate for themselves and/or their children\u003csup\u003e\u003cspan additionalcitationids=\"CR66 CR67\" citationid=\"CR65\" class=\"CitationRef\"\u003e65\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR68\" class=\"CitationRef\"\u003e68\u003c/span\u003e,\u003cspan citationid=\"CR73\" class=\"CitationRef\"\u003e73\u003c/span\u003e,\u003cspan citationid=\"CR79\" class=\"CitationRef\"\u003e79\u003c/span\u003e,\u003cspan citationid=\"CR84\" class=\"CitationRef\"\u003e84\u003c/span\u003e,\u003cspan citationid=\"CR86\" class=\"CitationRef\"\u003e86\u003c/span\u003e,\u003cspan citationid=\"CR92\" class=\"CitationRef\"\u003e92\u003c/span\u003e,\u003cspan citationid=\"CR118\" class=\"CitationRef\"\u003e118\u003c/span\u003e,\u003cspan citationid=\"CR123\" class=\"CitationRef\"\u003e123\u003c/span\u003e,\u003cspan citationid=\"CR129\" class=\"CitationRef\"\u003e129\u003c/span\u003e,\u003cspan citationid=\"CR133\" class=\"CitationRef\"\u003e133\u003c/span\u003e,\u003cspan citationid=\"CR138\" class=\"CitationRef\"\u003e138\u003c/span\u003e,\u003cspan citationid=\"CR140\" class=\"CitationRef\"\u003e140\u003c/span\u003e,\u003cspan additionalcitationids=\"CR148\" citationid=\"CR147\" class=\"CitationRef\"\u003e147\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR149\" class=\"CitationRef\"\u003e149\u003c/span\u003e\u003c/sup\u003e.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;\u003c/em\u003e \u003cb\u003eIn Syria, I used to read the leaflet to understand everything including side effects. If I took a medicine and something happened, I could check if this medicine is causing the side effect, but here in Belgium I can't do this\u003c/b\u003e.\u003cem\u003e\u0026rdquo; (W8)\u003c/em\u003e\u003csup\u003e\u003cspan citationid=\"CR79\" class=\"CitationRef\"\u003e79\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003eCv. Lack of informed consent\u003c/h2\u003e \u003cp\u003eConfidence in Review Finding: high confidence\u003c/p\u003e \u003cp\u003eMany women reported disempowerment, helplessness and dependence on others due to language. barriers \u003csup\u003e\u003cspan citationid=\"CR70\" class=\"CitationRef\"\u003e70\u003c/span\u003e,\u003cspan citationid=\"CR76\" class=\"CitationRef\"\u003e76\u003c/span\u003e,\u003cspan citationid=\"CR77\" class=\"CitationRef\"\u003e77\u003c/span\u003e,\u003cspan citationid=\"CR80\" class=\"CitationRef\"\u003e80\u003c/span\u003e,\u003cspan citationid=\"CR88\" class=\"CitationRef\"\u003e88\u003c/span\u003e,\u003cspan citationid=\"CR92\" class=\"CitationRef\"\u003e92\u003c/span\u003e,\u003cspan citationid=\"CR100\" class=\"CitationRef\"\u003e100\u003c/span\u003e,\u003cspan citationid=\"CR101\" class=\"CitationRef\"\u003e101\u003c/span\u003e,\u003cspan citationid=\"CR107\" class=\"CitationRef\"\u003e107\u003c/span\u003e,\u003cspan citationid=\"CR111\" class=\"CitationRef\"\u003e111\u003c/span\u003e,\u003cspan citationid=\"CR118\" class=\"CitationRef\"\u003e118\u003c/span\u003e,\u003cspan citationid=\"CR121\" class=\"CitationRef\"\u003e121\u003c/span\u003e,\u003cspan citationid=\"CR123\" class=\"CitationRef\"\u003e123\u003c/span\u003e,\u003cspan citationid=\"CR125\" class=\"CitationRef\"\u003e125\u003c/span\u003e,\u003cspan citationid=\"CR127\" class=\"CitationRef\"\u003e127\u003c/span\u003e,\u003cspan citationid=\"CR140\" class=\"CitationRef\"\u003e140\u003c/span\u003e,\u003cspan citationid=\"CR143\" class=\"CitationRef\"\u003e143\u003c/span\u003e,\u003cspan citationid=\"CR144\" class=\"CitationRef\"\u003e144\u003c/span\u003e,\u003cspan citationid=\"CR155\" class=\"CitationRef\"\u003e155\u003c/span\u003e\u003c/sup\u003e. Inconsistencies in professional and non-professional interpreting provision, combined with limited understanding of medical terminology in the host language contributed to a lack of informed consent \u003csup\u003e\u003cspan citationid=\"CR66\" class=\"CitationRef\"\u003e66\u003c/span\u003e,\u003cspan citationid=\"CR67\" class=\"CitationRef\"\u003e67\u003c/span\u003e,\u003cspan additionalcitationids=\"CR76\" citationid=\"CR75\" class=\"CitationRef\"\u003e75\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR77\" class=\"CitationRef\"\u003e77\u003c/span\u003e,\u003cspan citationid=\"CR79\" class=\"CitationRef\"\u003e79\u003c/span\u003e,\u003cspan additionalcitationids=\"CR83\" citationid=\"CR82\" class=\"CitationRef\"\u003e82\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR84\" class=\"CitationRef\"\u003e84\u003c/span\u003e,\u003cspan additionalcitationids=\"CR87\" citationid=\"CR86\" class=\"CitationRef\"\u003e86\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR88\" class=\"CitationRef\"\u003e88\u003c/span\u003e,\u003cspan citationid=\"CR91\" class=\"CitationRef\"\u003e91\u003c/span\u003e,\u003cspan additionalcitationids=\"CR100\" citationid=\"CR99\" class=\"CitationRef\"\u003e99\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR101\" class=\"CitationRef\"\u003e101\u003c/span\u003e,\u003cspan citationid=\"CR107\" class=\"CitationRef\"\u003e107\u003c/span\u003e,\u003cspan citationid=\"CR108\" class=\"CitationRef\"\u003e108\u003c/span\u003e,\u003cspan citationid=\"CR112\" class=\"CitationRef\"\u003e112\u003c/span\u003e,\u003cspan citationid=\"CR113\" class=\"CitationRef\"\u003e113\u003c/span\u003e,\u003cspan citationid=\"CR115\" class=\"CitationRef\"\u003e115\u003c/span\u003e,\u003cspan citationid=\"CR118\" class=\"CitationRef\"\u003e118\u003c/span\u003e,\u003cspan citationid=\"CR122\" class=\"CitationRef\"\u003e122\u003c/span\u003e,\u003cspan citationid=\"CR125\" class=\"CitationRef\"\u003e125\u003c/span\u003e,\u003cspan citationid=\"CR127\" class=\"CitationRef\"\u003e127\u003c/span\u003e,\u003cspan citationid=\"CR133\" class=\"CitationRef\"\u003e133\u003c/span\u003e,\u003cspan citationid=\"CR135\" class=\"CitationRef\"\u003e135\u003c/span\u003e,\u003cspan citationid=\"CR138\" class=\"CitationRef\"\u003e138\u003c/span\u003e,\u003cspan additionalcitationids=\"CR144 CR145\" citationid=\"CR143\" class=\"CitationRef\"\u003e143\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR146\" class=\"CitationRef\"\u003e146\u003c/span\u003e,\u003cspan additionalcitationids=\"CR150\" citationid=\"CR149\" class=\"CitationRef\"\u003e149\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR151\" class=\"CitationRef\"\u003e151\u003c/span\u003e,\u003cspan citationid=\"CR155\" class=\"CitationRef\"\u003e155\u003c/span\u003e\u003c/sup\u003e. Experiences of disempowerment and poor treatment sometimes led to women disengaging from care (Cii: reduced access to and disengagement from care)\u003csup\u003e\u003cspan citationid=\"CR70\" class=\"CitationRef\"\u003e70\u003c/span\u003e,\u003cspan citationid=\"CR77\" class=\"CitationRef\"\u003e77\u003c/span\u003e,\u003cspan citationid=\"CR91\" class=\"CitationRef\"\u003e91\u003c/span\u003e,\u003cspan citationid=\"CR125\" class=\"CitationRef\"\u003e125\u003c/span\u003e,\u003cspan citationid=\"CR150\" class=\"CitationRef\"\u003e150\u003c/span\u003e\u003c/sup\u003e. Women felt dependent on HCPs, fuelling a \u0026lsquo;culture of compliance\u0026rsquo;\u003csup\u003e91\u003c/sup\u003e and found it challenging to explain their experiences and concerns, or advocate for themselves during pregnancy and birth. Some studies described a \u0026lsquo;happy migrant effect\u0026rsquo;\u003csup\u003e149\u003c/sup\u003e, whereby behaviours such as nodding, smiling and agreement reflected coping strategies (e.g., \u0026lsquo;fawning\u0026rsquo;) or resignation, to sub-standard care, rather than genuine understanding or informed agreement to care or treatment options.\u003c/p\u003e \u003cp\u003eWomen reported that ineffective communication limited their ability to feel heard and to participate in decision-making\u003csup\u003e\u003cspan citationid=\"CR68\" class=\"CitationRef\"\u003e68\u003c/span\u003e,\u003cspan citationid=\"CR92\" class=\"CitationRef\"\u003e92\u003c/span\u003e,\u003cspan citationid=\"CR110\" class=\"CitationRef\"\u003e110\u003c/span\u003e,\u003cspan citationid=\"CR144\" class=\"CitationRef\"\u003e144\u003c/span\u003e,\u003cspan citationid=\"CR150\" class=\"CitationRef\"\u003e150\u003c/span\u003e,\u003cspan citationid=\"CR153\" class=\"CitationRef\"\u003e153\u003c/span\u003e\u003c/sup\u003e. These imbalanced communication dynamics reduced women\u0026rsquo;s agency in influencing decisions at crucial points during pregnancy and labour and made them less likely to question HCPs actions or raise concerns (Cii: reduced access to care and disengagement from services; Civ: risk to safety of mother or baby).\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;\u003c/em\u003e\u003cb\u003eIt was critical for me and the baby. They had to do something. I didn\u0026rsquo;t understand anything [\u0026hellip;] I just signed blindly. I did not know what happened to me, what happened to the baby. Is my baby still alive or has it died? I had no idea what help I should get, I was scared, I started to cry.\u003c/b\u003e\u003cem\u003e\u0026rdquo; (Albanian woman)\u003c/em\u003e\u003csup\u003e\u003cspan citationid=\"CR150\" class=\"CitationRef\"\u003e150\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eWomen frequently described not understanding the reasons for medical interventions, local maternity care and clinical processes\u003csup\u003e\u003cspan citationid=\"CR66\" class=\"CitationRef\"\u003e66\u003c/span\u003e,\u003cspan citationid=\"CR68\" class=\"CitationRef\"\u003e68\u003c/span\u003e,\u003cspan citationid=\"CR82\" class=\"CitationRef\"\u003e82\u003c/span\u003e,\u003cspan citationid=\"CR84\" class=\"CitationRef\"\u003e84\u003c/span\u003e,\u003cspan citationid=\"CR88\" class=\"CitationRef\"\u003e88\u003c/span\u003e,\u003cspan citationid=\"CR100\" class=\"CitationRef\"\u003e100\u003c/span\u003e,\u003cspan citationid=\"CR107\" class=\"CitationRef\"\u003e107\u003c/span\u003e,\u003cspan citationid=\"CR108\" class=\"CitationRef\"\u003e108\u003c/span\u003e,\u003cspan citationid=\"CR116\" class=\"CitationRef\"\u003e116\u003c/span\u003e,\u003cspan citationid=\"CR118\" class=\"CitationRef\"\u003e118\u003c/span\u003e,\u003cspan citationid=\"CR125\" class=\"CitationRef\"\u003e125\u003c/span\u003e,\u003cspan citationid=\"CR127\" class=\"CitationRef\"\u003e127\u003c/span\u003e,\u003cspan citationid=\"CR129\" class=\"CitationRef\"\u003e129\u003c/span\u003e,\u003cspan citationid=\"CR132\" class=\"CitationRef\"\u003e132\u003c/span\u003e,\u003cspan citationid=\"CR135\" class=\"CitationRef\"\u003e135\u003c/span\u003e,\u003cspan citationid=\"CR143\" class=\"CitationRef\"\u003e143\u003c/span\u003e,\u003cspan citationid=\"CR145\" class=\"CitationRef\"\u003e145\u003c/span\u003e,\u003cspan citationid=\"CR150\" class=\"CitationRef\"\u003e150\u003c/span\u003e,\u003cspan citationid=\"CR153\" class=\"CitationRef\"\u003e153\u003c/span\u003e\u003c/sup\u003e. Issues relating to informed consent were particularly evident in relation to screening tests and during labour, often causing distress. Studies reported women feeling uncomfortable, fearful, worried and/or anxious due to poorly understood communication, and in some cases, the attitude of HCPs\u003csup\u003e\u003cspan citationid=\"CR80\" class=\"CitationRef\"\u003e80\u003c/span\u003e,\u003cspan citationid=\"CR84\" class=\"CitationRef\"\u003e84\u003c/span\u003e,\u003cspan citationid=\"CR92\" class=\"CitationRef\"\u003e92\u003c/span\u003e,\u003cspan citationid=\"CR100\" class=\"CitationRef\"\u003e100\u003c/span\u003e,\u003cspan citationid=\"CR101\" class=\"CitationRef\"\u003e101\u003c/span\u003e,\u003cspan citationid=\"CR106\" class=\"CitationRef\"\u003e106\u003c/span\u003e,\u003cspan citationid=\"CR108\" class=\"CitationRef\"\u003e108\u003c/span\u003e,\u003cspan citationid=\"CR118\" class=\"CitationRef\"\u003e118\u003c/span\u003e,\u003cspan citationid=\"CR125\" class=\"CitationRef\"\u003e125\u003c/span\u003e,\u003cspan citationid=\"CR127\" class=\"CitationRef\"\u003e127\u003c/span\u003e,\u003cspan additionalcitationids=\"CR132\" citationid=\"CR131\" class=\"CitationRef\"\u003e131\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR133\" class=\"CitationRef\"\u003e133\u003c/span\u003e,\u003cspan citationid=\"CR138\" class=\"CitationRef\"\u003e138\u003c/span\u003e,\u003cspan citationid=\"CR140\" class=\"CitationRef\"\u003e140\u003c/span\u003e,\u003cspan citationid=\"CR144\" class=\"CitationRef\"\u003e144\u003c/span\u003e,\u003cspan citationid=\"CR147\" class=\"CitationRef\"\u003e147\u003c/span\u003e,\u003cspan citationid=\"CR150\" class=\"CitationRef\"\u003e150\u003c/span\u003e,\u003cspan citationid=\"CR155\" class=\"CitationRef\"\u003e155\u003c/span\u003e\u003c/sup\u003e (Cvi: perceptions of discrimination and racism). This lack of understanding led to \u0026lsquo;blind\u0026rsquo; agreement in some cases, where women accepted interventions without full awareness of the context or detail, while in others it resulted in refusal of care due to uncertainty\u003csup\u003e\u003cspan citationid=\"CR144\" class=\"CitationRef\"\u003e144\u003c/span\u003e\u003c/sup\u003e (also increasing Civ: risk to safety, from a wider public health perspective).\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003eLack of shared meaning was the biggest issue between the immigrants presenting for maternity care and their HCPs\u003c/em\u003e. \u003cem\u003eP55\u003c/em\u003e: \u003cb\u003eNurse ask me, \u0026lsquo;You know about that HPV test?\u0026rsquo; So I said, \u0026lsquo;I don\u0026rsquo;t know.\u0026rsquo; She said to me, \u0026lsquo;You suggest yes or no?\u0026rsquo; So I said no because I can\u0026rsquo;t understand so that\u0026rsquo;s why I said no\u003c/b\u003e.\u003cem\u003e\u0026rdquo;\u003c/em\u003e\u003csup\u003e\u003cem\u003e101\u003c/em\u003e\u003c/sup\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003eCvi. Perceptions of discrimination and racism\u003c/h2\u003e \u003cp\u003eConfidence in Review Finding: high confidence\u003c/p\u003e \u003cp\u003eWomen without interpreter support to overcome language barriers frequently experienced maternity care, and interactions with some healthcare professionals as disrespectful, stigmatising, and discriminatory\u003csup\u003e\u003cspan citationid=\"CR66\" class=\"CitationRef\"\u003e66\u003c/span\u003e,\u003cspan citationid=\"CR68\" class=\"CitationRef\"\u003e68\u003c/span\u003e,\u003cspan citationid=\"CR69\" class=\"CitationRef\"\u003e69\u003c/span\u003e,\u003cspan citationid=\"CR72\" class=\"CitationRef\"\u003e72\u003c/span\u003e,\u003cspan citationid=\"CR77\" class=\"CitationRef\"\u003e77\u003c/span\u003e,\u003cspan citationid=\"CR82\" class=\"CitationRef\"\u003e82\u003c/span\u003e,\u003cspan additionalcitationids=\"CR87\" citationid=\"CR86\" class=\"CitationRef\"\u003e86\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR88\" class=\"CitationRef\"\u003e88\u003c/span\u003e,\u003cspan additionalcitationids=\"CR91\" citationid=\"CR90\" class=\"CitationRef\"\u003e90\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR92\" class=\"CitationRef\"\u003e92\u003c/span\u003e,\u003cspan citationid=\"CR106\" class=\"CitationRef\"\u003e106\u003c/span\u003e,\u003cspan citationid=\"CR110\" class=\"CitationRef\"\u003e110\u003c/span\u003e,\u003cspan citationid=\"CR111\" class=\"CitationRef\"\u003e111\u003c/span\u003e,\u003cspan citationid=\"CR117\" class=\"CitationRef\"\u003e117\u003c/span\u003e,\u003cspan citationid=\"CR118\" class=\"CitationRef\"\u003e118\u003c/span\u003e,\u003cspan citationid=\"CR122\" class=\"CitationRef\"\u003e122\u003c/span\u003e,\u003cspan citationid=\"CR127\" class=\"CitationRef\"\u003e127\u003c/span\u003e,\u003cspan citationid=\"CR129\" class=\"CitationRef\"\u003e129\u003c/span\u003e,\u003cspan citationid=\"CR136\" class=\"CitationRef\"\u003e136\u003c/span\u003e,\u003cspan citationid=\"CR137\" class=\"CitationRef\"\u003e137\u003c/span\u003e,\u003cspan citationid=\"CR143\" class=\"CitationRef\"\u003e143\u003c/span\u003e,\u003cspan citationid=\"CR144\" class=\"CitationRef\"\u003e144\u003c/span\u003e,\u003cspan citationid=\"CR149\" class=\"CitationRef\"\u003e149\u003c/span\u003e,\u003cspan citationid=\"CR150\" class=\"CitationRef\"\u003e150\u003c/span\u003e\u003c/sup\u003e. Language barriers, together with perceived discrimination, further amplified existing power imbalances and the dominance of HCPs within care interactions.\u003csup\u003e\u003cspan citationid=\"CR70\" class=\"CitationRef\"\u003e70\u003c/span\u003e,\u003cspan citationid=\"CR150\" class=\"CitationRef\"\u003e150\u003c/span\u003e\u003c/sup\u003e Women were less likely to communicate openly or make decisions in their own best interests and, in some cases, became increasingly dependent on family members or friends to interpret on their behalf\u003csup\u003e\u003cspan citationid=\"CR68\" class=\"CitationRef\"\u003e68\u003c/span\u003e,\u003cspan citationid=\"CR69\" class=\"CitationRef\"\u003e69\u003c/span\u003e,\u003cspan citationid=\"CR71\" class=\"CitationRef\"\u003e71\u003c/span\u003e,\u003cspan citationid=\"CR75\" class=\"CitationRef\"\u003e75\u003c/span\u003e,\u003cspan citationid=\"CR77\" class=\"CitationRef\"\u003e77\u003c/span\u003e,\u003cspan citationid=\"CR79\" class=\"CitationRef\"\u003e79\u003c/span\u003e,\u003cspan citationid=\"CR80\" class=\"CitationRef\"\u003e80\u003c/span\u003e,\u003cspan citationid=\"CR88\" class=\"CitationRef\"\u003e88\u003c/span\u003e,\u003cspan citationid=\"CR153\" class=\"CitationRef\"\u003e153\u003c/span\u003e\u003c/sup\u003e (mediator 2.1 alternatives to professionals; resulting in Ciii: isolation and negative self-perception, Cv: lack of informed consent, Cii: reduced access to and disengagement form services; Civ: risk to safety of mother and/or baby). Women reported experiences of discrimination associated with a lack of respect, absences of shared language, and different cultural frames of reference,\u003csup\u003e88,91,92,106,110,125,127,136,137,140,144,150\u003c/sup\u003e and for some, racism was also involved where HCPs were perceived as behaving in unkind or disrespectful ways.\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eOne woman noted, \u003cb\u003e\u0026ldquo;It\u0026rsquo;s awful because I personally feel discriminated against...\u0026rdquo;\u003c/b\u003e Another participant discouragingly shared that she has been made fun of by nurses, and continued\u003c/strong\u003e \u003cp\u003e \u003cb\u003eI don\u0026rsquo;t really speak the language, so I just keep quiet, but it really bothers me because sometimes you go with an emergency or a pain or something and they are really angry. They aren\u0026rsquo;t nice in some clinic. It\u0026rsquo;s awful because I personally feel discriminated against because if someone goes in with an emergency with pain and they have an angry face when they are with you. I don\u0026rsquo;t like it. You know, I understand a little, and they are laughing and talking, and I know because they say, \u0026ldquo;Spanish,\u0026rdquo; and I ask why are they like that? But oh well, I have to ignore it. But it is sad\u003c/b\u003e.\u003cem\u003e\u0026rdquo;\u003c/em\u003e \u003csup\u003e\u003cem\u003e92\u003c/em\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/p\u003e \u003cp\u003eWomen also felt stereotyped and \u0026lsquo;othered\u0026rsquo; when HCPs assumed they could not speak the local language based on visible characteristics such as skin colour or traditional clothing (e.g., hijabs)\u003csup\u003e\u003cspan citationid=\"CR110\" class=\"CitationRef\"\u003e110\u003c/span\u003e,\u003cspan citationid=\"CR150\" class=\"CitationRef\"\u003e150\u003c/span\u003e\u003c/sup\u003e. Discrimination was also reported in accent bias with women from one study sharing feeling that their care was deprioritised when contacting services by phone due to their non-British accent.\u003csup\u003e\u003cspan citationid=\"CR106\" class=\"CitationRef\"\u003e106\u003c/span\u003e\u003c/sup\u003e Additional findings, while not always explicitly labelled as discrimination by study participants, were interpreted as such, including perceptions of negative stereotyping from staff\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026lsquo;\u0026ldquo;\u003c/em\u003e \u003cb\u003eWhen she (the midwife) was talking to me, I felt like there wasn't a great deal of respect. I felt as though she was thinking \u0026ldquo;you stupid Somali mothers\u0026rdquo;.\u003c/b\u003e \u003cem\u003e\u0026rsquo; (Fatima)\u003c/em\u003e \u003csup\u003e\u003cem\u003e\u003cspan citationid=\"CR110\" class=\"CitationRef\"\u003e110\u003c/span\u003e\u003c/em\u003e\u003c/sup\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eConversely, other participants described positive and respectful care experiences, mediated by staff who were able to \u003cem\u003e2. Work around communication barriers\u003c/em\u003e. The associated factor of (2b) alternative communication practices led to women experiencing effective communication (Bi); positive, culturally safe birth experiences (Bii) and supportive relationships with providers developed through continuity of care (Biii).\u003c/p\u003e \u003cp\u003e \u003cb\u003eCvii. Accessing care outside of health systems.\u003c/b\u003e \u003c/p\u003e \u003cp\u003eConfidence in Review Finding: high confidence\u003c/p\u003e \u003cp\u003eWomen with limited proficiency in the host country\u0026rsquo;s language sought support in their preferred language and medium outside the formal host healthcare systems and structures (Cvii), through two primary pathways. These were either through accessing healthcare information from their country of origin or in their native language. The second was reliance on locally available community networks composed of individuals sharing similar linguistic and cultural backgrounds.\u003c/p\u003e \u003cp\u003eWhen women had questions or concerns and were unable to obtain relevant information from their HCPs, some turned to the internet or to contacts in their country of origin\u003csup\u003e\u003cspan citationid=\"CR65\" class=\"CitationRef\"\u003e65\u003c/span\u003e,\u003cspan citationid=\"CR66\" class=\"CitationRef\"\u003e66\u003c/span\u003e,\u003cspan citationid=\"CR68\" class=\"CitationRef\"\u003e68\u003c/span\u003e,\u003cspan citationid=\"CR69\" class=\"CitationRef\"\u003e69\u003c/span\u003e,\u003cspan citationid=\"CR76\" class=\"CitationRef\"\u003e76\u003c/span\u003e,\u003cspan citationid=\"CR80\" class=\"CitationRef\"\u003e80\u003c/span\u003e,\u003cspan citationid=\"CR84\" class=\"CitationRef\"\u003e84\u003c/span\u003e,\u003cspan citationid=\"CR100\" class=\"CitationRef\"\u003e100\u003c/span\u003e,\u003cspan citationid=\"CR106\" class=\"CitationRef\"\u003e106\u003c/span\u003e,\u003cspan citationid=\"CR130\" class=\"CitationRef\"\u003e130\u003c/span\u003e,\u003cspan citationid=\"CR134\" class=\"CitationRef\"\u003e134\u003c/span\u003e,\u003cspan citationid=\"CR139\" class=\"CitationRef\"\u003e139\u003c/span\u003e,\u003cspan citationid=\"CR143\" class=\"CitationRef\"\u003e143\u003c/span\u003e,\u003cspan citationid=\"CR145\" class=\"CitationRef\"\u003e145\u003c/span\u003e,\u003cspan citationid=\"CR146\" class=\"CitationRef\"\u003e146\u003c/span\u003e,\u003cspan citationid=\"CR153\" class=\"CitationRef\"\u003e153\u003c/span\u003e\u003c/sup\u003e, where information was not always evidence based, for example, \u0026lsquo;using unproven folk remedies from their home countries\u0026rsquo;\u003csup\u003e80\u003c/sup\u003e thus potentially increasing risk to safety (Civ). Women accessed care outside formalised health care systems in their host country sometimes also sought advice directly from HCPs in their country of origin\u003csup\u003e\u003cspan citationid=\"CR68\" class=\"CitationRef\"\u003e68\u003c/span\u003e,\u003cspan citationid=\"CR69\" class=\"CitationRef\"\u003e69\u003c/span\u003e,\u003cspan citationid=\"CR100\" class=\"CitationRef\"\u003e100\u003c/span\u003e,\u003cspan citationid=\"CR106\" class=\"CitationRef\"\u003e106\u003c/span\u003e,\u003cspan citationid=\"CR146\" class=\"CitationRef\"\u003e146\u003c/span\u003e\u003c/sup\u003e. For some, this provided reassurance, improved health literacy, and encouraged engagement with healthcare in their host country.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026lsquo;Women have formed transnational networks, which also contributed to their access to health care. By receiving vital information about pregnancy, delivery, and childcare from female relatives in their countries of origin, they compensated for information gaps and were able to perceive needs for health care, seek health-care providers, and utilize health-care services. As shown in this study, one of the participants decided to seek health care only after calling her mother in Syria, who alerted her to the urgency of the situation.\u0026rsquo;\u003c/em\u003e \u003csup\u003e \u003cem\u003e100\u003c/em\u003e \u003c/sup\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eWhen women were not provided with enough information or appropriate translated leaflets from HCPs, they reported turning to other available sources including the internet, apps, and books\u003csup\u003e\u003cspan citationid=\"CR65\" class=\"CitationRef\"\u003e65\u003c/span\u003e,\u003cspan citationid=\"CR66\" class=\"CitationRef\"\u003e66\u003c/span\u003e,\u003cspan citationid=\"CR77\" class=\"CitationRef\"\u003e77\u003c/span\u003e,\u003cspan citationid=\"CR79\" class=\"CitationRef\"\u003e79\u003c/span\u003e,\u003cspan citationid=\"CR80\" class=\"CitationRef\"\u003e80\u003c/span\u003e,\u003cspan citationid=\"CR100\" class=\"CitationRef\"\u003e100\u003c/span\u003e,\u003cspan citationid=\"CR130\" class=\"CitationRef\"\u003e130\u003c/span\u003e,\u003cspan citationid=\"CR134\" class=\"CitationRef\"\u003e134\u003c/span\u003e,\u003cspan citationid=\"CR153\" class=\"CitationRef\"\u003e153\u003c/span\u003e\u003c/sup\u003e. These sources were perceived to meet their information needs and addressed their concerns.\u003c/p\u003e \u003cp\u003eThe second pathway involved support accessed through local community networks in their host country. Women sought information and social support from local networks of friends, family, connections and/or doulas in a language they understood\u003csup\u003e\u003cspan citationid=\"CR73\" class=\"CitationRef\"\u003e73\u003c/span\u003e,\u003cspan citationid=\"CR74\" class=\"CitationRef\"\u003e74\u003c/span\u003e,\u003cspan citationid=\"CR76\" class=\"CitationRef\"\u003e76\u003c/span\u003e,\u003cspan citationid=\"CR77\" class=\"CitationRef\"\u003e77\u003c/span\u003e,\u003cspan citationid=\"CR79\" class=\"CitationRef\"\u003e79\u003c/span\u003e,\u003cspan citationid=\"CR80\" class=\"CitationRef\"\u003e80\u003c/span\u003e,\u003cspan citationid=\"CR86\" class=\"CitationRef\"\u003e86\u003c/span\u003e,\u003cspan citationid=\"CR92\" class=\"CitationRef\"\u003e92\u003c/span\u003e,\u003cspan citationid=\"CR100\" class=\"CitationRef\"\u003e100\u003c/span\u003e,\u003cspan citationid=\"CR107\" class=\"CitationRef\"\u003e107\u003c/span\u003e,\u003cspan citationid=\"CR112\" class=\"CitationRef\"\u003e112\u003c/span\u003e,\u003cspan citationid=\"CR117\" class=\"CitationRef\"\u003e117\u003c/span\u003e,\u003cspan citationid=\"CR125\" class=\"CitationRef\"\u003e125\u003c/span\u003e,\u003cspan citationid=\"CR127\" class=\"CitationRef\"\u003e127\u003c/span\u003e,\u003cspan citationid=\"CR130\" class=\"CitationRef\"\u003e130\u003c/span\u003e,\u003cspan citationid=\"CR135\" class=\"CitationRef\"\u003e135\u003c/span\u003e,\u003cspan citationid=\"CR138\" class=\"CitationRef\"\u003e138\u003c/span\u003e,\u003cspan citationid=\"CR139\" class=\"CitationRef\"\u003e139\u003c/span\u003e,\u003cspan citationid=\"CR145\" class=\"CitationRef\"\u003e145\u003c/span\u003e,\u003cspan citationid=\"CR148\" class=\"CitationRef\"\u003e148\u003c/span\u003e,\u003cspan citationid=\"CR153\" class=\"CitationRef\"\u003e153\u003c/span\u003e\u003c/sup\u003e. However, this sometimes led to the circulation of inaccurate information, increasing fear\u003csup\u003e\u003cspan citationid=\"CR138\" class=\"CitationRef\"\u003e138\u003c/span\u003e\u003c/sup\u003e when combined with limited understanding of, and trust in, healthcare professionals. further contributed to negative experiences when engaging with unfamiliar maternity systems (Civ: risk to safety of mother and/or baby). (Ci: lack of understanding of host healthcare system and medical terminology).\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;The misinformation on the negative effects of caesarean section came from other Somali mothers. Other concerns learnt from Somali mothers included a risk of becoming disabled after interventions or that an epidural could possibly prolong labor or hinder labor progress. This kind of information made the women worried, and some said they therefore refused interventions or help with labor pain during labor. One parous woman explained it in the following way: \u0026lsquo;\u003c/em\u003e \u003cb\u003eI was afraid they would put a needle in my back. I had heard from other Somali women that the needle was bad for me, and that the procedure can leave you paralyzed [for life].\u003c/b\u003e \u003cem\u003e\u0026rsquo;\u0026rdquo;\u003c/em\u003e (Interview 7)\u003csup\u003e138\u003c/sup\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eThe absence of wider familial support networks typically available in women\u0026rsquo;s countries of origin contributed to experiences of isolation\u003csup\u003e\u003cspan citationid=\"CR68\" class=\"CitationRef\"\u003e68\u003c/span\u003e,\u003cspan citationid=\"CR69\" class=\"CitationRef\"\u003e69\u003c/span\u003e,\u003cspan citationid=\"CR77\" class=\"CitationRef\"\u003e77\u003c/span\u003e,\u003cspan citationid=\"CR80\" class=\"CitationRef\"\u003e80\u003c/span\u003e,\u003cspan citationid=\"CR81\" class=\"CitationRef\"\u003e81\u003c/span\u003e,\u003cspan citationid=\"CR86\" class=\"CitationRef\"\u003e86\u003c/span\u003e,\u003cspan citationid=\"CR91\" class=\"CitationRef\"\u003e91\u003c/span\u003e,\u003cspan citationid=\"CR92\" class=\"CitationRef\"\u003e92\u003c/span\u003e,\u003cspan citationid=\"CR107\" class=\"CitationRef\"\u003e107\u003c/span\u003e,\u003cspan citationid=\"CR144\" class=\"CitationRef\"\u003e144\u003c/span\u003e,\u003cspan citationid=\"CR153\" class=\"CitationRef\"\u003e153\u003c/span\u003e\u003c/sup\u003e, (Ciii: isolation and negative self-perception), although local community members from similar background were sometimes able to partially fulfil this role\u003csup\u003e\u003cspan citationid=\"CR76\" class=\"CitationRef\"\u003e76\u003c/span\u003e,\u003cspan citationid=\"CR77\" class=\"CitationRef\"\u003e77\u003c/span\u003e,\u003cspan citationid=\"CR79\" class=\"CitationRef\"\u003e79\u003c/span\u003e,\u003cspan citationid=\"CR80\" class=\"CitationRef\"\u003e80\u003c/span\u003e,\u003cspan citationid=\"CR100\" class=\"CitationRef\"\u003e100\u003c/span\u003e,\u003cspan citationid=\"CR112\" class=\"CitationRef\"\u003e112\u003c/span\u003e,\u003cspan citationid=\"CR125\" class=\"CitationRef\"\u003e125\u003c/span\u003e,\u003cspan citationid=\"CR139\" class=\"CitationRef\"\u003e139\u003c/span\u003e,\u003cspan citationid=\"CR148\" class=\"CitationRef\"\u003e148\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003e \u003cb\u003e3.2 Benefits of women\u0026rsquo;s positive experiences and interactions with maternity staff in host countries\u003c/b\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec20\" class=\"Section2\"\u003e \u003ch2\u003eBi. Improved host language and healthcare system fluency, and community integration\u003c/h2\u003e \u003cp\u003eConfidence in Review Finding: moderate confidence (minor concerns regarding adequacy, because of limited data within the included studies, and how much the included studies focused on research questions, which are specific to this review finding.)\u003c/p\u003e \u003cp\u003eFor many women, supportive relationships with the same HCPs were integral to positive maternity care and childbirth experiences\u003csup\u003e\u003cspan citationid=\"CR84\" class=\"CitationRef\"\u003e84\u003c/span\u003e,\u003cspan citationid=\"CR100\" class=\"CitationRef\"\u003e100\u003c/span\u003e,\u003cspan citationid=\"CR112\" class=\"CitationRef\"\u003e112\u003c/span\u003e,\u003cspan citationid=\"CR142\" class=\"CitationRef\"\u003e142\u003c/span\u003e,\u003cspan citationid=\"CR145\" class=\"CitationRef\"\u003e145\u003c/span\u003e,\u003cspan citationid=\"CR150\" class=\"CitationRef\"\u003e150\u003c/span\u003e\u003c/sup\u003e. For women with language barriers continuity of care supported the development of trust and relationships (Biii), and in some cases enhanced language confidence and fluency\u003csup\u003e\u003cspan citationid=\"CR104\" class=\"CitationRef\"\u003e104\u003c/span\u003e,\u003cspan citationid=\"CR137\" class=\"CitationRef\"\u003e137\u003c/span\u003e,\u003cspan citationid=\"CR140\" class=\"CitationRef\"\u003e140\u003c/span\u003e,\u003cspan citationid=\"CR145\" class=\"CitationRef\"\u003e145\u003c/span\u003e\u003c/sup\u003e with the potential to negate or reduce experiences of isolation and helplessness observed in other immigrant women\u003csup\u003e\u003cspan citationid=\"CR148\" class=\"CitationRef\"\u003e148\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eWomen in multiple studies expressed a desire to improve their language proficiency\u003csup\u003e\u003cspan citationid=\"CR88\" class=\"CitationRef\"\u003e88\u003c/span\u003e,\u003cspan citationid=\"CR107\" class=\"CitationRef\"\u003e107\u003c/span\u003e,\u003cspan citationid=\"CR137\" class=\"CitationRef\"\u003e137\u003c/span\u003e,\u003cspan citationid=\"CR140\" class=\"CitationRef\"\u003e140\u003c/span\u003e\u003c/sup\u003e to better navigate and support their own and their family\u0026rsquo;s healthcare needs, as well as to facilitate integration into the host society, which was often perceived as a safer environment to raise their families\u003csup\u003e\u003cspan citationid=\"CR140\" class=\"CitationRef\"\u003e140\u003c/span\u003e\u003c/sup\u003e. Supportive positive care experiences therefore functioned not only to improve language and healthcare system fluency but also encourages women\u0026rsquo;s motivation to further develop language skills and integrated into the host country.\u003csup\u003e\u003cspan citationid=\"CR137\" class=\"CitationRef\"\u003e137\u003c/span\u003e,\u003cspan citationid=\"CR140\" class=\"CitationRef\"\u003e140\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003e\u0026ldquo;\u003cem\u003eLearning Norwegian as a part of the Introductory Programme was very important to all the participants. They wished to improve their language skills and have an opportunity to practise the language.\u003c/em\u003e\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;\u003c/em\u003e \u003cb\u003eI have a positive opinion of the municipality. I obtained all the information I needed about pregnancy and delivery. I also had the opportunity to learn Norwegian and earn money by attending \u0026ldquo;The Introductory Programme.\u0026rdquo;\u0026rdquo;\u003c/b\u003e \u003cem\u003e(P6)\u0026rdquo;\u003c/em\u003e\u003csup\u003e137\u003c/sup\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec21\" class=\"Section2\"\u003e \u003ch2\u003eBii. Positive, culturally safe birth experiences\u003c/h2\u003e \u003cp\u003eConfidence in Review Finding: moderate confidence (minor concerns regarding adequacy, because of limited data within the included studies, and how much the included studies focused on research questions, which are specific to this review finding.)\u003c/p\u003e \u003cp\u003eWomen valued opportunities to access information and connect with other mothers in in prenatal classes where interpreters or language-specific classes were provided\u003csup\u003e\u003cspan citationid=\"CR100\" class=\"CitationRef\"\u003e100\u003c/span\u003e,\u003cspan citationid=\"CR107\" class=\"CitationRef\"\u003e107\u003c/span\u003e,\u003cspan citationid=\"CR112\" class=\"CitationRef\"\u003e112\u003c/span\u003e,\u003cspan citationid=\"CR126\" class=\"CitationRef\"\u003e126\u003c/span\u003e,\u003cspan citationid=\"CR150\" class=\"CitationRef\"\u003e150\u003c/span\u003e\u003c/sup\u003e. The ability to communicate effectively and develop positive relationships with HCPs further contribute to improved and more culturally safe birth experiences\u003csup\u003e\u003cspan citationid=\"CR69\" class=\"CitationRef\"\u003e69\u003c/span\u003e,\u003cspan citationid=\"CR76\" class=\"CitationRef\"\u003e76\u003c/span\u003e,\u003cspan citationid=\"CR80\" class=\"CitationRef\"\u003e80\u003c/span\u003e,\u003cspan additionalcitationids=\"CR84\" citationid=\"CR83\" class=\"CitationRef\"\u003e83\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR85\" class=\"CitationRef\"\u003e85\u003c/span\u003e,\u003cspan citationid=\"CR91\" class=\"CitationRef\"\u003e91\u003c/span\u003e,\u003cspan citationid=\"CR103\" class=\"CitationRef\"\u003e103\u003c/span\u003e,\u003cspan citationid=\"CR104\" class=\"CitationRef\"\u003e104\u003c/span\u003e,\u003cspan citationid=\"CR107\" class=\"CitationRef\"\u003e107\u003c/span\u003e,\u003cspan citationid=\"CR108\" class=\"CitationRef\"\u003e108\u003c/span\u003e,\u003cspan citationid=\"CR112\" class=\"CitationRef\"\u003e112\u003c/span\u003e,\u003cspan citationid=\"CR118\" class=\"CitationRef\"\u003e118\u003c/span\u003e,\u003cspan citationid=\"CR126\" class=\"CitationRef\"\u003e126\u003c/span\u003e,\u003cspan citationid=\"CR135\" class=\"CitationRef\"\u003e135\u003c/span\u003e,\u003cspan citationid=\"CR142\" class=\"CitationRef\"\u003e142\u003c/span\u003e,\u003cspan citationid=\"CR145\" class=\"CitationRef\"\u003e145\u003c/span\u003e,\u003cspan citationid=\"CR151\" class=\"CitationRef\"\u003e151\u003c/span\u003e\u003c/sup\u003e.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;Women revealed how care experiences made them feel understood, culturally safe and heard. [\u0026hellip;] Many women felt \u0026lsquo;\u003c/em\u003e \u003cb\u003eheard and understood\u0026rsquo;\u003c/b\u003e \u003cem\u003eby their midwives, in contrast to standard hospital care, where they struggled to communicate, be heard, and have their needs met. This is a known strength of caseload midwifery models, where women and midwives build strong relationships, helping midwives understand women better\u003c/em\u003e.\u0026rdquo;\u003csup\u003e85\u003c/sup\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec22\" class=\"Section2\"\u003e \u003ch2\u003eBiii. Continuity of care supports trusting therapeutic relationship development\u003c/h2\u003e \u003cp\u003eConfidence in Review Finding: moderate confidence (minor concerns regarding adequacy, because of limited data within the included studies, and how much the included studies focused on research questions, which are specific to this review finding.)\u003c/p\u003e \u003cp\u003eWomen with language barriers reported valuing the development of trusting relationships with HCPs which were strengthened over time through continuity of care \u003csup\u003e\u003cspan citationid=\"CR65\" class=\"CitationRef\"\u003e65\u003c/span\u003e,\u003cspan citationid=\"CR71\" class=\"CitationRef\"\u003e71\u003c/span\u003e,\u003cspan citationid=\"CR72\" class=\"CitationRef\"\u003e72\u003c/span\u003e,\u003cspan citationid=\"CR77\" class=\"CitationRef\"\u003e77\u003c/span\u003e,\u003cspan citationid=\"CR79\" class=\"CitationRef\"\u003e79\u003c/span\u003e,\u003cspan citationid=\"CR85\" class=\"CitationRef\"\u003e85\u003c/span\u003e,\u003cspan citationid=\"CR88\" class=\"CitationRef\"\u003e88\u003c/span\u003e,\u003cspan citationid=\"CR91\" class=\"CitationRef\"\u003e91\u003c/span\u003e,\u003cspan citationid=\"CR94\" class=\"CitationRef\"\u003e94\u003c/span\u003e,\u003cspan citationid=\"CR100\" class=\"CitationRef\"\u003e100\u003c/span\u003e,\u003cspan citationid=\"CR104\" class=\"CitationRef\"\u003e104\u003c/span\u003e,\u003cspan citationid=\"CR110\" class=\"CitationRef\"\u003e110\u003c/span\u003e,\u003cspan citationid=\"CR117\" class=\"CitationRef\"\u003e117\u003c/span\u003e,\u003cspan citationid=\"CR120\" class=\"CitationRef\"\u003e120\u003c/span\u003e,\u003cspan citationid=\"CR123\" class=\"CitationRef\"\u003e123\u003c/span\u003e,\u003cspan additionalcitationids=\"CR126\" citationid=\"CR125\" class=\"CitationRef\"\u003e125\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR127\" class=\"CitationRef\"\u003e127\u003c/span\u003e,\u003cspan citationid=\"CR131\" class=\"CitationRef\"\u003e131\u003c/span\u003e,\u003cspan citationid=\"CR132\" class=\"CitationRef\"\u003e132\u003c/span\u003e,\u003cspan citationid=\"CR142\" class=\"CitationRef\"\u003e142\u003c/span\u003e,\u003cspan citationid=\"CR145\" class=\"CitationRef\"\u003e145\u003c/span\u003e,\u003cspan citationid=\"CR146\" class=\"CitationRef\"\u003e146\u003c/span\u003e,\u003cspan citationid=\"CR148\" class=\"CitationRef\"\u003e148\u003c/span\u003e,\u003cspan citationid=\"CR150\" class=\"CitationRef\"\u003e150\u003c/span\u003e,\u003cspan citationid=\"CR153\" class=\"CitationRef\"\u003e153\u003c/span\u003e\u003c/sup\u003e. For some there was a perception of receiving more individualised and responsive care, even with limited interpretation\u003csup\u003e\u003cspan citationid=\"CR65\" class=\"CitationRef\"\u003e65\u003c/span\u003e,\u003cspan citationid=\"CR72\" class=\"CitationRef\"\u003e72\u003c/span\u003e,\u003cspan citationid=\"CR76\" class=\"CitationRef\"\u003e76\u003c/span\u003e,\u003cspan citationid=\"CR91\" class=\"CitationRef\"\u003e91\u003c/span\u003e,\u003cspan citationid=\"CR123\" class=\"CitationRef\"\u003e123\u003c/span\u003e,\u003cspan citationid=\"CR126\" class=\"CitationRef\"\u003e126\u003c/span\u003e,\u003cspan citationid=\"CR127\" class=\"CitationRef\"\u003e127\u003c/span\u003e,\u003cspan citationid=\"CR142\" class=\"CitationRef\"\u003e142\u003c/span\u003e,\u003cspan citationid=\"CR145\" class=\"CitationRef\"\u003e145\u003c/span\u003e\u003c/sup\u003e. These trusted relationships were associated with increased increase safety for both mother and baby and facilitated more accurate and open information sharing,\u003csup\u003e110,127,131,148\u003c/sup\u003e in contrast to experiences of discriminatory care (Cvi) which were linked to increased risk of mother and baby (Civ) through reduced engagement and diminished trust in services (Cii).\u003c/p\u003e \u003cp\u003e \u003cstrong\u003e\u0026lsquo;The women expressed how trusting the caregiver afforded them the opportunity to share matters of an intimate nature, or ask questions they might never have had the courage to ask. One woman with four children was especially grateful for her midwife, who made her feel welcome at any time\u003c/strong\u003e \u003cp\u003e\u003cb\u003e\u0026ldquo;I would rather go to a midwife than a doctor (\u0026hellip;) The midwife takes her time, gives me good advice and asks me how I\u0026rsquo;m doing (\u0026hellip;) The doctor asks me more basic things. (\u0026hellip;) I like talking to my midwife (\u0026hellip;) The midwife always had time to talk to me (\u0026hellip;) She made me feel welcome and that she genuinely cared about me.\u0026rdquo;\u003c/b\u003e\u003cem\u003e\u0026rsquo; (Fatima)\u003c/em\u003e\u003csup\u003e\u003cem\u003e\u003cspan citationid=\"CR110\" class=\"CitationRef\"\u003e110\u003c/span\u003e\u003c/em\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/p\u003e \u003cp\u003eSupportive relationships with HCPs and interpreters, particularly those who demonstrated time, patience and understanding of the additional complexities faced by migrant women, enhanced women\u0026rsquo;s confidence in navigating the host healthcare system and contributed to improving their language skills\u003csup\u003e\u003cspan citationid=\"CR79\" class=\"CitationRef\"\u003e79\u003c/span\u003e,\u003cspan citationid=\"CR88\" class=\"CitationRef\"\u003e88\u003c/span\u003e,\u003cspan citationid=\"CR100\" class=\"CitationRef\"\u003e100\u003c/span\u003e,\u003cspan citationid=\"CR107\" class=\"CitationRef\"\u003e107\u003c/span\u003e,\u003cspan citationid=\"CR115\" class=\"CitationRef\"\u003e115\u003c/span\u003e,\u003cspan citationid=\"CR137\" class=\"CitationRef\"\u003e137\u003c/span\u003e,\u003cspan citationid=\"CR140\" class=\"CitationRef\"\u003e140\u003c/span\u003e,\u003cspan citationid=\"CR148\" class=\"CitationRef\"\u003e148\u003c/span\u003e\u003c/sup\u003e.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026lsquo;\u0026hellip;women point out they needed the cooperation of their providers to make communication effective. Providers can help by slowing down when speaking, taking time to explain unusual words and answer questions, and by listening carefully. Participant A said, \u0026ldquo;\u003c/em\u003e\u003cb\u003eIt\u0026rsquo;s important for doctors to have an open mind and be flexible because there is more than one way to do things. It\u0026rsquo;s so helpful to listen to what is important for the patient.\u0026rdquo;\u003c/b\u003e\u003cem\u003e\u0026rsquo;\u003c/em\u003e\u003csup\u003e\u003cem\u003e115\u003c/em\u003e\u003c/sup\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cdiv id=\"Sec23\" class=\"Section3\"\u003e \u003ch2\u003eConfidence in Review Findings\u003c/h2\u003e \u003cp\u003eMost of the 15 review findings were assessed as high confidence (Additional File 5). We had moderate confidence in three findings (Bi. ii, iii) due to minor concerns regarding data adequacy, reflecting limited data within the included studies specific to these findings. For one finding (1.2) we had moderate confidence due to data adequacy and relevant, including, and limited data within the included studies, and the extent to which these studies address the specific review finding.\u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003e \u003cb\u003eOvercoming structural barriers\u003c/b\u003e \u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e \u003cp\u003eAccording to the WHO Quality of Care framework\u003csup\u003e\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e,\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e\u003c/sup\u003e, \u0026ldquo;effective communication\u0026rdquo; and \u0026ldquo;experience of care\u0026rdquo; are core domains of quality, aligning with the provision of universal healthcare which is \u003cb\u003esafe\u003c/b\u003e, \u003cb\u003eeffective\u003c/b\u003e and \u003cb\u003eperson centred\u003c/b\u003e.\u003csup\u003e\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e outlines the information and support needs of women with language barriers to address gaps in, and consequences of, inconsistent interpreter provision identified in this review. These needs are framed in reference to the WHO recommendations on intrapartum care,\u003csup\u003e35\u003c/sup\u003e which aim to address mistreatment and abuse of women and babies in maternity systems, and the FIGO statement of respectful maternity care which emphasises that healthcare practitioners should provide respectful and dignified care, ensure clear communication and informed decision-making, and support collaborative care involving women, their families, and healthcare providers.\u003csup\u003e\u003cspan citationid=\"CR162\" class=\"CitationRef\"\u003e162\u003c/span\u003e\u003c/sup\u003e These domains provide a framework through which the findings of this review can be operationalised into practice.\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eRespectful maternity care\u003csup\u003e\u003cspan citationid=\"CR163\" class=\"CitationRef\"\u003e163\u003c/span\u003e\u003c/sup\u003e\u003c/strong\u003e \u003cp\u003eOrganised and delivered in a way that maintains dignity, privacy, and confidentiality; ensures freedom from harm and mistreatment; and enables informed choice and continuous support during labour and childbirth.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eCompanion of choice during labour and childbirth\u003c/strong\u003e \u003cp\u003eThe presence of a companion of choice is recommended for all women throughout labour and childbirth.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eEffective communication\u003c/strong\u003e \u003cp\u003eCommunication between maternity care providers and women should be clear, accessible, and delivered using simple and culturally appropriate methods.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eKey domain(s) of gaps in access framed within Respectful Maternity Care framework\u003csup\u003e\u003cspan citationid=\"CR162\" class=\"CitationRef\"\u003e162\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\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 \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eSafe, respectful maternity care\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDescription\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSuggestions to improve access and care\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSafe and \u003cb\u003erespectful maternity care\u003c/b\u003e is a fundamental right for all women giving birth. All women are entitled to make informed choices about their care and that of their unborn child or infant. For safety, trauma-informed care, and the provision of informed consent, it is essential that parents understand both the choices available to them and what is happening to themselves and/or their baby.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026bull; Families should be provided with clear information on how maternity services and healthcare access operate within their local area.\u003c/p\u003e \u003cp\u003e\u0026bull; Healthcare professionals (e.g., doctors, midwives, and nurses) should clearly indicate which services are free and which may incur additional costs, for example prescription medications, additional testing or screening, or the use of private interpreting services outside formal healthcare provision.\u003c/p\u003e \u003cp\u003e\u0026bull; All parents, including those new to the host country or with limited host-language proficiency, should be encouraged to provide feedback on their care experiences. This is important for capturing data on underrepresented groups, including the availability and appropriateness of interpreting services.\u003c/p\u003e \u003cp\u003e\u0026bull; Women should be encouraged to ask questions without fear of judgement or discrimination, particularly where they do not understand information provided by healthcare professionals. This may relate to their clinical situation, medication use, or decisions regarding screening or vaccination.\u003c/p\u003e \u003cp\u003e\u0026bull; For all interventions, women should be offered additional appointments with appropriate interpreter support and supported to ask questions until they have a clear understanding, thereby enabling informed consent.\u003c/p\u003e \u003cp\u003e\u0026bull; Parents should be encouraged to highlight both positive and negative aspects of their care experiences.\u003c/p\u003e \u003cp\u003e\u0026bull; Healthcare providers should be informed of areas for improvement, to strengthen service delivery, while also recognising and reinforcing examples of good practice.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCompanion of choice during labour and childbirth\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDescription\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSuggestions to improve access and care\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026ldquo;Each health care practitioner that a woman sees during the childbirth continuum should [\u0026hellip;] communicate health knowledge and information in a culturally safe and sensitive manner, and in a language that the woman and her family understand.\u003csup\u003e\u003cspan citationid=\"CR162\" class=\"CitationRef\"\u003e162\u003c/span\u003e\u003c/sup\u003e\u0026rdquo;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026bull; A companion of choice may include an appropriate interpreter selected by the woman.\u003c/p\u003e \u003cp\u003e\u0026bull; The use of non-professional interpreters is complex and context dependent. Systems should ensure that no woman is required to rely on family members for interpretation unless this is her explicit preference.\u003c/p\u003e \u003cp\u003e\u0026bull; \u003cb\u003eSome women may prefer a known and trusted individual to act as both companion and interpreter\u003c/b\u003e, particularly during intimate or stressful situations such as labour and birth. However, this must be considered within safeguarding frameworks, including risks of coercive control or intimate partner violence.\u003c/p\u003e \u003cp\u003e\u0026bull; The relationship between the woman, healthcare professional, and interpreter is nuanced and multi-faceted.\u003c/p\u003e \u003cp\u003e\u0026bull; Strong existing relationships between healthcare professionals and interpreters may, in some cases, influence the woman\u0026rsquo;s ability to develop a direct therapeutic relationship with her provider.\u003c/p\u003e \u003cp\u003e- Continuity between the woman, her healthcare professional, and an appropriate interpreter can support sustained engagement with services.\u003c/p\u003e \u003cp\u003e- Women should be provided with opportunities to give feedback on interpreter experiences, and to request continuity or change of interpreter for future appointments.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEffective communication\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDescription\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSuggestions to improve access and care\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMidwives should be encouraged to discuss women\u0026rsquo;s communication preferences to enable and support \u003cb\u003eeffective communication\u003c/b\u003e. This may include literacy in spoken languages, other languages women might read and or speak, and needs and preferences for online or paper/written communications.\u003c/p\u003e \u003cp\u003e8Health and language literacy and alternative or preferred communication methods\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026bull; Women whose primary language differs from the host language should be routinely offered interpreter support. This should be part of standard care and made available at all stages, including where women and their families appear fluent in the host language. Conversational fluency does not necessarily equate to understanding medical terminology or navigating unfamiliar healthcare systems.\u003c/p\u003e \u003cp\u003e\u0026bull; Women should be supported to enquire about the availability of interpreter services at each appointment.\u003c/p\u003e \u003cp\u003e\u0026bull; Where awareness is limited, healthcare professionals should proactively provide this information, beginning at the initial booking appointment.\u003c/p\u003e \u003cp\u003e\u0026bull; Where healthcare professionals identify gaps in understanding, they should utilise interpreter support or translated materials to facilitate communication.\u003c/p\u003e \u003cp\u003e\u0026bull; Developing a central repository of multilingual information resources may support access to information.\u003c/p\u003e \u003cp\u003e\u0026bull; Women may be encouraged to share externally sourced language resources with their midwife. These resources can be reviewed to:\u003c/p\u003e \u003cp\u003e\u0026bull; ensure the information is safe and accurate, including consultation with professional interpreting services where needed.\u003c/p\u003e \u003cp\u003e\u0026bull; assess relevance to local care pathways, intervention availability, and alignment with health policies and maternity practices in the host country.\u003c/p\u003e \u003cp\u003e\u0026bull; Where resources are deemed appropriate, they may be incorporated into central repositories and shared with other parents as appropriate.\u003c/p\u003e \u003cp\u003e\u0026bull; Access to local support groups with shared linguistic or cultural backgrounds should be promoted; peer support is highly valued by parents.\u003c/p\u003e \u003cp\u003e\u0026bull; Engagement with diverse groups, including those involving host-country parents, may also support social integration and language development.\u003c/p\u003e \u003cp\u003e\u0026bull; Women\u0026rsquo;s communication preferences should be regularly reviewed and updated throughout the perinatal period, particularly during discussions regarding birth options.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003c/div\u003e "},{"header":"Discussion","content":"\u003cdiv id=\"Sec24\" class=\"Section2\"\u003e \u003cp\u003eThis review examined women\u0026rsquo;s experiences of accessing maternity care in the context of language barriers, framed against the navigation of complex, unfamiliar healthcare systems. Women\u0026rsquo;s access to and understanding of health and maternity care were shaped by the presence or absence of a shared language. Their ability to engage with maternity care was mediated not only by the availability of professional interpreting services, but also by how accessible, trustworthy, and appropriate these services were perceived to be. Women facing inconsistencies in availability and suitability of professional interpreters sometimes described examples of HCPs working to overcome language barriers, whereas other interactions contributed to feelings of \u0026lsquo;othering\u0026rsquo; and experiences of discrimination. Respectful maternity care has been identified as a global area for improvement within the inequality agenda\u003csup\u003e\u003cspan citationid=\"CR164\" class=\"CitationRef\"\u003e164\u003c/span\u003e\u003c/sup\u003e. One recent synthesis of 12 respectful midwifery care frameworks proposes \u0026lsquo;an approach to maternity care that honours the dignity, personhood, autonomy, and interests of birthing people; prevents disrespect, mistreatment, or abuse toward individuals who are using maternal care services; and provides a practical paradigm for the delivery and receipt of peripartum care through a rights- and reproductive justice\u0026ndash;based framework\u0026rsquo;.\u003csup\u003e163\u003c/sup\u003e Within this context, women may decline interpreting services due to concerns about cost, confidentiality, or a preference for a trusted non-professional interpreter\u003csup\u003e\u003cspan citationid=\"CR165\" class=\"CitationRef\"\u003e165\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eHCPs may face additional challenges in accurately assessing the need for interpretation as medical staff often overestimate how much patients understand\u003csup\u003e\u003cspan citationid=\"CR166\" class=\"CitationRef\"\u003e166\u003c/span\u003e,\u003cspan citationid=\"CR167\" class=\"CitationRef\"\u003e167\u003c/span\u003e\u003c/sup\u003e, while conversational fluency may not extend to understanding obstetric or medical terminology\u003csup\u003e\u003cspan citationid=\"CR124\" class=\"CitationRef\"\u003e124\u003c/span\u003e,\u003cspan citationid=\"CR168\" class=\"CitationRef\"\u003e168\u003c/span\u003e,\u003cspan citationid=\"CR169\" class=\"CitationRef\"\u003e169\u003c/span\u003e\u003c/sup\u003e. Interpreter needs are often recorded at the start of pregnancy; however, regular review throughout the perinatal period, particularly during periods of increased complexity or stress, may be necessary to ensure appropriate support.\u003c/p\u003e \u003cp\u003eThese findings must be understood within the broader context of women\u0026rsquo;s pre-existing social, cultural, and structural positions. Women enter pregnancy with diverse social, cultural and health-related characteristics that shape their prior experiences, including those within their home countries. Disparities in maternity outcomes are already well documented among underserved populations within countries.\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e,\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e,\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eWomen who migrate to a host country, whether through either choice, economic migration, or as refugees or asylum seekers, are frequently at higher risk of poorer maternal and infant outcomes\u003csup\u003e\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e,\u003cspan citationid=\"CR102\" class=\"CitationRef\"\u003e102\u003c/span\u003e,\u003cspan additionalcitationids=\"CR171\" citationid=\"CR170\" class=\"CitationRef\"\u003e170\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR172\" class=\"CitationRef\"\u003e172\u003c/span\u003e\u003c/sup\u003e. These communities often experience socio-economic disadvantage and may experience social discrimination and prejudice due to their ethnicity, positioning them amount the most vulnerable groups globally\u003csup\u003e\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e,\u003cspan citationid=\"CR173\" class=\"CitationRef\"\u003e173\u003c/span\u003e\u003c/sup\u003e. These intersecting characteristics contribute to compounding forms of disadvantage, amplifying both vulnerability and risk\u003csup\u003e\u003cspan additionalcitationids=\"CR174 CR175\" citationid=\"CR173\" class=\"CitationRef\"\u003e173\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR176\" class=\"CitationRef\"\u003e176\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eHealthcare systems in host countries are typically structured around population-level models of care, whether publicly funded or insurance-based, and often operate as \u0026lsquo;one-size-fits-all\u0026rsquo; systems. As a result, structural inequities embedded within service design and resource allocation may persist, contributing to and exacerbating disparities in access, care, and outcomes \u003csup\u003e\u003cspan citationid=\"CR150\" class=\"CitationRef\"\u003e150\u003c/span\u003e,\u003cspan additionalcitationids=\"CR178\" citationid=\"CR177\" class=\"CitationRef\"\u003e177\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR179\" class=\"CitationRef\"\u003e179\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eWithin clinical encounters language barriers result in disrupted shared decision making and person-centred communication between women and their HCPs, where informed consent, understanding and emotional safety all rely on shared language and meaning\u003csup\u003e\u003cspan additionalcitationids=\"CR181 CR182 CR183\" citationid=\"CR180\" class=\"CitationRef\"\u003e180\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR184\" class=\"CitationRef\"\u003e184\u003c/span\u003e\u003c/sup\u003e. Drawing on cultural safety frameworks, safety is understood not only as physical but also relational and psychological, requiring both clinicians and institutions to reflect on power, bias and trust within communication.\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e,\u003cspan citationid=\"CR180\" class=\"CitationRef\"\u003e180\u003c/span\u003e,\u003cspan citationid=\"CR185\" class=\"CitationRef\"\u003e185\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eInterpreting these findings through a socio-ecological lens suggests that language inequities are reinforced across multiple layers of the maternity care system\u003csup\u003e\u003cspan additionalcitationids=\"CR187 CR188 CR189 CR190\" citationid=\"CR186\" class=\"CitationRef\"\u003e186\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR191\" class=\"CitationRef\"\u003e191\u003c/span\u003e\u003c/sup\u003e. Women\u0026rsquo;s accounts highlight not only gaps in individual communication but also the broader structural conditions that allow these gaps to persist. Addressing these gaps requires coordinated action across each level, from individual encounters to policy development, implementation, and system level reform\u003csup\u003e\u003cspan additionalcitationids=\"CR189 CR190 CR191\" citationid=\"CR188\" class=\"CitationRef\"\u003e188\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR192\" class=\"CitationRef\"\u003e192\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cdiv id=\"Sec25\" class=\"Section3\"\u003e \u003ch2\u003eIndividual\u003c/h2\u003e \u003cp\u003eAt the individual level, efforts should focus on strengthening both women\u0026rsquo;s and clinicians\u0026rsquo; capacity for meaningful communication\u003csup\u003e\u003cspan citationid=\"CR193\" class=\"CitationRef\"\u003e193\u003c/span\u003e,\u003cspan citationid=\"CR194\" class=\"CitationRef\"\u003e194\u003c/span\u003e\u003c/sup\u003e. For women, this may include improved awareness of their right to request professional interpreters and support for language confidence where appropriate (see overcoming structural barriers Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e). For clinicians, reflective practice is essential, \u0026mdash;recognising assumptions about \u0026lsquo;good\u0026rsquo; communication, developing awareness of power dynamics, and adopting clear, inclusive language, alongside training on communication practices and their downstream impact on clinical interactions and outcomes\u003csup\u003e\u003cspan additionalcitationids=\"CR196\" citationid=\"CR195\" class=\"CitationRef\"\u003e195\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR197\" class=\"CitationRef\"\u003e197\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec26\" class=\"Section3\"\u003e \u003ch2\u003eInterpersonal\u003c/h2\u003e \u003cp\u003eAt the interpersonal level, the quality of the care relationship is pivotal. Trust and mutual respect may mitigate vulnerabilities arising from language barriers, whereas reliance on, or removal of, family members as interpreters may intensify these vulnerabilities\u003csup\u003e\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e,\u003cspan citationid=\"CR198\" class=\"CitationRef\"\u003e198\u003c/span\u003e,\u003cspan citationid=\"CR199\" class=\"CitationRef\"\u003e199\u003c/span\u003e\u003c/sup\u003e. Continuity of care, across relationships between women, HCPS, and interpreters, alongside attentive listening, and validation of women\u0026rsquo;s voices, is central to enabling shared decision-making and respectful care\u003csup\u003e\u003cspan additionalcitationids=\"CR201 CR202\" citationid=\"CR200\" class=\"CitationRef\"\u003e200\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR203\" class=\"CitationRef\"\u003e203\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec27\" class=\"Section3\"\u003e \u003ch2\u003eCommunity\u003c/h2\u003e \u003cp\u003eAt the community level, social networks and local organisations play a key role in shaping access. Community advocates and migrant women\u0026rsquo;s groups often fill informational gaps left by formal systems\u003csup\u003e\u003cspan citationid=\"CR148\" class=\"CitationRef\"\u003e148\u003c/span\u003e,\u003cspan citationid=\"CR204\" class=\"CitationRef\"\u003e204\u003c/span\u003e\u003c/sup\u003e; involving these actors in maternity outreach may strengthen engagement and ensure resources are culturally and linguistically appropriate. However, reliance on community interpretation and translation alone risks entrenching inequity if institutional responsibility is not maintained\u003csup\u003e\u003cspan citationid=\"CR119\" class=\"CitationRef\"\u003e119\u003c/span\u003e,\u003cspan citationid=\"CR183\" class=\"CitationRef\"\u003e183\u003c/span\u003e,\u003cspan additionalcitationids=\"CR206\" citationid=\"CR205\" class=\"CitationRef\"\u003e205\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR207\" class=\"CitationRef\"\u003e207\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eA lack of trust in, and understanding of, host healthcare systems may lead to over reliance on community and peer support. Local community organisations can function as conduits for information exchange and support integration into the host community. These often third sector organisations may alleviate pressure on statutory systems; however, they frequently operate within unstable funding structure and fragile networks, leaving them financially and politically vulnerable. At times, local peer support may also contribute to circulation of inaccurate or non-contextualised health information. This disconnect between host and home maternity care, shaped by differing cultural understandings and experiences, may further isolate communities and perpetuate divisions in access to care\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e,\u003cspan citationid=\"CR195\" class=\"CitationRef\"\u003e195\u003c/span\u003e,\u003cspan additionalcitationids=\"CR209 CR210 CR211\" citationid=\"CR208\" class=\"CitationRef\"\u003e208\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR212\" class=\"CitationRef\"\u003e212\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec28\" class=\"Section2\"\u003e \u003ch2\u003eInstitutional\u003c/h2\u003e \u003cp\u003eAt the institutional level, these findings underscore the need for consistent, high-quality interpreter provision as a core component of safe maternity care. Safe care encompasses not only physical but also psychological dimensions, therefore culturally competent interpreters with a nuanced understanding of trauma informed practice should be available and accessible to all women experiencing language barriers\u003csup\u003e\u003cspan citationid=\"CR208\" class=\"CitationRef\"\u003e208\u003c/span\u003e,\u003cspan citationid=\"CR213\" class=\"CitationRef\"\u003e213\u003c/span\u003e\u003c/sup\u003e. Such provision supports women\u0026rsquo;s ability to engage with care, provide informed consent, and experience culturally safe care\u003csup\u003e\u003cspan citationid=\"CR214\" class=\"CitationRef\"\u003e214\u003c/span\u003e,\u003cspan citationid=\"CR215\" class=\"CitationRef\"\u003e215\u003c/span\u003e\u003c/sup\u003e. This requires resourcing interpreter services on a continuous basis, embedding language access into clinical governance, and collecting data on interpreter use across the maternity pathway. Interpreter provision should be recognised as a patient safety measure, equivalent in importance to infection control or emergency readiness.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec29\" class=\"Section2\"\u003e \u003ch2\u003ePolicy\u003c/h2\u003e \u003cp\u003eAt the policy level, aligning national standards in each country, with the WHO Quality of Care framework\u003csup\u003e\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e\u003c/sup\u003e would formalise and embed communication as a dimension of care quality and equity\u003csup\u003e\u003cspan citationid=\"CR188\" class=\"CitationRef\"\u003e188\u003c/span\u003e,\u003cspan citationid=\"CR189\" class=\"CitationRef\"\u003e189\u003c/span\u003e,\u003cspan citationid=\"CR192\" class=\"CitationRef\"\u003e192\u003c/span\u003e\u003c/sup\u003e. Routine monitoring, accountability mechanisms, and investment in interpreter training would help close the gap between policy intent and women\u0026rsquo;s direct experiences\u003csup\u003e\u003cspan citationid=\"CR215\" class=\"CitationRef\"\u003e215\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eTaken together, these levels illustrate how structural inequities and interpersonal power imbalances intersect to shape maternity experiences \u003csup\u003e\u003cspan citationid=\"CR216\" class=\"CitationRef\"\u003e216\u003c/span\u003e\u003c/sup\u003e.. Addressing language barriers requires coordinated action across all levels of the system, not as a peripheral concern, but as a central condition of safe, respectful and equitable care.\u003csup\u003e\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e,\u003cspan citationid=\"CR216\" class=\"CitationRef\"\u003e216\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eThis review synthesised women\u0026rsquo;s experiences of accessing maternity care in the context of language barriers within complex and unfamiliar healthcare systems. Women\u0026rsquo;s access to and understanding of health and maternity care were shaped by the presence or absence of a shared language, with consequences for their ability to engage with services. Engagement with maternity care was mediated not only by the availability of professional interpreting services, but also by how accessible, trustworthy, and appropriate these services were perceived to be. Inconsistent provision and perceived appropriateness of interpreting services contributed to variable experiences, with some healthcare professionals working to overcome communication barriers, while other interactions reinforced feelings of \u0026lsquo;othering\u0026rsquo; and discrimination.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eStrengths and limitations\u003c/h3\u003e\n\u003cp\u003eAs far as the authors are aware, this is the first qualitative systematic review and synthesis focussing on women\u0026rsquo;s experiences on language barriers in high income maternity care. The findings build on and extend the existing evidence base. A key strength of this review is the methodological rigour applied throughout. The literature search was developed with the input of specialist librarians, and search terms were iteratively refined to ensure sufficient sensitivity and breadth to capture relevant studies, although grey literature was excluded due to volume of studies identified, which may have limited the inclusion of additional relevant evidence. A second reviewer was involved in screening, study selection, data extraction and thematic synthesis. The themes and conceptual model were discussed as a team in which FCS, SD, SK have a midwifery background, some of whom have worked with interpreters, which may have influenced interpretation of the data. However, the inclusion of other team members (EM, LLJ, VM, AD) with expertise in qualitative analysis, synthesis, and women\u0026rsquo;s health strengthened the analytical process and overall rigour of the findings. The heterogeneity of the included studies provided a wider range of data and experiences, which presented challenges for coherent synthesis given the volume and richness of the data. The breadth of the included studies may limit transferability, as differences in healthcare systems across countries influence service delivery and experiences of language barriers. Women\u0026rsquo;s experiences are shaped by cultural norms, as well as individual differences in language proficiency, attitudes, education, and prior experiences, in addition to country context. Nevertheless, all included studies were conducted in high-income settings, and no substantial differences in reported experiences were identified across contexts. Overall, these strengths support confidence in the findings, while limitations should be considered when interpreting transferability.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis synthesis reveals that language barriers in maternity care are not isolated communication breakdowns but expressions of deeper structural inequities. When women cannot participate fully in their own care, safety, dignity, and respect are compromised. While respectful care is presumed in high-income settings, women\u0026rsquo;s accounts of exclusion and misunderstanding demonstrate that it is inconsistent and must be actively enacted. These findings highlight that inequitable communication reflects systemic priorities rather than inevitability. Recognising language access as fundamental to both clinical quality and human rights reframe interpreter provision from a logistical concern to an ethical imperative. A multi-level response is required. Aligning with the WHO Quality of Care framework\u003csup\u003e\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e,\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e\u003c/sup\u003e, effective communication, respect, and experience of care must be prioritised across all levels of the system.\u003c/p\u003e \u003cp\u003eThe Socio-Ecological Model highlights meaningful change must occur across individual, interpersonal, community, institutional and policy levels, supported by training for HCPS to meet the complex needs of women experiencing language barriers. Professional interpreting services remain inconsistently available and, at times, inappropriate. This reflects and reinforces inequities within maternity systems. Ultimately, ensuring that women are understood, and able to understand, is not an adjunct to care, but a fundamental condition of safe, equitable, and respectful maternity services.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eEnhancing transparency in Reporting the synthesis of qualitative research (ENTREQ); Health care provider (HCP); Mothers and babies: reducing risk through audits and confidential enquiries across the UK (MBRRACE-UK); Maternal mortality rate (MMR); National institute for health and care excellence (NICE); NHS (National Health Service – UK) systematic review (SR); United Kingdom (UK); United States of America (USA); World Health Organisation (WHO)\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eEthics approval\u0026nbsp;\u003c/h2\u003e\n\u003cp\u003eHuman research ethical approval was not required as we have synthesised published literature available.\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003ePatient consent for publication\u0026nbsp;\u003c/h2\u003e\n\u003cp\u003eNot applicable.\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003eData availability statement\u0026nbsp;\u003c/h2\u003e\n\u003cp\u003eAs a systematic review and qualitative thematic evidence synthesis all data is available from published works.\u003c/p\u003e\n\u003ch2\u003eCompeting interests\u0026nbsp;\u003c/h2\u003e\n\u003cp\u003eNone declared.\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003eFunding\u0026nbsp;\u003c/h2\u003e\n\u003cp\u003eThis work was funded by the National Institute for Health Research (NIHR) grant 970014 through the Applied Research Collaborative (ARC) West Midlands (Maternity Theme) programme. The views expressed are those of the authors and not necessarily of the NIHR or the Department of Health and Social Care.\u003c/p\u003e\n\u003ch2\u003eAuthor contributions:\u0026nbsp;\u003c/h2\u003e\n\u003cp\u003eSK had the original idea for the review, which was refined with LJ. AT wrote the original proposal and protocol and submitted the protocol to PROSPERO as part of an intercalation project supervised by LJ, FCS and SK. AT and FCS, with support from LJ and SK, led the original review process and with SD identified and screened and undertook preliminary analysis of the findings and creation of the original conceptual model. LJ led on the methodology with contributions from EM. EM, SD, AD and SB undertook further screening and analysis of the included articles, updated searches, and additional refinement of the conceptual model. EM and AD undertook assessment of all included findings using GRADE-Cerqual. All authors contributed to the interpretation of the analysis and the writing of the manuscript. All authors actively participated in the final version for submission. LJ is responsible for the overall content as the guarantor.\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003eAcknowledgements\u003c/h2\u003e\n\u003cp\u003eMany thanks to James Barnett, specialist librarian and the library services team for their help and encouragement while conducting this review. Many thanks also to the wider ARC team within University of Birmingham, and specifically the West-Midlands ARC PPIE members for their valuable contributions to this piece of work.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eAl Shamsi H, Almutairi AG, Al Mashrafi S, Al Kalbani T. Implications of Language Barriers for Healthcare: A Systematic Review. Oman Med J. 2020;35(2):e122. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.5001/OMJ.2020.40\u003c/span\u003e\u003cspan address=\"10.5001/OMJ.2020.40\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVertovec S. Super-diversity and its implications. Ethn Racial Stud. 2007;30(6):1024\u0026ndash;54. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1080/01419870701599465\u003c/span\u003e\u003cspan address=\"10.1080/01419870701599465\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLanguage interpreting and translation: migrant health guide - GOV.UK. Accessed April 2. 2026. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.gov.uk/guidance/language-interpretation-migrant-health-guide\u003c/span\u003e\u003cspan address=\"https://www.gov.uk/guidance/language-interpretation-migrant-health-guide\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOverview. | Pregnancy and complex social factors: a model for service provision for pregnant women with complex social factors | Guidance | NICE.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGrant AP. Multilingual Capital: The Languages of London\u0026rsquo;s Schoolchildren and Their Relevance to Economic, Social and Educational Policies (review). Lang (Baltim). 2002;78(4):814\u0026ndash;5. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1353/LAN.2003.0031\u003c/span\u003e\u003cspan address=\"10.1353/LAN.2003.0031\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003evan Rosse F, de Bruijne M, Suurmond J, Essink-Bot ML, Wagner C. Language barriers and patient safety risks in hospital care. A mixed methods study. Int J Nurs Stud. 2016;54:45\u0026ndash;53. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.ijnurstu.2015.03.012\u003c/span\u003e\u003cspan address=\"10.1016/j.ijnurstu.2015.03.012\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSuurmond J, Ulters E, De Bruljne MNC, Stronks K, Essink-Bot ML. Explaining ethnic disparities in patient safety: a qualitative analysis. Am J Public Health. 2010;100(Suppl 1). \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.2105/AJPH.2009.167064\u003c/span\u003e\u003cspan address=\"10.2105/AJPH.2009.167064\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWasserman M, Renfrew MR, Green AR, et al. Identifying and preventing medical errors in patients with limited English proficiency: key findings and tools for the field. J Healthc Qual. 2014;36(3):5\u0026ndash;16. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1111/JHQ.12065\u003c/span\u003e\u003cspan address=\"10.1111/JHQ.12065\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSentell T, Chang A, Ahn HJ, Miyamura J. Maternal language and adverse birth outcomes in a statewide analysis. Women Health. 2016;56(3):257\u0026ndash;80. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1080/03630242.2015.1088114\u003c/span\u003e\u003cspan address=\"10.1080/03630242.2015.1088114\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDiamond L, Izquierdo K, Canfield D, Matsoukas K, Gany F. A Systematic Review of the Impact of Patient-Physician Non-English Language Concordance on Quality of Care and Outcomes. J Gen Intern Med. 2019;34(8):1591\u0026ndash;606. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/S11606-019-04847-5\u003c/span\u003e\u003cspan address=\"10.1007/S11606-019-04847-5\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePhillimore J. Migrant maternity in an era of superdiversity: New migrants\u0026rsquo; access to, and experience of, antenatal care in the West Midlands, UK. Soc Sci Med. 2016;148:152\u0026ndash;9. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/J.SOCSCIMED.2015.11.030\u003c/span\u003e\u003cspan address=\"10.1016/J.SOCSCIMED.2015.11.030\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAbubakar I, Aldridge RW, Devakumar D, et al. The UCL\u0026ndash;Lancet Commission on Migration and Health: the health of a world on the move. Lancet. 2018;392(10164):2606\u0026ndash;54. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/S0140-6736(18)32114-7\u003c/span\u003e\u003cspan address=\"10.1016/S0140-6736(18)32114-7\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGagnon AJ, Dougherty G, Wahoush O, et al. International migration to Canada: The post-birth health of mothers and infants by immigration class. Soc Sci Med. 2013;76(1):197\u0026ndash;207. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.socscimed.2012.11.001\u003c/span\u003e\u003cspan address=\"10.1016/j.socscimed.2012.11.001\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLanguage interpreting and translation: migrant health guide - GOV.UK. Accessed April 30. 2026. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.gov.uk/guidance/language-interpretation-migrant-health-guide\u003c/span\u003e\u003cspan address=\"https://www.gov.uk/guidance/language-interpretation-migrant-health-guide\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDivi C, Koss RG, Schmaltz SP, Loeb JM. Language proficiency and adverse events in US hospitals: a pilot study. Int J Qual Health Care. 2007;19(2):60\u0026ndash;7. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1093/INTQHC/MZL069\u003c/span\u003e\u003cspan address=\"10.1093/INTQHC/MZL069\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCull J, Anwar N, Brooks E, Cunningham J, Forman J, Hall D. Why does the inequity in outcomes remain? Hot Topic.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKnight M, Bunch K, Vousden N, et al. A national cohort study and confidential enquiry to investigate ethnic disparities in maternal mortality. EClinicalMedicine. 2021;43:101237. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/J.ECLINM.2021.101237\u003c/span\u003e\u003cspan address=\"10.1016/J.ECLINM.2021.101237\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAccessed Mmortality. October 7, 2025. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.npeu.ox.ac.uk/mbrrace-uk/data-brief/maternal-mortality-2020-2022\u003c/span\u003e\u003cspan address=\"https://www.npeu.ox.ac.uk/mbrrace-uk/data-brief/maternal-mortality-2020-2022\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSaving Lives I, Mothers. \u0026rsquo; Care 2020 - Lessons learned to inform maternity care from the UK and Ireland Confidential Enquiries in Maternal Death and Morbidity 2016-18 | MBRRACE-UK | NPEU. Accessed October 8, 2025. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.npeu.ox.ac.uk/mbrrace-uk/reports/maternal-reports/maternal-report-2016-2018\u003c/span\u003e\u003cspan address=\"https://www.npeu.ox.ac.uk/mbrrace-uk/reports/maternal-reports/maternal-report-2016-2018\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eProviding feedback and comment on HSIB reports. Published online 2021. Accessed October 7. 2025. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e\u003c/span\u003e\u003cspan address=\"http://www.hsib.org.uk/tell-us-what-you-think\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCosstick E, Nirmal R, Cross-Sudworth F, Knight M, Kenyon S. The role of social risk factors and engagement with maternity services in ethnic disparities in maternal mortality: A retrospective case note review. EClinicalMedicine. 2022;52. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.eclinm.2022.101587\u003c/span\u003e\u003cspan address=\"10.1016/j.eclinm.2022.101587\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHeath M, Hvass AMF, Wejse CM. Interpreter services and effect on healthcare - a systematic review of the impact of different types of interpreters on patient outcome. J Migr Health. 2023;7. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.jmh.2023.100162\u003c/span\u003e\u003cspan address=\"10.1016/j.jmh.2023.100162\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRayment-Jones H, Harris J, Harden A, Khan Z, Sandall J. How do women with social risk factors experience United Kingdom maternity care? A realist synthesis. Birth. 2019;46(3):461\u0026ndash;74. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1111/BIRT.12446\u003c/span\u003e\u003cspan address=\"10.1111/BIRT.12446\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePerinatal Confidential Enquiry: The care of recent migrant women with language barriers who have experienced a stillbirth or neonatal death | MBRRACE-UK | NPEU. Accessed April 29. 2026. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.npeu.ox.ac.uk/mbrrace-uk/reports/perinatal-mortality-and-morbidity-confidential-enquiries/perinatal-ce-migrant-women\u003c/span\u003e\u003cspan address=\"https://www.npeu.ox.ac.uk/mbrrace-uk/reports/perinatal-mortality-and-morbidity-confidential-enquiries/perinatal-ce-migrant-women\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKnight M, Bunch K, Vousden N, et al. A national cohort study and confidential enquiry to investigate ethnic disparities in maternal mortality. EClinicalMedicine. 2022;43:101237. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.eclinm.2021.101237\u003c/span\u003e\u003cspan address=\"10.1016/j.eclinm.2021.101237\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMartijn L, Jacobs A, Amelink-Verburg M, Wentzel R, Buitendijk S, Wensing M. Adverse outcomes in maternity care for women with a low risk profile in The Netherlands: a case series analysis. BMC Pregnancy Childbirth. 2013;13:219. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/1471-2393-13-219\u003c/span\u003e\u003cspan address=\"10.1186/1471-2393-13-219\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCosstick E, Nirmal R, Cross-Sudworth F, Knight M, Kenyon S. The role of social risk factors and engagement with maternity services in ethnic disparities in maternal mortality: A retrospective case note review. EClinicalMedicine. 2022;52. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.eclinm.2022.101587\u003c/span\u003e\u003cspan address=\"10.1016/j.eclinm.2022.101587\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMcKnight P, Goodwin L, Kenyon S. A systematic review of asylum-seeking women\u0026rsquo;s views and experiences of UK maternity care. Midwifery. 2019;77:16\u0026ndash;23. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.midw.2019.06.007\u003c/span\u003e\u003cspan address=\"10.1016/j.midw.2019.06.007\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHigginbottom GMA, Evans C, Morgan M, Bharj KK, Eldridge J, Hussain B. Experience of and access to maternity care in the UK by immigrant women: a narrative synthesis systematic review. BMJ Open. 2019;9(12). \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1136/BMJOPEN-2019-029478\u003c/span\u003e\u003cspan address=\"10.1136/BMJOPEN-2019-029478\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBillett H, Vazquez Corona M, Bohren MA. Women from migrant and refugee backgrounds\u0026rsquo; perceptions and experiences of the continuum of maternity care in Australia: A qualitative evidence synthesis. Women Birth. 2022;35(4):327\u0026ndash;39. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.wombi.2021.08.005\u003c/span\u003e\u003cspan address=\"10.1016/j.wombi.2021.08.005\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHeys S, Downe S, Thomson G. I know my place\u0026rsquo;; a meta-ethnographic synthesis of disadvantaged and vulnerable women\u0026rsquo;s negative experiences of maternity care in high-income countries. Midwifery. 2021;103. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.midw.2021.103123\u003c/span\u003e\u003cspan address=\"10.1016/j.midw.2021.103123\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLyberg A, Viken B, Haruna M, Severinsson E. Diversity and challenges in the management of maternity care for migrant women. J Nurs Manag. 2012;20(2):287\u0026ndash;95. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1111/J.1365-2834.2011.01364.X\u003c/span\u003e\u003cspan address=\"10.1111/J.1365-2834.2011.01364.X\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePhillimore J. Delivering maternity services in an era of superdiversity: the challenges of novelty and newness. Ethn Racial Stud. 2015;38(4):568\u0026ndash;82. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1080/01419870.2015.980288\u003c/span\u003e\u003cspan address=\"10.1080/01419870.2015.980288\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWorld Health Organization. WHO recommendations. Intrapartum care for a positive childbirth experience. Published online 200AD:200.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWHO. Compendium on respectful maternal and newborn care. Published online 2025. Accessed October 7. 2025. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://iris.who.int/\u003c/span\u003e\u003cspan address=\"https://iris.who.int/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eThomas J, Harden A. Methods for the thematic synthesis of qualitative research in systematic reviews. BMC Med Res Methodol. 2008;8(1):1\u0026ndash;10. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/1471-2288-8-45/FIGURES/2\u003c/span\u003e\u003cspan address=\"10.1186/1471-2288-8-45/FIGURES/2\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFlemming K, Booth A, Garside R, Tun\u0026ccedil;alp \u0026Ouml;, Noyes J. Qualitative evidence synthesis for complex interventions and guideline development: clarification of the purpose, designs and relevant methods. BMJ Glob Health. 2019;4(Suppl 1):e000882. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1136/BMJGH-2018-000882\u003c/span\u003e\u003cspan address=\"10.1136/BMJGH-2018-000882\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTong A, Flemming K, McInnes E, Oliver S, Craig J. Enhancing transparency in reporting the synthesis of qualitative research: ENTREQ. BMC Med Res Methodol. 2012;12. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/1471-2288-12-181\u003c/span\u003e\u003cspan address=\"10.1186/1471-2288-12-181\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMethley AM, Campbell S, Chew-Graham C, McNally R, Cheraghi-Sohi S, PICO. PICOS and SPIDER: a comparison study of specificity and sensitivity in three search tools for qualitative systematic reviews. BMC Health Serv Res. 2014;14(1):579. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/S12913-014-0579-0\u003c/span\u003e\u003cspan address=\"10.1186/S12913-014-0579-0\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCooke A, Smith D, Booth A, Beyond PICO. the SPIDER tool for qualitative evidence synthesis. Qual Health Res. 2012;22(10):1435\u0026ndash;43. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1177/1049732312452938\u003c/span\u003e\u003cspan address=\"10.1177/1049732312452938\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNew World Bank country classifications by income level: 2022\u0026ndash;2023. Accessed April 2. 2026. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://blogs.worldbank.org/en/opendata/new-world-bank-country-classifications-income-level-2022-2023\u003c/span\u003e\u003cspan address=\"https://blogs.worldbank.org/en/opendata/new-world-bank-country-classifications-income-level-2022-2023\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWorld Bank Country and Lending Groups \u0026ndash; World Bank Data Help Desk. Accessed April 2. 2026. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://datahelpdesk.worldbank.org/knowledgebase/articles/906519-world-bank-country-and-lending-groups\u003c/span\u003e\u003cspan address=\"https://datahelpdesk.worldbank.org/knowledgebase/articles/906519-world-bank-country-and-lending-groups\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCovidence - Better systematic review management. Accessed October 8. 2025. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.covidence.org/\u003c/span\u003e\u003cspan address=\"https://www.covidence.org/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWaffenschmidt S, Knelangen M, Sieben W, B\u0026uuml;hn S, Pieper D. Single screening versus conventional double screening for study selection in systematic reviews: a methodological systematic review. BMC Med Res Methodol. 2019;19(1). \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/S12874-019-0782-0\u003c/span\u003e\u003cspan address=\"10.1186/S12874-019-0782-0\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eQualitative Studies Checklist - CASP, Accessed. April 2, 2026. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://casp-uk.net/casp-tools-checklists/qualitative-studies-checklist/\u003c/span\u003e\u003cspan address=\"https://casp-uk.net/casp-tools-checklists/qualitative-studies-checklist/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGarside R. Should we appraise the quality of qualitative research reports for systematic reviews, and if so, how? Innovation: Eur J Social Sci Res. 2014;27(1):67\u0026ndash;79. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1080/13511610.2013.777270\u003c/span\u003e\u003cspan address=\"10.1080/13511610.2013.777270\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNVivo. by Lumivero | Qualitative data analysis (QDA) software. Accessed April 2, 2026. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://lumivero.com/products/nvivo/\u003c/span\u003e\u003cspan address=\"https://lumivero.com/products/nvivo/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMoher D, Liberati A, Tetzlaff J, Altman DG. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. BMJ. 2009;339(7716):b2535. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1136/bmj.b2535\u003c/span\u003e\u003cspan address=\"10.1136/bmj.b2535\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBarnett-Page E, Thomas J. Methods for the synthesis of qualitative research: a critical review. BMC Med Res Methodol. 2009;9(1). \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/1471-2288-9-59\u003c/span\u003e\u003cspan address=\"10.1186/1471-2288-9-59\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHong A, Baker L, Curiel RP, et al. Reconciling big data and thick data to advance the new urban science and smart city governance. Published online. 2022. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1080/07352166.2021.2021085\u003c/span\u003e\u003cspan address=\"10.1080/07352166.2021.2021085\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFlemming K. The synthesis of qualitative research and evidence-based nursing. Evid Based Nurs. 2007;10(3):68\u0026ndash;71. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1136/EBN.10.3.68\u003c/span\u003e\u003cspan address=\"10.1136/EBN.10.3.68\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLewin S, Booth A, Glenton C, et al. Applying GRADE-CERQual to qualitative evidence synthesis findings: Introduction to the series. Implement Sci. 2018;13(1):1\u0026ndash;10. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/S13012-017-0688-3/TABLES/4\u003c/span\u003e\u003cspan address=\"10.1186/S13012-017-0688-3/TABLES/4\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBritten N. Qualitative interviews in medical research. BMJ. 1995;311(6999):251. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1136/BMJ.311.6999.251\u003c/span\u003e\u003cspan address=\"10.1136/BMJ.311.6999.251\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVARIETIES OF QUALITATIVE. RESEARCH METHODS: selected contextual. Published online 2023.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePope C, Mays N. Qualitative Research: Reaching The parts other methods cannot reach: An introduction to qualitative methods in health and health services research. BMJ. 1995;311(6996):42. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1136/BMJ.311.6996.42\u003c/span\u003e\u003cspan address=\"10.1136/BMJ.311.6996.42\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePolit DF, Beck CT. Generalization in quantitative and qualitative research: Myths and strategies. Int J Nurs Stud. 2010;47(11):1451\u0026ndash;8. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/J.IJNURSTU.2010.06.004\u003c/span\u003e\u003cspan address=\"10.1016/J.IJNURSTU.2010.06.004\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMauthner NS, Doucet A. \u003cem\u003eReflexive Accounts and Accounts of Reflexivity in Qualitative Data Analysis\u003c/em\u003e. Vol 37. 2003.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSilverio SA, Sheen KS, Bramante A, et al. Sensitive, Challenging, and Difficult Topics: Experiences and Practical Considerations for Qualitative Researchers. Regul Article Int J Qualitative Methods. 2023;21:1\u0026ndash;16. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1177/16094069221124739\u003c/span\u003e\u003cspan address=\"10.1177/16094069221124739\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDempsey L, Dowling M, Larkin P, Murphy K. Sensitive Interviewing in Qualitative Research. Res Nurs Health. 2016;39(6):480\u0026ndash;90. 10. 1002/NUR.21743;ISSUE:ISSUE:DOI.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDodgson JE. Reflexivity in Qualitative Research. J Hum Lactation. 2019;35(2):220\u0026ndash;2. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1177/0890334419830990\u003c/span\u003e\u003cspan address=\"10.1177/0890334419830990\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCarter N, Bryant-Lukosius D, Dicenso A, Blythe J, Neville AJ. The use of triangulation in qualitative research. Oncol Nurs Forum. 2014;41(5):545\u0026ndash;7. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1188/14.ONF.545-547\u003c/span\u003e\u003cspan address=\"10.1188/14.ONF.545-547\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMays N, Pope C. Rigour and qualitative research. BMJ. 1995;311(6997):109\u0026ndash;12. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1136/bmj.311.6997.109\u003c/span\u003e\u003cspan address=\"10.1136/bmj.311.6997.109\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAlruwaili TA, Fooladi E, Crawford K. Women and husbands\u0026rsquo; experiences and expectations of shared decision-making during pregnancy and childbirth in Saudi Arabia: A qualitative study. Midwifery. 2025;148:104533. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/J.MIDW.2025.104533\u003c/span\u003e\u003cspan address=\"10.1016/J.MIDW.2025.104533\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAlsamman S, Tadesse RT, Sarferaz K, Mohamed AS, Mody SK. Barriers to postpartum health and opinions on a postpartum peer navigator program amongst refugee women resettled in California. \u003cem\u003eBMC Pregnancy and Childbirth 2025 25:1\u003c/em\u003e. 2025;25(1):372-. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/S12884-025-07479-2\u003c/span\u003e\u003cspan address=\"10.1186/S12884-025-07479-2\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAndr\u0026eacute;n A, Akselsson A, R\u0026aring;destad I, et al. Miscommunication influences how women act when fetal movements decrease an interview study with Swedish Somali migrant women. Midwifery. 2023;126. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.midw.2023.103796\u003c/span\u003e\u003cspan address=\"10.1016/j.midw.2023.103796\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAppiah-Kubi R, Kim YH, Attanasio LB. African Immigrant Women\u0026rsquo;s Experiences of Maternity Care in the United States. MCN Am J Matern Child Nurs. 2024;49(6):341\u0026ndash;7. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1097/NMC.0000000000001043\u003c/span\u003e\u003cspan address=\"10.1097/NMC.0000000000001043\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAyers BL, Purvis RS, Bing WI, et al. Structural and Socio-cultural Barriers to Prenatal Care in a US Marshallese Community. Matern Child Health J. 2018;22(7):1067\u0026ndash;76. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s10995-018-2490-5\u003c/span\u003e\u003cspan address=\"10.1007/s10995-018-2490-5\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBains S, Skr\u0026aring;ning S, Sundby J, Vangen S, S\u0026oslash;rbye IK, Lindskog BV. Challenges and barriers to optimal maternity care for recently migrated women - a mixed-method study in Norway. BMC Pregnancy Childbirth. 2021;21(1). \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/s12884-021-04131-7\u003c/span\u003e\u003cspan address=\"10.1186/s12884-021-04131-7\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBawadi H, Al-Hamdan Z, Ahmad MM. Needs of Migrant Arab Muslim Childbearing Women in the United Kingdom. J Transcult Nurs. 2020;31(6):591\u0026ndash;7. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1177/1043659620921219\u003c/span\u003e\u003cspan address=\"10.1177/1043659620921219\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBelton S, Kruske S, Jackson Pulver L, et al. Rheumatic heart disease in pregnancy: How can health services adapt to the needs of Indigenous women? A qualitative study. Aust N Z J Obstet Gynaecol. 2018;58(4):425\u0026ndash;31. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1111/ajo.12744\u003c/span\u003e\u003cspan address=\"10.1111/ajo.12744\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBenzaken T, Siracusa F, D\u0026rsquo;souza M, et al. Supporting infants and parents in the perinatal period (SIPP): Co-creating an improved journey. Published online. 2025. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1371/journal.pone.0305786\u003c/span\u003e\u003cspan address=\"10.1371/journal.pone.0305786\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBiggs LJ, Yelland J, Due C, et al. Conversations about stillbirth prevention during pregnancy care from the perspectives of recent parents of refugee and migrant backgrounds, health professionals, and interpreters: A qualitative study. Women\u0026rsquo;s Health. 2025;21. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1177/17455057251365726\u003c/span\u003e\u003cspan address=\"10.1177/17455057251365726\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBitar D, Oscarsson M. Arabic-speaking women\u0026rsquo;s experiences of communication at antenatal care in Sweden using a tablet application\u0026mdash;Part of development and feasibility study. Midwifery. 2020;84. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.midw.2020.102660\u003c/span\u003e\u003cspan address=\"10.1016/j.midw.2020.102660\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFelek Boyvat S, Hinderstein S, Aragona E, Loyal J. Perspectives of Spanish-Speaking Families on RSV Immunoprophylaxis for Healthy Newborns. \u003cem\u003eJournal of Immigrant and Minority Health 2025 27:6\u003c/em\u003e. 2025;27(6):1009\u0026ndash;1017. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s10903-025-01742-6\u003c/span\u003e\u003cspan address=\"10.1007/s10903-025-01742-6\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBrown-Johnson CG, Kling SMR, Saliba-Gustafsson EA, et al. Hispanic Birthing Parents\u0026rsquo; Experiences With Lactation Support Received In-Hospital: A Quality Improvement Needs Assessment. J Hum Lactation. 2025;41(2):207\u0026ndash;19. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1177/08903344251321777\u003c/span\u003e\u003cspan address=\"10.1177/08903344251321777\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCai D, Villanueva P, Lu H, Zimmermann B, Horsch A. What matters to migrant women during labor and birth: Chinese mothers\u0026rsquo; experiences in Switzerland. BMC Pregnancy Childbirth. 2024;24(1). \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/s12884-024-06271-y\u003c/span\u003e\u003cspan address=\"10.1186/s12884-024-06271-y\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCai D, Villanueva P, Stuijfzand S, Lu H, Zimmermann B, Horsch A. The pregnancy experiences and antenatal care services of Chinese migrants in Switzerland: a qualitative study. BMC Pregnancy Childbirth. 2022;22(1). \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/s12884-022-04444-1\u003c/span\u003e\u003cspan address=\"10.1186/s12884-022-04444-1\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCarlsson T, Marttala UM, Mattsson E, Ringn\u0026eacute;r A. Experiences and preferences of care among Swedish immigrants following a prenatal diagnosis of congenital heart defect in the fetus: A qualitative interview study. BMC Pregnancy Childbirth. 2016;16(1). \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/s12884-016-0912-1\u003c/span\u003e\u003cspan address=\"10.1186/s12884-016-0912-1\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCeulemans M, Chaar R, Van Calsteren K, Allegaert K, Foulon V. Arabic-speaking pregnant women with a migration background: A vulnerable target group for prenatal counseling on medicines. Res Social Administrative Pharm. 2020;16(3):377\u0026ndash;82. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.sapharm.2019.06.004\u003c/span\u003e\u003cspan address=\"10.1016/j.sapharm.2019.06.004\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChu MS, Park M, Kim JA. First childbirth experience of international marriage migrant women in South Korea. Women Birth. 2017;30(4):e198\u0026ndash;206. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.wombi.2017.01.001\u003c/span\u003e\u003cspan address=\"10.1016/j.wombi.2017.01.001\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eClaerbout A, Steppe J, Joni G, van kelst L. Challenges and facilitators to perinatal mental healthcare among first-generation migrant women: A qualitative ethnographic study in Flanders, Belgium. Eur J Midwifery. 2024;8(December):1\u0026ndash;10. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.18332/ejm/194682\u003c/span\u003e\u003cspan address=\"10.18332/ejm/194682\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eClaisse C, Durrant AC, Lie M. Understanding Antenatal Care Needs through Co-Creation with Roma Women to Inform the Design of mHealth Technologies. \u003cem\u003eConference on Human Factors in Computing Systems - Proceedings\u003c/em\u003e. Published online May 11, 2024. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1145/3613904.3642584\u003c/span\u003e\u003cspan address=\"10.1145/3613904.3642584\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDarivemula SM, Massengale KEC, Montiel C, Stuebe AM, Tully KP. Postpartum menstrual equity: Video and audio analysis of vaginal bleeding counseling during postpartum inpatient care at a southeastern US tertiary hospital. Women\u0026rsquo;s Health. 2024;20. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1177/17455057241274897\u003c/span\u003e\u003cspan address=\"10.1177/17455057241274897\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDoering RMKA, Patterson RMJB, Griffiths RMCB, Corresponding Author A. Experience of the New Zealand maternity care system by a group of Japanese women in one centre ABSTRACT. New Z Coll Midwives J. 2015;(51).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDube M, Ireland S, Bromley A, Steel M, Gao Y, Kildea S. It\u0026rsquo;s all about cultural understanding: A reflexive thematic analysis of women\u0026rsquo;s experiences at a dedicated refugee midwifery group practice service. Women Birth. 2024;37(2):410\u0026ndash;8. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.wombi.2023.12.006\u003c/span\u003e\u003cspan address=\"10.1016/j.wombi.2023.12.006\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDullat JK, McDonnell T, Hendrick L, et al. Understanding a Minority Group\u0026rsquo;s (Roma) Experiences of Access and Quality in Maternity Services. Health Expect. 2025;28(4):e70389. 10. 1111/HEX.70389;WGROUP:STRING:PUBLICATION.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEngelhardt M, Gaudion M, Mohr E et al. Exclusion and Othering in maternity care for forced migrant women: a qualitative study with forced migrant mothers and health care professionals in Germany. Published online 2025. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.ssmqr.2025.100614\u003c/span\u003e\u003cspan address=\"10.1016/j.ssmqr.2025.100614\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEvans M, Plows J, McCarthy R, McConville B, Haith-Cooper M. What refugee women want from maternity care: a qualitative study. Br J Midwifery. 2022;30.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFurness A, Salmon A, Fair F, Soltani H. Exploring research and healthcare priorities in maternal health: A qualitative ethnographic study with mothers from ethnic minority backgrounds in the UK. Eur J Midwifery. 2025;9(September):1\u0026ndash;9. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.18332/ejm/209195\u003c/span\u003e\u003cspan address=\"10.18332/ejm/209195\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFair F, Furness A, Higginbottom G, Oddie S, Soltani H. Parent\u0026rsquo;s experiences of the impact of ethnicity and skin pigmentation on perinatal care. Ethn Health. 2025;30(5):581\u0026ndash;601. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1080/13557858.2025.2488893\u003c/span\u003e\u003cspan address=\"10.1080/13557858.2025.2488893\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFilby A, Robertson W, Afonso E. A service evaluation of a specialist migrant maternity service from the user\u0026rsquo;s perspective. Br J Midwifery. 2020;(9).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFitzgerald EM, Cronin SN, Boccella SH. Anguish, Yearning, and Identity: Toward a Better Understanding of the Pregnant Hispanic Woman\u0026rsquo;s Prenatal Care Experience. J Transcult Nurs. 2016;27(5):464\u0026ndash;70. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1177/1043659615578718\u003c/span\u003e\u003cspan address=\"10.1177/1043659615578718\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGallimore A, Irshad T, Cooper M, Cameron S. Influence of culture, religion and experience on the decision of Pakistani women in Lothian, Scotland to use postnatal contraception: a qualitative study. BMJ Sex Reprod Health. 2020;47(1):43\u0026ndash;8. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1136/bmjsrh-2019-200497\u003c/span\u003e\u003cspan address=\"10.1136/bmjsrh-2019-200497\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGarnweidner-Holme LM, Lukasse M, Solheim M, Henriksen L. Talking about intimate partner violence in multi-cultural antenatal care: A qualitative study of pregnant women\u0026rsquo;s advice for better communication in South-East Norway. BMC Pregnancy Childbirth. 2017;17(1). \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/s12884-017-1308-6\u003c/span\u003e\u003cspan address=\"10.1186/s12884-017-1308-6\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGewalt SC, Berger S, Ziegler S, Szecsenyi J, Bozorgmehr K. Psychosocial health of asylum seeking women living in state-provided accommodation in Germany during pregnancy and early motherhood: A case study exploring the role of social determinants of health. PLoS ONE. 2018;13(12). \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1371/journal.pone.0208007\u003c/span\u003e\u003cspan address=\"10.1371/journal.pone.0208007\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGardner A, Oduola S, Teague B. Culturally Sensitive Perinatal Mental Health Care: Experiences of Women From Minority Ethnic Groups. Health Expect. 2024;27(4). \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1111/HEX.14160\u003c/span\u003e\u003cspan address=\"10.1111/HEX.14160\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGuo Y, Hildebrand J, Rousseau J, Brown B, Pimentel P, Olshansky E. Underserved pregnant and postpartum women\u0026rsquo;s access and use of their health records. MCN Am J Maternal/Child Nurs. 2018;43(3):164\u0026ndash;70. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1097/NMC.0000000000000432\u003c/span\u003e\u003cspan address=\"10.1097/NMC.0000000000000432\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHatherall B, Morris J, Jamal F, et al. Timing of the initiation of antenatal care: An exploratory qualitative study of women and service providers in East London. Midwifery. 2016;36:1\u0026ndash;7. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.midw.2016.02.017\u003c/span\u003e\u003cspan address=\"10.1016/j.midw.2016.02.017\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJose Henrique A, Rodney P, Hall W, Thorne S, Joolaee S. Women\u0026rsquo;s autonomy for managing labour pain in a relational context: An interpretive description study. J Clin Nurs. 2023;32(19\u0026ndash;20):7390\u0026ndash;401. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1111/jocn.16780\u003c/span\u003e\u003cspan address=\"10.1111/jocn.16780\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHenry J, Beruf C, Fischer T. Access to Health Care for Pregnant Arabic-Speaking Refugee Women and Mothers in Germany. Qual Health Res. 2020;30(3):437\u0026ndash;47. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1177/1049732319873620\u003c/span\u003e\u003cspan address=\"10.1177/1049732319873620\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHigginbottom GMA, Safipour J, Yohani S, O\u0026rsquo;Brien B, Mumtaz Z, Paton P. An ethnographic study of communication challenges in maternity care for immigrant women in rural Alberta. Midwifery. 2015;31(2):297\u0026ndash;304. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.midw.2014.09.009\u003c/span\u003e\u003cspan address=\"10.1016/j.midw.2014.09.009\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOriglia Ikhilor P, Hasenberg G, Kurth E, Asefaw F, Pehlke-Milde J, Cignacco E. Communication barriers in maternity care of allophone migrants: Experiences of women, healthcare professionals, and intercultural interpreters. J Adv Nurs. 2019;75(10):2200\u0026ndash;10. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1111/JAN.14093\u003c/span\u003e\u003cspan address=\"10.1111/JAN.14093\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eIturralde E, Hsiao CA, Nkemere L, et al. Engagement in perinatal depression treatment: a qualitative study of barriers across and within racial/ethnic groups. BMC Pregnancy Childbirth. 2021;21(1). \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/s12884-021-03969-1\u003c/span\u003e\u003cspan address=\"10.1186/s12884-021-03969-1\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJohansson M, Kaminsky E, Str\u0026ouml;m I, Volgsten H. Migrant women with cultural doula support during pregnancy and after childbirth as a complement to midwifery care in Sweden \u0026ndash; An interview study. Midwifery. 2025;146:104420. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/J.MIDW.2025.104420\u003c/span\u003e\u003cspan address=\"10.1016/J.MIDW.2025.104420\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJohnsen H, Christensen U, Juhl M, Villadsen SF. Organisational barriers to implementing the MAMAACT intervention to improve maternity care for non-Western immigrant women: A qualitative evaluation. Int J Nurs Stud. 2020;111. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.ijnurstu.2020.103742\u003c/span\u003e\u003cspan address=\"10.1016/j.ijnurstu.2020.103742\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJohn JR, Curry G, Cunningham-Burley S. Exploring ethnic minority women\u0026rsquo;s experiences of maternity care during the SARS-CoV-2 pandemic: A qualitative study. BMJ Open. 2021;11(9). \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1136/bmjopen-2021-050666\u003c/span\u003e\u003cspan address=\"10.1136/bmjopen-2021-050666\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKirkendall A, Dutt A. Refugee women\u0026rsquo;s pregnancy and childbirth experiences in the US: Examining context through a reproductive justice framework. Fem Psychol. 2023;33(4):529\u0026ndash;49. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1177/09593535221149166\u003c/span\u003e\u003cspan address=\"10.1177/09593535221149166\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKonje JK, Konje JC. Experiences of accessing maternity care in the UK: Perspectives from Somali migrant women in Leicester. Eur J Midwifery. 2021;5:1\u0026ndash;10. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.18332/EJM/143167\u003c/span\u003e\u003cspan address=\"10.18332/EJM/143167\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLi L. The vicious circle: how systemic barriers perpetuate maternity interpreting service inadequacies for migrant women in the UK. Front Glob Womens Health. 2025;6:1638434. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3389/fgwh.2025.1638434\u003c/span\u003e\u003cspan address=\"10.3389/fgwh.2025.1638434\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eUtne R, Antrobus-Johannessen CL, Aasheim V, Aaseskj\u0026aelig;r K, Vik ES. Somali women\u0026rsquo;s experiences of antenatal care: A qualitative interview study. Midwifery. 2020;83. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.midw.2020.102656\u003c/span\u003e\u003cspan address=\"10.1016/j.midw.2020.102656\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLindsay AC, De Oliveira MG, Wallington SF, et al. Access and utilization of healthcare services in Massachusetts, United States: A qualitative study of the perspectives and experiences of Brazilian-born immigrant women. BMC Health Serv Res. 2016;16(1). \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/s12913-016-1723-9\u003c/span\u003e\u003cspan address=\"10.1186/s12913-016-1723-9\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLiu R, Chao MT, Jostad-Laswell A, Duncan LG. Does CenteringPregnancy Group Prenatal Care Affect the Birth Experience of Underserved Women? A Mixed Methods Analysis. J Immigr Minor Health. 2017;19(2):415\u0026ndash;22. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s10903-016-0371-9\u003c/span\u003e\u003cspan address=\"10.1007/s10903-016-0371-9\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLukasse M, Akhmedova F, Oommen H. Ukrainian refugee women\u0026rsquo;s experience with maternity care in Norway: A qualitative study. Eur J Midwifery. 2025;9(February):1\u0026ndash;8. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.18332/ejm/200613\u003c/span\u003e\u003cspan address=\"10.18332/ejm/200613\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMalmstr\u0026ouml;m N, Lydell M, Carlsson IM. Womanhood, a shared experience of participating in a lifestyle intervention with a focus on integration and physical activity to promote health among pregnant women: perspectives from pregnant women, midwives, and cultural interpreter doulas. Int J Qual Stud Health Well-being. 2022;17(1). \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1080/17482631.2022.2043527\u003c/span\u003e\u003cspan address=\"10.1080/17482631.2022.2043527\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMcClellan C, Madler B. Lived Experiences of Mongolian Immigrant Women Seeking Perinatal Care in the United States. J Transcult Nurs. 2022;33(5):594\u0026ndash;602. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1177/10436596221091689\u003c/span\u003e\u003cspan address=\"10.1177/10436596221091689\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMcEvoy B, Watson K, Farrant K, Stacey TT, Heazell AEP, Haith-Cooper M. Evaluation of a co-designed digital animation in service improvement (DAISI) sharing messages around modifiable behaviours to reduce the risk of stillbirth. Midwifery. 2025;148(8):104517. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.midw.2025.104517\u003c/span\u003e\u003cspan address=\"10.1016/j.midw.2025.104517\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNagesh N, Hoi C, Ip L et al. South Asian women\u0026rsquo;s views on and experiences of maternity care services in Hong Kong: A qualitative study. Published online 2024. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.wombi.2024.101806\u003c/span\u003e\u003cspan address=\"10.1016/j.wombi.2024.101806\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNiner S, Kokanovic R, Cuthbert D. Displaced Mothers: Birth and Resettlement, Gratitude and Complaint. Med Anthropology: Cross Cult Stud Health Illn. 2013;32(6):535\u0026ndash;51. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1080/01459740.2013.769103\u003c/span\u003e\u003cspan address=\"10.1080/01459740.2013.769103\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNithianandan N, Gibson-Helm M, McBride J, et al. Factors affecting implementation of perinatal mental health screening in women of refugee background. Implement Sci. 2016;11(1). \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/s13012-016-0515-2\u003c/span\u003e\u003cspan address=\"10.1186/s13012-016-0515-2\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePope C. The comparison of shared decision making in monolingual and bilingual health encounters. Commun Med. 2018;2(5):206\u0026ndash;21.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePullon S, Pullon MPHCS, Gray FRNZCGPB, Steinmetz Midwifery MB. Molineux MBChB C. \u003cem\u003eVOLUME 6 \u0026bull; NUMBER 4 \u0026bull; DECEMBER\u003c/em\u003e. Vol 319. 2014.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRambaldini-Gooding D, Olcoń K. Molloy | Luke. et al Health Expect Published online. 2024. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1111/hex.70106\u003c/span\u003e\u003cspan address=\"10.1111/hex.70106\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRayment-Jones H, Harris J, Harden A, Silverio SA, Turienzo CF, Sandall J. Project20: interpreter services for pregnant women with social risk factors in England: what works, for whom, in what circumstances, and how? Int J Equity Health. 2021;20(1). \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/s12939-021-01570-8\u003c/span\u003e\u003cspan address=\"10.1186/s12939-021-01570-8\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eReid CN, Fryer K, Cabral N, Marshall J. Health care system barriers and facilitators to early prenatal care among diverse women in Florida. Birth. 2021;48(3):416\u0026ndash;27. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1111/birt.12551\u003c/span\u003e\u003cspan address=\"10.1111/birt.12551\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eToke S, Correa-Velez I, Riggs E. Exploring Trauma- and Violence-Informed Pregnancy Care for Karen Women of Refugee Background: A Community-Based Participatory Study. Int J Environ Res Public Health. 2024;21(3). \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3390/ijerph21030254\u003c/span\u003e\u003cspan address=\"10.3390/ijerph21030254\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRiggs E, Muyeen S, Brown S, et al. Cultural safety and belonging for refugee background women attending group pregnancy care: An Australian qualitative study. Birth. 2017;44(2):145\u0026ndash;52. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1111/birt.12272\u003c/span\u003e\u003cspan address=\"10.1111/birt.12272\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRowe A, Bhardwaj M, McCauley M. Maternal multimorbidity - experiences of women seeking asylum during pregnancy and after childbirth: a qualitative study. BMC Pregnancy Childbirth. 2023;23(1). \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/s12884-023-06054-x\u003c/span\u003e\u003cspan address=\"10.1186/s12884-023-06054-x\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSami J, L\u0026ouml;tscher KCQ, Eperon I, et al. Giving birth in Switzerland: A qualitative study exploring migrant women\u0026rsquo;s experiences during pregnancy and childbirth in Geneva and Zurich using focus groups. Reprod Health. 2019;16(1). \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/s12978-019-0771-0\u003c/span\u003e\u003cspan address=\"10.1186/s12978-019-0771-0\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSmith DC, Thumm EB, Tien NC, Kissler K. Respectful maternity care experiences of South Asian refugees in the US: a qualitative study. Front Public Health. 2025;13:1613249. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3389/fpubh.2025.1613249\u003c/span\u003e\u003cspan address=\"10.3389/fpubh.2025.1613249\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eS\u0026ouml;derstr\u0026ouml;m E, Alexandrou C, Bressanutti S, Sandborg J, Lindqvist AK, L\u0026ouml;f M. Adapting a pregnancy app (HealthyMoms) to support healthy habits in migrant women\u0026mdash;a qualitative study on women\u0026rsquo;s preferences and perceived needs to support health behaviors during pregnancy. Digit Health. 2024;10. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1177/20552076241304045\u003c/span\u003e\u003cspan address=\"10.1177/20552076241304045\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eStapleton H, Murphy R, Correa-Velez I, Steel M, Kildea S. Women from refugee backgrounds and their experiences of attending a specialist antenatal clinic. Narratives from an Australian setting. Women Birth. 2013;26:260\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTernstr\u0026ouml;m E, Small R, Lindgren H. Migrant women\u0026rsquo;s experiences of an individual language-assisted information and support visit to the labor ward before giving birth \u0026ndash; A qualitative study from Sweden. Sex Reproductive Healthc. 2023;38. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.srhc.2023.100915\u003c/span\u003e\u003cspan address=\"10.1016/j.srhc.2023.100915\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTobin C, Murphy-Lawless J, Beck CT. Childbirth in exile: Asylum seeking women\u0026rsquo;s experience of childbirth in Ireland. Midwifery. 2014;30(7):831\u0026ndash;8. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.midw.2013.07.012\u003c/span\u003e\u003cspan address=\"10.1016/j.midw.2013.07.012\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTopa JB, Nogueira CO, Neves SA. Maternal health services: an equal or framed territory? Int J Hum Rights Healthc. 2017;10(2):110\u0026ndash;22. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1108/IJHRH-11-2015-0039\u003c/span\u003e\u003cspan address=\"10.1108/IJHRH-11-2015-0039\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVazquez Corona M, Hazfiarini A, Cao J, et al. Migrant Mums and Maternity Care: A Qualitative Participatory Health Research Study. BJOG. 2025;132(13):2121\u0026ndash;30. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1111/1471-0528.18249\u003c/span\u003e\u003cspan address=\"10.1111/1471-0528.18249\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVelem\u0026iacute;nsk\u0026yacute; M, Průchov\u0026aacute; D, Vr\u0026aacute;nov\u0026aacute; V, et al. Medical and salutogenic approaches and their integration in taking prenatal and postnatal care of immigrants. Neuroendocrinol Lett. 2014;35:67\u0026ndash;79. www.nel.edu.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eViken B, Lyberg A, Severinsson E. Maternal Health Coping Strategies of Migrant Women in Norway. Nurs Res Pract. 2015;2015:1\u0026ndash;11. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1155/2015/878040\u003c/span\u003e\u003cspan address=\"10.1155/2015/878040\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVik ES, Hashi RMA, Hamud ME, Aasheim V, Kringeland T, Aasekj\u0026aelig;r K. Migrant Somali women\u0026rsquo;s experiences with their first contact with the labor ward prior to admission: A qualitative study. Eur J Midwifery. 2022;6(July). \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.18332/EJM/150584\u003c/span\u003e\u003cspan address=\"10.18332/EJM/150584\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWan CS, Nankervis A, Teede H, Aroni R. Priorities to improve woman-centred gestational diabetes mellitus care: A qualitative study to compare views between clinical and consumer end-users. J Hum Nutr Dietetics. 2023;36(5):1636\u0026ndash;48. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1111/jhn.13191\u003c/span\u003e\u003cspan address=\"10.1111/jhn.13191\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWikberg A, Eriksson K, Bondas T. Immigrant New Mothers in Finnish Maternity Care: An Ethnographic Study of Caring. Int J Childbirth. 2014;4(2):86\u0026ndash;102. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1891/2156-5287.4.2.86\u003c/span\u003e\u003cspan address=\"10.1891/2156-5287.4.2.86\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWilley SM, Blackmore RP, Gibson-Helm ME, et al. If you don\u0026rsquo;t ask \u0026hellip; you don\u0026rsquo;t tell:Refugee women\u0026rsquo;s perspectives on perinatal mental health screening. \u003cem\u003eWomen and Birth\u003c/em\u003e. 2020;33(5):e429-e437. doi:10.1016/j.wombi.2019.10.003.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWiseman O, McCourt C, Mehay A, et al. Involving women with limited English proficiency in group antenatal care: Findings from the integrated process evaluation of the Pregnancy Circles pilot trial. Midwifery. 2024;139:104197. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/J.MIDW.2024.104197\u003c/span\u003e\u003cspan address=\"10.1016/J.MIDW.2024.104197\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWorabo HJ, Safi F, Gill SL, Farokhi M. It\u0026rsquo;s different here Afghan refugee maternal health experiences in the United States. BMC Pregnancy Childbirth. 2024;24(1). \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/s12884-024-06678-7\u003c/span\u003e\u003cspan address=\"10.1186/s12884-024-06678-7\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHigginbottom GM, Safipour J, Yohani S, et al. An ethnographic investigation of the maternity healthcare experience of immigrants in rural and urban Alberta, Canada. BMC Pregnancy Childbirth. 2016;16(1). \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/s12884-015-0773-z\u003c/span\u003e\u003cspan address=\"10.1186/s12884-015-0773-z\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGu\u0026eth;mundsd\u0026oacute;ttir E\u0026Yacute;, Nieuwenhuijze M, R\u0026uacute;d\u0026oacute;lfsd\u0026oacute;ttir AG, Gottfre\u0026eth;sd\u0026oacute;ttir H. Fostering empowerment through communication: The needs, expectations, and experience of maternity care among polish migrant women in Iceland. Sex Reproductive Healthc. 2025;44(4):101087. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.srhc.2025.101087\u003c/span\u003e\u003cspan address=\"10.1016/j.srhc.2025.101087\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePař\u0026iacute;zkov\u0026aacute; A, Glajchov\u0026aacute; A. Trust in maternity care: challenges for healthcare professionals and migrant women. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttp://kont.zsf.jcu.cz/doi/1032725/kont2024027.html\u003c/span\u003e\u003cspan address=\"http://kont.zsf.jcu.cz/doi/1032725/kont2024027.html\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. 2024;26(2):126\u0026ndash;132. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.32725/kont.2024.027\u003c/span\u003e\u003cspan address=\"10.32725/kont.2024.027\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYelland J, Riggs E, Szwarc J, et al. Compromised communication: A qualitative study exploring Afghan families and health professionals\u0026rsquo; experience of interpreting support in Australian maternity care. BMJ Qual Saf. 2016;25(4):e1. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1136/bmjqs-2014-003837\u003c/span\u003e\u003cspan address=\"10.1136/bmjqs-2014-003837\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOwens C, Dandy J, Hancock P. Perceptions of pregnancy experiences when using a community-based antenatal service: A qualitative study of refugee and migrant women in Perth, Western Australia. Women Birth. 2016;29(2):128\u0026ndash;37. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.wombi.2015.09.003\u003c/span\u003e\u003cspan address=\"10.1016/j.wombi.2015.09.003\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLi L. The vicious circle: how systemic barriers perpetuate maternity interpreting service inadequacies for migrant women in the UK. Front Glob Womens Health. 2025;6:1638434. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3389/FGWH.2025.1638434/BIBTEX\u003c/span\u003e\u003cspan address=\"10.3389/FGWH.2025.1638434/BIBTEX\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOriglia Ikhilor P, Hasenberg G, Kurth E, Asefaw F, Pehlke-Milde J, Cignacco E. Communication barriers in maternity care of allophone migrants: Experiences of women, healthcare professionals, and intercultural interpreters. J Adv Nurs. 2019;75(10):2200\u0026ndash;10. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1111/jan.14093\u003c/span\u003e\u003cspan address=\"10.1111/jan.14093\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAlruwaili TA, Fooladi E, Crawford K. Women and husbands\u0026rsquo; experiences and expectations of shared decision-making during pregnancy and childbirth in Saudi Arabia: A qualitative study. Midwifery. 2025;148(7):104533. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.midw.2025.104533\u003c/span\u003e\u003cspan address=\"10.1016/j.midw.2025.104533\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGardner A, Oduola S, Teague B. Culturally Sensitive Perinatal Mental Health Care: Experiences of Women From Minority Ethnic Groups. Health Expect. 2024;27(4):e14160. 10.1111. /HEX.14160;SUBPAGE:STRING:FULL.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAlsamman S, Tadesse RT, Sarferaz K, Mohamed AS, Mody SK. Barriers to postpartum health and opinions on a postpartum peer navigator program amongst refugee women resettled in California. \u003cem\u003eBMC Pregnancy and Childbirth 2025 25:1\u003c/em\u003e. 2025;25(1):372-. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/s12884-025-07479-2\u003c/span\u003e\u003cspan address=\"10.1186/s12884-025-07479-2\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGu\u0026eth;mundsd\u0026oacute;ttir E\u0026Yacute;, Nieuwenhuijze M, R\u0026uacute;d\u0026oacute;lfsd\u0026oacute;ttir AG, Gottfre\u0026eth;sd\u0026oacute;ttir H. Fostering empowerment through communication: The needs, expectations, and experience of maternity care among polish migrant women in Iceland. Sex Reproductive Healthc. 2025;44:101087. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/J.SRHC.2025.101087\u003c/span\u003e\u003cspan address=\"10.1016/J.SRHC.2025.101087\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGranada S, Quinteros Baumgart C, Rupley D. Birthing Experiences of Spanish Speakers During the COVID-19 Pandemic in NYC. J Immigr Minor Health. 2022;24(4):1013\u0026ndash;9. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s10903-022-01331-x\u003c/span\u003e\u003cspan address=\"10.1007/s10903-022-01331-x\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWainwright M. The Epistemonikos Foundation MWC and the NI of PH for the GCerqPG. Interactive Summary of Qualitative Findings. \u003cem\u003eNorwegian Institute of Public Health\u003c/em\u003e. Preprint posted online March 9, 2026:1.0. Accessed March 9, 2026. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://isoq.epistemonikos.org/#/\u003c/span\u003e\u003cspan address=\"https://isoq.epistemonikos.org/#/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSami J, Quack L\u0026ouml;tscher KC, Eperon I, et al. Giving birth in Switzerland: a qualitative study exploring migrant women\u0026rsquo;s experiences during pregnancy and childbirth in Geneva and Zurich using focus groups. Reprod Health. 2019;16(1):112. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/s12978-019-0771-0\u003c/span\u003e\u003cspan address=\"10.1186/s12978-019-0771-0\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eReid CN, Fryer K, Cabral N, Marshall J. Health care system barriers and facilitators to early prenatal care among diverse women in Florida. Birth. 2021;48(3):416\u0026ndash;27. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1111/birt.12551\u003c/span\u003e\u003cspan address=\"10.1111/birt.12551\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCai D, Villanueva P, Stuijfzand S, Lu H, Zimmermann B, Horsch A. The pregnancy experiences and antenatal care services of Chinese migrants in Switzerland: a qualitative study. BMC Pregnancy Childbirth. 2022;22(1):148. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/s12884-022-04444-1\u003c/span\u003e\u003cspan address=\"10.1186/s12884-022-04444-1\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eUtne R, Antrobus-Johannessen CL, Aasheim V, Aasekj\u0026aelig;r K, Vik ES. Somali women\u0026rsquo;s experiences of antenatal care: A qualitative interview study. Midwifery. 2020;83:102656. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.midw.2020.102656\u003c/span\u003e\u003cspan address=\"10.1016/j.midw.2020.102656\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCrowther S, Lau A. Migrant Polish women overcoming communication challenges in Scottish maternity services: A qualitative descriptive study. Midwifery. 2019;72:30\u0026ndash;8. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.midw.2019.02.004\u003c/span\u003e\u003cspan address=\"10.1016/j.midw.2019.02.004\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFIGO. Ethical Framework for Respectful Maternity Care During Pregnancy and Childbirth | Figo. 2025. Accessed October 7, 2025. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.figo.org/resources/figo-statements/ethical-framework-respectful-maternity-care-during-pregnancy-and-childbirth\u003c/span\u003e\u003cspan address=\"https://www.figo.org/resources/figo-statements/ethical-framework-respectful-maternity-care-during-pregnancy-and-childbirth\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCantor AG, Jungbauer RM, Skelly AC, et al. Respectful Maternity Care A Systematic Review. Ann Intern Med. 2024;177(1):50\u0026ndash;64. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.7326/M23-2676\u003c/span\u003e\u003cspan address=\"10.7326/M23-2676\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGoal 10: Reduce inequality within and among countries - United Nations Sustainable Development. Accessed May 7. 2026. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.un.org/sustainabledevelopment/inequality/\u003c/span\u003e\u003cspan address=\"https://www.un.org/sustainabledevelopment/inequality/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHaith-Cooper M, Bradshaw G. Meeting the health and social care needs of pregnant asylum seekers. Nurse Educ Today. 2013;33(9):1045\u0026ndash;50. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.nedt.2012.04.016\u003c/span\u003e\u003cspan address=\"10.1016/j.nedt.2012.04.016\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eArya AN, Hyman I, Holland T, et al. Medical Interpreting Services for Refugees in Canada: Current State of Practice and Considerations in Promoting this Essential Human Right for All. Int J Environ Res Public Health. 2024;21(5). \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3390/IJERPH21050588\u003c/span\u003e\u003cspan address=\"10.3390/IJERPH21050588\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBridle L, Bassett S, Silverio SA. We couldn\u0026rsquo;t talk to her: a qualitative exploration of the experiences of UK midwives when navigating women\u0026rsquo;s care without language. Int J Hum Rights Healthc. 2021;14(4):359\u0026ndash;73. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1108/IJHRH-10-2020-0089\u003c/span\u003e\u003cspan address=\"10.1108/IJHRH-10-2020-0089\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFlores G, Abreu M, Barone CP, Bachur R, Lin H. Errors of medical interpretation and their potential clinical consequences: A comparison of professional versus ad hoc versus no interpreters. Ann Emerg Med. 2012;60(5):545\u0026ndash;53. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.annemergmed.2012.01.025\u003c/span\u003e\u003cspan address=\"10.1016/j.annemergmed.2012.01.025\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSamkange-Zeeb F, Samerski S, Doos L, Humphris R, Padilla B, Bradby H. It\u0026rsquo;s the First Barrier \u0026ndash; Lack of Common Language a Major Obstacle When Accessing/Providing Healthcare Services Across Europe. Front Sociol. 2020;5:557563. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3389/FSOC.2020.557563/BIBTEX\u003c/span\u003e\u003cspan address=\"10.3389/FSOC.2020.557563/BIBTEX\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHayes I, Enohumah K, McCaul C. Care of the migrant obstetric population. Int J Obstet Anesth. 2011;20(4):321\u0026ndash;9. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.ijoa.2011.06.008\u003c/span\u003e\u003cspan address=\"10.1016/j.ijoa.2011.06.008\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEl Arab RA, Urbanavice R, Jakavonyte-Akstiniene A, et al. We want our freedom back, that\u0026rsquo;s our only need: a qualitative study of health and social needs among asylum seekers and undocumented migrants crossing the borders from Belarus to Lithuania. Front Public Health. 2024;12. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3389/fpubh.2024.1371119\u003c/span\u003e\u003cspan address=\"10.3389/fpubh.2024.1371119\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eP\u0026eacute;rez-S\u0026aacute;nchez M, Immordino P, Romano G, Giordano A, Garc\u0026iacute;a-Gil C, Morales F. Access of migrant women to sexual and reproductive health services: A systematic review. Midwifery. 2024;139. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.midw.2024.104167\u003c/span\u003e\u003cspan address=\"10.1016/j.midw.2024.104167\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDixon-Woods M, Cavers D, Agarwal S, et al. Conducting a critical interpretive synthesis of the literature on access to healthcare by vulnerable groups. BMC Med Res Methodol. 2006;6. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/1471-2288-6-35\u003c/span\u003e\u003cspan address=\"10.1186/1471-2288-6-35\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBowleg L. The problem with the phrase women and minorities: Intersectionality-an important theoretical framework for public health. Am J Public Health. 2012;102(7):1267\u0026ndash;73. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.2105/AJPH.2012.300750\u003c/span\u003e\u003cspan address=\"10.2105/AJPH.2012.300750\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMacLellan J, Collins S, Myatt M, Pope C, Knighton W, Rai T, Black. Asian and minority ethnic women\u0026rsquo;s experiences of maternity services in the UK: A qualitative evidence synthesis. J Adv Nurs. 2022;78(7):2175\u0026ndash;90. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1111/JAN.15233\u003c/span\u003e\u003cspan address=\"10.1111/JAN.15233\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSilverio SA, Varman N, Barry Z, et al. Inside the \u0026lsquo;imperfect mosaic\u0026rsquo;: Minority ethnic women\u0026rsquo;s qualitative experiences of race and ethnicity during pregnancy, childbirth, and maternity care in the United Kingdom. BMC Public Health. 2023;23(1). \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/s12889-023-17505-7\u003c/span\u003e\u003cspan address=\"10.1186/s12889-023-17505-7\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMangrio E, Sj\u0026ouml;gren Forss K. Refugees\u0026rsquo; experiences of healthcare in the host country: a scoping review. BMC Health Serv Res. 2017;17(1):814. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/S12913-017-2731-0/TABLES/2\u003c/span\u003e\u003cspan address=\"10.1186/S12913-017-2731-0/TABLES/2\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFloyd A, Sakellariou D. Healthcare access for refugee women with limited literacy: Layers of disadvantage. Int J Equity Health. 2017;16(1):1\u0026ndash;10. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/S12939-017-0694-8/TABLES/1\u003c/span\u003e\u003cspan address=\"10.1186/S12939-017-0694-8/TABLES/1\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMukhopadhyay S, Mahmood T. Healthcare inequalities in antenatal care in the European Region: EBCOG Scientific review. Eur J Obstet Gynecol Reproductive Biology. 2022;272:55\u0026ndash;7. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.ejogrb.2022.03.010\u003c/span\u003e\u003cspan address=\"10.1016/j.ejogrb.2022.03.010\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBinder P, Born\u0026eacute; Y, Johnsdotter S, Ess\u0026eacute;n B. Shared language is essential: communication in a multiethnic obstetric care setting. J Health Commun. 2012;17(10):1171\u0026ndash;86. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1080/10810730.2012.665421\u003c/span\u003e\u003cspan address=\"10.1080/10810730.2012.665421\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDecision making and consent Professional standards Decision making and consent Professional standards: More detailed guidance. Accessed October 8. 2025. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e\u003c/span\u003e\u003cspan address=\"http://www.gmc-uk.org/guidance\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLee JS, P\u0026eacute;rez-Stable EJ, Gregorich SE, et al. Increased Access to Professional Interpreters in the Hospital Improves Informed Consent for Patients with Limited English Proficiency. J Gen Intern Med. 2017;32(8):863\u0026ndash;70. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s11606-017-3983-4\u003c/span\u003e\u003cspan address=\"10.1007/s11606-017-3983-4\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePatterson J, Susam-Saraeva Ş. Translating informed consent in Scottish maternity services: perspectives from providers and researchers of both maternity care and translation/interpreting services. Lang Health. 2024;2(2):100023. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/J.LAHEAL.2024.06.001\u003c/span\u003e\u003cspan address=\"10.1016/J.LAHEAL.2024.06.001\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMorrice L, Tip LK, Collyer M, Brown R. You can\u0026rsquo;t have a good integration when you don\u0026rsquo;t have a good communication\u0026rsquo;: English language learning among resettled refugees in the UK. J Refug Stud. 2021;34(1):681\u0026ndash;99. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1093/JRS/FEZ023\u003c/span\u003e\u003cspan address=\"10.1093/JRS/FEZ023\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSchouten BC, Meeuwesen L. Cultural differences in medical communication: A review of the literature. Patient Educ Couns. 2006;64(1\u0026ndash;3):21\u0026ndash;34. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.pec.2005.11.014\u003c/span\u003e\u003cspan address=\"10.1016/j.pec.2005.11.014\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYau SY, Zheng T. Socio-ecological Lens Towards Health Behaviours. Published online 2026:1\u0026ndash;35. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/978-981-97-1788-0_22-1\u003c/span\u003e\u003cspan address=\"10.1007/978-981-97-1788-0_22-1\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKilanowski JF. Breadth of the Socio-Ecological Model. J Agromedicine. 2017;22(4):295\u0026ndash;7. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1080/1059924X.2017.1358971\u003c/span\u003e\u003cspan address=\"10.1080/1059924X.2017.1358971\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTaylor J, Novoa C, Hamm K, Phadke S. \u003cem\u003eEliminating Racial Disparities in Maternal and Infant Mortality A Comprehensive Policy Blueprint\u003c/em\u003e. 2019.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChalmers I. Trying to do more good than harm in policy and practice: the role of rigorous, transparent and up-to-date evaluations. Ann Am Acad Pol Soc Sci. 2003;589:22\u0026ndash;40. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1177/0002716203254762\u003c/span\u003e\u003cspan address=\"10.1177/0002716203254762\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFerrie JE. Evidence and policy: Mind the gap. Int J Epidemiol. 2015;44(1):1\u0026ndash;7. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1093/IJE/DYV002\u003c/span\u003e\u003cspan address=\"10.1093/IJE/DYV002\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eStevenson K, Edwards S, Ogunlana K, et al. Public health, policy, and clinical interventions to improve perinatal care for migrant women and infants in high-income countries: a systematic review. EClinicalMedicine. 2024;78:102938. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.eclinm.2024.102938\u003c/span\u003e\u003cspan address=\"10.1016/j.eclinm.2024.102938\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBarnish MS, Tan SY, Robinson S, Taeihagh A, Melendez-Torres GJ. A realist synthesis to develop an explanatory model of how policy instruments impact child and maternal health outcomes. Soc Sci Med. 2023;339:116402. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/J.SOCSCIMED.2023.116402\u003c/span\u003e\u003cspan address=\"10.1016/J.SOCSCIMED.2023.116402\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHamwi S, Lorthe E, Severo M, Barros H. Migrant and native women\u0026rsquo;s perceptions of prenatal care communication quality: the role of host-country language proficiency. BMC Public Health. 2023;23(1):1\u0026ndash;12. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/S12889-023-15154-4/TABLES/2\u003c/span\u003e\u003cspan address=\"10.1186/S12889-023-15154-4/TABLES/2\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSchinkel S, Schouten BC, Kerpiclik F, Van Den Putte B, Van Weert JCM. Perceptions of Barriers to Patient Participation: Are They Due to Language, Culture, or Discrimination? Health Commun. 2019;34(12):1469\u0026ndash;81. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1080/10410236.2018.1500431\u003c/span\u003e\u003cspan address=\"10.1080/10410236.2018.1500431\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eShim JK. Cultural health capital: A theoretical approach to understanding health care interactions and the dynamics of unequal treatment. J Health Soc Behav. 2010;51(1):1\u0026ndash;15. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1177/0022146509361185\u003c/span\u003e\u003cspan address=\"10.1177/0022146509361185\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWilliams DR, Rucker TD. Understanding and Addressing Racial Disparities in Health Care. Health Care Financ Rev. 2000;21(4):75\u0026ndash;91.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDrewniak D, Krones T, Wild V. Do attitudes and behavior of health care professionals exacerbate health care disparities among immigrant and ethnic minority groups? An integrative literature review. Int J Nurs Stud. 2017;70:89\u0026ndash;98. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.ijnurstu.2017.02.015\u003c/span\u003e\u003cspan address=\"10.1016/j.ijnurstu.2017.02.015\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRogers W, Ballantyne A. \u003cem\u003eGender and Trust in Medicine: Vulnerabilities, Abuses, and Remedies\u003c/em\u003e. Vol 1. Spring; 2008.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDixon-Woods M, Cavers D, Agarwal S, et al. Conducting a critical interpretative synthesis of the literature on access to healthcare by vulnerable groups. BMC Med Res Methodol. 2006;6:35. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/1471-2288-6-35\u003c/span\u003e\u003cspan address=\"10.1186/1471-2288-6-35\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePerriman N, Davis DL, Ferguson S. What women value in the midwifery continuity of care model: A systematic review with meta-synthesis. Midwifery. 2018;62:220\u0026ndash;9. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/J.MIDW.2018.04.011\u003c/span\u003e\u003cspan address=\"10.1016/J.MIDW.2018.04.011\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSandall J, Soltani H, Gates S, Shennan A, Devane D. Midwife-led continuity models versus other models of care for childbearing women. Cochrane Database Syst Reviews. 2016;2016(4). \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1002/14651858.CD004667.PUB5\u003c/span\u003e\u003cspan address=\"10.1002/14651858.CD004667.PUB5\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHsu C, Liss DT, Frosch DL, Westbrook EO, Arterburn D. Exploring provider reactions to decision aid distribution and shared decision making: Lessons from two specialties. Med Decis Making. 2017;37(1):113\u0026ndash;26. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1177/0272989X16671933\u003c/span\u003e\u003cspan address=\"10.1177/0272989X16671933\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJoosten EAG, DeFuentes-Merillas L, De Weert GH, Sensky T, Van Der Staak CPF, De Jong CAJ. Systematic review of the effects of shared decision-making on patient satisfaction, treatment adherence and health status. Psychother Psychosom. 2008;77(4):219\u0026ndash;26. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1159/000126073\u003c/span\u003e\u003cspan address=\"10.1159/000126073\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFlanagan SM, Hancock B. Reaching the hard to reach - lessons learned from the VCS (voluntary and community Sector). A qualitative study. BMC Health Serv Res. 2010;10:92. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/1472-6963-10-92\u003c/span\u003e\u003cspan address=\"10.1186/1472-6963-10-92\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSobande F. \u003cem\u003eLecture on Racism Institutional Racism \u0026amp; Workplace Cultures: Addressing Intersecting Oppression and Demystifying Data\u003c/em\u003e. 2020.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAdegoke TM, Pinder LF, Ndiwane N, Parker SE, Vragovic O, Yarrington CD. Inequities in Adverse Maternal and Perinatal Outcomes: The Effect of Maternal Race and Nativity. Matern Child Health J. 2022;26(4):823\u0026ndash;33. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s10995-021-03225-0\u003c/span\u003e\u003cspan address=\"10.1007/s10995-021-03225-0\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eInterpretation and Translation Services Framework Agreement | SBS10519. Accessed April 2. 2026. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.sbs.nhs.uk/services/framework-agreements/interpretation-and-translation-services/\u003c/span\u003e\u003cspan address=\"https://www.sbs.nhs.uk/services/framework-agreements/interpretation-and-translation-services/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBoakye PN, Prendergast N. There is nothing to protect us from dying: Black women\u0026rsquo;s perceived sense of safety accessing pregnancy and intrapartum care. Nurs Inq. 2024;31(3). \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1111/NIN.12638\u003c/span\u003e\u003cspan address=\"10.1111/NIN.12638\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBehruzi R. Understanding childbirth practices as an organizational cultural phenomenon: a conceptual framework. BMC Pregnancy Childbirth. 2013;13(205):1\u0026ndash;10.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eThomas PE, Beckmann M, Gibbons K. The effect of cultural and linguistic diversity on pregnancy outcome. Aust N Z J Obstet Gynaecol. 2010;50(5):419\u0026ndash;22. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1111/J.1479-828X.2010.01210.X\u003c/span\u003e\u003cspan address=\"10.1111/J.1479-828X.2010.01210.X\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTeam V, Vasey K, Manderson L. \u003cem\u003eCULTURAL DIMENSIONS OF PREGNANCY, BIRTH AND POST-NATAL CARE\u003c/em\u003e. 2009.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMacLellan J, McNiven A, Kenyon S. Provision of interpreting support for cross-cultural communication in UK maternity services: A Freedom of Information request. Int J Nurs Stud Adv. 2024;6:100162. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/J.IJNSA.2023.100162\u003c/span\u003e\u003cspan address=\"10.1016/J.IJNSA.2023.100162\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHwang SS, Rybin DV, Kerr SM, Heeren TC, Colson ER, Corwin MJ. Predictors of Maternal Trust in Doctors About Advice on Infant Care Practices: The SAFE Study. Acad Pediatr. 2017;17(7):762\u0026ndash;9. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.acap.2017.03.005\u003c/span\u003e\u003cspan address=\"10.1016/j.acap.2017.03.005\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTamene M, MicelandcKenzie-Sampson S, Ahern J, Bradshaw PT, Carmichael SL, Mujahid MS. Structural racism and perinatal mental health \u0026ndash; The role of racialized economic segregation. Soc Sci Med. 2025;381:118296. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/J.SOCSCIMED.2025.118296\u003c/span\u003e\u003cspan address=\"10.1016/J.SOCSCIMED.2025.118296\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSadler M, Santos MJ, Ruiz-Berd\u0026uacute;n D, et al. Moving beyond disrespect and abuse: addressing the structural dimensions of obstetric violence. Reprod Health Matters. 2016;24(47):47\u0026ndash;55. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.rhm.2016.04.002\u003c/span\u003e\u003cspan address=\"10.1016/j.rhm.2016.04.002\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJolly Y, Aminu M, Mgawadere F, Van Den Broek. N. we are the ones who should make the decision - Knowledge and understanding of the rights-based approach to maternity care among women and healthcare providers. BMC Pregnancy Childbirth. 2019;19(1). \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/s12884-019-2189-7\u003c/span\u003e\u003cspan address=\"10.1186/s12884-019-2189-7\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTong A, Flemming K, McInnes E, Oliver S, Craig J. Enhancing transparency in reporting the synthesis of qualitative research: ENTREQ. BMC Med Res Methodol. 2012;12(1):1\u0026ndash;8. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/1471-2288-12-181/TABLES\u003c/span\u003e\u003cspan address=\"10.1186/1471-2288-12-181/TABLES\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"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":"international-journal-for-equity-in-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ijeh","sideBox":"Learn more about [International Journal for Equity in Health](http://equityhealthj.biomedcentral.com)","snPcode":"12939","submissionUrl":"https://submission.nature.com/new-submission/12939/3","title":"International Journal for Equity in Health","twitterHandle":"@equityhealthj","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"pregnant women, pregnancy, language barriers, interpreter services, translation, maternity care, qualitative evidence synthesis, high income settings, communication, systematic review","lastPublishedDoi":"10.21203/rs.3.rs-9645588/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9645588/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn high-income countries (HIC), an increasing number of women giving birth require support to communicate in the host-country language. Interpreter services and translated resources should be provided for all who require them in healthcare settings. However, interpreter and translation provision in maternity services remain inconsistent. Language barriers are associated with poorer birth outcomes and contribute to maternal morbidity and mortality. This qualitative systematic review and synthesis explored women’s experiences of language barriers in high-income maternity settings.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSystematic searches across six electronic databases yielded 2652 results between January 2023 and November 2025. Two reviewers independently screened titles, abstracts, and full text against eligibility criteria, resolving discrepancies through discussion with team members. Data were analysed using interpretive thematic synthesis and reported and interpreted against the Socio-Ecological Model framework.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEighty-four studies (86 articles) encompassing 1,801 women’s voices from 22 HICs were included. Themes were integrated into a model describing outcomes for women based on interactions with maternity services and interpreting provision in the context of language barriers. Women’s experiences of maternity services in the context of a language barrier were mediated by two key factors: 1) interactions with professional interpreters and 2) ‘Work arounds’ in the absence of a professional interpreter. Women frequently reported inadequate or lack of interpreter and translation provision, inconsistent communication and system-level failures to recognise and address linguistic needs. These experiences contributed to disengagement, isolation and reduced trust in services, while increasing perceived and actual risk for women and infants. The model illustrates how structural and organisational constraints perpetuate inequalities in maternity care.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis synthesis highlights the inconsistency in provision of professional interpreting services and how this perpetuates disparities in care in high-income maternity settings. Institutional and individual level understanding of language barriers may contribute to perpetuating lack of access to safe care for women. System and personal changes are required to improve equity, understanding, and safety in maternity care. Appropriate, effective, 24/7 interpreter services and enhanced cultural awareness among healthcare providers are essential. Failure to address language barriers negatively impacts women’s maternity experiences leading to disengagement and isolation of women, increasing risks to safety.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eRegistration: \u003c/strong\u003eThis review was prospectively registered on PROSPERO (CRD42023416095).\u003c/p\u003e","manuscriptTitle":"Exploring Women’s Views and Experiences of Language Barriers in High Income Maternity Care Settings: A Qualitative Systematic Review and Thematic Synthesis","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-05-18 09:13:55","doi":"10.21203/rs.3.rs-9645588/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"international-journal-for-equity-in-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ijeh","sideBox":"Learn more about [International Journal for Equity in Health](http://equityhealthj.biomedcentral.com)","snPcode":"12939","submissionUrl":"https://submission.nature.com/new-submission/12939/3","title":"International Journal for Equity in Health","twitterHandle":"@equityhealthj","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"516b57d1-0484-4d6e-b934-dc573c057803","owner":[],"postedDate":"May 18th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-05-20T13:54:17+00:00","versionOfRecord":[],"versionCreatedAt":"2026-05-18 09:13:55","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9645588","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9645588","identity":"rs-9645588","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}