SCOPING REVIEW

Health care in the process of parturition of immigrant women: a review of scope

Isabella Zerbeto dos Santos1, Tatiane Herreira Trigueiro1, Fabio André Miranda de Oliveira1, Silvana Regina Rossi Kissula Souza1, Helena Hornung1

1Universidade Federal do Paraná, Curitiba, PR, Brazil

ABSTRACT

Objective: to identify what has been published in Brazil about immigrant women in the process of parturition. Method: structured scope review, according to the PRISMA-ScR flowchart and following the steps of the method proposed by the Joanna Briggs Institute (JBI). Publications in English, Spanish, and Portuguese were included between 2011 and 2023 and addressed the theme process of parturition of immigrant women in Brazil. The search was carried out in four databases and the gray literature. Results: seven articles were included, and it was observed that the difficulties existing during the delivery assistance of immigrants in Brazil involve communication barriers and difficulties of cultural manifestation of women. Strategies such as interpreters, material preparation, and training of professionals were identified. Conclusion: strategies need to be raised and implemented by health institutions and professionals to improve care.

Descriptors: Emigrants and Immigrants; Midwifery; Pregnant Women; Parturition.

INTRODUCTION

Economic, political-social, and demographic transformations erupt the need for immigration(1). Brazil receives immigrants from several countries in different situations, with 1,085,673 immigrants registered between 2011 and 2019, emphasizing 2019 for Venezuelans and Haitians(2).

Women represented approximately 37% of the total number of immigrants in Brazil between 2011 and 2019, with Venezuelans, Paraguayans, Bolivians, and Haitians being the most expressive(2). As of 2015, there was an increase in immigrant women, representing 44.8% of the total number of records in the country(3). Approximately 67% of them are of reproductive age(2), which brings to the Brazilian health system the responsibility of looking at the specificities of this population on issues such as pregnancy, childbirth, and puerperium. In a study carried out in the city of São Paulo from 2012 to 2017, 3% of live birth records were from immigrants(4), bringing the need for health professionals to be able to deal with the differences in this population.

Studies with immigrants bring the language as a hindrance to health care(5-8). The difference in language is a characteristic of this population, which influences the process of parturition because verbal communication is indispensable to care(9). Swedish midwives, who assisted immigrants in prenatal clinics, reported that communication difficulties were both cultural and linguistic, bringing the need to develop of new communication tools with this public(5).

It is recommended that adequate obstetric care provide the parturient with adequate and informed decision-making, and communication is essential to ensure that their needs are met(10). Communication is one of the main work tools of the nurse(11), and because it is the professional responsible for the follow-up of the woman in the parturition course(9), it is up to this professional to prepare the message to be passed, planning this action in the best way and encouraging his or her team to use effective and culturally adapted communication techniques, aiming at a positive delivery experience.

For this, the care offered to women should be directed to individual needs, especially regarding immigrants, who carry a whole cultural baggage. Research has been published to give visibility to experiences in each health service since the migration process takes place worldwide. Thus, a scope review can offer an overview of this phenomenon and, when performed nationally, it can direct the efforts of professionals or raise problems that deserve discussion in the care of parturient. Thus, the objective was to identify what has been published in Brazil about immigrant women in the process of parturition.

METHOD

Scope review elaborated according to the steps proposed by Joanna Briggs Institute (JBI)(12) and following the recommendations of Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR)(13). Thus, this review was registered in the Open Science Framework (OSF) platform (DOI: 10.17605/OSF.IO/849XC)(14).

The research question “What has been published about the care of immigrant women in the process of parturition in the Brazilian health system?” It was elaborated by the PCC strategy indicated for scope revisions by the JBI, being “P” the population (immigrant women), “C” the concept (parturition process), and “C” the context (Brazil). The search was carried out from December 2022 to January 2023, in the VHL (Virtual Health Library), Embase (Excerpta Medica Database), PubMed, and SciELO (Scientific Electronic Library Online) databases and in the gray literature in the Catalogue of Theses and Dissertations of the Coordination for the Improvement of Higher Education Personnel (CAPES). The choice of bases occurred due to the diversity of publications in the area of health and wide dissemination.

The following descriptors DeCS/MeSH (Descriptors in Health Sciences/Medical Subject Headings) were used to construct the search strategies: Emigrants and Immigrants, Women, Pregnant Women, childbirth, Tocology, Maternal and Child Health Services and Brazil. These descriptors, some of their alternative terms and keywords related to the theme, were combined through the Boolean operators “AND“ or ”OR” in Portuguese, English and Spanish, as provided by the DeCS/MeSH index of terms, to search according to the strategies indicated in Figure 1 and following the specificities of each base, in order to identify the largest number of publications on the subject.

Figure 1 – Bases and search strategies. Curitiba, PR, Brazil, 2023

Online texts published in English, Spanish and Portuguese between 2011 and 2023 were included and addressed the theme Process of parturition of immigrant women in Brazil. It was decided that this time frame was made by the immigration process in Brazil to have accentuated in the last decade. There was no restriction on the method of studies and publications of gray literature were also considered. Those who addressed the process of parturition of Brazilian women in other countries and the prenatal care of immigrants in Brazil were excluded.

The selection took place in three stages:1) Deletion of duplicates; 2) Reading of title and abstract; 3) Reading of the full text. The exclusion of duplicates and selection of the studies was carried out through the Rayyan software, by two evaluators independently and, in cases of divergence, a third evaluator was invited to resolve the impasse. Studies that were within the scope were selected, otherwise, excluded. After that, the full reading of the pre-selected texts was carried out.

After defining the included articles, they were reread in full and the data organized in a table elaborated in Microsoft Office Excel 2007.For analysis, the extracted items were grouped and reorganized in a framework elaborated in Microsoft Office Word 2007, in order to understand the weaknesses existing in care during the process of parturition of immigrant women in Brazil and what there is potential and/or tools, that facilitate care for this population.

The analysis considered obstetric care for immigrants in Brazil, in general, not focusing on border regions with the Integrated Health System at Frontiers (SIS Frontiers), which organizes the health system in the Brazilian border municipalities(15), that serve the population of countries that border with Brazil, because it is not the reality from which the research restlessness arose.

RESULTS

928 publications and 178 publications of gray literature were identified, totaling 1106 publications. Of these, 43 duplicate publications were excluded. After reading the title and summary of the 1063 publications, 1048 were excluded because they did not address the theme of the research. Among these were analyzes of literature books, Brazilian historical periods and immigrant populations in Brazil antecedents to 2011, and studies on animals, and immigrants in other countries, that addressed the prenatal of immigrants and the process of childbirth of immigrants in other countries. Thus, 15 texts were read in full, leading to the exclusion of seven publications because they did not address the parturition process and one because it was a summary of an oral presentation published in the Proceedings of Congress. Therefore, seven publications were included in this review, as shown in Figure 2 of the PRISMA flowchart.

Source: Adapted from Tricco et al., 2018.

Figure 2 – PRISMA Flowchart. Curitiba, PR, Brazil, 2023

According to data in Figure 3, seven publications were composed of this review. Of these, three are journal articles, three master dissertations and one doctoral thesis. The oldest study is in 2015 and the most recent study is 2022. The dissertations and thesis were developed by nurses or midwives, while the articles had at least one of these professional categories among the authors. As for the method, five presented a qualitative approach. Two publications addressed specific cultural issues related to pregnancy, childbirth, and after childbirth of the nationalities studied and their influence on the experience experienced in Brazil(16-17). The most observed nationality among immigrant parturients was Bolivian(16,18-20).

Four main thematic categories addressed by the studies were identified: 1) Perception of care during childbirth and after childbirth; 2) Language as a hindrance of assistance; 3) cultural aspects of the birth and birth process; and 4) instruments facilitating care for immigrants.

Figure 3 – Characterization of publications according to the professions of the authors, year of publication and main findings. Curitiba, PR, Brazil, 2023

Some feelings of the parturients during their birth experiences in Brazil were fear and sadness related to the attitudes of the professionals, due to childbirth occurring late or in advance to planned or by way other than that of their preference, the shame, for not speaking Portuguese, the loneliness, because they were far from the family and the pain that relieved after birth(16-17,21). There was disagreement with confidence in the team: some reported insecurity because they did not understand their customs and imposed conduct(16,21) and others were supported by the team taking on the role of the family during the process, providing care and emotional support and listening to their needs(17,21).

In a comparison between the delivery experiences, in their countries of origin and in Brazil, the Brazilian health service was seen as good because it is free, because the care provided by the team and babies were born healthy, but they saw as bad the need for several touch tests, joint care with students and the difficulty in meeting their cultural needs such as typical food and clothing, positions and delivery routes and bathing behaviors(16-17,21).

Regarding the vision and experiences of health professionals, the most frequent feelings were apprehension and concern related to communication and social factors of patients and families after childbirth(20). They saw assistance to immigrants as a difficult and learning experience, often permeated with prejudice and neglect by professionals (16,19,21).

The preference for delivery routes varied according to nationality and previous experiences. Bolivians preferred vaginal delivery in verticalized positions and did not accept cesarean section(16,18,19,21), whereas Chinese and Syrian women opted for cesarean section, with the latter taking as a positive point the possibility of accompanying and being aware during birth, since this procedure is performed under general anesthesia in Syria(17-18) .

One study shows that cesarean section was the most common way of delivery among immigrants(22), while another one shows that half of the immigrant mothers had vaginal deliveries, especially the Bolivian ones(18). The studies bring reports of the preference and attempts of immigrants for vaginal delivery, but that most of these have as an outcome the cesarean section done in haste, bringing feelings of fear and sadness(16,21).

The common theme for the studies was the difficulty regarding communication, because most immigrants did not speak Portuguese, bringing the language as a barrier in childbirth care, both by professionals and by parturients(16-22).

The strategies brought to overcome the difficulty with the language were the use of gestures(16,20), paused speech and calm(16,21), translation applications(19-20), know or have written keywords in the most recurrent foreign languages(19,21), value bilingual professionals and promote language training courses(16-17,19-20,22), encourage the presence of accompanying persons and interpreters in the services(16,20-22), provide visual resources and translation of materials to parturients(16,19,21) .

The cultural difference was another difficulty raised(16,19,20,22). A study that addresses the vision of professionals, in the figure of the obstetrician nurse, in the care of immigrants(20), meets those who bring the vision of parturients by mentioning the prejudice and difficulty of professionals in accepting and adhering to cultural behaviors of this public, having tendencies to impose the culture of the country and the institution(16,19,22) .

The strategies raised to overcome this difficulty were the cultural training of professionals about the main nationalities served by the service, mainly birth and birth rituals(16,19,21), permission and respect for the use of typical clothing and execution of cultural practices, or adaptation of these practices and clothing(16-17), aid in the introduction of typical food(17,20), elaboration of the birth plan for knowledge of the rituals and culture of parturients(20) and the existence of culturally adapted delivery rooms(16).

The studies mentioned practices of obstetric violence against immigrants, such as conducting maneuvers by Kristeller and episiotomies, various vaginal touches, imposition of the lithotomic position and bathing routine, not having the permission of the companion, and no explanation of procedures during childbirth and with the newborn. These practices were derived from the difficulty of communication due to language difference, lack of knowledge of cultural practices and prejudice and stereotypes carried by professionals regarding certain nationalities of immigrants(16-17,19-21).

DISCUSSION

Beliefs vary between cultures, especially those focused on childbirth and birth, making this experience more than a physiological event, a cultural phenomenon. Women have their expectations and behaviors influenced by their culture, and want to live the birth, according to what they know(20,23-24).

The studies of this review brought aspects related to childbirth in the Syrian and Bolivian cultures, mainly. Bolivian women prefer home deliveries with midwives and in vertical positions at hospital delivery(16). A survey of professionals who attended home births in Brazil showed that almost all women had parched in verticalized positions, with the home environment favoring freedom to choose position and the opportunity of vaginal delivery without many interventions(25), a fact also observed in a study with women in a support group for the model of care respectful to childbirth in São Paulo, in which 81.4% stopped in non-lithotomic positions(26).

This explains the preference of Bolivians and meets the recommendation regarding the adoption of upright positions during labor(10). In addition, home birth allows family participation and cultural practices, without the need for submission to institutional flows, such as bathing routines, that go against Bolivian beliefs of keeping themselves and their babies warm during the process, and bathing eight days after childbirth with herbal preparations(16,18-20) .

The bath of the baby can be postponed up to 24 hours for cultural reasons and it is recommended to use one to two layers of clothing more in newborns to keep them warm(10), going against Bolivian bathing practices, use of warm clothes with typical blanket and cloth diapers(16,18-20).

The Syrians feed on dates and cinnamon and mint teas to help with contractions, have their births in hospitals mediated by female professionals, are accompanied by family women, and can use traditional clothing. In addition, they have support from the family in the period after childbirth and the care of the baby. After birth, prayers are performed by the father, and the bath is done right after birth. Puerperas only take an immersion bath 5 to 14 days after delivery(17).

Food, protective and bathing practices are not limited to Syrian and Bolivian cultures(27-28), and there are also recommendations on the supply of food and liquids during the parturition process(10), emphasizing respect for the wishes of the parturient woman, for the preparation of the mind and body is important at this time(23).

Professionals should be able to provide the parturient with all information, comfort, and freedom, considering their preferences, expectations, beliefs, values and culture (10,23,29). Knowing the process and having support from the team contributes to a good experience(23).

Institutions with obstetrician nurses adopt better practices than institutions without these professionals, showing the importance of shared interprofessional care for a better delivery experience(30-31). Thus, nurses should think about their assistance with a cross-cultural approach, improving technical-scientific, ethical-political, socio-educational, and cultural knowledge(32).

The studies of this review bring an ambiguous view of assistance, in the view of immigrants, with experiences permeated by fear, sadness, shame, loneliness, prejudice and insecurity(16,19,20) and others by satisfaction, acceptance and gratitude(17,21). The immigrant carries a greater burden compared to native parturients, making them experience feelings that may not let them experience the process of childbirth in its fullness.

The emotional support promoted by the companions and family brings satisfaction to the parturients and favors their autonomy(10,23,33). For immigrants, who do not have a wide network of family support, light technologies such as reception and health guidelines are the most important when considering good practices of childbirth care, and it is up to professionals to understand their uniqueness(11).

Despite the difficulties faced, immigrants classify childbirth care in Brazil as satisfactory. This fact can be linked to the gratuitousness of the health system, the birth of healthy babies, and negative previous experiences, and there are also reports of the good care of the team, which replaces the role of the family in emotional support, perinatal care and counseling linked to health guidelines.

The greatest difficulty assisting the delivery of immigrants was communication, hampered by the difference in language. The language is difficult to assist not only during labor, but during any health care(5-8).

During the parturition process, the parturient must have their needs met, doubts clarified and wishes respected and have emotional support, on the part of the team, besides being informed, in a simple and culturally adapted way, about the progress of the process and have your family included(10). Thus, verbal communication during the delivery process becomes an indispensable tool of care(9), and for this the team must be enabled to communicate with patients who do not understand Portuguese, using strategies for effective communication.

Some strategies such as the provision of visual resources and the translation of materials for immigrants (16,19,21), professionals know keywords in the most recurrent foreign languages(19,21), encouraging the presence of escorts and/or interpreters(16,20-22) and the use of instant translation applications(19) were also addressed by other studies (34-36,40) and are present in the proposals for protocols for welcoming immigrants in health services(39). The training of professionals in languages(16-17,19,22) can be mediated by internal training and institutional stimuli aimed at permanent education.

The nurse has as work tools the reception, active listening and communication(11). Therefore, in the role of leader and care manager, it is up to the nurse to prepare the message to be passed, planning this action in the best way, and encourage their team to use effective and culturally adapted communication techniques aiming at a positive delivery experience for immigrants.

Dignified and respectful obstetric care encompasses respect for culture, beliefs, and values, and this point cannot be underestimated in caring for immigrants(10). Some strategies such as cultural training of professionals(16,19,21) and elaboration of the birth plan for immigrants(20) were also raised by other studies(35-36). Several procedures can be adapted, according to the cultural reality of parturients(10), and it is up to professionals to promote a culturally adapted assistance.

The limited number of studies on the subject in Brazil was a limitation found by this review, showing the need for continuity of the discussion to understand the construction of tools and the application of strategies that facilitate the care of immigrant pregnant women, given the growing wave of immigration to Brazil and the increase in obstetric assistance to this population.

CONCLUSION

Potential and difficulties were elucidated during the delivery assistance of immigrants in Brazil. These involve aspects related to differences in language and cultural behaviors, while those refer to the fact that the health system is free and accessible and the possibility of accompanying during the entire hospitalization process.

The humanization of the labor process of immigrant women requires a sensitive and culturally adapted approach, ensuring adequate communication, respect for cultural practices and the role of women in decision-making.

This review brings as practical implications some strategies for improving obstetric care to this population. Namely: presence of interpreters, professionals, or companions who can communicate in the language of patients; elaboration of illustrated and translated materials that help in communication; encouragement to use the delivery plan; training of professionals in languages, from an institutional study on the incidence of immigrants in the region; and training and permanent education in relation to the cultural practices of childbirth and birth of the main nationalities served by the services.

The nurse plays a fundamental role in perinatal care, being a key part of implementing the strategies raised here and thus ensuring effective communication, respect for cultural practices, emotional and educational support, and making immigrants protagonists of the process.

ACKNOWLEDGMENTS

We thank Librarian Letícia P. A. de Souza for the collaboration in the elaboration of search strategies.

CONFLICT OF INTERESTS

The authors have declared that there is no conflict of interests.

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Submission: 06-Sep-2023

Approved: 20-May-2024