title: Conceptualising the prevention of adverse obstetric outcomes among immigrants using the 'three delays' framework in a high-income context.
abstract: Women from high-mortality settings in sub-Saharan Africa can remain at risk for adverse maternal outcomes even after migrating to low-mortality settings. To conceptualise underlying socio-cultural factors, we assume a 'maternal migration effect' as pre-migration influences on pregnant women's post-migration care-seeking and consistent utilisation of available care. We apply the 'three delays' framework, developed for low-income African contexts, to a high-income western scenario, and aim to identify delay-causing influences on the pathway to optimal facility treatment. We also compare factors influencing the expectations of women and maternal health providers during care encounters. In 2005-2006, we interviewed 54 immigrant African women and 62 maternal providers in greater London, United Kingdom. Participants were recruited by snowball and purposive sampling. We used a hermeneutic, naturalistic study design to create a qualitative proxy for medical anthropology. Data were triangulated to the framework and to the national health system maternity care guidelines. This maintained the original three phases of (1) care-seeking, (2) facility accessibility, and (3) receipt of optimal care, but modified the framework for a migration context. Delays to reciprocal care encounters in Phase 3 result from Phase 1 factors of 'broken trust, which can be mutually held between women and providers. An additional factor is women's 'negative responses to future care', which include rationalisations made during non-emergency situations about future late-booking, low-adherence or refusal of treatment. The greatest potential for delay was found during the care encounter, suggesting that perceived Phase 1 factors have stronger influence on Phase 3 than in the original framework. Phase 2 'language discordance' can lead to a 'reliance on interpreter service', which can cause delays in Phase 3, when 'reciprocal incongruent language ability' is worsened by suboptimal interpreter systems. 'Non-reciprocating care conceptualisations', 'limited system-level care guidelines', and 'low staff levels' can additionally delay timely care in Phase 3.
authors.affiliation: Department of Women's and Children's Health (IMCH), Uppsala University Hospital, 75185 Uppsala, Sweden. pauline.binder@kbh.uu.se
authors.forename: Pauline
authors.initials: P
authors.lastname: Binder
authors.forename: Sara
authors.initials: S
authors.lastname: Johnsdotter
authors.forename: Birgitta
authors.initials: B
authors.lastname: Essén
mesh_terms: D000293:Adolescent; D000328:Adult; D000349:Africa / Q000208:ethnology; D003466:Cultural Characteristics; D054242:Emigrants and Immigrants / Q000523:psychology*; D005260:Female; D006297:Health Services Accessibility / Q000706:statistics & numerical data*; D006801:Humans; D008131:London; D008427:Maternal Health Services / Q000592:standards / Q000706:statistics & numerical data*; D008875:Middle Aged; D010342:Patient Acceptance of Health Care / Q000706:statistics & numerical data*; D017410:Practice Guidelines as Topic; D011247:Pregnancy; D011248:Pregnancy Complications / Q000517:prevention & control*; D036301:Qualitative Research; D012307:Risk Factors; D012959:Socioeconomic Factors; D061665:Time-to-Treatment / Q000706:statistics & numerical data*; D055815:Young Adult