Sex trafficking survivors' experiences with the healthcare system during exploitation: A qualitative study.

While most individuals who have experienced sex trafficking will seek medical attention during their exploitation, very few will be identified by healthcare professionals (HCP). It constitutes a lost opportunity to provide appropriate support, resources, and services. In this study, we examined the experiences of accessing care of sex trafficking survivors in the Greater Montreal area and their interactions with HCPs to inform trafficking education programs for HCPs and allied health professionals regarding the needs of this patient population. We conducted seven semi-structured in-depth interviews with purposively selected sex trafficking survivors participating in "Les Survivantes," a program of the SPVM (Service de Police de la Ville de Montréal), designed to support trafficked individuals' exit journey. We used interpretive description to understand the lived experiences of trafficked individuals with direct applications to clinical education and care. Our results revealed that trafficked individuals accessing care present with a fragile trust in HCPs and how HCPs have many opportunities to conduct comprehensive examinations and query trafficking. Trafficked individuals' initial trust in HCPs can be strengthened by non-judgemental approaches or damaged by stigmatizing conduct, serving to isolate further and alienate this patient population. Health professionals' attitudes combined with healthcare settings' cultures of care (i.e., community vs emergency) and exposure to marginalized groups were key influencers of survivors' perception of healthcare interactions. The findings also emphasized the importance of routinely querying trafficking through sensitive psychosocial questioning based on observation of trafficking cues. Survivors reported a list of trafficking cues to recognize and emphasized the importance of trust as a condition of disclosure. Finally, survivors identified the need for exit planning to be centered around trafficked individuals' agency and holistic needs, and for streamlined community-based multidisciplinary collaboration to better serve this population. Our results highlight that most challenges experienced by trafficking survivors in accessing care and resources are modifiable through HCP education and training. Our study also provides new insights and concrete advice to improve care and support throughout the exiting process. We argue that healthcare services for this population be modeled harm reduction approaches that focus on victims' agency and needs, independent of their desire to exit trafficking. We emphasize the urgent need for proper case management and intersectoral and multidisciplinary care coordination in community-based settings as well as facilitated access to mental health support.

Interventions to Support International Migrant Women's Reproductive Health in Western-Receiving Countries: A Systematic Review and Meta-Analysis.

Purpose: The reproductive health outcomes of international migrant women differ in comparison with receiving-country-born women, depending on country of birth and immigrant status. Effective interventions to support the reproductive health of international migrant women are not well known. Methods: We conducted a systematic review and meta-analysis of studies between 2010 and 2017 evaluating interventions directly or indirectly affecting the reproductive health (as defined by the World Health Organization) of international migrant women in Western-receiving countries. Results: Sixteen studies representing 5080 migrants were identified. Interventions consisted of linguistically (e.g., translated brochures) or culturally adapted (e.g., cultural narratives) routine care or new interventions. Meta-analysis showed that interventions increased rates of preventive reproductive health activities, including mammography, condom use, and Pap test completion, by almost 18% (95% confidence interval 7.61-28.3) compared with usual care or interventions not adapted to migrant women. Conclusion: Culturally and linguistically adapted care practices congruent with target populations of international migrant women are effective in improving their reproductive health outcomes, particularly their participation in preventative reproductive health activities.

Refugee maternal and perinatal health in Ontario, Canada: a retrospective population-based study.

OBJECTIVES: Immigrants are thought to be healthier than their native-born counterparts, but less is known about the health of refugees or forced migrants. Previous studies often equate refugee status with immigration status or country of birth (COB) and none have compared refugee to non-refugee immigrants from the same COB. Herein, we examined whether: (1) a refugee mother experiences greater odds of adverse maternal and perinatal health outcomes compared with a similar non-refugee mother from the same COB and (2) refugee and non-refugee immigrants differ from Canadian-born mothers for maternal and perinatal outcomes. DESIGN: This is a retrospective population-based database study. We implemented two cohort designs: (1) 1:1 matching of refugees to non-refugee immigrants on COB, year and age at arrival (±5 years) and (2) an unmatched design using all data. SETTING AND PARTICIPANTS: Refugee immigrant mothers (n=34 233), non-refugee immigrant mothers (n=243 439) and Canadian-born mothers (n=615 394) eligible for universal healthcare insurance who had a hospital birth in Ontario, Canada, between 2002 and 2014. PRIMARY OUTCOMES: Numerous adverse maternal and perinatal health outcomes. RESULTS: Refugees differed from non-refugee immigrants most notably for HIV, with respective rates of 0.39% and 0.20% and an adjusted OR (AOR) of 1.82 (95% CI 1.19 to 2.79). Other elevated outcomes included caesarean section (AOR 1.04, 95% CI 1.00 to 1.08) and moderate preterm birth (AOR 1.08, 95% CI 0.99 to 1.17). For the majority of outcomes, refugee and non-refugee immigrants experienced similar AORs when compared with Canadian-born mothers. CONCLUSIONS: Refugee status was associated with a few adverse maternal and perinatal health outcomes, but the associations were not strong except for HIV. The definition of refugee status used herein may not sensitively identify refugees at highest risk. Future research would benefit from further refining refugee status based on migration experiences.

Postpartum depression risk factors among recent refugee, asylum-seeking, non-refugee immigrant, and Canadian-born women: results from a prospective cohort study.

PURPOSE: The objective was to examine and compare risk factors for postpartum depression among: (1) recent (≤5 years) migrant and Canadian-born women, and (2) refugee, asylum-seeking, and non-refugee immigrant women. METHODS: A sample of 1536 women (1024 migrant and 512 Canadian-born) were recruited from 12 hospitals. Women completed questionnaires at 1-2 and 16 weeks postpartum including questions on socio-demographics, biomedical history, health services, and migration and resettlement factors. Bivariate analyses and multivariate logistic regression were performed to examine and compare risk factors for postpartum depressive symptoms at 16 weeks postpartum. RESULTS: Recent migrant women had significantly higher rates (6%) of depressive symptoms at 16 weeks postpartum than Canadian-born women (2.9%). Asylum-seekers had the highest rate (14.3%), followed by refugee (11.5%) and non-refugee immigrant women (5.1%). Migrant women at greatest risk to develop depressive symptoms were those who experienced abuse, had pain post-birth, worried about family members left behind, had food insecurity, and had reduced access to healthcare (limited insurance and/or no regular care-provider). Conversely, those with higher levels of social support and who felt they belonged to a community had a lower risk of developing depressive symptoms. CONCLUSION: All childbearing recent migrant women should be considered at risk for postpartum depression. To prevent and support migrant women suffering postpartum depressive symptoms, barriers to healthcare need to be addressed and interventions should include assessments and support/programmes for abuse/violence, lack of social support, food insecurity, and stress/poor mental health. Treatment of pain during the postpartum period is also critical.

Challenges newly-arrived migrant women in Montreal face when needing maternity care: Health care professionals' perspectives.

BACKGROUND: People who leave their country of origin, or the country of habitual residence, to establish themselves permanently in another country are usually referred to as migrants. Over half of all births in Montreal, Canada are to migrant women. To understand healthcare professionals' attitudes towards migrants that could influence their delivery of care, our objective was to explore their perspectives of challenges newly-arrived migrant women from non-Western countries face when needing maternity care. METHOD: In this qualitative multiple case study, we conducted face-to-face interviews with 63 health care professionals from four teaching hospitals in Montreal, known for providing maternity care to a high volume of migrant women. Interviews were transcribed and thematically analysed. RESULTS: Physicians, nurses, social workers, and therapists participated; 90% were female; and 17% were themselves migrants from non-Western countries. According to participants, newly-arrived migrant women face challenges at two levels: (a) direct care (e.g., understanding Canadian health care professionals' expectations, communicating effectively with health care professionals), and (b) organizational (e.g., access to appropriate health care). Challenges women face are strongly influenced by the migrant woman's background as well as social position (e.g., general education, health literacy, socio-cultural integration) and by how health care professionals balance women's needs with perceived requirement to adhere to standard procedures and regulations. CONCLUSIONS: Health care professionals across institutions agreed that maternity care-related challenges faced by newly-arrived migrant women often are complex in that they are simultaneously driven by conflicting values: those based on migrant women's sociocultural backgrounds versus those related to the implementation of Canadian guidelines for maternity care in which consideration of migrant women's particular needs are not priority.

Postpartum Pain in the Community Among Migrant and Non-migrant Women in Canada.

International migrant women of childbearing age represent a large proportion of immigrants to high-income countries, yet research focusing on their postpartum health is limited. We investigated predictive factors for breast and non-breast pain 1 week post-birth in migrant and non-migrant women in Canada. Among migrant women, difficulty accessing health services; being from a middle-or high-income country; poor functionality in English and French; living with the father of their infant; and having no regular care provider were predictive of breast pain. Among non-migrant women, difficulties accessing health services, multiparity and prenatal education were predictive of breast pain, while receiving an epidural and having no regular care provider were predictive of non-breast pain. Among both groups, difficulties accessing health services and having no regular care provider were predictive of breast pain, while second degree or higher perineal tearing was predictive of non-breast pain. Migration-specific indicators should be considered in postpartum care planning.

Prevalence, continuation, and identification of postpartum depressive symptomatology among refugee, asylum-seeking, non-refugee immigrant, and Canadian-born women: results from a prospective cohort study.

This study assessed the prevalence, continuation, and identification of maternal depressive symptomatology over the first 16 weeks postpartum among refugee, asylum-seeking, non-refugee immigrant, and Canadian-born women. A sample of 1125 women (143 refugees, 369 asylum-seekers, 303 non-refugee immigrant, and 310 Canadian-born) completed the Edinburgh Postnatal Depression Scale (EPDS) at 1 and 16 weeks postpartum. The sensitivity, specificity, and predictive power of the 1-week EPDS to identify women with elevated EPDS scores at 16 weeks were determined. The total number of women with EPDS scores >9 for each group at 1 and 16 weeks, respectively, was 26.6 and 18.2 % for refugees; 25.2 and 24.1 % for asylum-seekers; 22.4 and 14.2 % for non-refugee immigrants, and 14.8 and 7.4 % for Canadian-born. Using the cut-off score of 9/10, the 1-week EPDS accurately classified 77.6 % refugee, 73.4 % asylum-seeking, 76.6 % non-refugee immigrant, and 85.5 % Canadian-born women at 16 weeks with or without postpartum depressive symptomatology. The 1-week EPDS was significantly correlated to the 16-week EPDS (r = 0.46, p < 0.01). All groups were significantly more likely to exhibit depressive symptomatology at 16 weeks if they had EPDS scores >9 at 1 week postpartum: refugees (OR = 6.9, 95 % CI = 2.8-17.3), asylum-seekers (OR = 4.0, 95 % CI = 2.4-6.7), non-refugee immigrants (OR = 3.8, 95 % CI = 2.0-7.6), and Canadian-born women (OR = 8.0, 95 % CI = 3.3-19.8). Our findings suggest that refugee, asylum-seeking, non-refugee immigrant, and Canadian-born women at risk of postpartum depression may be identified early in the postpartum period such that secondary preventive interventions may be implemented.

International migration as a determinant of emergency caesarean.

BACKGROUND: High caesarean rates are of concern given associated risks. International migrant women (women born abroad) represent a substantial proportion of women giving birth in high-income countries (HICs) and face social conditions that may exacerbate childbearing health risks. Among migrant women, emergency rather than planned caesareans, tend to be more prevalent. This method of delivery can be stressful, physically harmful and result in an overall negative birth experience. Research establishing evidence of risk factors for emergency caesareans in migrants is insufficient. AIMS: (1) Describe potential pathways (with a focus on modifiable factors) by which migration, using internationally recommended migration indicators: country of birth, length of time in country, fluency in receiving-country language, migration classification and ethnicity, may lead to emergency caesarean; and (2) propose a framework to guide future research for understanding "potentially preventable" emergency caesareans in migrant women living in HICs. DISCUSSION: "Potentially preventable" emergency caesareans in migrant women are likely due to several modifiable, interrelated factors pre-pregnancy, during pregnancy and during labour. Migration itself is a determinant and also shapes other determinants. Complications and ineffective labour progress and/or foetal distress and ultimately the decision to perform an emergency caesarean may be the result of poor health (i.e., physiological effects), lack of support and disempowerment (i.e., psychological effects) and sub-optimal care. CONCLUSION: Understanding the direct and indirect effects of migration on emergency caesarean is crucial so that targeted strategies can be developed and implemented for reducing unnecessary caesareans in this vulnerable population.

Predictors of Unplanned Cesareans among Low-Risk Migrant Women from Low- and Middle-Income Countries Living in Montreal, Canada.

BACKGROUND: Research has yielded little understanding of factors associated with high cesarean rates among migrant women (i.e., women born abroad). The objective of this study was to identify medical, migration, social, and health service predictors of unplanned cesareans among low-risk migrant women from low- and middle-income countries (LMICs). METHODS: We used a case-control research design. The sampling frame included migrant women from LMICs living in Canada less than 8 years, who gave birth at one of three Montreal hospitals between March 2014 and January 2015. Data were collected from medical records and by interview-administration of the Migrant-Friendly Maternity Care Questionnaire. We performed multi-variable logistic regression for low-risk women (i.e., vertex, singleton, term pregnancies) who delivered vaginally (1,615 controls) and by unplanned cesarean indicated by failure to progress, fetal distress, or cephalopelvic disproportion (233 cases). RESULTS: Predictors of unplanned cesarean included being from sub-Saharan Africa/Caribbean (OR 2.37 [95% CI 1.02-5.51]) and admission for delivery during early labor (OR 5.43 [95% CI 3.17-9.29]). Among women living in Canada less than 2 years predictors were having a humanitarian migration classification (OR 4.24 [95% CI 1.16-15.46]) and admission for delivery during early labor (OR 7.68 [95% CI 3.12-18.88]). CONCLUSION: Migrant women from sub-Saharan Africa/Caribbean and recently arrived migrant women with a humanitarian classification are at greater risk for unplanned cesareans compared with other low-risk migrant women from LMICs after controlling for medical factors. Strategies to prevent cesareans should consider the circumstances of migrant women that may be contributing to the use of unplanned cesareans in this population.

Global and public health core competencies for nursing education: A systematic review of essential competencies.

OBJECTIVES: Nurses are learning and practicing in an increasingly global world. Both nursing schools and nursing students are seeking guidance as they integrate global health into their learning and teaching. This systematic review is intended to identify the most common global and public health core competencies found in the literature and better inform schools of nursing wishing to include global health content in their curricula. DESIGN: Systematic review. DATA SOURCES: An online search of CINAHL and Medline databases, as well as, inclusion of pertinent gray literature was conducted for articles published before 2013. REVIEW METHODS: Relevant literature for global health (GH) and public and community health (PH/CH) competencies was reviewed to determine recommendations of both competencies using a combination of search terms. Studies must have addressed competencies as defined in the literature and must have been pertinent to GH or PH/CH. The databases were systematically searched and after reading the full content of the included studies, key concepts were extracted and synthesized. RESULTS AND CONCLUSION: Twenty-five studies were identified and resulted in a list of 14 global health core competencies. These competencies are applicable to a variety of health disciplines, but particularly can inform the efforts of nursing schools to integrate global health concepts into their curricula.

Use of reproductive health care services among urban migrant women in Bangladesh.

BACKGROUND: Recent internal migration flows from rural to urban areas pose challenges to women using reproductive health care services in their migratory destinations. No studies were found which examined the relationship between migration, migration-associated indicators and reproductive health care services in Bangladesh. METHODS: We analyzed the 2006 Bangladesh Urban Health Survey (data made publically available in June 2013) of 14,191 ever-married women aged 10-59 years. Cross tabulations and logistic regression were conducted. RESULTS: Migrants and non-migrants did not differ significantly in their use of modern contraceptives and treatment for STI but were less likely to receive ANC even after controlling for a range of variables. Compared to non-migrants, more migrants had home births, did not take vitamin A after delivery, and had no medical exam post-birth. Migrant women being village-born (rather than urban-born) were associated with risk of diminished: use of ANC; treatment for STI; medical exam post-birth; vitamin A post-birth. Migrating for work or education (rather than other reasons) was associated with risk of diminished: use of ANC; use of modern facilities for birth; and medical exam post-birth. Each additional year lived in urban areas was associated with a greater likelihood of receiving ANC. CONCLUSIONS: Women who migrated to urban areas in Bangladesh were significantly less likely than non-migrants to use reproductive health care services related to pregnancy care. Pro-actively identifying migrant women, especially those who originated from villages or migrated for work or education may be warranted to ensure optimal use of pregnancy-related services.

Reproductive health research of women migrants to Western countries: A systematic review for refining the clinical lens.

Influxes of migrant women of childbearing age to Western receiving countries have made their reproductive health a priority in those countries. Yet, providing optimal care to these women may be hampered by an inadequate volume or quality of research to inform practice. We reviewed reports of studies recently published to assess the extent to which current research is able to inform reproductive health care practices for migrant women (i.e., those born in countries other than the receiving country)--in so doing, we sought to offer a view of the landscape from which clinicians may interpret relevant publications. Additionally, we sought to identify topics for which clinicians may choose to advocate for additional research to be performed.

Responses of International Migrant Women to Abuse Associated With Pregnancy.

The current study aims to identify what newly arrived migrant women do, in the early months post-birth, to respond to abuse associated with pregnancy. Textual data from 59 migrant women were analyzed thematically to identify common responses to abuses. The most common response was to physically leave their countries of origin and move to Canada, or to move out of the shared dwelling. Other responses included taking legal action, remaining silent, reporting the abuse, seeking counseling, isolating themselves, and supporting anger management for the abuser. These results enhance our understanding of the decisions, including inaction, made by migrant women.

Participation of childbearing international migrant women in research: the ethical balance.

Fear of burdening or harming childbearing, migrant women, particularly refugees or others who have experienced war, torture, abuse, or rape, can result in their exclusion from research. This exclusion prohibits health issues and related solutions to be identified for this population. For this reason, while it may be challenging to include these women in studies, it is ethically problematic not to do so. Using ethical guidelines for research involving humans as a framework, and drawing on our research experiences. This discussion article proposes a number of strategies to improve the conditions for childbearing migrant women to participate in health research. What emerged as key for studying this diverse population and ensuring an ethically responsible approach are the use of methods that are adapted to the circumstances of childbearing migrant women and the involvement and support from "migrant-friendly" organizations. Ensuring migrant women are involved in the research process and knowledge produced is also critical. The more researchers working in this field communicate their experiences, the more will be learnt about how best to approach research with migrants. More migration and health research will enable a greater contribution to the knowledge base upon which the needs of this population can be met and their strengths maximized.

Knowledge about pandemic influenza preparedness among vulnerable migrants in Thailand.

This study was designed to assess factors associated with a high level of knowledge about influenza among displaced persons and labor migrants in Thailand. We conducted a cross-sectional study of 797 documented and undocumented migrants thought to be vulnerable to influenza during the early stages of the 2009 H1N1 pandemic. Data were collected on socio-demographic factors, migration status, health information sources, barriers to accessing public healthcare services and influenza-related knowledge using a 201-item interviewer-assisted questionnaire. Among the different types of influenza, participants' awareness of avian influenza was greatest (81%), followed by H1N1 (78%), human influenza (61%) and pandemic influenza (35%). Logistic regression analyses identified 11 factors that significantly predicted a high level of knowledge about influenza. Six or more years of education completed [odds ratio (OR) 6.89 (95% confidence interval (CI) 3.58-13.24)] and recent participation in an influenza prevention activity [OR 5.27 (95% CI 2.78-9.98)] were the strongest predictors. Recommendations to aid public health efforts toward pandemic mitigation and prevention include increasing accessibility of education options for migrants and increasing frequency and accessibility of influenza prevention activities, such as community outreach and meetings. Future research should seek to identify which influenza prevention activities and education materials are most effective.

Measuring perinatal health equity and migration indicators for international comparisons.

An international research collaboration answered, "Can equity in perinatal health for migrant women be measured for comparison across countries?" In nine countries, perinatal databases were assessed for the availability of equity indicators. Equity data were also sought from women and health records. Optimal sources of data differed depending on the migrant perinatal health equity indicator. Health and migration data, required to capture equity, were often not reported in the same location. Migration indicators other than country of birth were underreported. Perinatal health equity can be measured for international comparisons, although a standardized protocol is required to capture all indicators.

Pandemic preparedness: perceptions of vulnerable migrants in Thailand towards WHO-recommended non-pharmaceutical interventions: a cross-sectional study.

BACKGROUND: Non-pharmaceutical interventions (NPIs) constituted the principal public health response to the previous influenza A (H1N1) 2009 pandemic and are one key area of ongoing preparation for future pandemics. Thailand is an important point of focus in terms of global pandemic preparedness and response due to its role as the major transportation hub for Southeast Asia, the endemic presence of multiple types of influenza, and its role as a major receiving country for migrants. Our aim was to collect information about vulnerable migrants' perceptions of and ability to implement NPIs proposed by the WHO. We hope that this information will help us to gauge the capacity of this population to engage in pandemic preparedness and response efforts, and to identify potential barriers to NPI effectiveness. METHODS: A cross-sectional survey was performed. The study was conducted during the influenza H1N1 2009 pandemic and included 801 migrant participants living in border areas thought to be high risk by the Thailand Ministry of Public Health. Data were collected by Migrant Community Health Workers using a 201-item interviewer-assisted questionnaire. Univariate descriptive analyses were conducted. RESULTS: With the exception of border measures, to which nearly all participants reported they would be adherent, attitudes towards recommended NPIs were generally negative or uncertain. Other potential barriers to NPI implementation include limited experience applying these interventions (e.g., using a thermometer, wearing a face mask) and inadequate hand washing and household disinfection practices. CONCLUSIONS: Negative or ambivalent attitudes towards NPIs combined with other barriers identified suggest that vulnerable migrants in Thailand have a limited capacity to participate in pandemic preparedness efforts. This limited capacity likely puts migrants at risk of propagating the spread of a pandemic virus. Coordinated risk communication and public education are potential strategies that may reduce barriers to individual NPI implementation.

Development of the Migrant Friendly Maternity Care Questionnaire (MFMCQ) for migrants to Western societies: an international Delphi consensus process.

BACKGROUND: Through the World Health Assembly Resolution, 'Health of Migrants', the international community has identified migrant health as a priority. Recommendations for general hospital care for international migrants in receiving-countries have been put forward by the Migrant Friendly Hospital Initiative; adaptations of these recommendations specific to maternity care have yet to be elucidated and validated. We aimed to develop a questionnaire measuring migrant-friendly maternity care (MFMC) which could be used in a range of maternity care settings and countries. METHODS: This study was conducted in four stages. First, questions related to migrant friendly maternity care were identified from existing questionnaires including the Migrant Friendliness Quality Questionnaire, developed in Europe to capture recommended general hospital care for migrants, and the Mothers In a New Country (MINC) Questionnaire, developed in Australia and revised for use in Canada to capture the maternity care experiences of migrant women, and combined to create an initial MFMC questionnaire. Second, a Delphi consensus process in three rounds with a panel of 89 experts in perinatal health and migration from 17 countries was undertaken to identify priority themes and questions as well as to clarify wording and format. Third, the draft questionnaire was translated from English to French and Spanish and back-translated and subsequently culturally validated (assessed for cultural appropriateness) by migrant women. Fourth, the questionnaire was piloted with migrant women who had recently given birth in Montreal, Canada. RESULTS: A 112-item questionnaire on maternity care from pregnancy, through labour and birth, to postpartum care, and including items on maternal socio-demographic, migration and obstetrical characteristics, and perceptions of care, has been created--the Migrant Friendly Maternity Care Questionnaire (MFMCQ)--in three languages (English, French and Spanish). It is completed in 45 minutes via interview administration several months post-birth. CONCLUSIONS: A 4-stage process of questionnaire development with international experts in migrant reproductive health and research resulted in the MFMCQ, a questionnaire measuring key aspects of migrant-sensitive maternity care. The MFMCQ is available for further translation and use to examine and compare care and perceptions of care within and across countries, and by key socio-demographic, migration, and obstetrical characteristics of migrant women.

Resilience in international migrant women following violence associated with pregnancy.

Exposure to violence associated with pregnancy (VAP) is an underrecognized public health and social problem that has an enormous impact on the physical and mental health of women and their children. Our recent study of 1,127 new mothers living in two urban areas of Canada found refugees and asylum-seekers to be more likely to have experienced VAP than immigrant or Canadian-born women. Interestingly, some migrants who had experienced VAP had low rates of postpartum depression risk on the Edinburgh Postpartum Depression Scale, suggesting that resilience may play an important role in maintaining their mental health. Hence, we sought to explore processes which enhance migrants' resilience to VAP. We conducted in-depth interviews with ten women who had been identified as experiencing VAP and having low risk of postpartum depression and performed thematic analyses. International migrant women found internal psychological and coping resources, external social supports, and systemic factors including government policies to be vital to their resilience. Participants perceived differences in resilience by gender and immigration status. International migrant women used a range of processes to maintain and enhance their resilience after VAP, and these may be helpful to less resilient women who are vulnerable to postpartum depression.

Developing population interventions with migrant women for maternal-child health: a focused ethnography.

BACKGROUND: Literature describing effective population interventions related to the pregnancy, birth, and post-birth care of international migrants, as defined by them, is scant. Hence, we sought to determine: 1) what processes are used by migrant women to respond to maternal-child health and psychosocial concerns during the early months and years after birth; 2) which of these enhance or impede their resiliency; and 3) which population interventions they suggest best respond to these concerns. METHODS: Sixteen international migrant women living in Montreal or Toronto who had been identified in a previous study as having a high psychosocial-risk profile and subsequently classified as vulnerable or resilient based on indicators of mental health were recruited. Focused ethnography including in-depth interviews and participant observations were conducted. Data were analyzed thematically and as an integrated whole. RESULTS: Migrant women drew on a wide range of coping strategies and resources to respond to maternal-child health and psychosocial concerns. Resilient and vulnerable mothers differed in their use of certain coping strategies. Social inclusion was identified as an overarching factor for enhancing resiliency by all study participants. Social processes and corresponding facilitators relating to social inclusion were identified by participants, with more social processes identified by the vulnerable group. Several interventions related to services were described which varied in type and quality; these were generally found to be effective. Participants identified several categories of interventions which they had used or would have liked to use and recommended improvements for and creation of some programs. The social determinants of health categories within which their suggestions fell included: income and social status, social support network, education, personal health practices and coping skills, healthy child development, and health services. Within each of these, the most common suggestions were related to creating supportive environments and building healthy public policy. CONCLUSIONS: A wealth of data was provided by participants on factors and processes related to the maternal-child health care of international migrants and associated population interventions. Our results offer a challenge to key stakeholders to improve existing interventions and create new ones based on the experiences and views of international migrant women themselves.