'I know my place' : a meta-ethnographic synthesis of disadvantaged and vulnerable women's negative experiences of maternity care in high-income countries

Objective: During pregnancy and childbirth, vulnerable and disadvantaged women have poorer outcomes, have less opportunities, face barriers in accessing care, and are at a greater risk of experiencing a traumatic birth. A recent synthesis of women's negative experiences of maternity care gathered data from predominantly low-income countries. However, these studies did not focus on vulnerable groups, and are not easily transferable into high-income settings due to differences in maternity care provision. The aim of this study was to synthesise existing qualitative literature focused on disadvantaged and vulnerable women's experience of maternity care in high-income countries. Methods: A systematic literature search and meta-ethnographic methods were used. Search methods included searches on four databases, author run, and backward and forward chaining. Searches were conducted in March 2016 and updated in May 2020. Findings: A total of 13,330 articles were identified and following checks against inclusion / exclusion criteria and quality appraisal 20 studies were included. Meta-ethnographic translation analytical methods were used to identify reciprocal and refutational findings, and to undertake a line of argument synthesis. Three third order reciprocal constructs were identified, 'Prejudiced and deindividualized care', 'Interpersonal relationships and interactions' and 'Creating and enhancing insecurities.' A line of argument synthesis entitled 'I know my place' encapsulates the experiences of disadvantaged and vulnerable women across the studies, acknowledging differential care practices, stigma and judgmental attitudes. A refutational translation was conceptualised as 'Being seen, being heard' acknowledging positive aspects of maternity care reported by women. Conclusion: Insights highlight how women's vulnerability was compounded by complex life factors, judgmental and stigmatizing attitudes by health professionals, and differential care provision. Further research is needed to identify suitable care pathways for disadvantaged and vulnerable women and the development of suitable training to highlight negative attitudes towards these women in maternity care settings.