The studies included in this review draw from women’s birthing experiences in mainstream maternity healthcare, which is medical facilities or highly specialised healthcare, mostly provided as a hospital in-patient on referral from primary or secondary health settings and can include complex medical or surgical procedures (62, 63). This review will focus on studies focussed on Indigenous women’s birthing experiences in Australia, Aotearoa (New Zealand), Canada, US, Kalaallit Nunaat (Greenland) and Sápmi, the cultural region traditionally inhabited by the Sámi people, assimilated by and spanning parts of countries Norway, Sweden, Finland, and to Russia’s Kola Peninsula. The Sámi are the Indigenous people inhabiting Sápmi, which is not a political entity, but a cultural and geographic area significant to the Sámi people. These countries comprise Indigenous populations, while also having similar histories inclusive of assimilation, and similar approaches to health systems and services (6, 33). All eight countries have diverse, multicultural populations, free and open presses and are closely aligned on key social and political issues (excluding the Russian part of Sápmi who is political and health systems, along with its lack of free press, differ vastly from those of Norway and other Scandinavian countries in Sápmi, leading to distinct challenges for the Sámi people in each region).

The research question guiding this review was: What is known about Indigenous women’s dissatisfaction of birthing experiences in mainstream maternity hospitals in Australia, Aotearoa, Canada, US, Kalaallit Nunaat and Sápmi? Including these countries in a scoping review on Indigenous women’s dissatisfaction with birthing in mainstream hospitals is justified due to the shared history of colonisation and the significant Indigenous populations in these countries. Each of these countries has distinct yet comparable healthcare systems and policies impacting Indigenous communities. By examining these countries, the review can provide a comprehensive understanding of how mainstream healthcare services address or fail to address the cultural needs of Indigenous women, offering insights into common challenges and potential solutions across different contexts.

For the purpose of this review, “dissatisfaction of birthing experience” was defined broadly to encompass any expressed discontent or unmet expectations regarding the cultural safety, accessibility, and quality of care received during the perinatal period in mainstream settings. The review goal was to gain a comprehensive understanding of factors contributing to Indigenous women’s dissatisfaction globally, providing a foundation for justifying changes in care delivery and guiding future local research on this issue.

The search strategy aimed to locate both published and unpublished studies. A three-step search strategy was utilised in this review and considered primary research studies that report on reasons for dissatisfaction of birthing experiences, and strategies implemented to improve quality of clinical practice around women’s dissatisfaction of birthing experiences in mainstream maternity hospitals.

To ensure rigorous evidence synthesis, a research protocol was developed highlighting the inclusion and exclusion criteria and identifying how data would be extracted and presented. This was registered on the Open Science Framework (OSF) on May 14, 2024 (31).

A preliminary search was conducted in Medline (via Ovid) to identify articles, keywords and scope of topic. The identified keywords guided development of a comprehensive search strategy in Medline (see Supplementary material). Keywords included combinations of all variations of the following words: “Indigenous,” “birthing,” “dissatisfaction,” “hospital,” “mainstream.” The retrieved articles from the preliminary search were assessed to ensure the inclusion of key publications. The search strategy, including keywords and relevant index terms, was adapted for other bibliographic databases by a research librarian (JG), including PsycINFO (via OVID SP), Cumulated Index to Nursing and Allied Health Literature CINAHL (EBSCOhost), Web of Science (Clarivate Analytics), Scopus (Elsevier), ProQuest Central, ProQuest Social Science Premium Collection (Clarivate). ProQuest Dissertations and Theses was searched for unpublished material. Each database search strategy was run on May 28, 2024. Additionally, a supplemental search was conducted using Google Scholar and hand searching of key journals to identify studies meeting inclusion criteria. The search included articles from the inception of each database until 2024, with no restrictions on the publication date of the articles meeting the keyword inclusion criteria.

To expand the search, reference lists of all included sources were screened for additional studies. The 22 citations were also entered into Research Rabbit, an Artificial Intelligence (AI) tool for data mining scholarly publications, to conduct a final forward/backward search and identify timeline trends (34). This Artificial Intelligence (AI) tool is designed to support unstructured searching via data mining of publicly available scholarly papers and information relevant to seed papers uploaded (35). The tool was used for two main purposes: (1) to perform a final forward/backward check for any items that might have been missed during the systematic and hand-searching processes, and (2) to identify timeline trends for the included studies and related works. No additional relevant studies were found.

For an illustration of the search and screening process see Figure 1 (PRISMA). The study titles and abstracts were screened for relevance, and if there was insufficient abstract information to determine eligibility the full text was retrieved. Full-text articles were evaluated against the following criteria: (a) those that included Indigenous women accessing perinatal services in mainstream health facilities; (b) those studies located in the geographical area of Australia, Aotearoa (New Zealand), Canada, Kalaallit Nunaat (Greenland), and Sápmi; (c) those which presented the results of peer-reviewed and non-peer-reviewed research based on qualitative or mixed-methods methodology that provided data on Indigenous women’s dissatisfaction in the perinatal in mainstream health facilities.

Language was restricted to English publications from inception of databases onwards. Studies were excluded if they (a) were an opinion article; (b) not a primary study; (c) not able to retrieve full text; (d) duplicate from the included full text articles; (e) no qualitative section of study; (f) not responding to the research question; or (g) studies published in languages other than English.

The inclusion and exclusion criteria were decided upon through discussions with the research team, which comprised three Indigenous and two non-Indigenous members. Both the perspectives of Indigenous women and of non-Indigenous women birthing Indigenous babies were included. By this, we refer to cases where a non-Indigenous mother and an Indigenous father have an Indigenous child. We included studies that presented firsthand accounts from Indigenous women or from non-Indigenous women birthing Indigenous babies, as well as studies documenting women’s experiences and implemented strategies to address dissatisfaction in care. We excluded studies that did not contain Indigenous women’s voices or direct experiences, including those focused on healthcare professional perspectives, as these may not accurately represent Indigenous women’s experiences. Additionally, studies reporting general birthing stories, which do not specifically address Indigenous women’s unique experiences and concerns, were excluded. This approach ensured that our review centred on the firsthand perspectives of Indigenous women regarding perinatal care.

Following the search, the 1,474 citations identified were collated and uploaded into Covidence (36), and 514 duplicates removed. After pilot testing, 960 articles underwent title and abstract screening by four reviewers (NS, TMN, GM, and TJ). The relevant studies were retrieved in full, and their citation details imported into Covidence. The full text of 69 citations was assessed in detail against the inclusion criteria by four independent reviewers (NS, GM, SS, and TJ). A manual search in Google Scholar and thorough examination of the reference lists of the included articles retrieved a further 8 articles which were also screened for eligibility. The reasons for excluding papers at the full-text stage, which did not meet the inclusion criteria, were documented as shown in Figure 1 (PRISMA chart). Disagreements between reviewers during the selection process were resolved through discussion or, if necessary, with the involvement of an additional reviewer. There were seven conflicts in Covidence, attributed to ambiguity around what mainstream health services encompass. These disagreements were resolved through discussion among the reviewers to ensure consistency and rigour in our inclusion decisions. This collaborative approach helped us reach a consensus on all disputed studies, strengthening the reliability of our selection process.

At the end of the selection process, 22 full-text articles were identified.

Three reviewers (NS, TMN, and SS) independently evaluated each article that met the inclusion criteria using a data extraction tool created by the authors, adapted from the JBI extraction tool (37), which was pilot tested and then used in Covidence for extraction. The reviewers (NS, TMN, and SS) extracted details such as author names, publication date, title, study setting, study design, data collection methods, and sample characteristics. Also extracted were outcome of studies in relation to dissatisfaction of birthing in mainstream hospitals and critical findings.

Any disagreements during the data extraction process were resolved through discussion between the reviewers to reach consensus. Four reviewers (NS, SS, TMN and TJ) collaboratively identified key themes and patterns to provide a descriptive overview of the main content and findings of each article, in line with the review’s objective. These themes and patterns were then discussed, further developed, and refined in consultation with the entire authorship team.

The included articles were analysed using basic descriptive summaries following a template developed and pilot tested by two authors (NS and SS). This abridged thematic synthesis (38) approach to assess and extract data from the included studies involved summarising content across studies and identifying recurring themes related to Indigenous women’s dissatisfaction with perinatal care. Key parameters guiding the analysis included cultural safety, accessibility of services, continuity of care, and experiences of discrimination within healthcare settings. This adapted thematic synthesis (38) allowed us to systematically organise and interpret findings, providing a comprehensive view of Indigenous women’s perinatal care experiences in mainstream settings. This analysis was guided by the research question of the scoping review.

The Research Rabbit AI tool generated a timeline visualisation for the 22 studies (shown in green) and identified 679 similar works, of which the 50 most relevant works (shown in blue) are presented in Figure 2. The visualisation highlighted growing interest in Indigenous women’s birthing experiences from 2011 to 2021. However, the similar works primarily focused on health care professional’s perspectives of providing care to Indigenous women and families, community service provision, antenatal services in remote locations, and models of midwifery care.

Database searches resulted in 1,474 initial records, then 514 duplicate records removed, with 890 excluded following title and abstract screening. We assessed 69 full texts for eligibility, 48 were excluded. One study was included from Google Scholar. This meant that n = 22 studies, published within the last 21 years (1993–2024), met all eligibility criteria, with a total of 1,578 participants. Key characteristics of the included studies are summarised in Supplementary Table 1 where each study is numbered and referred to in the results reported here.

Study sizes ranged from 4 to 344 participants, with an average of 72. Together, the studies included 1,437 women, 36 Elders, 14 fathers and family members, and 91 healthcare professionals.

While many Indigenous women are aware of the dangers inherent in birthing without appropriate supports, all studies identified a preference for birthing in home communities or as near as possible, if appropriate services were available (10, 33, 39–41). The Australian study by Ireland et al. (5) identified that the current model of care which involved evacuation to regional hospital, as an infringement of Women’s Business laws. The participants in the study believed that all matters relating to reproduction are “Women’s Business,” and while the boundaries of Women’s Business are changing, this study highlighted the dislocation of birthing women from their culturally appointed carers. The women reporting ongoing emotional impacts, and lasting emotional impacts of shame and technological violation during childbirth. This preference to receive antenatal and perinatal care in the community was also evident in Canadian and Māori Indigenous women (40, 42). Indigenous women universally reported that evacuation to a regional hospital resulted in a geographic and emotional disconnect from community, a lack of social supports and feelings of isolation, lack of meaningfulness and concern about the wellbeing of older children left behind in communities (6, 7, 10, 43–45). The Canadian study by Wiebe et al. (7) further highlighted how according to elders, the separation of childbirth from the geographic and cultural community, from the woman’s home community, is traumatic, and this trauma also changed the way childbirth was experienced by labouring mothers. In addition to the isolation, mothers also reported greater physical pain when birthing in the hospital, compared to at home or in their community. In Canada, Kornelsen (40) study found that women reported feeling powerless in the urban birthing environment, and missing family, and estrangement from cultural norms.

Many studies identified the need for a culturally appropriate support person for women who are evacuated to regional hospitals while awaiting the birth of their child (40–42, 46, 47). The studies highlighted the value family support to improve women’s experiences of care (41). It was identified that evacuation to a regional hospital results in the loss of emotional support from their family members and culturally appointed carers (5, 40, 42). Additionally, the study by Ireland et al. (5) identified that a support person can assist with appropriate communication, can act as a cultural adviser, and can enhance wellbeing and improve experiences of care (41, 42, 47). Women in a Canadian study (48) emphasised that giving birth alone and being separated from family could negatively impact their mental health, whereas being accompanied by a partner could support their overall wellbeing. Additionally, the adoption of a support person was found to prevent misunderstandings in discussions with healthcare providers and may also improve attendance at antenatal care (47). There is evidence to suggest that there is a strong cultural connection for the family when a baby is due and without support the complication of relocation to a regional acute care facility may result in resistance to attend antenatal classes and disengagement from antenatal care in general (46). The inclusion of Aboriginal health workers and greater numbers of Aboriginal midwives may improve the women’s’ feeling of safety and being welcomed in an unfamiliar place (46).

Three of the studies included in this scoping review evaluated the perceptions of Indigenous Women who attended venues employing continuity of care practices (17, 41, 49). All studies reported positive experiences from participating in this type of care and participants expressed appreciation of having a health care provider with knowledge of their background and insight into living within a remote environment (17). Aside from enhanced continuity of care, one study reported greater cultural responsiveness of the wider midwifery services and staff (17). The women reported feeling culturally safe, connected, and supported while experiencing emotional and clinical safety (49). A further positive finding was the presence of respectful relationships and shared decision-making (49). However, not all findings were positive, and negative experiences persisted including structural and systemic issues such as fragmented care and unsupported or culturally unsafe care within the broader health system (49). While the continuity of care model is safe and highly valued by Indigenous women, there was evidence to suggest that some women still experienced incidences of being ignored, having concerns dismissed, experienced racism and felt talked down to and limited choice in care (41).

Lack of cultural understanding or relationships and trust were pervasive in many studies, and Brown et al. (50) Australian study found up to 51% of women reported receiving discrimination or unfair treatment from hospitals or health services during pregnancy or shortly after. Vang et al. (44) study in Canada, found issues of perceived cultural stereotypes, labelling, communication issues and medical mistrust were identified. Women identified hospital bureaucracy including waiting times, the feeling of being rushed and lack of time to build relationships with staff as a negative experience creating stress. The Australian study by Dietsch et al. (39) reported that women are impacted by closures of maternity services in rural areas, and experience feelings of loneliness, fear, isolation, and alienation when forced to relocate to large city hospitals to deliver. They felt disrespected, oppressed, culturally unsafe and experienced racism. The study recommends that Aboriginal women’s’ ties to country (Birthing on Country) and kinship networks should be valued and models of midwifery care developed to ensure healthy pregnant women have a choice as to whether they remain on country or transfer, from their country and kin, to birth (39).

Watson (45) study in Australia found women experienced feelings of loneliness when confined to birth in a mainstream hospital. Participants reported inadequate interactions with staff, were frightened and described miscommunication, lack of empathy and misunderstanding of cultural and spiritual beliefs. Additionally, the women described negative experiences including the need for explanations regarding their birthing experience. This was also found in the Canadian study by Varcoe et al. (10) where most participants described distressing experiences during pregnancy and birthing including healthcare professionals who lacked understanding of historical and ongoing colonial relations which impacted choice and affect birth outcomes. The critical finding of this study was that prior negative experiences and discrimination were deterrents to accessing prenatal care.

It has become evident throughout this review, that healthcare professionals can have a profound effect on women’s perception of the birth experience and encounters with healthcare professionals can be positive or negative (10, 44). The studies included in this review cited incidences of judgment, racism, cultural misunderstandings, poor relationships, improper care, patronising behaviour as well as demeaning and poor communication (10, 19, 33). Health inequities are evident, and in Australia Aboriginal women are most at risk of poor infant health outcomes and they are also the least likely to perceive that they received care well matched to their needs (50).

Indigenous women, most at risk of poor infant health outcomes, were the least likely to perceive that the care they received was well matched to their needs (50). Many of the studies included in this review identified the need for cultural safety education of health care providers as well as greater inclusion of Indigenous perspectives (7, 10, 33, 43, 44, 46, 48, 49, 51–53).

A Canadian study Vang et al. (44) highlighted the social disconnect and social isolation experienced and concluded the need for institutions to instigate cultural sensitivity training that highlights the larger historical, social, and political issues experienced by Indigenous women. Women in Varcoe (10) study described distressing experiences during pregnancy and birthing including healthcare professionals who lacked understanding of historical and ongoing colonial relations which impacted choice and affect birth outcomes. Churchill et al. (52) found that culturally safe care included having personalised continuous relationships with midwives, and having a space that made participants feel “at home” and acknowledged that Indigenous and non-Indigenous participants conceptualised and experienced cultural safety in diverse ways (52). In Australia, women reported feelings of being judged by midwives and that this negatively impacted their experience (43). However, the same study reported that positive outcomes came when staff practised open inclusive communication with the women (43). The critical finding of this study is that culturally safe care, emphasising inclusive communication and active decision-making involvement, is essential to improve childbirth experiences for Aboriginal and Torres Strait Islander women, who often face judgment and cultural misunderstandings (43). Similarly, the Canadian study by Browne and Fiske (51) found a need for cultural safety training to ensure Western nurses challenge their own cultural assumptions about Indigenous women.

This is the first review to systematically synthesise existing evidence on Indigenous women’s dissatisfaction of birthing in mainstream hospitals. The strength of this scoping review is its novel nature. Additionally, a further strength is in its global approach to the experiences of Indigenous women. This review has included the experiences of Indigenous women across eight countries and at least 11 specific cultural groups including Australian Aboriginal women from Ngaanyatjarra, Aboriginal women from Western Australia, Queensland, the Northern Territory, New South Wales and Victoria (Cultural groups not identified), Canadian Inuit women and Aboriginal women from Alexander, Alexis, Enoch, Paul, Nuxálk, Haida and Namgis nations. Indigenous women from Wemindji Cree nation, Cree from Moose Factory zone and Stoney nation. Finally, Māori women from Aotearoa as well as Inuit women from Kalaallit Nunaat. However, the findings should be considered with acknowledgement of the following limitations. The review included only English-language studies, potentially missing relevant studies in other languages. Although the search strategy was comprehensive, studies around dissatisfaction of Indigenous women’s birthing published in non-traditional mediums or grey literature may not be fully represented. The generalisability of the results to non-English-speaking contexts is uncertain, and future research could expand to include non-English studies. While grey literature was not excluded from the initial search no unpublished papers were detected.