Introduction

Global migration is escalating, especially among women fleeing humanitarian crises and sexual violence [1,2,3,4]. Refugee claims are increasing [5,6,7], and approximately half of migrants globally are women [8]. Im/migrant women face barriers to health, including insufficient health insurance coverage, discriminatory policies, and inadequate support—yet the structural determinants of im/migrant women’s healthcare access remain poorly understood [9,10,11], with previous research relying on acculturation, the ‘healthy immigrant effect’, and individual and behavioural explanations for differences among im/migrants [43, 44]. In this study, the term “im/migrant women” includes the diversity of international migrants, refugees, asylum seekers, temporary workers, long-term and recent arrivals, and individuals with and without legal immigration status [12] who self-identify as women (trans-inclusive).

Canada is a key destination for im/migrants globally, who represented 20.6% of its population in 2011, the highest proportion of G8 countries [13]. Im/migrants are projected to represent nearly half of Canada’s population by 2036 [14], continuing to primarily reside in Ontario (32.9%) and British Columbia (BC) (32.3%) [14, 15]. About 20% of women in Canada are im/migrants, most of whom are of reproductive age(15–49 years) and racialized [16, 17], with a projected rise to 27% by 2031 [18]. Women have migrated for reasons including better economic and working conditions, and refuge from hostile and xenophobic policy environments [6, 19]. Despite Canada’s growing im/migrant women population, relatively little is known about their access to and engagement in sexual and reproductive health(SRH) care [20].

Im/migrant women in Canada may face unique migration-related disparities in maternal health care [20,21,22,23], pregnancy care [24, 25], mental health support [26,27,28,29,30], contraception [31, 32], sexually transmitted infections (STIs) and HIV testing [33,34,35,36], and cervical cancer screening [37,38,39]; however, diverse migration and SRH experiences, along with varying migrant categorizations, definitions and conceptualizations, make it difficult to compare and draw conclusions to inform policy and practice. Prior reviews of im/migrant health in Canada have infrequently considered gendered inequities in health access [40, 41] such as unequal power dynamics and intimate partner violence. Previous quantitative research has shown differences in perinatal health outcomes across ethnic groups and countries of origin, demonstrating diverse impacts of migration on health [42]. However, there is a need for research to also consider qualitative understandings of women’s lived experiences and the impacts of a wider range of migration experiences (e.g., migration duration, language, immigration status, xenophobia) and types of SRH care.

This analysis was informed by a structural determinants of health approach [46], considering the impacts of macro-structural factors (e.g., policies), im/migration-specific factors (e.g., immigration status, migration duration), health service use and delivery (e.g., system navigation), and individual-level factors (e.g., age, gender) [47] shaping SRH access. This was complemented by intersectionality theory to attend to the cumulative effect of various intersecting forms of marginalization and axes of oppression in influencing health access, such as racism, xenophobia, and ‘othering’ [43,44,45]. Finally, we drew from frameworks of the multi-staged nature of migrant health [3, 44] to highlight the influence of diverse and complex migration experiences, exposures, and engagement in care in destination, transit, and origin locations. Given gaps in existing research and evidence of SRH inequities among im/migrant women in Canada and globally, this review drew upon 10 years of peer-reviewed literature to (1) describe inequities and determinants of engagement in SRH services among im/migrant women in Canada, and (2) understand their lived experiences of barriers and facilitators.

Methods

Search Strategy

Our search began by exploring SRH inequities faced by im/migrant women globally. As this yielded a large number of records (n = 313), we narrowed our scope to the Canadian context at the final stage of screening using a comprehensive review methodology (see PRISMA diagram [48], Fig. 1). We searched the peer-reviewed literature for qualitative, quantitative and mixed-methods studies describing the determinants and lived experiences of SRH inequities amongst im/migrant women. The review methodology was designed by SM and SG, in consultation with MW; a UBC librarian with specialized skills in systematic reviews also supported development of the search strategy. We searched four databases (Ovid Medline, Social Sciences Citation Index (SSCI), Sciences Citation Index, and CINAHL) using combinations of terms related to SRH, migration, women and research methodologies (Appendix A), subsequently cross-referencing articles and hand-searching to ensure no key studies were missed. These databases were selected based on the scope and topics covered by the comprehensive review. For example, Ovid Medline was selected as an appropriate tool for conducting comprehensive reviews of medical literature, CINAHL for including studies on SRH, migration and women, and SSCI for ensuring coverage of social sciences literature. A limiter was used to identify articles published between 2008 and 2018. Guided by the PRISMA diagram (Fig. 1), we: (1) reviewed titles and abstracts to ensure their relevance to our initial objectives that were globally-focused; (2) reviewed abstracts and narrowed focus to studies describing determinants and lived experiences of SRH access amongst im/migrant women; (3) reviewed full texts to include only Canadian studies.

Fig. 1
figure 1

PRISMA Diagram of screening process for studies on determinants of access to and engagement in sexual and reproductive health (SRH) services among im/migrant women in Canada (2008–2018) based on searches in Ovid Medline, Social Sciences Citation Index, Sciences Citation Index, and CINAHL

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Inclusion Criteria

Eligible studies at the final stage of screening included primary, peer-reviewed studies that met the following criteria: (i) in English, (ii) published from January 2008 to July 2018, and (iii) focused on im/migrant women’s access to SRH care in Canada. We focused on studies in the last 10 years to ensure relevance to the current im/migration context and provide recent, updated evidence of factors shaping im/migrant women’s SRH access in Canada. Qualitative and quantitative studies were included to capture patterns of SRH service access, such as how often and frequently SRH services were used, as well as determinants of women’s access to and engagement in SRH care. The study population included all im/migrants who self-identify as women (trans-inclusive) of reproductive age, defined by the World Health Organization as 15–49 years. Studies on internal migration and men im/migrants were excluded. Secondary research, grey literature, and studies with no explicit focus on SRH and im/migrant women were also excluded.

Data Extraction and Analysis

Retrieved studies were managed in standard reference management software. We tabulated study characteristics (Table 1) and the following data when available: barrier or facilitator, type of SRH care needed or accessed, qualitative narratives, and epidemiological associations (Appendix B). Tabulated groupings were decided based on similar approaches reported in the literature [49, 50]. We synthesized findings by grouping studies until a comprehensive understanding of key themes (Appendix B) that emerged from both qualitative and quantitative studies was generated. For qualitative studies, we extracted narrative exemplars based on key barriers and facilitators that determined whether and how women accessed SRH care. For quantitative studies, we extracted epidemiological data of relevance to our objectives, such as proportions that described how often and frequently SRH services were accessed, as well as statistical associations (e.g., odds ratios). Finally, we grouped both qualitative and quantitative findings according to determinants of SRH access and engagement amongst im/migrant women in Canada. We interpreted findings considering the various contributions of macro-structural factors, immigration-specific factors, health service use and delivery, and individual-level factors.

Table 1 Summary of included studies (N = 38) on determinants of access to and engagement in sexual and reproductive health (SRH) services amongst im/migrant women in Canada (2008–2018)
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Results

Our search yielded 782 studies describing SRH inequities faced by im/migrant women globally to determine eligibility, of which we excluded 469 after reviewing abstracts. We hand-reviewed full-texts of 313 potentially eligible studies that focused on access to and engagement in SRH care for im/migrant women globally (Fig. 1). Of 38 Canadian studies that met inclusion criteria, most were conducted in Ontario (n = 18), followed by BC (n = 6), Alberta (n = 6), Quebec (n = 5), Saskatchewan (n = 1), Manitoba (n = 1), and Newfoundland and Labrador (n = 1). Most studies did not differentiate between im/migration categories, and characterized participants as “immigrant women”, “newcomers”, or by ethnicity and/or religion (n = 28). Where immigration status was specified, most studies focused on sponsored refugees and asylum seekers (n = 17); others included temporary workers and students (n = 7), permanent residents (n = 5), visitors (n = 5), family sponsored (n = 3), and undocumented women (n = 3). Only two studies recruited participants below the age of 20 [37, 51].

Of 38 studies, 23 were qualitative and 15 were quantitative (Table 1). No mixed-methods studies met our inclusion criteria. Most studies focused on maternity care (n = 20), followed by sexual health screenings (cervical cancer, HIV/STI) (n = 12), contraception (n = 3), and gender-based violence (GBV) support (n = 3) (Appendix B). While all studies discussed barriers faced by im/migrant women, only seven identified facilitators [52,53,54,55,56,57,58].

Our findings are organized by eight determinants of SRH access and engagement, which we identified by grouping and categorizing key barriers and facilitators highlighted in each study (Appendix C): (i) health system navigation and access to SRH service information; (ii) positive and negative experiences with health personnel; (iii) availability of culturally safe care; (iv) language barriers and availability of language-specific care; (v) social isolation and support; (vi)immigration-specific factors; (vii) stigma, discrimination and racialization; and, (viii) gender inequities and power relations. We synthesized quantitative data (e.g., descriptive statistics, odd ratios) to understand determinants of SRH care access, and synthesized narratives and themes reported in qualitative studies to understand inequities and lived experiences of barriers and facilitators to SRH services faced by im/migrant women. Although eligibility included all im/migrants who self-identified as women, few studies specified gender identities [59, 60].

Determinants of SRH Access and Engagement

Our analysis found that existing literature on im/migrant women’s access to and engagement in SRH care in Canada has primarily focused on health service use and delivery, and less on macro-structural and immigration-specific factors.

Health System Navigation and Access to SRH Service Information

Nineteen studies described links between health system navigation challenges and limited access to maternity care [23, 54, 55, 61,62,63,64,65], sexual health screenings (cervical cancer [37, 39, 58, 66,67,68], HIV/STIs [69]), GBV support [56, 70], and contraception [71, 72].

Qualitative and quantitative studies described the Canadian health system as inconvenient and inadequate due to institutional health system barriers, including challenges finding a family doctor, long wait times, quick hospital discharges, limited and confusing health insurance coverage, and high costs [37, 55, 58, 61, 64, 66, 74]. In a Quebec study, a permanent resident accessing HIV/STI testing during pregnancy explained, “We signed up for a family doctor[…] four years ago, and they still have not called me[…]I had already had two miscarriages and I had a baby with a high-risk pregnancy and I am still waiting”(p. 421) [69]. While few studies described greater access to women providers in Canada compared to home countries [54], accessing women doctors was reported as a key barrier [37, 38, 55, 58, 65,66,67,68, 74, 75] for providers, as well as im/migrant women who expressed discomfort with men physicians [55, 58, 66, 75]. Government-funded provincial health insurance influenced access to sexual health screenings and maternity care in several studies [39, 55, 62,63,64]. In Ontario, for example, rates of cervical cancer screening were low among low-income im/migrant women with health insurance for the last 10 years (31.0%) compared to high-income women who lived in Ontario longer (70.5%) [39].

Health system differences between countries of origin and Canada, as well as limited availability of SRH service information, were common concerns and often limited uptake [56, 61, 63, 76]. Some women feared hospital-based deliveries in Canada, believing caesarean sections were the preferred method of delivery [73], and others’ unfamiliarity with Canadian guidelines for cervical cancer screening determined whether they accessed this service. However, women expressed the desire to learn and made recommendations to raise awareness of available services and health information, such as electronic annual reminders for routine cervical cancer screening, information sessions on available services and referral requirements, and resource booklets [68].

Positive and Negative Experiences with Health Personnel

Sixteen qualitative and quantitative studies identified negative experiences with HCPs for racialized im/migrants– notably judgmental attitudes, insensitive care, and violations of privacy and consent—as barriers to maternity care [52, 53, 55, 61, 62, 73, 75,76,77,78,], cervical cancer screening [58, 66], HIV/STI [60] testing, GBV support [56, 70], and family planning [71].

Violations of privacy and consent were reported across qualitative studies [61, 66, 69, 70] and negatively impacted healthcare experiences. A woman in Newfoundland & Labrador explained, “I asked nurses if they can knock before they enter so I can get dressed. I also put a sign on the door but they didn’t respect it. This man came and saw me. I was very upset and crying” (p. 106) [78]. In a situation where consent had not been appropriately obtained due to inadequate translation support and rushed interactions, patients who were unclear of the conditions of consent still underwent a procedure [61]. An HCP in Alberta noted, “You’re trying to offer them an operation for what you feel are correct reason[s], so whether they understand English or don’t […] their consent is perhaps not optimal in a stressful situation.” (p. 9) [61].

Unequal power dynamics between providers and patients were also shown to strongly influence im/migrant women’s SRH experiences, and sometimes prevented women from asking for critical health information [66]. Encouragingly, in Ontario and BC, experiences with HCPs were often perceived as culturally safe, supporting im/migrant women’s engagement in maternity care [52, 53, 55], GBV support [56], and sexual health screenings (cervical cancer [58], HIV [57]). In a quantitative study with African, Caribbean and Black im/migrant women living with HIV, tailored, needs-based care and clear communication were positively associated with enhanced quality of life and increased engagement in and continuity of care [57].

Where available, providers with specialized training and experience in refugee health described active, im/migrant-sensitive referrals and collaboration with settlement organizations as critical for facilitating patient engagement with SRH services. In Alberta, HCPs described tailored knowledge of refugee needs and culturally safe models of maternity care, highlighting the ways in which they endeavoured to address complex structural factors influencing im/migrant women’s health access (e.g., transportation, knowledge of available services, language issues [55]). Other HCPs reflected on their unfamiliarity with im/migrant health and expressed a desire for increased training in culturally safe and im/migrant-specific care [55].

Availability of Culturally Safe Care

Eleven studies identified disparities in culturally safe services as barriers to maternity care [26, 28, 54, 63, 65, 73], contraception [71, 72], sexual health screenings (cervical cancer [67], HIV/STI [69]), and GBV support [70]. Sociocultural differences in SRH norms between home countries and Canada, including gender expectations, sexuality, GBV, and mental health, had profound impacts on access to and engagement in SRH services [26, 66,67,68, 75]. Community stigma limited knowledge of available GBV support as related discussions were ‘taboo’ and avoided [56]. Anticipated stigma around mental illness in the context of pregnancy was also commonly described as a challenge related to accessing support [26, 74]. Some experienced negative interactions with physicians from the same culture due to fears of confidentiality violations or negative assumptions [66, 67], whereas seeing doctors of the same culture facilitated conversations around SRH for others [67]. A woman accessing cervical cancer screening in Ontario explained how her appearance led to preconceived assumptions: “I’m wearing hijab but maybe I am sexually active so they should not assume.” (p.8) [67].

Language Barriers and Availability of Language-Specific Care

Fourteen studies identified language barriers and disparities in language-specific services as barriers to maternity care(54,63,65), sexual health screenings (cervical cancer [37, 58, 66], HIV/STI [57, 69]), GBV support [70], and family planning [71].

Several studies described the availability of interpretation services as critical to address language barriers faced by different communities of im/migrant women, and highlighted challenges associated with different modalities (e.g., phone, in-person) [54, 55, 63, 69,70,71, 77, 78]. These included limited time and resources, potentially limited knowledge of medical terminology among interpreters, and concern of stigma or breaches in confidentiality by interpreters with shared cultural backgrounds or communities [63, 70, 71, 77, 78]. An HCP described time constraints: “When you’re in the delivery and there’s an acute situation, and you’ve got to do a vacuum or the obstetrics[…], sometimes there’s not time to go get the language line phone, and then be put on hold, having to have a back and forth conversation translated, back to do you understand what the risks are…” (p. 6) [55]. Although analyses of interpretation services in the context of HIV/STI care were limited, a Quebec study found that im/migrant women often brought members of their social network to appointments when translation services were unavailable; however, this sometimes led to confidentiality issues within smaller communities [69].

Conversely, some women felt that a wide range of SRH services expanded options for language-specific care and enhanced engagement. A Chinese woman in Ontario explained, “My OB didn’t provide me with much pregnancy related information. The nurse[…] can only speak English[…] I can get similar information from the community health centre.”(p. 5) [54]

Social Isolation and Support

Twelve studies identified social isolation as a barrier to maternity care [51, 52, 61, 62, 78], GBV support [56, 79], and sexual health screenings (HIV/STI [69]) attributed to disconnections from family, friends, and community due to migration [56]. Quantitative studies found that im/migrant women were less likely than their Canadian-born peers to have access to social support during pregnancy (74.1% vs. 90%) and postpartum (67.8% vs. 87.1%) [51]. Isolation among im/migrant women experiencing postpartum depression (PPD) also commonly limited health access [51, 52, 62, 78]. Qualitative studies found that social isolation enhanced im/migrant women’s vulnerability to GBV, and providers and advocates explained that immigration policies created significant challenges in reporting GBV for women who lacked social support. For example, in addition to written reports from police or medical services, immigration officials required women to be “settled” in Canada [79]. However, given challenges related to isolation and other factors, an immigration lawyer in Ontario explained, “They have to be these “super women”, so despite being abused, they have to have worked throughout the abuse,[…] established an extensive social network and community ties,[…] it's a little unrealistic.”(p. 338) [79]. On a positive note, few studies found that support from family members, friends, providers and community organizations mitigated language barriers and fear through accompaniment for appointments and emotional support, enhancing access to healthcare for some [52, 53, 58].

Immigration-Specific Factors

Thirteen studies identified pre-migration experiences, immigration status, and migration duration as determinants of access to maternity care [26, 62,63,64, 74, 80, 81], sexual health screenings (cervical cancer [37, 73, 82], HIV/STIs [69]), contraception [72], and GBV support [79].

Few studies highlighted differences in SRH access based on immigration status [64, 69, 73], where permanent residents had greater access to services and asylum seekers and undocumented women faced additional barriers [69]. A quantitative study found that compared to insured women, uninsured undocumented women had fewer routine screening tests (93.7% vs. 100%, p = 0.045) and presented later in pregnancy (25.6 vs. 12.0 weeks, p < 0.001) [64]. Asylum seekers and refugees have access to government programmes in Canada, whereas undocumented individuals are somewhat ‘invisible’ in the eyes of the government and healthcare system. Additionally, while some services for asylum seekers are covered by Canada’s Interim Federal Health Program (IFHP) there remain numerous disparities, including pre-approval required from Immigration, Refugees and Citizenship Canada (IRCC) to access some mental health services, impeding access to needed care upon arrival [62]. Qualitative studies found that fear of negative consequences related to having precarious immigration status (i.e. status marked by the absence of rights and entitlements normally associated with permanent residence and citizenship), such as deportation and family separation, prevented women from accessing SRH support [80]. An undocumented woman experiencing PPD explained, “I don’t have insurance. It’s been nine months that I have given birth[…] I need a pap smear but I just don’t have support. I don’t have papers[…] I don’t have the money[…]” (p. 719) [26]. HCPs echoed similar concerns, including high costs of services for those without health insurance [74].

Migration duration also influenced im/migrant women’s access to SRH care [37, 60, 72, 82] where some studies demonstrated improvements in SRH access over integration in Canada [60, 82], while others showed additional barriers for recently arrived im/migrant women. A BC study found that the odds of unmet health needs were highest for recent im/migrants(AOR 3.23, 95% CI 1.93–5.40) [long-term im/migrants (AOR 1.90, 95% CI 1.22–2.96)] [60], while others found that that recent im/migrants (< 10 years in Canada) were at higher risk for never having a Pap test (AOR 2.2) than long-term im/migrants (AOR 1.1) [37], and less likely to have had a Pap test in the past three years (PR 0.77, 95% CI 0.71–0.84) [82] compared to Canadian-born women.

Stigma, Discrimination and Racialization

Eight studies described how experiences of racism, xenophobia, and discrimination based on gender and religion limited im/migrant women’s access to maternity care [26, 61, 78], GBV support [56, 70], and HIV/STI services [60, 69].

A Quebec study with HCPs providing care for uninsured pregnant im/migrant women (N = 237) found that most believed they were “undeserving” of healthcare due to xenophobic and discriminatory perceptions of im/migrants, and an unwillingness to provide care for those with precarious status [77]. Negative interactions with HCPs reported across studies were often due to racial or religious prejudice and resulted in inadequate care, incomplete assessments and culturally unsafe approaches [58, 62, 66, 74, 75, 78]. In a study of asylum seekers, a participant explained, “Here they say that there is no discrimination, well this is the easiest way to be discriminated against, because you have no status. In all situations, you need to take out your papers and they see that you are not a tourist, nor are resident, you are nothing.” (p. 419) [69].

GBV survivors reported that racialization, stigma and shame from community, family members [56] and HCPs [66, 70] often delayed access to support. Narratives of HCPs in some studies reflected discriminatory, or ‘othering’ attitudes towards im/migrants from particular immigration classes or regions of origin: “mostly refugees, I think they come to Canada and [expect] everything to be given to them[…] some of them are very demanding[…] They are all quite easy except for the [ethnic group name]” (p. 10) [68]. One study found that HCPs perceived discrimination to be an instinctive response, as opposed to a structural issue [66], while others were more sensitive to racism and xenophobia faced by im/migrant women, and used approaches that were culturally safe and patient-centered [61].

Gender Inequities and Unequal Power Relations

Five qualitative studies showed that gender inequities undermined access to maternity care [83], sexual health screenings (HIV/STI [60, 69]), GBV support [56], and family planning [71]. Across studies, gender norms related to women’s status and social positioning strongly shaped access to and engagement in SRH care. Studies demonstrated that unequal gendered power dynamics increased unsafe sexual behaviours and exploitation, increasing barriers to SRH support. A Latin American woman needing HIV/STI care explained, “He told me[…] what I want is to sleep with you whether you want it or not, I told him no, […] he got so angry with me that he fired me.” (p. 420) [69].

Unequal gender roles and power dynamics especially hindered access to GBV support, resulting in silence and hidden abuse [56]. One study reported that financial dependence on abusive partners who had control over their immigration status posed additional healthcare barriers [60]. An HCP demonstrated the extent to which women covertly sought birth control: “the women are saying ‘please don’t tell my husband’ or they have come here on the sly[…] they are like, ‘quick, give me a Depo Provera injection and don’t tell him’” (p. 376) [71].

Discussion

This review sheds light on alarming inequities in SRH care for im/migrant women in Canada. Key findings demonstrated that structural challenges associated with health system navigation and knowledge of SRH services, experiences of racism and xenophobia within and outside the health system, and insufficient culturally safe and language-specific services posed the most significant barriers to healthcare. We found that while positive experiences with health personnel and social support facilitated SRH access for some women, social isolation, precarious immigration status, and discrimination and stigma by community members and HCPs presented severe challenges for others. Our study echoes prior research calling for attention to the impacts of immigration-specific factors (e.g., duration of migration, changes across migration, immigration status) on health access [42, 44], and provides unique insights on research gaps and findings regarding SRH access for im/migrant women.

Past reviews of im/migrant women’s SRH access have focused on specific sub-populations (e.g., refugees, internally displaced migrants) [40, 49, 84, 85] and services (e.g., maternal health, HIV/STIs) [20, 40, 42, 50, 84, 86,87,88]; our findings build on this work by providing a comprehensive overview of inequities and determinants of access to a broader range of SRH services (e.g., sexual health screenings, GBV) amongst im/migrant women in Canada. Consistent with gaps identified in previous literature, heterogeneous definitions of immigrants across studies limited comparisons and understandings of diverse SRH access experiences [42]. Amongst studies that focused on specific populations, most included sponsored refugees and asylum seekers, and few made comparisons between the experiences of diverse groups. However, evidence demonstrated severe SRH inequities based on immigration status where available, highlighting the need for future research unpacking the impacts of immigration status on SRH experiences [69].

Most studies were conducted in Ontario, and limited information was found from other key destination provinces (i.e., BC, Alberta, Quebec). Most studies focused on maternity care and cervical cancer screening, with a dearth of research on contraception services, GBV support, or other types of sexual health screenings. This presents a need for greater understandings of inequities faced by im/migrant women across the full spectrum of SRH services. Some studies included both im/migrant women and provider perspectives, highlighting several multi-level opportunities to address challenges and strengthen supports. For example, women’s preference to see women doctors to avoid potential re-traumatization of sexual violence [80] speaks to a critical need for trauma-informed care in health and settlement settings. Insights provided by immigration lawyers, legal advocates and HCPs demonstrate the impacts of macro-structural factors and the need to include other stakeholders (e.g., settlement workers, government officials) in research to address structural challenges in SRH care.

Qualitative and quantitative findings complemented one another and provided unique insights regarding inequities and determinants of SRH access for im/migrant women. Quantitative findings highlighted statistical descriptions of im/migrant women’s use and access to SRH care, which was explained by various determinants of SRH access highlighted by qualitative findings. However, most studies were cross-sectional, and research using longitudinal methods to understand women’s SRH access over time, across arrival and settlement, is needed.

Although most literature continues to focus on health service use and delivery environments, several studies that did identify macro-structural and immigration-specific determinants of SRH care highlighted the critical influence of immigration status on limited health insurance coverage and other barriers to SRH care. Policies that exacerbate barriers for women experiencing pre-migration trauma or PPD, for example, demonstrate structural inequities that ignore intersecting forms of marginalization based on gender, race, age, and poverty. Most studies did not focus on the roles of macro-structural factors such as stigma, ‘othering’ [43], and immigration policies or the nuances of how these may influence whether and how im/migrant women engage with SRH services [43, 45].

Research gaps identified by our review include a limited focus on SRH access experiences of younger women, undocumented women, and women who speak languages other than English. Although reproductive age is understood to begin at the age of 15, only two studies included women below the age of 20 [37, 51]. While only three studies included undocumented women, one excluded this population [79] and others did not specify explicit inclusion or exclusion of certain subgroups. A large number of studies excluded women who could not communicate in English [56, 61, 67, 70, 77, 80], presenting significant inequities as available evidence demonstrated severe language barriers.

Strengths and Limitations

To our knowledge, our findings are the first to highlight the heterogeneous experiences of different im/migrant women sub-groups across a wide spectrum of SRH care. Our review also uniquely builds on past work by highlighting the nuances of how immigration-specific factors, including how variations based on the duration and type of migration, interact with cross-cutting factors such as gender and socioeconomic status [3, 44, 89], to shape im/migrant women’s SRH access in Canada. However, limitations exist. The studies included may not have captured the many, diverse experiences of im/migrant women’s access to SRH care in Canada. Articles that examined the health access of both im/migrant men and women and that did not have a clear focus on SRH were excluded, thus potentially missing some information on im/migrant women’s SRH access.

Recommendations for Future Research

The findings of this review call for additional research in im/migrant women’s health to highlight the nuanced ways in which structural and intersectional experiences shape SRH access, particularly in the context of maternity care and cervical cancer screening. Future research must engage a broader diversity of im/migrant populations, including youth, undocumented women, and asylum seekers, whose experiences remain underrepresented; this is critical to generate comparable data to inform im/migrant-sensitive health services and system planning. Narratives from stakeholders also demonstrate value in consulting service providers, policymakers and community advocates to understand varied perspectives on im/migrant women’s health access. Certain parts of Canada (e.g., Ontario) were better represented in the literature, and there remains a need for additional research particularly in BC, Alberta, and Quebec. Finally, longitudinal and mixed-methods designs are recommended to examine changes in health experiences and access over time and triangulate epidemiological findings with lived experiences.

Conclusions

The findings of this review highlighted important issues in SRH services faced by racialized im/migrant women in Canada across different types of SRH care, and pointed to key roles of macro-structural, immigration-specific factors, health service use and delivery, and individual-level factors in shaping inequities. Our analysis helps draws on both quantitative and lived experiences of im/migrant women, and points to the need for different types of interventions. Findings provide a comprehensive overview of challenges and supports faced by im/migrant women accessing SRH care in Canada; future research that compares and includes experiences of different im/migrant groups, addresses a wider spectrum of SRH services, and includes marginalized sub-groups is needed. This is essential to expand existing understandings of the diverse and shared needs and realities of im/migrant women to develop responsive, equity-oriented policies and interventions.