Transnationalism and care of migrant families during pregnancy, postpartum and early-childhood: an integrative review

Background Migrant families’ transnational ties (i.e., connections to their countries of origin) may contribute to their hardships and/or may be a source of resiliency. A care approach that addresses these transnational ties may foster a positive identity and give coherence to experiences. We conducted an integrative review to determine what is known about transnational ties and the care of migrant families during pregnancy, postpartum and early childhood. Methods We searched 15 databases to identify literature reporting on a health or social program, service, or care experience of migrant families during pregnancy up to age five in a Western country (i.e., Canada, US, Australia, New Zealand or a European country). Information regarding if and how the service/program/care considered transnational ties, and care-providers’ perceptions of transnational ties, was extracted, analyzed and synthesized according to transnational ‘ways of belonging’ and ‘ways of being’. Results Over 34,000 records were screened; 69 articles were included. Care, programs and services examined included prenatal interventions (a mhealth app, courses, videos, and specialized antenatal care), doula support, maternity care, support groups, primary healthcare and psycho-social early intervention and early childhood programs. The results show that transnational ties in terms of ‘ways of belonging’ (cultural, religious and linguistic identity) are acknowledged and addressed in care, although important gaps remain. Regarding ‘ways of being’, including emotional, social, and economic ties with children and other family members, receipt of advice and support from family, and use of health services abroad, there is very little evidence that these are acknowledged and addressed by care-providers. Perceptions of ‘ways of belonging’ appear to be mixed, with some care-providers being open to and willing to adapt care to accommodate religious, cultural and linguistic differences, while others are not. How care-providers perceive the social, emotional and economic ties and/or the use of services back home, remains relatively unknown. Conclusion Significant knowledge gaps remain regarding care-providers’ perceptions of transnational ‘ways of being’ and whether and how they take them into account, which may affect their relationships with migrant families and/or the effectiveness of their interventions. Continued efforts are needed to ensure care is culturally safe for migrants.


Background
Having and raising children can be challenging, particularly during resettlement in a new country [1]. Migrant parents (e.g., immigrants, refugees) may struggle financially and encounter difficulties managing cultural differences related to childbearing and parenting, for example different approaches for disciplining and socializing children. Many families must also adjust to shifting family relationships associated with changes in the family structure and gender dynamics [2][3][4][5] and cope with the loss of social networks, discrimination and navigating new health and social systems [2,3,[6][7][8][9][10]. Migrant families stay connected to their countries of origin and their transnational ties may contribute to their hardships and/ or may be a source of strength and resiliency [1].
Transnational ties include 'ways of being' as well as 'ways of belonging' [11,12]. 'Ways of being' refers to the transnational practices and relations that are sustained (i.e., economic, social, emotional and/or civic relationships and involvement) with the home country whereas 'ways of belonging' refers to the maintenance of a transnational identity (i.e., religious, cultural/ethnic, linguistic, and/or political) [11,12]. Transnational 'ways of being' and 'ways of belonging' can influence the childbearing and parenthood experiences in a new country in a multitude of ways. Many migrant families continue to support family via sending remittances and this may affect them financially [2,[13][14][15][16]. A number of families also parent children and care for elderly family members from a distance and this too may cause financial strain as well as psychological distress [3,15,[17][18][19]. Staying connected to family and friends back home may enhance feelings of isolation and loneliness and hinder cultural adaptation, while use of health services back home may have an effect on continuity of care [20][21][22]. Conversely, transnational ties can serve as a resource for migrant families. Connecting and visiting the home country can help maintain language and to pass on traditions to children and serve as a source of support for parenting [15,16,[23][24][25][26]. Bilingualism may contribute to social and economic capital; maintaining culture can promote family closeness and well-being and help resist oppression [5,7,24,27]. Migrants may rely on advice from family members for staying healthy during pregnancy and postpartum, for parenting (e.g., nutrition, discipline, socialization) and for resolving family conflicts [24,25]. Family and friends back home may also provide emotional support and childcare either for children who remained behind, or for infants/children who are sent to the home country temporarily [15,16,[28][29][30][31]. Health services may also be accessed for reasons of cost or cultural acceptability, and work/business activities may be an additional source of income [21,[32][33][34]. Continued engagement civically and politically may also function as a coping strategy to deal with cultural and social losses associated with migration [7,30].
In the health field there is a growing interest in transnationalism and its relevance to health and care [35,36]. In mental health it has also been shown that an approach in care that acknowledges and addresses transnational ties may foster a positive identity and give meaning and coherence to migrant families' experiences [37,38]. The early years (0-5 years) is a time when migrant families may first come into contact with health and social services, especially around the time when a child is born. It's also an opportune moment for intervention, since pregnancy and early childhood are crucial periods for child development and it is also when parents may feel overwhelmed. During this period families may interact with a range of care-providers (e.g., nurses, doctors, social-workers, educators) in various settings such as hospitals, clinics/health centers, early childhood programs and community organizations. Some may be involved in specialized programs which aim specifically to support more vulnerable families, particularly in the context of adapting to a new culture and language [31]. General care as well as specialized programs may offer services to enhance parenting skills, foster child development, promote a healthy lifestyle, and provide social connection for families experiencing isolation [31,[39][40][41][42]. In this literature review, we sought to determine what is known regarding transnational ties and the health and social care of migrant parents/families during pregnancy, postpartum and early childhood in Western, high-income countries. The following research questions were addressed: 1-Do health and social services aimed towards promoting health and providing support to parents/families during pregnancy, postpartum and early childhood (0-5 years) consider the transnational contexts and experiences of migrants? 2-How do careproviders address transnational ties in their care and interventions with migrant families during pregnancy, postpartum and early-childhood? and 3-What are these care-providers' perspectives on migrant families' transnational ties to their home country?

Methods
We conducted an integrative review [43]. This type of review allows for the inclusion of diverse literature (research and discussion papers). We searched broadly to identify papers that described either the care-giving experiences of health or social care professionals or the care-receiving experiences of migrant families during pregnancy, postpartum or early childhood in Western countries. We also included papers that generally described or reported on the development or evaluation of a health or social program/intervention, or service for migrant families during pregnancy up to age five. All papers were then assessed to determine if there is any evidence that health and social services supporting migrant families during pregnancy, postpartum and early childhood consider and address transnational ties, including 'ways of being' and 'ways of belonging', during care with these families. We also assessed to see what information exists on care-providers' perspectives of transnational ties.

Search strategy
Searches were conducted by VS and NLH in 15 online databases: EMBASE, Web of Science, Medline, PubMed, PsycINFO, CINAHL, Scopus, Family Studies Abstracts, Global Health, Social Sciences Abstracts, Social Work Abstracts, Campbell Collaboration, Social Services Abstracts, Sociological Abstracts, and Dissertations and Thesis. The searches in CINAHL and EMBASE excluded Medline records. We selected the databases and developed the search strategy in consultation with a university librarian. Subject headings/descriptors and keywords were identified to capture key concepts including migration (e.g., immigrant, refugee, transient, asylum, resettlement), parenthood (e.g., mother, father, child-caregiver), early childhood (e.g., child, toddler, infant, pre-schooler, newborn, early childhood, child birth, pregnancy), and health/social services (e.g., health services, health care services, social services, counseling, mental health, social support). Terms were adjusted according to the vocabulary used in each database. The searches for parenthood, early childhood, migration, and health/social services were then combined using the AND Boolean operator. Keywords were searched within titles, abstracts, and keywords of articles. To ensure the literature obtained was relevant to the current migration and health and social care context, we limited the searches to the last 15 years (January 2004 to December 2018; from January to July 2019 we set-up alerts to notify us when potentially relevant literature was published after the initial searches were conducted). We also applied a language restriction (English and French) based on our language capacities. An example of a detailed database search strategy (Web of Science) is shown in Table 1.
In addition to the database searches we also handsearched the reference lists of included papers. The same time and language limitations were applied. Table 2 provides a summary of the inclusion and exclusion criteria. Peer-reviewed publications including research (qualitative, quantitative, or mixed methods) and discussion papers, were considered. We also considered dissertations, however if results were published in an article, we only kept the latter. Literature reviews, study protocols, commentaries and books were excluded.  Literature was included if it reported on a health or social program, intervention, or service, or if it described the care-giving experiences of health or social care professionals or if it examined the care-receiving experiences of families during pregnancy, postpartum or early childhood in Canada, the US, Australia, New Zealand or European countries. The care/service/program/intervention had to involve general health promotion activities; to keep the results manageable, literature focusing on care/services/programs/interventions that targeted only one aspect of health (e.g., breastfeeding, nutrition, dental care) were excluded. Papers must have included and examined or discussed migrant parents' (mothers, fathers, and extended family involved in parenting) care experiences and/or described or discussed implications for the care of migrant parents/child caregivers (i.e., if the focus was only on children's experiences or outcomes, the paper was excluded). Literature that examined care and services targeting families with parents or children who were ill or who had disabilities, or that focused on childhood without specifying child ages, or that did not report results for, or discuss pregnancy, postpartum or early childhood specifically, were excluded. "Migrant" was defined as anyone born outside of the country (including migrants without status); migration could have been for any reason (e.g., forced, economic) and could have been temporary or permanent [44]. If both migrants and non-migrants were included in a study or discussion paper, we retained the article only if migrant parents' experiences and/or implications for care of migrant parents/child-caregivers were reported and discussed separately from those of non-migrants. All citations were downloaded and managed using Mendeley Desktop software (version 1.19.4). VS and NLH conducted the screening of all titles and abstracts to select potentially eligible literature. Full papers were then retrieved and reviewed to confirm eligibility. If eligibility was uncertain, a decision was made via group discussion. LM reviewed and confirmed the final selection of the included literature.

Data extraction, analysis and synthesis
For all eligible literature, we extracted and entered data into an Excel database. Data extracted included basic descriptors: the year, language and type of publication (original research, discussion paper, dissertation); the location of the study/discussion (Canada, US, Australia, New Zealand and/or European countries), information about the type of service/program/intervention and/or care given/received, the objective of the paper, and if applicable, the research design, methods, and population studied (parents and/or care-providers). For studies that examined parents, we noted who was included (mothers and/or fathers), their migration status, countries/regions of origin, length of time in the country, and/or their ethnicity. To address the research questions, information regarding if and how the service/program/care/intervention addressed transnationalism (ways of being and/or ways of belonging), as well care-providers' perspectives on transnational ties, were also extracted. We also noted any general reference made to transnational ties in the article even if it was not in relation to the intervention/ service/program/care. LM, with the support of a research assistant, assessed the methodological quality of empirical studies (qualitative, quantitative and mixed methods) using the Mixed Methods Appraisal Tool (MMAT) [45]. The MMAT uses a checklist (Yes/No/ can't tell) format with five questions that vary depending on the type of research being assessed. For qualitative research, studies were appraised on the appropriateness of the methodology and data collection methods, the adequacy of the data and its interpretation and the coherence between the data collection, analyses and findings. Quantitative studies were evaluated on the appropriateness of the sampling, randomization (if relevant), measurement and analyses, and the risk for bias. Mixed methods studies were assessed for the suitability of using a mixed methods design for the research questions being addressed, the methodological quality of each component, and the appropriateness of the 'mixing' of the qualitative and quantitative aspects of the study. No studies were excluded based on the quality assessment. All information gathered from the literature was synthesized into summary tables and text.

Results
The database searches resulted in over 93,000 records (see Additional file 1 for the search results for each database). Once duplicates were removed and the initial screening was conducted, 318 records were considered for inclusion. Thirteen articles could not be located and 236 were excluded following reading of the full text. The main reasons for exclusion at this stage were: 1-the child ages were not specified and/or results or discussion points were reported for all child age groups together; 2migrant parents' maternity and parenthood experiences were described generally without any reference to health or social care experiences/interactions or implications for care; and 3-results and implications for migrants and non-migrants were not reported separately. Sixtynine articles were included in the review; The PRISMA flow diagram is presented in Fig. 1 and a summary of the included literature is reported in Table 3.
Almost all of the papers were published in English, only two were published in French [22,69] and just over 40% (n = 28) were published within the last 5 years (2015-2019). Three papers were discussion papers [57,76,99], while the remaining were studies, mostly qualitative research (n = 57); five of these were dissertations [52,80,82,95,105]. Sixteen papers were discussions or studies conducted in the United States, while 13 papers were focused in Australia, followed by 11 in Canada. Papers from Europe reflected a range of countries, including Sweden (5 papers), Finland and the UK (4 papers respectively), and Germany and Ireland (3 papers respectively). (see Table 4).
Eleven papers focused on a specific maternity service or intervention (see Tables 3 and 4). Ten of these were directed towards migrant mothers including doula support [46,47], a mobile health application to enhance pregnancy well-being for women from the Caribbean (by providing health information and social support) [48,49], a nurse-practitioner led prenatal program for migrant farm-workers [57], a support group to enhance prenatal and postnatal education [41], a prenatal training course [75], a community-based antenatal service [86], a group pregnancy care initiative for Karen women from Burma [92] and a specialized antenatal clinic for refugee women [100]. One paper examined a culturally tailored prenatal health education video series that was developed for both mothers and fathers from Somalia [68].
Sixteen papers (23% of the literature) focused on care, an intervention or a program during early-childhood (see Tables 3 and 4). These included: studies that examined migrant mothers' general experiences of accessing primary healthcare [52,62,79] or early-childhood programs [105] for their children; one study that explored nurses' experiences in providing primary healthcare to            [108]; papers that reported on parents and care-providers' perspectives of peer support group interventions meant to enhance parenting skills, promote child development and reduce isolation among immigrant mothers [22] and refugee mothers/parents [80,[101][102][103]; and literature that described and/or evaluated specialized earlyeducation programs for migrant and refugee families, or that investigated the experiences of educators in providing these services [60,73,76,90,98,99].
The five remaining papers examined care or programs that spanned the periods of maternity and early-childhood (see Tables 3 and 4). These included: three that examined asylum seeker and refugee mothers' experiences accessing various health and social services during pregnancy and early motherhood [81,91,110]; two of these [91,110] also considered the perspectives of healthcare professionals, and one also included the experiences of fathers [110]; one article that inquired on mothers' experiences at a community based perinatal health and social centre which provides medical and psychosocial care to families living in vulnerable contexts from pregnancy up to age five [31]; and another paper that explored the experiences of community workers who provide care and support to refugee and asylum seeker mothers in the perinatal and post-birth periods [54].
The research literature (n = 66 studies) primarily reflects parents' views and experiences with care, services and/or programs/interventions; 80% of studies included parents and 42% included care-providers (see Table 4). Parents' perspectives are mainly those of mothers' (n = 52 studies); ten studies included fathers [68, 79, 85, 98, 101-103, 105, 109, 110]. The migrant populations studied were mostly from non-western countries; more than Interviews and focus groups a For qualitative research in cases where the methodology was not explicitly named or it was unclear, we applied a label based on the description provided. General 'qualitative' exploratory studies were categorized as 'qualitative descriptive' b The description of migrants is based on what was provided in the paper (country of origin, length of time (LOT*) in country, immigration status, and/or ethnicity); Often 'immigrant' is used to generally refer to anyone foreign-born without specifying which immigration statuses are included half of the studies (57%) included migrant parents from Sub-Saharan Africa. South Asia, North Africa/Middle East and Latin America were represented in 43, 42 and 32% of the research respectively (see Table 4). The most common source countries were Somalia (n = 11), Sudan (n = 11), Afghanistan (n = 10), India (n = 9) and Iraq (n = 8), and refugees were represented in over half of the studies (55%) (see Table 4).
Regarding the quality of the research, for the qualitative studies, generally it was good-responses to the quality criteria were positive for all of the MMAT items across all papers. The majority of these studies were 'qualitative descriptive' (n = 37), which was an appropriate approach given most of the studies sought to explore or describe experiences of receiving or providing care. Grounded theory was the methodology used in three studies [67,69,78], however 'theories' were not generated, raising some question about the validity of using this approach. However, overall the findings across the research were well substantiated by the data and most papers provided in-depth interpretations and discussions of the results.
For the two quantitative studies, one was a small, primarily descriptive, pilot project [68]. The sample of parent participants in this study was relatively small, and based on convenience sampling, but did represent approximately 30% of the target population, which were Somali clients who were receiving care in the obstetrics department where the study was conducted. Details on the number of care-provider participants were not provided. The measurements and analyses were appropriate for the research objectives. The second study, a randomized control trial, only reported preliminary descriptive data about the participants and their participation in the intervention [90]. The methods, nonetheless, were well described, randomization was appropriate, and differences between intervention groups at baseline were explained; one important limitation was that measurement tools were not translated to migrants' languages which may affect the validity of the eventual outcomes of the research.
For the mixed-methods studies, one study provided inadequate details on the methods and was therefore deemed poor quality [75]; the other six were all good quality-there was a clear rationale for using mixedmethods, and the qualitative and quantitative components were sufficiently described and 'mixed' [60,88,97,[100][101][102]. Two strengths across the research, irrespective of the design, were: 1-the inclusion of minority language migrants as participants; of the 53 studies with migrant parents, 36 accommodated those speaking a language other than the host-country language; and 2-the migrant populations were generally well-described using key indicators (i.e., country of origin, length of time, and migration status). Asylum-seeker 20.8% (11) Undocumented (non-status migrants) 17.0% (9) a Includes Austria, Belgium, Finland, France, Germany, Greece, Ireland, Italy, Netherlands, Norway, Portugal, Spain, Sweden and the United Kingdom b One study also included grandparents and other members of their community c A study may be counted in more than one category so percentages do not add to 100% d Immigrant was often used as a general term to describe the foreignborn population and so may have included migrants with other statuses (i.e., other than economic immigrants)

Transnationalism and care
Across the literature, it was evident that many migrant families value their 'ways of belonging' and wish to maintain a transnational identity, especially for their children [21, 31, 49, 67, 69-72, 85, 86, 89, 93-100, 102, 103, 105, 109]. A number of papers also showed that cultural, religious and linguistic ties are often acknowledged and addressed in health and social care. Cultural and religious ways of belonging were attended to in various ways. These included: the use of community-based doulas, mostly other mothers from the same communities, who acted as "cultural bridges" and provided information on different cultural birthing customs [47]; hiring of a cleric to conduct religious traditions and prayers in the hospital [21]; the involvement of peers in support/community groups and programs towards enhancing social support and healthy behaviors through the sharing of knowledge [41,70,80,[90][91][92]101]; the creation and use of culturally-adapted materials including a prenatal training course [75], a psycho-education program [99], a specialized antenatal clinic [100], perinatal health education videos [68], and a mhealth application developed to support a healthy pregnancy and to connect women to services and other women in their ethnic community [48,49]; and the adaptation or tailoring of care to respond to different cultural and religious needs and expectations, for example having a female care-provider, asking about food preferences and providing culturally appropriate recommendations on prenatal nutrition, baby care, and parenting [41, 53, 54, 58, 61, 65, 78, 79, 84, 86, 92-95, 97, 98, 103, 106-108, 110].
Language was also addressed in care using different approaches. This was mostly done by accommodating migrants through the use of interpreters, inter-bicultural/lingual health workers or liaisons and translated materials [41, 46, 47, 49, 53-55, 58, 61, 65, 73, 76-78, 84, 86, 90-92, 94, 96, 98, 100, 103-108, 110]. Referring women to community supports where care providers speak migrants' language, was also used to ensure linguistically adapted care [108]. When language could not be accommodated, some care-providers used smiling and having a kind demeanor as a means to make women feel accepted and to show compassion and empathy, regardless of language barriers [59,104]. Some careproviders made an effort to learn a few words of the migrants' language to create connection and make women feel more comfortable [53]. Speaking more slowly, adjusting their words and using miming or non-verbal expression was also used when language was a challenge [77-79, 86, 91, 106, 107]. In three papers, care-providers actively encouraged families to speak their native language and to pass it on to their children [31,101,105]; in one of these, maintaining culture was also promoted [2]. And lastly, accessing care from care-providers who were from the same ethnic community was also a way for migrants to feel respected and understood in their culturally and linguistically 'ways of belonging' [52,62,74,96].
Other forms of transnational ties (i.e., 'ways of being') were mentioned in fewer papers. This included references to families worrying about relatives, including children who remained in the home country [54,55,59,60,67,86,105] and families staying connected via phone/ communication technologies and/or visits as a source of social and emotional support, to maintain cultural identity, and/or for assistance with childcare [21,22,31,48,49,67,69,85,90,95,96,102,105]. It also included families sending money back home [105], women seeking healthcare in their country to give birth [21], and families using transnational networks to obtain advice and health information-partly due to local care not being adapted [21,49,88,94,96,105].
Overall, there was very little evidence showing that care-providers consider and address 'ways of being' in their interventions or care. Some literature showed that care-providers were aware that family separation was causing distress and/or the papers concluded that this issue should be addressed in care [54,60,86,110]. In Yelland (2014), two-thirds of women reported being asked by a doctor, midwife or maternal and child health nurse about their family members in Australia and back home; one participant expressed that she would have liked to have been asked about her parents [110]. In Rickmeyer et al. (2015), care for a refugee woman participating in an early-childhood program included discussing the relationships that a woman maintained with her family back home (a source of support for her). This intervention was comforting for the woman and also enhanced the rapport with the care-provider who was then able to support the woman to work through her trauma [90]. Another paper mentioned that midwives thought that women may be having children in order to receive more governmental family allowance with the intention to use the money to financially support family members back home, although there was no indication on whether this was discussed or addressed with families [77]. In two other papers (by the same authors), the role of family back home as a source of emotional and social support during pregnancy was recognized and incorporated into a mhealth intervention; the application provided a forum for sharing information and could also be used to involve family members in prenatal care visits via conference calls [48,49].
No studies explicitly examined care-providers' perceptions of transnational ties, however a number of studies suggest that there is a mix of views, including some healthcare professionals having a positive attitude towards different ways of belonging, including a tolerance and/or openness to different cultures, religions and/or identities [53,58,66,78,84,95,104,106,107,110], and others having the view that migrants should fully assimilate and conform to the healthcare system of the new country, such as learning the country's language and not having issue with male care-providers [53,58,65,66,78,84,104]. In some instances, healthcare professionals reported feeling left-out when providing care across languages [47,58]. On the other hand, some migrants felt that their care-providers did not care about them [70] while others reported experiencing stereotyping and discrimination [55,66,82,102,106,107,109]. Careproviders also reported witnessing migrants being treated differently due to their cultural, religious and linguistic differences [87,88,104].
Regarding migrants' transnational 'ways of being', it remains unknown what care-providers think-none of the literature revealed how care-providers perceive the connections that migrants maintain with their home country, including social, emotional and economic ties and/ or the use of health or other services abroad. However, there is some suggestion that some care-providers are concerned about, and empathize with migrant families that are distressed and worried about their loved ones who have remained in the home country [60]. In this paper, educators working with refugees reported that they found it distressing to hear what families were dealing with and they felt that more support should be provided in this regard. Conversely, there is also a suggestion that some healthcare providers are unsympathetic to migrants' connections to the home country and/or feel that it is not within their scope of practice to inquire about them [69,88].

Discussion
The results of the review show that transnational ties in terms of 'ways of belonging' are acknowledged and addressed in care provided to migrant families during pregnancy, postpartum and early childhood, although important gaps remain. There is little evidence however, that transnational ties, in terms of 'ways of being', are acknowledged and addressed by care providers. Perceptions of 'ways of belonging' appear to be mixed, with some care-providers being open to and willing to adapt care to accommodate religious, cultural and linguistic differences, while others are not. How care-providers perceive the social, emotional and economic ties and/or the use of services abroad, remains relatively unknown.
Significant attention has been given to cultural competency and cultural safety as approaches to improve the quality of care and to reduce health inequities among migrants, as well as indigenous and other ethnic minority groups [111][112][113]. Cultural competency generally refers to a set of attitudes and practices towards creating health and social care environments where cultural, religious and linguistic ties are respected and accommodated [114]. Cultural safety involves acknowledging and addressing power differentials in clinical interactions and the broader system and structures that result from social, economic, political, and historical circumstances [112]. Results from the current review show that continued efforts are needed to ensure that pregnancy, postbirth and early childhood care and interventions are adapted and culturally safe for migrants (recommendations and some additional resources are reported in Table 5). Given that many migrant families value maintaining a transnational identity, especially for their children, care should also involve supporting migrants to practice their cultural and religious traditions and to speak their native languages. Although there is evidence that diversity is respected and accommodated, it does not appear to be promoted, and emphasis still tends to be on integration (i.e., addressing settlement issues and encouraging the learning of the host-country language and culture) [39-41, 115, 116]. Maintaining a transnational identity, however, is not counter to integration, both processes may occur simultaneously [12], and preserving cultural, religious and linguistic ties may provide an alternate source of belonging, contribute to social and economic capital and have health benefits for migrant families [5,7,24,27,94]. In turn, these positive outcomes may actually reinforce integration.
The review findings are consistent with other research that shows migrant families maintain emotional, social and economic ties with family, and also use health services and receive support from the home country [1]. There is a growing body of research that shows that these transnational ties can have both positive and negative impacts on migrants' lifestyle behaviours, disease management, social well-being, mental health and information and treatment seeking activities [20,29,[117][118][119][120][121]. Moreover, migrants have reported having to reconcile differences between advice received from family members back home and care-providers on health related matters in maternal or child care [105]. Evidently, if care-providers do not consider the transnational stresses (concern for family members, economic strain), sources of support and use of healthcare, they will lack a full understanding of migrants' everyday lives and of the potential impact that these ties may have on migrants' health. This may then affect care-providers' relationships with migrant families and/or the effectiveness of their health and social care interventions. Although the review did not shed much light on how exactly these forms of transnational ties should be addressed in care, it did show that inquiring about family members back home could be used to build rapport [90,110], and that technology could be used to foster the involvement and support of family living far away in maternity care [49]. Without evidence, it is premature to make specific recommendations for care, however, based on the findings, healthcare providers should at minimum, be cognizant of and inquire about migrants' transnational contexts that may affect their health and well-being (see Table 5).
Care-providers' views of migrants also have an impact on care. Othering and discrimination towards migrants in the healthcare system based on culture, language, race and religious differences are known issues and affect access to and quality of services [122][123][124]. These practices involve implicit biases as well as overt racism and discrimination where migrants are viewed differently and provided sub-optimal care, which are justified through explanations of culturalism and racialization [122]. Through culturalism and racialization migrants' are perceived as inherently inferior due to their worldviews, beliefs and race, and their health and care disparities are seen as being the result of their cultural and religious practices and genetics. In this process migrants are also categorized into differentiated groups and not viewed as individuals, thus further contributing to an 'us' vs. 'them' dichotomy. Having a 'foreign' status, especially being a refugee or not having a legal status, exacerbates this divisiveness and adds to the notion that migrants merit less. Recognizing these biases and harmful ideologies and actively countering racism and discrimination are therefore also key to supporting ways of belonging and creating a care environment that is safe (Table 5). Care-providers can combat racism and discrimination by first being aware of their prejudices and consciously altering their language and behaviours while interacting with migrants [122,125]. They may also sensitize and educate others by modelling behaviour, speaking openly about issues of racism and discrimination and condemning unjust treatment of migrants [122,125]. Cultural competency training should also be complemented with anti-racism training.
To further develop care approaches and foster a safe care environment, it would be informative to know what care professionals think about transnational 'ways of Table 5 Recommendations for practice and resources Inquire about family members, including children back home being'-whether they deem economic, social and emotional ties to the home countries as problematic-for example, as a hindrance to integration, or as a factor that contributes to social isolation; and/or whether they view them positively, for example as a source of support and/ or for maintaining cultural and linguistic identity. It would also be useful to know whether they consider these to be within their scope of care. While careproviders may be open to accommodating different cultures and languages, they may be less willing to consider and involve people abroad and/or to extend their care to concerns outside their borders.
The review highlighted research gaps. Future research is needed to determine if and how care providers acknowledge and address transnational 'ways of being' (social, emotional, economic ties and use of health services) in care during pregnancy, postpartum and early childhood. We also need research to learn about what careproviders think and feel regarding migrants' 'ways of being' and also to hear the perspectives of migrants on how they feel these transnational ties should (or should not) be addressed in care. The viewpoints of both mothers and fathers should be examined since these are likely gendered experiences [119,121], and since fathers overall are less represented in research on pregnancy, postpartum and early intervention care.

Limitations and strengths
The searches yielded a vast amount of records to sort through, therefore it is possible that some literature was missed. We only included papers that focused on health promotion generally and with healthy populations, papers that focused on treatments or one aspect of health promotion, and/or ill or disabled populations, may have included pertinent information regarding transnational ties and care. We also did not include grey literature which may have had relevant information as well. It is worthy to note that no papers specifically inquired about transnational ties and care, so the conclusions drawn in this review are based on the examination of study results that generally captured experiences of care and/or descriptions of interventions and programs. Given this indirect approach and the type of data extracted, it was not possible to draw definitive conclusions regarding the extent to which transnational ties are acknowledged and addressed in care or about the views of healthcare professionals on transnational ties. Despite these limitations, we used a thorough approach to identify, select and analyse papers and we synthesized a broad body of literature representing a range of migrant populations living in a number of different countries. We only used primary sources to ensure we could assess data directly, and we included studies that examined parents' experiences as well as those that examined care-providers' experiences.
As far as we are aware this is the first review to examine transnational ties and health and social care supporting migrant families during pregnancy, postpartum and early childhood.

Conclusion
To ensure migrants have equitable access to effective, quality care during pregnancy, postpartum and early childhood, further work is needed to raise the critical consciousness of care-providers and to create more culturally safe interventions and care environments. Future research is needed to know whether and how careproviders' take into account transnational 'ways of being', including relationships with children and other family members who remained in the home country, use of health services abroad, and receipt of advice and support from family back home, which may affect their relationships with migrant families and/or the effectiveness of their health and social care interventions. Research is also needed to know the perspectives of care-providers on migrant families' transnational 'ways of being'.