Access to ANC

Globally, it is estimated that 82% of delivering women at least attend one ANC visit during pregnancy . The World Health Organization (WHO) recommends four visits during pregnancy as a minimum ; however, in most high-income countries, more visits are provided as the standard. Despite universal access to health care in most industrialized Western countries, the general trend is that non-Western migrant women are less likely to initiate ANC timely, and totally they have fewer visits during pregnancy compared with non-migrant women . In a systematic review, it was found that barriers for ANC attendance among non-Western migrant women most frequently were lack of knowledge regarding Western health systems and poor language proficiencies . Multiparity, unplanned pregnancy, perceiving ANC as unnecessary and socio-economic hardship were classified as individual barriers. At the health system level, the accessibility was challenged by incompatible opening hours, transport issues, lack of cultural sensitive health-care providers, indirect discrimination and the feeling of being treated badly by the health-care provider . For undocumented migrants, lack of entitlements and insurance coverage are barriers for access to health care . A study from the US shows that undocumented migrant women, who had obtained an identification document by being involved in an integration project, had similar utilization levels as documented migrants, indicating that health-care access can be mitigated by integration policy .

Quality of ANC

Studies in general indicate inadequate quality of care for migrant women during the perinatal period , for example, lower rate of interventions during childbirth and less assessment of maternal mental well-being after childbirth among migrant women . Audits of perinatal deaths in Norway and Sweden have shown that suboptimal obstetrical care more often occurred to women of non-Western origin, and that this was a cause of increased risk of perinatal death . In Sweden, miscommunication and lack of implementation of clinical guidelines were identified as key parameters. In the Norwegian study, incoherent assessment and management of fetal growth restriction was reported. Further, the risk of maternal death has been found to be higher among migrant women than among non-migrants , and this disparity has also been linked to suboptimal care, indicating that some of these deaths were preventable and due to health system delays in general or due to inappropriate management of pre-eclampsia specifically .

In a literature review, Small et al. assessed the expectation to care from the migrant women’s perspectives, and they found that migrant women expect the same from maternity care as non-migrant women (safe, high quality, attentive and individualized care); however, migrant women’s expectations to care were less often fulfilled .

Insufficient use of interpreter services in health care for migrants and the importance of overcoming the language barriers by good-quality interpreter service are consistently reported . Challenges for implementing interpretation services are related to quality and accessibility of and trust in professional interpreters as well as lack of time in the care provision. It is documented that the linguistic barriers interact with cultural differences between migrants and health-care providers, and they challenge the interpersonal interaction . Lack of mutual understanding and trust between providers and migrant women are considered to result in delays in optimal facility-based maternal health care, expressed as women’s choice of late booking, non-adherence or inappropriate decision-making as well as provider frustration resulting from the inability to initiate optimal treatment . The challenges of interpreter services and cross-cultural communication potentially result in an increased risk of incorrect diagnosis, compromised quality of care and less satisfaction with care .

Health system responses

The response of health-care systems to the challenge of ensuring the health of migrants is under debate , and it is mainly characterized by principles . There is very little evidence on effective health system initiatives , and evidence on best practice for ensuring health care for pregnant and delivering migrant women is lacking. Currently, the most important steps at government level for improved access to health care for migrants are to ensure the entitlement of all groups to health care, including undocumented migrants. Further, the development of migrant health policies in order to operationalize the entitlements, to ensure responsiveness of the health system to the needs of migrants and finally to ensure good quality and comparative data collection on migrant health are highlighted . An overview of current migrant health policies in Europe shows that only 11 countries in the European Union (EU) have migrant health policies, and these address very different aspects of users or providers as well as specific health topics or migrants in general . At the health system level, the responsibility to accommodate the potential needs of migrants should be seen as a task for entire organizations as much as for individuals . Health systems could ensure diversity among health-care providers, and they actively aspire to involve migrant communities in user boards when planning and evaluating health-care delivery and health-promoting interventions . When it comes to the individual effort of health-care providers to overcome social and cultural barriers in care provision, training in cultural competencies in undergraduate studies (like universities in medical schools in US, Canada, UK, Sweden and the Netherlands) or at later stages as well as the use of cultural mediators seems promising . Complicating the matter of cultural sensitive health care is the risk of stereotyping and further marginalizing migrants. It has been found that too much attention to presumed cultural factors from the provider’s side can obscure the attention to the obstetric needs of the woman . Previously, training in cultural competencies was based on an understanding of homogeneous cultural groups; however, currently, ensuring that health-care providers are open and respectful towards diverging cultural perceptions of health and reflective about their own culture and implicit assumptions is central . Kleinman and Benson suggest a model for how providers could learn to make the patients’ understanding of what matters most to them regarding their health and treatment central to the care provision .

We have identified four intervention studies for improved reproductive health among migrants. A controlled non-randomized intervention study conducted group-based perinatal education for women of Turkish background in the Netherlands, and it was found that the women improved their knowledge and intentions for behaviours regarding smoking, infant care and psychosocial maternal health; however, no changes in practice were demonstrated . The study was well received by health-care providers as well as the ethnic minority women . In the US, Rasinski et al. indicated a positive effect of a targeted 2-year educational initiative for black women on the risk of sudden infant death syndrome (SIDS) in a pre- and post-design, as effect was seen on safe sleep locations . It was significantly more beneficial for the women to be guided by health professionals in how to put their newborn to sleep, as compared with observing the health professional doing it. A randomized controlled trial (RCT) from the US found that individually tailored counselling sessions (eight times, 35 min) in primary care for pregnant African-American women had better effect on eliminating risk behaviours regarding smoking, depression and intimate partner violence than routine group care . We conclude that the studies were diverging regarding quality, outcome, target group and context; however, they all indicated encouraging effects of educational health system interventions on migrants’ health behaviours.

Members of the ROAM research collaboration state that efforts should be made to increase women’s understanding of the care provision and to improve the communication as well as reduce the discrimination in the health system . They stress that the assessment of quality and effectiveness of current care for migrant women is hampered by the lack of measurement tools for international comparative studies. The Migrant Friendly Maternity Care Questionnaire (MFMCQ) involving scientific experts in identifying important topics and validated questions and migrant women in making it culturally appropriate has therefore been developed .

Access to ANC

Globally, it is estimated that 82% of delivering women at least attend one ANC visit during pregnancy . The World Health Organization (WHO) recommends four visits during pregnancy as a minimum ; however, in most high-income countries, more visits are provided as the standard. Despite universal access to health care in most industrialized Western countries, the general trend is that non-Western migrant women are less likely to initiate ANC timely, and totally they have fewer visits during pregnancy compared with non-migrant women . In a systematic review, it was found that barriers for ANC attendance among non-Western migrant women most frequently were lack of knowledge regarding Western health systems and poor language proficiencies . Multiparity, unplanned pregnancy, perceiving ANC as unnecessary and socio-economic hardship were classified as individual barriers. At the health system level, the accessibility was challenged by incompatible opening hours, transport issues, lack of cultural sensitive health-care providers, indirect discrimination and the feeling of being treated badly by the health-care provider . For undocumented migrants, lack of entitlements and insurance coverage are barriers for access to health care . A study from the US shows that undocumented migrant women, who had obtained an identification document by being involved in an integration project, had similar utilization levels as documented migrants, indicating that health-care access can be mitigated by integration policy .

Quality of ANC

Studies in general indicate inadequate quality of care for migrant women during the perinatal period , for example, lower rate of interventions during childbirth and less assessment of maternal mental well-being after childbirth among migrant women . Audits of perinatal deaths in Norway and Sweden have shown that suboptimal obstetrical care more often occurred to women of non-Western origin, and that this was a cause of increased risk of perinatal death . In Sweden, miscommunication and lack of implementation of clinical guidelines were identified as key parameters. In the Norwegian study, incoherent assessment and management of fetal growth restriction was reported. Further, the risk of maternal death has been found to be higher among migrant women than among non-migrants , and this disparity has also been linked to suboptimal care, indicating that some of these deaths were preventable and due to health system delays in general or due to inappropriate management of pre-eclampsia specifically .

In a literature review, Small et al. assessed the expectation to care from the migrant women’s perspectives, and they found that migrant women expect the same from maternity care as non-migrant women (safe, high quality, attentive and individualized care); however, migrant women’s expectations to care were less often fulfilled .

Insufficient use of interpreter services in health care for migrants and the importance of overcoming the language barriers by good-quality interpreter service are consistently reported . Challenges for implementing interpretation services are related to quality and accessibility of and trust in professional interpreters as well as lack of time in the care provision. It is documented that the linguistic barriers interact with cultural differences between migrants and health-care providers, and they challenge the interpersonal interaction . Lack of mutual understanding and trust between providers and migrant women are considered to result in delays in optimal facility-based maternal health care, expressed as women’s choice of late booking, non-adherence or inappropriate decision-making as well as provider frustration resulting from the inability to initiate optimal treatment . The challenges of interpreter services and cross-cultural communication potentially result in an increased risk of incorrect diagnosis, compromised quality of care and less satisfaction with care .

Health system responses

The response of health-care systems to the challenge of ensuring the health of migrants is under debate , and it is mainly characterized by principles . There is very little evidence on effective health system initiatives , and evidence on best practice for ensuring health care for pregnant and delivering migrant women is lacking. Currently, the most important steps at government level for improved access to health care for migrants are to ensure the entitlement of all groups to health care, including undocumented migrants. Further, the development of migrant health policies in order to operationalize the entitlements, to ensure responsiveness of the health system to the needs of migrants and finally to ensure good quality and comparative data collection on migrant health are highlighted . An overview of current migrant health policies in Europe shows that only 11 countries in the European Union (EU) have migrant health policies, and these address very different aspects of users or providers as well as specific health topics or migrants in general . At the health system level, the responsibility to accommodate the potential needs of migrants should be seen as a task for entire organizations as much as for individuals . Health systems could ensure diversity among health-care providers, and they actively aspire to involve migrant communities in user boards when planning and evaluating health-care delivery and health-promoting interventions . When it comes to the individual effort of health-care providers to overcome social and cultural barriers in care provision, training in cultural competencies in undergraduate studies (like universities in medical schools in US, Canada, UK, Sweden and the Netherlands) or at later stages as well as the use of cultural mediators seems promising . Complicating the matter of cultural sensitive health care is the risk of stereotyping and further marginalizing migrants. It has been found that too much attention to presumed cultural factors from the provider’s side can obscure the attention to the obstetric needs of the woman . Previously, training in cultural competencies was based on an understanding of homogeneous cultural groups; however, currently, ensuring that health-care providers are open and respectful towards diverging cultural perceptions of health and reflective about their own culture and implicit assumptions is central . Kleinman and Benson suggest a model for how providers could learn to make the patients’ understanding of what matters most to them regarding their health and treatment central to the care provision .

We have identified four intervention studies for improved reproductive health among migrants. A controlled non-randomized intervention study conducted group-based perinatal education for women of Turkish background in the Netherlands, and it was found that the women improved their knowledge and intentions for behaviours regarding smoking, infant care and psychosocial maternal health; however, no changes in practice were demonstrated . The study was well received by health-care providers as well as the ethnic minority women . In the US, Rasinski et al. indicated a positive effect of a targeted 2-year educational initiative for black women on the risk of sudden infant death syndrome (SIDS) in a pre- and post-design, as effect was seen on safe sleep locations . It was significantly more beneficial for the women to be guided by health professionals in how to put their newborn to sleep, as compared with observing the health professional doing it. A randomized controlled trial (RCT) from the US found that individually tailored counselling sessions (eight times, 35 min) in primary care for pregnant African-American women had better effect on eliminating risk behaviours regarding smoking, depression and intimate partner violence than routine group care . We conclude that the studies were diverging regarding quality, outcome, target group and context; however, they all indicated encouraging effects of educational health system interventions on migrants’ health behaviours.

Members of the ROAM research collaboration state that efforts should be made to increase women’s understanding of the care provision and to improve the communication as well as reduce the discrimination in the health system . They stress that the assessment of quality and effectiveness of current care for migrant women is hampered by the lack of measurement tools for international comparative studies. The Migrant Friendly Maternity Care Questionnaire (MFMCQ) involving scientific experts in identifying important topics and validated questions and migrant women in making it culturally appropriate has therefore been developed .

The needs assessment

Interventions have to build up from a clear specification of the problems and identification of the target population . Explorative and detailed approaches to singling out problems and target groups are recommended as previously hidden aspects might emerge and the ideal approach to the problem can be selected . We started out by getting an overview of research in the field, and then we initiated a thorough mixed-method needs assessment in order to fill the gaps in current knowledge regarding possible mechanisms behind the poor reproductive health, but also to gain contextual understanding of the care provision for pregnant migrant women in Denmark.

A series of epidemiological studies were conducted to better understand the reproductive health patterns among migrant women in Denmark. We found that non-Western migrant women used ANC less than women of Danish origin ; however, no differences were seen between descendants of migrants and women of Danish origin. Suboptimal breastfeeding was more frequent among non-Western migrant women and their descendants than among women of Danish origin. There was no evidence for ethnic differences in the frequency of breastfeeding support provided at the hospital level . Further, using an indirect approach analysing diseases with autosomal recessive inheritance, we found that consanguinity most likely accounts for some, however, a minor part, of the ethnic disparity in child mortality .

A case-series study was initiated to analyse the characteristics of perinatal deaths at the largest maternity ward in Denmark in 2006–2010 according to the maternal country of origin . This study included 125 perinatal deaths. The data indicated that intra-partum death could be more frequent in the non-Western group, and that death caused by maternal disease (pre-eclampsia), lethal malformation and preterm birth may be more frequent than among offspring of Danish-born women. There seemed to be a delayed response in getting the appropriate care when experiencing warning signs like bleeding, lack of fetal movements or symptoms of pre-eclampsia, maybe due to late response of the women, maybe due to delays in communication and negotiation of access to the right care at the facility level.

We included all public-financed maternity wards in a telephone survey to assess the organization of the midwife-based ANC for migrant women in Denmark . After the identification of clinics providing migrant-targeted ANC, structured interviews with the midwives responsible for the targeted care were conducted. Six of 24 maternity wards were providing some kind of migrant-targeted ANC, which implied longer consultations and increased attention to the individual needs of the women. The care was described as emphasizing navigation in the health-care system, supporting body awareness, and using interpreters. Arguments for not providing targeted care were that migrant women had nothing more in common than non-migrant pregnant, and that targeted care was stigmatizing. With migrant-targeted ANC, the identification of women to target was a critical issue, including a risk of stigmatizing. With universal care, there was a risk of neglecting the disadvantages pregnant migrant women may experience regarding communication beyond the dominant cultural health perceptions.

We conducted a qualitative study on the perception of migrant women regarding pregnancy and childbirth and their experiences with the Danish ANC to ensure that the intervention would be based on the target groups’ own needs and priorities. We conducted 10 semi-structured interviews with Danish , Somali , Lebanese and Pakistani born mothers, who had given birth in Denmark recently. Women were recruited through visiting nurses, mothers groups and snow balling. All interviews were in Danish; however, a Somali interpreter participated and translated a few difficult parts in three of the interviews. All interviews were recorded, transcribed and analysed thematically. Social isolation, gender issues and being ethnic minority were important contextual issues. In general, the women described their ANC services in positive terms; however, the midwife-based ANC was evaluated as rushed and merely a physiological check rather than a needs-based dialogue with attention to the matters important to the women.

Further, to include the perceptions of health professionals and to gain insight into the context of ANC provision, we conducted semi-structured qualitative interviews with GPs and a visiting nurse, and we observed ANC visits at midwives , the first ANC visit at GPs , home visits with a visiting nurse and a mothers group, all located in areas with high density of migrant residents. We learnt that the provision of ANC is occurring under a tight schedule, and the demands for registration lead to standardization of the communication especially between the midwives and the women, and directs focus towards healthy behaviours like nutritional supplements and physical activity. It seemed that the standardized communication did not promote active engagement of the women. A high number of consecutive consultations with no breaks scheduled, but 30-min break for lunch and telephone consultations, caused frustrations amongst the midwives. It was explained as a choice between being attentive to the woman in the consultation and then delayed and having to work beyond the paid hours or keeping the time not giving time to the needs-based communication. Communication on warning signs of pregnancy and how to navigate in the health system was inconsistent and not a high priority. The procedure of screening for glucose and proteins in the urine was organized so that women had to conduct this individually before the consultations, and the manual in the toilets was in Danish only. The women often forgot to stix the urine before the consultation and in those cases the midwives instructed the women to do so after and to interrupt the next consultation if there were any questions or abnormalities. There was a limited use of professional interpreters at both the midwife and the GP, and also family members were used. If interpreters were attending a midwife consultation, no extra time followed.

The selection of project outcomes

The findings of the needs assessment were summed up, and the potential mechanisms behind the increased risk of poor reproductive outcomes among migrant women were mapped. We included socio-economic, demographic, cultural and obstetric factors as well as perspectives related to health care, health behaviours and health status. It was clear that the mechanisms behind the ethnic disparity in reproductive health were multiple and complex, and it was only possible to address a small part in the intervention study. Our attention shifted from attention to determinants to attention to what needed to change in order to prevent the health problem . We narrowed down the explorative needs assessment to a specific intervention by considering the overall pattern and clustering, strength and changeability of the different determinants of stillbirth and infant mortality. Both the strength and changeability of determinants were analysed according to epidemiological research, theoretical perspectives of the interaction between health-care providers and users, and the contextual data from the needs assessment.

From the needs assessment, we saw that there was a range of aspects related to the organization and communication in the midwife-based ANC, which potentially hindered active engagement of women during consultations and attention to the individual needs and diversity of women, warning signs of pregnancy as well as how to navigate in the health system. We assumed that the current organization and communication resulted in delays in appropriate care when pregnancy complications occurred, and finally this could lead to an increased risk of poor reproductive outcomes among migrants. This emerging pattern could be supported by the above-mentioned research in migrant reproductive health, especially the aspects of mutual broken trust between user and provider and suboptimal maternity care . The ability to respond to body signals and take appropriate health decisions has similarities with the term ‘health literacy’ . Cultural health capital (CHC) is a Bourdieu-inspired elaboration of health literacy, where attention is given to how broad social inequalities operate in patient–provider interactions, and shape the content and tone of health-care encounters . Thus, also from a theoretical perspective, it seemed relevant to improve the interaction between migrant women and health-care providers in order to diminish the disparity between migrant and non-migrant women in pregnancy and delivery outcomes. Finally, the incipient experiences of positive effects of educational health system interventions directed us towards addressing when to react and where to go in a facility-based approach. Thus, we chose to work the project objective of improving the management of pregnancy complications through timely and appropriate response to warning signs of pregnancy.

The development of the programme theory

With this project objective, the research group drafted the initial thoughts of potential activities for how to achieve this, including both an individual level (migrant women) and societal level (health system). The study was to be implemented at the largest maternity ward in Denmark, where 22% of delivering women were first- or second-generation migrants. We organized a project group with the leading ANC midwives in order to assure contextual relevance, ownership and intervention fit. Thereafter, we met regularly with the project group to discuss and adjust project development.

How the study activities (input) were expected to lead to the project outcomes were drafted as a programme theory , which is shown in Fig. 2 . We used an educational approach where the midwives were the frontline workers, who should drive the change at the facility level in order to create change amongst the pregnant migrant women. Although the study was designed to address the needs of migrant women, it was decided to include all women no matter the origin, because we considered it beneficial for all.

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