Rationale, development and feasibility of group antenatal care for immigrant women in Sweden: a study protocol for the Hooyo Project

Obstetric outcomes and uptake of care among 149 non-Swedish speaking migrant women attending a birth preparation visit during pregnancy - An observational study from Sweden

Introduction

In Sweden almost one third of the population is born in another country and a large number of the women who do not speak Swedish are of reproductive age. Women migrating from low-income countries have higher risks for poor obstetric outcomes than receiving country-born citizens. INFOR (a Swedish word for "before" or "ahead of") is an intervention offering language-assisted, individual birth preparation for non-Swedish speaking pregnant women unfamiliar with the maternity care system. The aim of this study was to describe the uptake of care and obstetric outcomes among non-Swedish speaking migrant women attending INFOR.

Methods

A descriptive study of the obstetric outcomes and uptake of care was conducted of the 149 non-Swedish speaking pregnant women who participated in INFOR between 2016 and 2020. The data were accessed retrospectively from the medical record system Obstetrix and the population-based Swedish Pregnancy Registry and analysed descriptively.

Results

Women participating in INFOR originated from 44 countries and spoke 35 different languages. During late pregnancy, 20 percent of the women sought care for decreased fetal movements and 80 percent of the women attended the postpartum visit. While the majority of the participants were offered professional language support during pregnancy, almost none had a professional interpreter present during labour and birth. After birth, 80 percent of the primiparous women were asked to rate their birth experience, but only half of the multiparous women were asked. Further, only half of the primiparous women attending the postpartum visit were asked about their self-rated health.

Conclusion

INFOR may increase uptake of some important aspects of care during pregnancy, birth and postpartum among migrants of diverse backgrounds. The findings raise concerns however about communication support for migrant women, especially during labour and birth. The offer of professional interpreting as part of standard maternity care for women who need it is essential and must be improved in order to provide equitable care for all.

Group antenatal care compared with standard antenatal care for Somali-Swedish women: a historically controlled evaluation of the Hooyo Project

OBJECTIVES

Comparing language-supported group antenatal care (gANC) and standard antenatal care (sANC) for Somali-born women in Sweden, measuring overall ratings of care and emotional well-being, and testing the feasibility of the outcome measures.

DESIGN

A quasi-experimental trial with one intervention and one historical control group, nested in an intervention development and feasibility study.

SETTING

Midwifery-led antenatal care clinic in a mid-sized Swedish town.

PARTICIPANTS

Pregnant Somali-born women (<25 gestational weeks); 64 women in gANC and 81 in sANC.

INTERVENTION

Language-supported gANC (2017-2019). Participants were offered seven 60-minute group sessions with other Somali-born women led by one to two midwives, in addition to 15-30 min individual appointments with their designated midwife.

OUTCOMES

Primary outcomes were women's overall ratings of antenatal care and emotional well-being (Edinburgh Postnatal Depression Scale (EPDS)) in gestational week ≥35 and 2 months post partum. Secondary outcomes were specific care experiences, information received, social support, knowledge of pregnancy danger signs and obstetric outcomes.

RESULTS

Recruitment and retention of participants were challenging. Of eligible women, 39.3% (n=106) declined to participate. No relevant differences regarding overall ratings of antenatal care between the groups were detected (late pregnancy OR 1.42, 95% CI 0.50 to 4.16 and 6-8 weeks post partum OR 2.71, 95% CI 0.88 to 9.41). The reduction in mean EPDS score was greater in the intervention group when adjusting for differences at baseline (mean difference -1.89; 95% CI -3.73 to -0.07). Women in gANC were happier with received pregnancy and birth information, for example, caesarean section where 94.9% (n=37) believed the information was sufficient compared with 17.5% (n=7) in standard care (p<0.001) in late pregnancy.

CONCLUSIONS

This evaluation suggests potential for language-supported gANC to improve knowledge acquisition among pregnant Somali-born women with residence in Sweden ˂10 years. An adequately powered randomised trial is needed to evaluate the effectiveness of the intervention.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov Registry (NCT03879200).

Group antenatal care (gANC) for Somali-speaking women in Sweden - a process evaluation

Background

Language supported group antenatal care (gANC) for Somali-born women was implemented in a Swedish public ANC clinic. The women were offered seven 60-min sessions, facilitated by midwives and starting with a presentation of a selected topic, with an additional 15-min individual appointment before or after. The aim of this study was to assess the feasibility for participants and midwives of implementing The Hooyo (“mother” in Somali) gANC intervention, including implementation, mechanisms of impact and contextual factors.

Methods

A process evaluation was performed, using The Medical Research Council (MRC) guidelines for evaluating complex interventions as a framework. A range of qualitative and quantitative data sources were used including observations (n = 9), complementary, in-depth and key-informant interviews (women n = 6, midwives n = 4, interpreters and research assistants n = 3) and questionnaire data (women n = 44; midwives n = 8).

Results

Language-supported gANC offered more comprehensive ANC that seemed to correspond to existing needs of the participants and could address knowledge gaps related to pregnancy, birth and the Swedish health care system. The majority of women thought listening to other pregnant women was valuable (91%), felt comfortable in the group (98%) and supported by the other women (79%), and they said that gANC suited them (79%). The intervention seemed to enhance knowledge and cultural understanding among midwives, thus contributing to more women-centred care. The intervention was not successful at involving partners in ANC.

Conclusions

The Hooyo gANC intervention was acceptable to the Somali women and to midwives, but did not lead to greater participation by fathers-to-be. The main mechanisms of impact were more comprehensive ANC and enhanced mutual cultural understanding. The position of women was strengthened in the groups, and the way in which the midwives expanded their understanding of the participants and their narratives was promising. To be feasible at a large scale, gANC might require further adaptations and the “othering” of women in risk groups should be avoided.

Trial registration

The study was registered in ClinicalTrials.gov (Identifier: NCT03879200).

Implementation, Mechanisms and Context of the MAMAACT Intervention to Reduce Ethnic and Social Disparity in Stillbirth and Infant Health

The MAMAACT intervention aimed to address ethnic and social disparity in stillbirth and infant health by improving management of pregnancy complications. This process evaluation of the intervention was guided by the British Medical Research Council’s framework. We examined implementation through dose, reach, and fidelity, important mechanisms and the influence of contextual factors. The intervention included a six-hour training session for antenatal care (ANC) midwives in intercultural communication and cultural competence, two follow-up dialogue meetings, and health education materials (leaflet and app) on warning signs of severe pregnancy complications and how to respond for pregnant women. A mixed-methods approach was applied. Cross-sectional survey data and administrative data were used to assess intervention reach and dose. Qualitative data (records from dialogue meetings with midwives, participant observations and field notes from ANC visits, focus group interviews with midwives, and individual interviews with non-Western immigrant women) evaluated intervention fidelity, mechanisms, and contextual barriers. More than 80% of women received the MAMAACT leaflet and many found the content useful. The app was used more selectively. Midwives described being more aware and reflective in their communication with women from various cultural backgrounds. Organizational factors in ANC (time pressure, lack of flexibility in visits, poor interpreter services), barriers in women’s everyday life (lack of social network, previous negative experiences/lack of trust and domestic responsibilities), and habitual interaction patterns among midwives served as contextual barriers. The reach of the intervention was high and it was evaluated positively by both pregnant women and midwives. Organizational factors hindered changes towards more needs-based communication in ANC potentially hindering the intended mechanisms of the intervention. When interpreting the intervention effects, attention should be drawn to both organizational and interpersonal factors in the clinic as well as the pregnant women’s life situations.

Pregnancy outcomes among women born in Somalia and Sweden giving birth in the Stockholm area - a population-based study

Background

Studies report that women born in some African countries, after migrating to the Nordic countries, have worse pregnancy outcomes than women born in the receiving countries. With the aim of identifying unmet needs among Somali-born women, we here study this subgroup.

Objective

We compared pregnancy outcomes among women born in Somalia to women born in Sweden. Further, we investigated whether the proactive maternal observation of fetal movements has effects on birth outcomes among women born in Somalia.

Methods

In Stockholm, half of the maternity clinics were randomized to intervention, in which midwives were instructed to be proactive towards women by promoting daily self-monitoring of fetal movements. Data for 623 women born in Somalia and 26 485 born in Sweden were collected from a population-based register.

Results

An Apgar score below 7 (with stillbirth counting as 0) at 5 minutes was more frequent in babies of women born in Somalia as compared to babies of women born in Sweden (RR 2.17, 95% CI 1.25–3.77). Babies born small for gestational age were more common among women born in Somalia (RR 2.22, CI 1.88–2.61), as were babies born after 41 + 6 gestational weeks (RR 1.65, CI 1.29–2.12). Somali-born women less often contacted obstetric care for decreased fetal movements than did Swedish-born women (RR 0.19, CI 0.08–0.36). The differences between women born in Somalia and women born in Sweden were somewhat lower (not statistically significant) among women allocated to proactivity as compared to the Routine-care group.

Conclusions

A higher risk of a negative outcome for mother and baby is seen among women born in Somalia compared to women born in Sweden. We suggest it may be worthwhile to investigate whether a Somali-adapted intervention with proactivity concerning self-monitoring of fetal movements may improve pregnancy outcomes in this migrant population.

Community-based doula support for migrant women during labour and birth: study protocol for a randomised controlled trial in Stockholm, Sweden (NCT03461640)

INTRODUCTION

Migrant women consistently rate their care during labour and birth more negatively than non-migrant women, due to communication difficulties, lack of familiarity with how care is provided, and discrimination and prejudicial staff attitudes. They also report being left alone, feeling fearful, unsafe and unsupported, and have poorer birth outcomes than non-migrant women. Community-based doulas (CBDs) are bilingual women from migrant communities who are trained in childbirth and labour support, and who facilitate communication between woman-partner-staff during childbirth. This study protocol describes the design, rationale and methods of a randomised controlled trial that aims to evaluate the effectiveness of CBD support for improving the intrapartum care experiences and postnatal well-being of migrant women giving birth in Sweden.

METHODS AND ANALYSIS

A randomised controlled trial. From six antenatal care clinics in Stockholm, Sweden, we aim to recruit 200 pregnant Somali, Arabic, Polish, Russian and Tigrinya-speaking women who cannot communicate fluently in Swedish, are 18 years or older and with no contraindications for vaginal birth. In addition to standard labour support, women are randomised to CBD support (n=100) or no such support during labour (n=100). Trained CBDs meet with women once or twice before the birth, provide emotional, physical and communication support to women throughout labour and birth in hospital, and then meet with women once or twice after the birth. Women's ratings of the intrapartum care experiences and postnatal well-being are assessed at 6-8 weeks after the birth using selected questions from the Migrant Friendly Maternity Care Questionnaire and by the Edinburgh Postnatal Depression Scale. The intervention group will be compared with the control group using intention-to-treat analyses. ORs and 95% CIs will be estimated and adjustments made if key participant characteristics differ between trial arms.

ETHICS AND DISSEMINATION

The study was approved by the Regional Ethical Review Board in Stockholm (approval number: 2018/12 - 31/2).

TRIAL REGISTRATION NUMBER

NCT03461640; Pre-results.