Universal or Targeted Antenatal Care for Immigrant Women? Mapping and Qualitative Analysis of Practices in Denmark

Unlocking the mechanisms of change in the MAMAACT intervention to reduce ethnic disparity in stillbirth and newborns' health: integration of evaluation findings

Ethnic disparities in stillbirth exist in Europe and suboptimal care due to miscommunication is one contributing cause. The MAMAACT intervention aimed to reduce ethnic disparity in stillbirth and newborns' health through improved management of pregnancy complications. The intervention encompassed training of antenatal care midwives in cultural competencies and intercultural communication combined with health education materials for the expecting parents about symptoms of pregnancy complications. The evaluation consisted of a qualitative in-depth implementation analysis and a process evaluation embedded in a cluster randomized trial including 19 of 20 maternity wards in Denmark. In this article, the findings from the different evaluation perspectives are integrated. The integration follows the principles of realist evaluation by analyzing to what extent the MAMAACT activities were generating mechanisms of change in interaction with the context. The integration analysis shows that the health education materials in the MAMAACT intervention contributed to heightened health literacy concerning pregnancy complications among pregnant women. Additionally, the training of midwives in cultural competency and intercultural communication raised awareness among midwives. Nonetheless, the exclusive emphasis on midwives and the inflexibility in care provision hindered them from changing their communication practices. To enhance the cultural competence in maternity care, it is essential to implement more comprehensive initiatives involving healthcare professionals in maternity care at all levels, from pregraduate to postgraduate. Adequate interpreter services and management support should also be ensured. Currently, the Danish antenatal care system faces challenges including inadequate information transfer between healthcare sectors, insufficient differentiation of care, and inflexibility in midwife scheduling. This results in a lack of responsiveness to the individual needs of women with immigrant backgrounds, potentially reproducing health inequities.

Differences in postpartum mental healthcare among women with identified needs: The role of migration status

AIMS

The aim of this study was to examine the association between women's migrant status (majority, immigrant, descendant) and use of postpartum mental healthcare and investigate whether migration characteristics are associated with mental healthcare use.

METHODS

Retrospective cohort study. We included all mothers of children born between 2002 and 2018 in 34 municipalities of Denmark who had an identified mental health need as clinically assessed by a child health visitor (CHV) or by a score of 11 or more on the Edinburgh Postpartum Depression Scale (EPDS). Women were followed until the first mental healthcare received 2 years' postpartum, death or emigration. Using Cox regression models, we estimated the time to mental healthcare by migrant status and explored the role of migration characteristics.

RESULTS

A total of 29% of women (n = 45,573) had a mental health need identified by the CHV, and 7% (n = 4968) had an EPDS ⩾ 11. Immigrants accounted for 19.5%, and descendants for 4.7% of the sample. Immigrants were at lower risk of using mental healthcare than the majority group (CHV: hazard ratio adjusted (HRa) 0.75 (0.70-0.79), EPDS: HRa 0.67 (0.58-0.78)), as were descendants (CHV: HRa 0.77 (0.70-0.86), EPDS: HRa 0.69 (0.55-0.88)). Among migrants, those not refugees, newly arrived, whose partners were immigrants or descendants, and those originally from Africa showed a lower risk of using postpartum mental healthcare.

CONCLUSIONS

Our findings emphasize the need to strengthen access to mental healthcare for immigrants and descendants experiencing postpartum mental health concerns and consider migration characteristics as indicators of potential inequalities in access to maternal mental healthcare.

Evidence in public health: An integrated, multidisciplinary concept

AIMS

Traditionally, evidence in public health has been founded in health sciences using the hierarchy of evidence. In this Commentary, we argue that we need a combination of evidence based on a broad range of scientific disciplines and methodologies to best translate research into improved public health.

METHODS

Using existing concepts of evidence such as the hierarchy of evidence and the evidence typology, we discuss their pitfalls in public health science and suggest a way forward. We use the case of the MAMAACT intervention to exemplify our claims.

RESULTS

Public health does not apply an either/or perspective, but an integrated, theoretically informed approach based on mixed and multiple methods to understand complex health problems and how to tackle them. Ideally, public health decisions should always incorporate scientific evidence, although we need to fully acknowledge that the quality of evidence is defined by more than just being placed highest in the hierarchy of evidence. No method or study design is superior in obtaining evidence, but we need the combined and supplemented contributions from a range of scientific approaches to form a whole. Thus, we propose an integrated, multidisciplinary concept of evidence in the form of cogwheels, where the public health problem followed by the research question(s) will guide the components to be studied and the use of method(s) in an interplay with the decisions of the scientific perspective(s) that include choice of theories.

CONCLUSIONS

We cannot understand or solve public health challenges without multidisciplinary approaches in a complimentary formation.

Palliative Care Utilisation Among Non-Western Migrants in Denmark: A Qualitative Study Of the Experiences of Patients, Family Caregivers and Healthcare Professionals

This study explores care experiences while utilising palliative care services of non-western migrant families from the perspectives of patients, family caregivers, and healthcare professionals in Denmark. Twenty-three semi-structured individual and group interviews were conducted among eight patients with a life-threatening disease, 11 family caregivers, and ten healthcare professionals. Thematic analysis revealed three themes: 1) Communication between families and healthcare professionals; 2) Building and lack of trusting relations, and feeling safe, and 3) Access to information and navigating in the healthcare system. Moreover, ''language and culture'' emerged as transaction themes that are not mutually exclusive, however, interconnect across the mentioned three themes. Non-western migrant families can be supported by healthcare professionals' cultural competency training, negotiating on providing services concerning information, patient preferences, family involvement, and palliative care setting. This study findings urge inter-sectoral collaboration to ensure needs-oriented and linguistically and culturally appropriate palliative care services for non-western migrant families in Denmark.

Knowledge About How to Manage Warning Signs of Pregnancy Complications Among Immigrants and Their Descendants Compared to Women of Danish Origin

OBJECTIVES

Ethnic differences in perinatal morbidity and mortality are starting points for social inequality in health. Increased incidence and severity of some pregnancy complications are found among immigrant women compared to ethnic majority women in high-income settings. However, little is known about immigrant women's assessment and management of warning signs. We aimed to assess women's knowledge about how to manage warning signs of pregnancy complications among immigrants and their descendants compared to women of Danish origin.

METHODS

A cross-sectional study including phone-based interviews with 1899 women. Women were interviewed during gestational week 30-37 in one of six languages. Maternal ethnicity was categorized as; immigrants, their descendants and ethnic Danes. The outcomes were yes or no to; do you know what to do if you experience 1) sudden swelling, redness, and heat in one leg 2) severe headache and 3) vaginal bleeding.

RESULTS

Immigrant women had lower levels of knowledge about how to manage all three types of warning signs of pregnancy complications compared to women of Danish origin. Adjusted OR for vaginal bleeding for women of European (4.33, 95% CI: 2.24-8.37), Asian (9.26, 95% CI: 5.10-16.83) and African (8.66, 95% CI: 3.26-23.05) origin.

CONCLUSIONS FOR PRACTICE

Immigrant women had lower levels of knowledge about how to manage warning signs of pregnancy complications compared to women of Danish origin. Improved needs-based health education in pregnancy complications and body symptoms during antenatal care is needed to address delays in the management of complications and could potentially improve the health of women and children.

Implementing the MAMAACT intervention in Danish antenatal care: a qualitative study of non-Western immigrant women's and midwives' attitudes and experiences

INTRODUCTION

Immigrant women have an increased risk of negative pregnancy and birth outcomes compared to women from European host populations. Similar trends are seen in Denmark, where especially some groups of non-Western immigrant women have an increased risk of stillbirth and infant mortality. This study reports on an implementation analysis of The MAMAACT Intervention, which was developed to increase midwives' and women's responses to pregnancy complications (trial registration number: NCT03751774). The intervention consisted of a training session and two dialogue meetings for midwives, and a leaflet and mobile application for women.

OBJECTIVE

To explore midwives' and non-Western immigrant women's attitudes towards and experiences of using the MAMAACT intervention to enhance mutual interactions and improve responses to potential pregnancy complications.

DESIGN

A multi-method qualitative study was used to collect data. Data consisted of non-participant observations of midwifery visits, field notes, focus group interviews with midwives and in-depth interviews with non-Western immigrant women. Data were initially analysed using systematic text condensation according to Malterud. Subsequently, Shim's concept of cultural health capital was applied to the data analysis.

SETTING

Data were collected from ten Danish antenatal care facilities affiliated with five maternity care wards.

PARTICIPANTS

Twenty-three midwives participated in observations of 40 midwifery visits, and 27 midwives participated in nine focus group interviews. Twenty-one non-Western immigrant women each participated in one in-depth interview.

FINDINGS

Two main themes were identified: 'the MAMAACT intervention as a tool to build knowledge and skills' and 'intervention experiences'. Training sessions and dialogue meetings promoted midwives' reflection on practice, however, at the visits, habitual ways of interacting impacted encounters between midwives and non-Western immigrant women. Among midwives, informing was a more dominant communication strategy than the use of dialogue, and competing tasks affected their follow-up on women's use of the information material. Women seemed hesitant to use the MAMAACT leaflet and app to actively engage with midwives at the visits although they used this material to distinguish between normal and abnormal conditions in pregnancy and to contact emergency maternity care services when at home.

CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

The acceptability and usability of the intervention were high among participants. The leaflet and app showed potential in prompting women to contact emergency care maternity services. Despite midwives' increased reflections on immigrant women's care provision, this did not appear to increase their use of a needs-based dialogue at the antenatal visits. Institutional structures, especially power relationships between midwives and non-Western immigrant women, affected mutual interactions. Attention to midwives' task loads and time resources are needed if midwives are to have the necessary space to adapt their interactional styles to immigrant women's individual needs.

"No Papers. No Doctor": A Qualitative Study of Access to Maternity Care Services for Undocumented Immigrant Women in Denmark

The purpose of this study is to explore undocumented immigrant women’s experiences of, as well as their access to, maternity care services during pregnancy in Denmark. Recruiting through the two branches of a non-governmental organization (NGO)-driven health clinic in Denmark, we conducted 21 semi-structured interviews with undocumented immigrant women in Denmark from January 2018 to January 2019. The undocumented immigrant women experienced barriers such as fear of deportation, concerns about payment for services, and uncertainties about rules for access. Many of them described depending on NGO-driven initiatives to access maternity care services and found these as providing a safe environment for care. Our findings contribute insights towards understanding the health behavior of undocumented immigrant women and highlight the need for inclusive care to safeguard the health of the women and their children.

Organisational barriers to implementing the MAMAACT intervention to improve maternity care for non-Western immigrant women: A qualitative evaluation

BACKGROUND

In Europe, the number of children born by non-Western immigrant women is rising and these women have an increased risk of negative pregnancy and birth outcomes, compared to the host populations. Several individual and system barriers are associated with immigrant women's access to maternity care. Scientific evaluations of interventions to enhance the health of immigrant women in the maternity setting are lacking, and there is a need for further development of the evidence base on how health care system initiatives may mitigate ethnic inequities in reproductive health. In Denmark, the MAMAACT intervention was developed to improve midwives' as well as non-Western immigrant women's response to pregnancy complications and to promote midwives' intercultural communication and cultural competence. The intervention included a training course for midwives as well as a leaflet and a mobile application. This study focuses on the significance of the antenatal care context surrounding the implementation of the MAMAACT intervention (Id. No: SUND-2018-01).

OBJECTIVES

To explore the main organisational barriers, which impacted the intended mechanisms of the MAMAACT intervention in Danish antenatal care.

DESIGN

A qualitative study design was used for data collection and analysis.

SETTING

Midwifery visits at ten antenatal facilities affiliated to five Danish maternity wards formed the setting of the study.

PARTICIPANTS AND METHODS

Data consisted of nine focus group interviews with midwives (n = 27), twenty-one in-depth interviews with non-Western immigrant women, forty observations of midwifery visits, and informal conversations with midwives at antenatal care facilities (50 h). Data were initially analysed using systematic text condensation. The candidacy framework was applied for further interpretation of data.

RESULTS

Analysis of data revealed three main categories: 'Permeability of antenatal care services', 'The interpreter as an aid to candidacy´, and 'Local conditions influencing the production of candidacy'.

CONCLUSIONS

Several organisational barriers impacted the intended mechanisms of the MAMAACT intervention. Major barriers were incomplete antenatal records, insufficient referrals to specialist care, inadequate interpreter assistance, and lack of local time resources for initiating a needs-based dialogue with the women. Immigrant targeted interventions must be understood as events within complex systems, and training midwives in intercultural communication and cultural competence cannot alone improve system responses to pregnancy complications among immigrant women. Changes in the legal, social, and political context of the health care system are needed to support organisational readiness for the MAMAACT intervention.