Background
Disparities in maternal health between migrants and host population in high-income countries remains a public health concern [
1]. It is well established that migrant women have increased risk for several adverse outcomes during pregnancy and birth [
2,
3]. The causes are complex. Both individual determinants, such as age, gender and genetics; and structural determinants, such as legal, political and socio-economic frameworks; play important roles in an individual’s health. Structural determinants can be especially important to a migrant’s health – both physical and mental – during the different stages of the migration and integration process [
4]. A migration experience may also be associated with loss of social network and direct economic loss [
5]. In addition, previous experience with fragmented healthcare and poor quality can affect trust in the health system of the host country.
Although migrant women are a heterogeneous group of people with huge variability in socioeconomic status and risk profiles, they share the experience of being new to a country. As such, recently migrated women are more likely to have a relative disadvantage compared to migrants with residence of more than 5 years, many of whom arrived as children and thus have greater language proficiency and familiarity with the health systems in host countries. Furthermore, women born in low- or middle-income countries constitute a vulnerable group with higher risk of receiving inadequate antenatal care, compared to the migrant women born in high-income countries [
6].
Migrants may encounter barriers and challenges in utilizing the healthcare system due to language barriers, low health literacy, socio-economic difficulties, lack of psychosocial support, cultural beliefs, and low-transcultural proficiency of healthcare personnel [
6‐
9]. ‘Barrier’ is understood as anything that restricts access, use or benefit from healthcare services, and a ‘challenge’ as a subjective experience of something that requires great effort to succeed and, in contrast to ´problem´, is an opportunity for growth [
7]. Health literacy includes both personal and organisational health literacy [
10]. The former focuses on the individual’s ability to find, understand and use information and healthcare services, whereas the latter focuses on the organisation’s ability to enable individuals to find, understand and use information and healthcare services [
10].
Even though maternity care in Norway is generally considered to be of good quality, sub-optimal maternity care [
11,
12] and barriers to health care access [
13,
14] among migrants have been reported. Previous systematic reviews have explored the experiences of migrant women in accessing and utilising the maternal healthcare in host countries [
15‐
17]. However, acculturalisation occurs over time and there is limited research on
recently migrated women’s perceived barriers to optimal maternity care in Norway. Furthermore, quantitative research exploring the patterns of access and utilisation of maternal healthcare among recently migrated women is lacking.
This article is a part of the project “The MiPreg Study: Closing the Gaps in Maternity Care to Migrant Women in Norway”. The results will be used to pilot an intervention to fill gaps in maternal healthcare that decrease health disparities between migrants and host population. In order to develop efficient interventions, we need to map the current patterns of access and utilisation, and better understand the challenges this group face. Thus, the aim of this article was to identify challenges and barriers recently arrived migrant women face in accessing and utilising the maternity healthcare service in Norway. We strive for a comprehensive approach by utilising both qualitative and quantitative methods, as well as including the perspectives of both migrant women and midwives.
Methods
Study setting
This study is set in urban Oslo, the city with the largest population of migrants in Norway, with migrants currently accounting for 26% of the population [
18]. The highest proportion of recent migrants born in low- or middle-income countries to Oslo in 2020, in descending order, were from Poland, Syria, Lithuania, Eritrea and the Philippines [
18]. Norway has universal health coverage and compulsory healthcare insurance paid through taxes, that covers all care rendered in hospitals. Essential maternity healthcare before, during and after birth is free of charge for all residents in the country with a national identification number or temporary identification number, including refugees and asylum seekers yet to receive a residence permit. Persons without legal residence, such as undocumented migrants, are entitled to healthcare during pregnancy and birth, but while antenatal services are offered free of charge, they are financially responsible for expenses related to childbirth [
19]. Pregnant women can choose to have their follow-up at their family doctor or a midwife at a Maternal and Child Health Centre (MCHC) [
20]. The standard antenatal package includes eight consultations, including one routine ultrasound screening at around week 18. Almost all births in Norway are institutionalised and there are only public hospitals for delivery. After discharge from hospital the midwives at MCHC provide the post-partum follow-up.
Inclusion criteria
We included pregnant migrant women in urban Oslo, with a length of stay ≤ 5 years in Norway and born in a low- or middle-income country. Thereafter, we used the Global Burden of Disease regional classification system, which is based on epidemiological similarity and geographic closeness, to classify women into different regions [
21]. We included midwives with extensive experience in providing maternity care for migrant women from hospitals and MCHCs in urban Oslo. In the Norwegian maternity care system, midwives often provide the majority of antenatal and post-partum care and deliver most normal births. They often have a relational and social approach to migrant women and their families throughout the pregnancy. Due to these factors, we chose to include midwives as representatives for healthcare personnel.
Study design and triangulation
The MiPreg project is a multidisciplinary, mixed-method project. It is organised into four parts, of which two are included in this article: quantitative part (structured questionnaire with migrant women) and qualitative part (in-depth interviews with migrants and healthcare personnel). We sought to triangulate our findings by technique, i.e., applying mixed-methods, with in-depth interviews from two different but interrelated groups – women and midwives, and a structured questionnaire among migrant women. Triangulation can be used to increase the validity in research as it combines different methods to answer a research question [
22]. It enabled a different perspective to our study objective, and thus provided a more complete and comprehensive understanding about the subject of barriers and challenges migrant women face.
Quantitative part: structured questionnaire
In this part we applied a quantitative questionnaire, using a modified version of the Migrant Friendly Maternity Care Questionnaire (Supplementary file
1), that measures maternity care related factors in migrant populations [
23]. To ensure accuracy and consistency of data collection the interviewers - three midwives and one physician, were trained and an interview guidebook was produced. In addition, the interviewers met regularly to discuss challenges and experiences. From January 2019 until February 2020 the interviewers at the two hospitals serving urban Oslo identified eligible pregnant women being admitted at the birth ward. The women were interviewed face-to-face in their own language of choice using an interpreter when needed, before discharge from the hospital. The mean completion time for the questionnaire was 44 min. A previously published article, provide detailed description on the methodology for the questionnaire-study [
24].
Qualitative part: in-depth interviews with migrant women
In this part, two anthropologists experienced in qualitative methods conducted in-depth, semi-structured interviews with migrant women from March until December 2019. The interviews took place at three MCHC in Oslo with high proportions of migrants. We ensured variation in country of birth in the sampling process. Of the women recruited,15 were in their third trimester, and the remaining five had recently given birth. The eligible women were identified by midwives working at the MCHC, who passed on contact information to the researchers upon consent. The women were interviewed face-to-face, using a professional interpreter for most of the interviews. The interviews, lasting from 50 min to 1.5 h explored in detail the women’s experiences with maternity care in Norway, including potential barriers and facilitators. The included women received a reimbursement of 250 NOK for their participation – a gift card for use in a grocery store.
Qualitative part: in-depth interviews with midwives
In the qualitative part we additionally conducted in-depth interviews with seven midwives, three from hospitals and four from MCHCs in urban Oslo. The age of the midwives varied from 31 to 57 years. The interviews lasted between 1 and 2 h and included themes that focused on experiences and perceptions of maternity care with pregnant migrant women, challenges faced in their daily work and structural limitations related to time, resources and organisation of maternity care. We had initially planned 10 interviews with healthcare workers, however due to coronavirus pandemic, we had to pause the inclusion of the last 3 interviews. After starting analysis of the obtained material, data saturation had been reached, judged to be attained when no new themes or information emerged in subsequent interviews. We therefore decided to stop further data collection.
Data analysis
The descriptive statistics from the quantitative data was analysed as mean with standard deviation (SD), median with interquartile range (IQR) and frequencies with percentage, using IBM SPSS version 25. The audio recorded in-depth interviews were transcribed and analysed using an inductive approach to identify recurring themes and sub-themes. The open-ended questions from the questionnaire and the qualitative data were analysed by thematic analysis. This involved reading and rereading the data, underlining key phrases and reoccurring topics and creating initial thematic codes. After reading the transcript, three researchers coded relevant sections separately, which were further discussed and modified if necessary. Themes and sub-themes were defined, and descriptive narrations were written and compared to the quantitative data material, drawing out quotes from migrant women and midwives that highlighted the four main themes identified in the transcribed interviews. In this article, the quotes from migrant women are followed by participant number, length of stay in Norway in whole years and reason for migration. For midwives, they are followed by number and workplace.
Ethical considerations
The questionnaire study (approvals 18/15786 + 18/05310) and the in-depth interviews (approvals 18/15786) were approved by Oslo University Hospital and Akershus University Hospital’s ethical review committees. Information about the study was provided both orally and written to the migrant women and midwives. Written consent, or oral consent based upon the women’s preference, was obtained from those who volunteered to participate in the study. To ensure confidentiality, personal identification was removed, and all collected information including audio recordings, transcripts and questionnaires were securely stored and accessible only to the research team.
As the aim of this artice was on the barriers and challenges, we were conscious that participants reflections on these have the potential to reinforce negative ethnic or racial stereotypes as well as play into public discussions in media, especially on internet, on issues related to immigration, health-related deservingness and integration. Another important concern when conducting the in-depth interviews with pregnant migrant women was that participation may result in distress, or further trauma for those with a traumatic history. We made clear to the participants at the start of the interviews that they did not have to talk about issues they found difficult or too personal. If participants voluntarily shared traumatic issues, the research team informed participants of professional resources, including their midwives, for further support.
Discussion
This article investigated potential barriers and challenges to optimal maternity care for recently arrived migrants as perceived by the migrant women and midwives. The challenges they reported as most difficult were related to navigating the healthcare system, language, psychosocial and structural factors, and expectations of care. Even though our findings are consistent with previous international literature on perceived barriers among migrant women, until now few studies have explored barriers in particular for recently migrated women. Lack of knowledge about the healthcare structure and limited social network during the first period after having migrated to the country emerged as significant challenges for the recently migrated women.
The healthcare services in Norway are comparably of a high standard [
25]. The fact that the accessibility and quality have been so high over many years, may also contribute to higher expectations of its service delivery, and potentially a lower threshold for criticising the health system and its services. Yet, our findings do suggest that some migrant women had variable layers of vulnerability factors that influenced their capacity and means to use the health services available and to understand and navigate the health system.
In agreement with previous studies, we found that migrant women lacked information about the healthcare system in host countries, including administrative procedures, which led to women not using the variety of available maternity care services [
9,
17,
26]. National guidelines in Norway recommends the first antenatal care consultation to be booked by the end of gestational week 12 [
20], which was done by 83.6% in our study. As we did not compare migrants to non-migrants, we cannot establish if there was a difference in how early the women started antenatal care. Nevertheless, studies from European countries have shown later initiation of antenatal care among migrants compared to non-migrants [
27,
28], first generation- compared to second generation migrants [
29], minority ethnic groups compared to White women [
28,
30] and especially profound among recently migrated women [
31]. Although our finding of a high percentage of timely initiation of antenatal care, midwives from the in-depth interviews indicate that subgroups of migrants may be at risk. Our findings should therefore be further explored by research on subgroups with low language proficiency, acculturation and among undocumented migrants [
13].
Slightly lower attendance was found for the standard routine ultrasound conducted at around week 18, which was 93.5% in our study, compared to 97% in national surveys [
32] . The high attendance for standard routine ultrasound in our study may be explained by the relatively high number of women from Central and Eastern Europe that were included, seeing that there is a practice and expectation of using ultrasound earlier and more frequently during pregnancies in those countries [
33]. We also found that 13.2% of the women had gotten an early ultrasound, a service often paid for privately as it is not a part of routine antenatal care in Norway, except for groups with elevated risk of fetal chromosomal abnormality. This is low compared to local surveys in Norway suggesting that half of the women had an early ultrasound in the first trimester [
32]. Women reported often using the emergency outpatient clinic in case of medical concerns, in line with a previous study that found more frequent use of emergency outpatient clinic by migrants compared to the host population [
34]. Educating the migrant women about the structure of healthcare system may be a solution in reducing the barriers of navigating the healthcare system.
Our findings on language barriers, complements previous work where language is highlighted as one of the main barriers for migrants [
1,
15‐
17]. Use of interpreter services have been shown to increase the understanding of maternal health information among migrants [
35]. However, we found that even when a professional interpreter was used, sometimes communication problems persisted as a result of dialect or gender of interpreter. Healthcare personnel, as well as the institutions they are part of, need to be aware of this and the need for appropriate interpretation services. Furthermore, previous research has linked low language proficiency to low attendance in pregnancy preparation courses among migrants [
36,
37]. Therefore, offering pregnancy preparation courses in English and other major languages could be beneficial in increasing the attendance among non-Norwegian speaking women.
Our findings show that recently migrated women often lacked social support, had limited social network and struggled to acclimate to the difference in community and familial support between their birth country and Norway. Previous studies on social support among migrants are not conclusive, as some are in concordance with our findings [
30], while others found no evidence of limited social support [
8], or even higher social support in migrant groups [
8,
38]. Longer length of stay in the host country often leads to wider social networks. This could explain why the recently arrived women in our study experienced limited social networks as challenging – psychosocially as well as in relation to practical and emotional support. Lack of social support has been shown to be linked with a number of adverse pregnancy outcomes, such as post-partum depression [
39,
40], low birth weight [
41] and preterm birth [
42]. Identifying women that lack or have little social support and providing them with additional social services may thus increase psychosocial wellbeing as well as potentially identify additional vulnerability factors.
Varying expectations of care and the healthcare system’s limited ability to provide differentiated care to women with special needs, may make it difficult for migrant women to adjust to the healthcare system in host countries [
14]. While coping with conflicting recommendations in the two countries, migrant women can even be viewed as “
difficult to manage” by healthcare personnel. Although some training in cultural competence is offered during professional education, efforts to include more targeted training for health personnel, both during professional education but also as continued learning could provide increased awareness and self-reflexivity. As explained by Phillimore et al. [
26], it is almost impossible to gain cultural knowledge about every ethnic group in an increasingly multi-ethnic world. Rather, focus should be on intercultural competence and treating patients individually while still being culturally sensitive. A newly published scoping review on different models of antenatal care targeted at migrant women, including group antenatal care and specialised clinics, found the models to be acceptable for women and increased access to care [
43]. Use of multicultural doulas for vulnerable migrant women have shown promising results in Norway [
44].
This article has not explored conceptions of ‘health related deservingness’ [
45] – who ‘deserves’ or have the right to access health services or who should or should not be financially supported when accessing services. The question of who deserves it most and the extent to which diverse migrant groups can claim state welfare goods is often debated in Norwegian media and on internet sites. The competing and black-and-white stances are often grounded in moral judgement, notions of exclusive citizen rights, and moral ideas about having to ‘earn’ access to goods. The extent to which these contentions and judgments find their way into healthcare provision in Norway needs further exploration.
Strengths and limitations
Strengths of this study include an emphasis on multidisciplinary research, from the design phase to interpretation of findings, as the authors hold background in medicine, gynaecology, anthropology and public health. Two authors, one physician and one medical anthropologist, performed the content analysis independently and discussed the findings before reaching consensus, thereby increasing the validity. Both the questionnaire study and the in-depth interviews were done face-to-face in the migrant women’s language of choice, enabling women with low language proficiency and literacy to participate. A high response-rate for the questionnaire study with few missing values limited response bias. The in-depth interviews were conducted by anthropologists, limiting the possible social desirability bias that using healthcare personnel can introduce.
Nonetheless, limitations exist. Administering the questionnaire-study within some days of birth could potentially introduce bias as the new mothers might be exhausted and not remember details about the pregnancy well. This timing, however, ensured responses from hard-to-reach groups, a factor we considered more important. As healthcare personnel conducted the quantitative interviews, social desirability bias could affect the answers of the migrant women. Limitations of the in-depth interviews include convenience sampling and selection bias. With midwives at the MCHCs holding responsibility for recruiting eligible migrant women, the women interviewed might represent a group of migrants who are more integrated, omitting those who were most isolated and did not attend MCHCs. The findings reported from the in-depth interviews with midwives are based on purposive sampling of healthcare personnel who volunteered to participate in the study. Therefore, the extent to which the midwife’s views are representative of all healthcare personnel serving migrant women is unknown. In addition, taking the sample only from a diverse urban area may limit the generalisability of the findings in rural areas.
We did not explicitly focus on gender relations and to what extent cultural understanding of gender influence access to maternal healthcare services. Issues related to not reaching hospital in time when experiencing symptoms, for example due to lack of childcare or transportation, may reflect gendered divisions of responsibilities or culturally shaped notions of birth belonging to the ‘women’s sphere’. Furthermore, the fact that all participants included in our study were women, men’s voices and perceptions have not been included, and thus gendered norms and the ways they may influence uptake of services have not been explored.
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