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

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

Johnsen H ，Christensen U ，Juhl M ，Villadsen SF ... -  《-》

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

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). To explore the main organisational barriers, which impacted the intended mechanisms of the MAMAACT intervention in Danish antenatal care. A qualitative study design was used for data collection and analysis. Midwifery visits at ten antenatal facilities affiliated to five Danish maternity wards formed the setting of the study. 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. 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'. 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.

Johnsen H ，Christensen U ，Juhl M ，Villadsen SF ... -  《-》

Addressing ethnic disparity in antenatal care: a qualitative evaluation of midwives' experiences with the MAMAACT intervention.

Johnsen H ，Ghavami Kivi N ，Morrison CH ，Juhl M ，Christensen U ，Villadsen SF ... -  《BMC Pregnancy and Childbirth》

Contextual Factors Influencing the MAMAACT Intervention: A Qualitative Study of Non-Western Immigrant Women's Response to Potential Pregnancy Complications in Everyday Life.

Johnsen H ，Christensen U ，Juhl M ，Villadsen SF ... -  《-》

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

Damsted Rasmussen T ，Johnsen H ，Smith Jervelund S ，Christensen U ，Nybo Andersen AM ，Villadsen SF ... -  《-》