Looking for "The Equalizer" in antenatal care : developing and evaluating language-supported group antenatal care in Sweden

Abstract: Group antenatal care (gANC) is an antenatal care (ANC) model that aims to empower women and has demonstrated potential to improve outcomes for groups of women with poorer reproductive health outcomes. The overall aim of this thesis was to develop and test the acceptability and impact of language-supported gANC for Somali-born women in Sweden. The purpose of the intervention was to improve experiences of antenatal care, emotional well-being, knowledge about childbearing and the Swedish healthcare system, and ultimately, pregnancy outcomes. Experiences of standard ANC were explored in focus group discussions with parents and midwives (Study I). Challenges and barriers in standard antenatal were described, both related to the encounters between midwives and parents-to-be, and organizational challenges. Utilising data from Study I, “language-supported group antenatal care” was developed and implemented in one clinic for 18 months. The intervention was evaluated, and women’s care experiences and emotional wellbeing were compared with those of women offered standard care (historical controls) and those subsequently offered gANC (intervention). Data were collected by means of questionnaires at baseline, in late pregnancy and at 6–8 weeks postpartum (Study II). The development, implementation, and feasibility of the intervention was assessed through a process evaluation using mixed data sources (observations, interviews, questionnaires, etc.) (Study III). In study II, no differences between the intervention group and the control group on the primary outcome of women’s overall rating of antenatal care were found. The reduction in mean EPDS score was greater in the intervention group when adjusting for differences at baseline (mean difference –1.89; CI 95% –3.73 to –0.07). Women in gANC were happier with received pregnancy and birth information; e.g., in the case of caesarean sections, where 94.9% believed the information was sufficient compared to 17.5% in standard care (p <0.001) in late pregnancy. In study III, women in language-supported gANC thought it was a positive experience as a complement to individual care, but the intervention was not successful at involving partners in ANC. In gANC, the midwives and women got to know each other better. The main mechanism of impact was more comprehensive care. The position of women was strengthened in the groups, and the way midwives expanded their understanding of the women, and their narratives, was promising. This evaluation suggests potential for language-supported gANC to improve information provision and knowledge acquisition for Somali–Swedish women during pregnancy (with residence in Sweden ˂10 years). Language-supported gANC is feasible and relevant if there is an adequate number of pregnant migrant or minority women in an uptake area who share a common language. To be feasible in other settings, gANC requires adaptations to local context. Reflection is called for when forming groups based on ethnicity or language, to avoid potential unintended consequences such as reinforcing stereotypes by grouping people according to country of birth or reducing privacy for individual women. The “othering” of women in risk groups should be avoided. There may also be a trade-off in gANC between peer-to-peer support and other important aspects such as the inclusion of partners and integration/inclusion in regular birth preparation and parenting activities. Person-centring seemed to be enhanced with gANC in this study with Somali–Swedish women. ANC interventions including gANC that target inequalities between migrants and non-migrants should adapt a culturally sensitive person-centred approach, as a means of providing individually tailored high quality care that counteracts stereotypes and biases.