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), twentyone 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. (c) 2020 The Authors. Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/)