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

BACKGROUND: In Denmark, 13% of all children are born by non-Western immigrant women. The public antenatal care has not adapted to this increased diversity of women. Compared to women coming from Western countries, non-Western immigrant women have an increased prevalence of severe maternal morbidity and higher risks of maternal death, stillbirth and infant death. Suboptimal care is a contributing factor to these ethnic disparities, and thus the provision of appropriate antenatal care services is pivotal to reducing these disparities and challenges to public health. Yet, little is known about the targeted interventions which have been developed to reduce these inequities in reproductive health. The MAMAACT intervention, which included a training course for midwives, a leaflet and a mobile application, as well as additional visit time, was developed and tested at a maternity ward to increase responses to pregnancy warning signs among midwives and non-Western immigrant women. AIM: To explore the feasibility and acceptability of the MAMAACT intervention among midwives and identify factors affecting midwives' delivery of the intervention. METHODS: Eight mini-group interviews with midwives (n = 18) were undertaken. Systematic text condensation was used to analyse data. RESULTS: Three main categories were identified, which were 'Challenges of working with non-Western immigrant women', 'Attitudes towards and use of the leaflet and mobile application', and 'Organisational factors affecting the use of the MAMAACT intervention'. CONCLUSIONS: The MAMAACT intervention was found to be feasible as well as acceptable among midwives. Women turning to relatives for pregnancy-related advice, time constraints during midwifery visits, incomplete clinical records and lack of professional interpreter assistance impacted midwives' delivery of the MAMAACT intervention. Midwives displayed a readiness for the MAMAACT intervention; however, there is a need to further examine how contextual factors may impact the use of the intervention in antenatal care. TRIAL REGISTRATION: ClinicalTrials.gov, Retrospective Registration (07/2/2020), registration number NCT04261400.

Using eHealth to Increase Autonomy Supportive Care: A Multicenter Intervention Study in Antenatal Care.

eHealth solutions are increasingly implemented in antenatal care to enhance women's involvement. The main aim of this study was to evaluate women's assessment of autonomy supportive care during the antenatal care visits among low-risk pregnant women. An intervention study was conducted including a control group attending standard antenatal care and an intervention group having access to an eHealth knowledge base, in addition to standard care. A total of 87 women were included in the control group and a total of 121 women in the intervention group. Data were collected using an online questionnaire 2 weeks after participants had given birth. Data were analyzed using χ tests and Wilcoxon rank sums. Use of an eHealth knowledge base was associated with statistically significant higher scores for women's overall assessment of antenatal care visits, the organization of antenatal care visits, confidence after antenatal care visits, and involvement during antenatal care visits. We also found a statistically significant higher overall self-perceived autonomy supportive care in the intervention group compared with the control group.

Nordic fathers' willingness to participate during pregnancy.

OBJECTIVE: This study aims to illuminate expectant first-time fathers' experiences of participation during pregnancy in three Nordic countries.  Background: Fathers' participation in pregnancy is associated with improved health for the family as a whole. Research so far has primarily explored fathers' participation in pregnancy within health care settings. It is important to know more about how fathers today engage in all aspects of pregnancy.  Methods: Content analysis was used to analyse semi-structured interviews with 31 first time fathers from Denmark, Finland and Sweden. Interviews were undertaken when their partner was pregnant 30 weeks or more.  Results: Data analysis resulted in the main category 'Willingness to participate' and the two generic categories: 'Being beside the "bump"' and 'Cementing the partnership'. 'Being beside the "bump"' was supported by the subcategories: 'Visualising the unborn child', 'Being included in the rites of motherhood,' 'Lacking full control', 'Compensating for lack of embodiment' and 'Adopting an active father role'. 'Cementing the partnership' encompassed the subcategories: 'Strengthening the partner relationship', 'Meeting the professionals, 'Sharing experiences with peers' and 'Protecting their child and their partner'. CONCLUSION: Fathers wanted to participate and be responsible from the beginning of pregnancy. Fathers' participation in pregnancy involves a wide range of activities and strategies both within the domestic and the professional care-giving sphere. Health care professional's approaches to the father-to-be can enhance or reduce experiences of inclusion in antenatal care.

Sputum neutrophils are elevated in smelter workers, and systemic neutrophils are associated with rapid decline in FEV1.

OBJECTIVES: In a previous study on smelter workers we, found significant relationship between exposure to dust and accelerated annual decline in forced expiratory volume in 1 s (FEV1). In this cross-sectional study at the end of a follow-up, we aimed to investigate the possible association between annual decline in FEV1 and markers of airways, and systemic inflammation in smelter workers. METHODS: Employees (n=76 (27 current smokers)) who had been part of a longitudinal study (9-13 years) that included spirometry (>6 measurements) and respiratory questionnaires, performed induced sputum, exhaled NO and had blood drawn. Participants with annual decline in FEV1≥45 mL were compared with participants with annual decline <45 mL; also 26 non-exposed controls were included. RESULTS: Compared with non-exposed controls, smelter workers demonstrated a significantly increased percentage of neutrophils (mean (SD)) (57% (17) vs 31% (15)) and matrix metalloproteinases 8 (MMP-8) levels in sputum, and MMP-9, surfactant protein D (SpD) and transforming growth factor ß (TGFb) levels in blood. A significant association in FEV1≥45 mL was found for blood neutrophils when controlling for smoking habits (OR=1.7 (95% CI 1.0 to 2.8), p=0.045). Airway and blood protein markers were not associated with annual decline in FEV1. CONCLUSIONS: All workers displayed airway and systemic inflammation characterised by increased levels of neutrophils and MMP-8 in sputum, and MMP-9, SpD and TGFß in blood compared with non-exposed controls. Blood neutrophils in particular were significantly elevated in those workers with the most rapid decline in lung function. A similar observation was not seen with airway neutrophils. In the present study, we were able to identify systemic but not airway inflammatory markers that can predict increased decline in FEV1 in smelter workers.

Combining the Antenatal Risk Questionnaire and the Edinburgh Postnatal Depression Scale in Early Pregnancy in Danish Antenatal Care-A Qualitative Descriptive Study.

Pregnant women with a history of mental disorders, neglect, or low social support are at increased risk of mental health problems. It is crucial to identify psychosocial risk factors in early pregnancy to reduce the risk of short- and long-term health consequences for mother and child. The Antenatal Risk Questionnaire has been found acceptable as a psychosocial screening tool among pregnant women in Australia, but it has not been tested in a Scandinavian context. The aim of this study was to explore the experiences of pregnant women when using the Antenatal Risk Questionnaire and the Edinburgh Postnatal Depression Scale as part of a model to identify psychosocial vulnerabilities in pregnancy in Denmark. We conducted individual interviews (n = 18) and used thematic analysis. We identified two main themes: (1) Feeling heard and (2) An occasion for self-reflection. Overall, the pregnant women deemed the online ANRQ/EPDS acceptable as a screening tool. The screening model provided a feeling of being heard and provided an occasion for self-reflection about mental health challenges related to pregnancy and motherhood. However, some women expressed that the screening raised concerns and fear of the consequences of answering honestly. A non-judgmental, open, emphatic, and reassuring approach by clinicians may help reduce stigma.

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.

Respiratory hazards of metal smelting.

PURPOSE OF REVIEW: The metal smelting industry is an important industry in the majority of countries in the world and employs millions of workers. In most of the production types, a variety of pollutants are emitted into the workplace atmosphere. Some of these pollutants have sensitizing properties, whereas other act as irritants in the respiratory tract. This review will explore the recent studies (2010-2012) which address the impact of exposure to pollutants in the smelting industry on nonmalignant respiratory disorders. RECENT FINDINGS: The association between different respiratory symptoms as well as pulmonary function and the level of exposure to different agents has been investigated. Likewise, the effect of primary prevention (exposure reduction) and secondary prevention (relocation) has been studied. Finally, the association between the incidence of community-acquired pneumonia and exposure to pollutants encountered at work in the smelting industry and the results from mortality studies are reported. SUMMARY: It appears that exposure to emissions of pollutants in the smelting industry is associated with respiratory symptoms, including asthma, lung function decline and chronic obstructive pulmonary disease, depending on the type of production. Moreover, it is possible that these exposures may enhance the risk of infectious pneumonia.

Dust exposure is associated with increased lung function loss among workers in the Norwegian silicon carbide industry.

OBJECTIVES: To investigate the relationship between dust exposure and annual change in lung function among employees in Norwegian silicon carbide (SiC) plants using a quantitative job exposure matrix (JEM) regarding total dust. METHODS: All employees, 20-55 years of age by inclusion (n=456), were examined annually for up to 5 years (1499 examinations). Spirometry was performed at each examination, and a questionnaire encompassing questions of respiratory symptoms, smoking status, job and smoking history, and present job held was completed. A JEM was constructed based on 1970 personal total dust exposure measurements collected during the study period. The association between lung function and total dust exposure was investigated using linear mixed models. RESULTS: The annual change in forced expiratory volume (FEV) in one second per squared height, FEV1/height(2), per mg/m(3) increase in dust exposure was -2.3 (95% CI -3.8 to -0.79) (mL/m(2))×year(-1). In an employee of average height (1.79 m) and exposure (1.4 mg/m(3)) the estimated contribution to the annual change in FEV1 associated with dust was 10.4 mL/year. The annual change in FEV1/height(2) in current, compared with non-smokers was -1.9 (-7.2 to 3.4) (mL/m(2))×year(-1). The estimated overall annual decline in FEV1 among current and non-smokers in the highest exposed group was -91.2 (-124.3 to -58.1) (mL/m(2))×year(-1) and -49.0 (-80.2 to -17.8) (mL/m(2))×year(-1), respectively. CONCLUSIONS: Dust exposure, expressed by a quantitative JEM, was found to be associated with an increased yearly decline in FEV1 in employees of Norwegian SiC plants.

The incidence of work-related asthma-like symptoms and dust exposure in Norwegian smelters.

RATIONALE: The prevalence of respiratory symptoms among employees in smelters is positively associated with dust exposure. OBJECTIVES: To investigate the association between the incidence of work-related asthma-like symptoms (WASTH) and dust exposure. METHODS: All the employees were invited to participate in a 5-year longitudinal study. The outcome of WASTH was defined as the combination of dyspnea and wheezing improving on rest days or vacation in an individual who had no asthma previously. Information about smoking and occupational status was obtained from a questionnaire. A job exposure matrix of total dust was developed. Multivariate data analyses were performed using Cox regression. MEASUREMENTS AND MAIN RESULTS: The total follow-up time of the employees (n = 2,476) was 8,469 years, and the median follow-up time for participants was 4.0 years. During the follow-up, 91 employees developed WASTH, and the corresponding incidence rate for WASTH per 1,000 person-years was 8.9 (7.3-10.9) (95% confidence interval in parentheses). The risk ratio of WASTH increased significantly (P = 0.0001) with dust exposure in the middle and high categories (1.0-2.9 and ≥ 3.0 mg/m(3)). Stratified analyses showed that the effect of current dust exposure varied with both previous exposure (PE) to dust and fumes (P = 0.006) and airflow limitation (AFL) (P = 0.033). The final analyses showed that the risk ratios for WASTH per 1 mg/m(3) increase in current dust exposure were 1.1 (0.93-1.2), 1.4 (1.1-1.8), 1.6 (1.1-2.3), and 1.9 (1.2-3.0) for the categories (PE+/AFL-), (PE-/AFL-), (PE+/AFL+, and (PE-/AFL+). CONCLUSIONS: In conclusion, dust exposure was associated with an increased incidence of WASTH.

The Feasibility of the Adverse Childhood Experiences Questionnaire among Women in Danish Antenatal Care: A Mixed-Methods Study.

A traumatic upbringing increases the risks of antenatal health problems, unfavourable pregnancy outcomes, and mental disorders. Such childhood experiences may affect women's pa-renting skills and the social-emotional functioning of their children. Research on screening for adverse childhood experiences in antenatal care is limited. The objective of this study was to explore pregnant women's attitudes towards and experiences of an adverse childhood experiences questionnaire, and to assess the relevance of the questionnaire among a population of pregnant women referred to antenatal care levels one and two, targeting women who are generally not perceived to be vulnerable. Data were collected at three maternity wards and consisted of quantitative data on 1352 women's adverse childhood experience scores, structured observations of 18 midwifery visits, and in-depth interviews with 15 pregnant women. Quantitative data were analysed by descriptive statistics, and qualitative data were analysed using systematic text condensation. The qualitative analysis revealed two main categories: "Being screened for childhood adversities" and "Having adverse childhood experiences". In the study population, the prevalence of adverse childhood experiences was high. The women assessed the adverse childhood experiences questionnaire to be a relevant and acceptable screening method. Furthermore, women's perceptions of their relationship with their midwife greatly impacted their attitudes towards and experiences of the questionnaire.

The Feasibility and Acceptability of the Adverse Childhood Experiences Questionnaire in Danish Antenatal Care-A Qualitative Study of Midwives' Implementation Experiences.

Adverse childhood experiences have a potential lifelong impact on health. A traumatic upbringing may increase antenatal health risks in mothers-to-be and impact child development in their offspring. Yet, little is known about the identification of adverse childhood experiences in antenatal care. The objective of this study was to explore the feasibility and acceptability of the adverse childhood experiences questionnaire among midwives and factors affecting its implementation. Three Danish maternity wards participated in the study. The data consisted of observations of midwifery visits and informal conversations with midwives, as well as mini group interviews and dialogue meetings with midwives. The data were analysed using systematic text condensation. Analysis of the data revealed three main categories; "Relevance of the adverse childhood experiences questionnaire", "Challenges related to use of the adverse childhood experiences questionnaire" and "Apprehensions, emotional strain, and professional support". The findings showed that the adverse childhood experiences questionnaire was feasible to implement in Danish antenatal care. Midwives' acceptability of the questionnaire was high. Training courses and dialogue meetings motivated the midwives to work with the questionnaire in practice. The main factors affecting the implementation process were time restrictions, worries of overstepping women's boundaries, and a lack of a specific intervention for women affected by their traumatic upbringing circumstances.

The association between symptoms and exposure is stronger in dropouts than in non-dropouts among employees in Norwegian smelters: a five-year follow-up study.

PURPOSE: We have investigated the association between respiratory symptoms and dust exposure among employees in 18 Norwegian smelters using a longitudinal design. METHODS: All employees (N = 3,084) were examined annually for 5 years (12,996 health examinations). At each examination, the subjects reported if they had respiratory symptoms, coded as 1 (yes) or 0 (no), on a respiratory questionnaire. Symptom score was constructed as the sum of symptoms (0-5). Full-time workers in the production line were classified as line operators; subjects never exposed in the production line were regarded as non-exposed. The remaining individuals were classified as non-line operators. A job-exposure matrix regarding dust exposure was also available. Analyses of repeated measurements were performed using generalised linear mixed model with log-link (Poisson regression). Adjustments were made for overdispersion. RESULTS: The mean age at inclusion was 39.0 years, and 89% were men. The median dust exposure in tertiles 1-3 was 0.19, 1.76 and 3.47 mg/m(3). The longitudinal analyses showed that the association between symptoms-score ratio (SSR) and job category was significantly stronger in dropouts compared with non-dropouts (p = 0.01). Among the dropouts, SSR was 1.61 (95% confidence interval: 1.27-2.05) and 1.39 (1.09-1.77) in line operators and non-line operators compared with non-exposed employees, respectively. The corresponding SSR for subjects who completed the study was 1.13 (1.01-1.27) and 1.12 (1.00-1.26), respectively. Similarly, among the dropouts, the SSR between the second and the first tertile was 1.28 (1.05-1.55) and 1.37 (1.13-1.66) between the third tertile and the first tertile. CONCLUSIONS: Line operators had more respiratory symptoms than non-exposed employees. This effect was significantly stronger in dropouts than in those who continued their jobs, indicating that there is a selection of subjects without respiratory symptoms in this industry.

Adult Daughters of Alcoholic Parents-A Qualitative Study of These Women's Pregnancy Experiences and the Potential Implications for Antenatal Care Provision.

The adult children of alcoholic parents are at increased risk of having health problems compared to the adult children of nonalcoholic parents. Little is known about how growing up with alcoholic parents affects women's experiences when pregnant. The objectives of this study were to explore how adverse childhood experiences related to parental alcohol abuse affect women during their pregnancy and to assess the potential implications of women's experiences for antenatal care provision. Twelve in-depth interviews were performed with women who were brought up by an alcoholic mother and/or father. Systematic text condensation was used to analyse the data. Two main categories were identified: 'establishing relationships and having social support' and 'antenatal care encounters and concerns during pregnancy'. Women's trust in others in adult life was impacted by their upbringing. Strained relationships with their parents and few friends meant that the women primarily relied on their partners for support. Neither antenatal care providers nor women talked about women's childhood experiences at the visits. The women described concerns related to the baby's health, lack of predictability and control during the pregnancy, as well as apprehensiveness regarding birth and motherhood. The potential implications for practice include systematic screening for adverse childhood experiences, antenatal preparation classes, parenting courses, and post-graduate training.

Prevalence of airflow limitation among employees in Norwegian smelters: a longitudinal study.

AIMS: To investigate the association between airflow limitation and occupational exposure and to compare a fixed limit with an age adjusted limit for airflow limitation. METHODS: 3924 employees in 24 Norwegian smelters and related workplaces were investigated annually over 5 years (n=16, 570) using spirometry and a respiratory questionnaire on smoking habits and job category. Employees working full time on the production line were classified as line operators; subjects who never worked on the production line were regarded as non-exposed. A job exposure matrix (JEM) was available in most smelters. Airflow limitation was expressed as (i) forced expiratory volume in 1 s/forced vital capacity (FEV(1)/FVC ratio) <0.7 and (ii) FEV(1)/FVC ratio less than the lower limit of normal (LLN). Longitudinal analyses on the prevalence of airflow limitation were performed using a generalised linear mixed model. RESULTS: The prevalence of airflow limitation was stable during follow-up. The OR of airflow limitation during follow-up was 1.24 (95% CI 1.03 to 1.50) in line operators compared with unexposed subjects for FEV(1)/FVC ratio <0.7 and 1.44 (1.14 to 1.81) for FEV(1)/FVC ratio

Dust exposure assessed by a job exposure matrix is associated with increased annual decline in FEV1: a 5-year prospective study of employees in Norwegian smelters.

RATIONALE: The relationship between dust exposure and annual decline in lung function among employees in the smelting industry is unknown. OBJECTIVES: The aim of the study was to investigate the relationship between annual change in lung function and occupational dust exposure among workers in 15 Norwegian smelters. METHODS: All employees (n = 2,620) were examined annually for 5 years (11,335 health examinations). At each examination spirometry was performed and a respiratory questionnaire was completed. The smelters were grouped as follows: (1) ferrosilicon alloys (FeSi) and silicon metal (Si-metal); and (2) silicon manganese (SiMn), ferromanganese (FeMn), and ferrochromium (FeCr). A job exposure matrix was available on the basis of 2,619 personal dust exposure measurements. The association between lung function expressed as FEV(1) and FVC per squared height (height(2)) and dust exposure was investigated using multivariate linear mixed model analyses. MEASUREMENTS AND MAIN RESULTS: The annual change in FEV(1)/height(2) (deltaFEV(1)) related to dust exposure in the FeSi/Si-metal and SiMn/FeMn/FeCr smelters was -0.42 (95% confidence interval, -0.95 to 0.11) and -1.1 (-2.1 to -0.12) (ml/m(2)) x (mg/m(3))(-1) x year(-1), respectively. The annual decline in FEV(1)/height(2) was 1.6 ml/m(2) (0.15 to 3.1) steeper in smokers than in nonsmokers. The median geometric mean of the time-weighted dust exposure concentration levels of the employees was 2.3 mg/m(3) in the FeSi/Si-metal smelters and 1.6 mg/m(3) in the SiMn/FeMn/FeCr smelters. Among nonsmokers, deltaFEV(1) was -0.86 (-1.6 to -0.10) and -1.1 (-2.5 to 0.25) (ml/m(2)) x (mg/m(3))(-1) x year(-1) in the FeSi/Si-metal and SiMn/FeMn/FeCr smelters, respectively. Thus, for a 1.80 m tall employee the annual decline in FEV(1) associated with average dust exposure was 5.7 ml/year in the SiMn/FeMn/FeCr smelters, and 6.4 ml/year for a nonsmoker in the FeSi/Si-metal smelters. CONCLUSIONS: In all smelters combined, the annual change in FEV(1) was negatively associated with increasing dust exposure. This association was also significant among workers in SiMn/FeMn/FeCr smelters and among nonsmokers in the FeSi/Si-metal smelters.

Incidence of airflow limitation among employees in Norwegian smelters.

We have investigated the association between the incidence of airflow limitation and occupational exposure. The employees (n = 3,924) were investigated annually during five years (n = 16,570) using spirometry. Exposure was classified using job category and a job exposure matrix. Airflow limitation was expressed using two indices: (i) as forced expiratory volume in one second/force vital capacity (FEV(1) /FVC) <0.7 and (ii) lower limit of normal (LLN). The incidence of airflow limitation was 21.2/1000 years(-1) and 15.1/1000 years(-1) using the fixed limit (0.7) and the LLN criterion, respectively. We found a dose-response relationship between the incidence of airflow limitation and tobacco consumption and with job-category in non-smokers. The associations between airflow limitation and covariates were independent of how airflow limitation was defined. The incidence of airflow limitation defined as FEV(l) /FVC <0.7 yielded higher incidence rates of airflow limitation than LLN. We found a significant association between the incidence of airflow limitation and occupational exposure in non-smokers.

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.

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

The MAMAACT intervention aimed to address ethnic and social disparity in stillbirth and infant health by improving management of pregnancy complications. This process evaluation of the intervention was guided by the British Medical Research Council's framework. We examined implementation through dose, reach, and fidelity, important mechanisms and the influence of contextual factors. The intervention included a six-hour training session for antenatal care (ANC) midwives in intercultural communication and cultural competence, two follow-up dialogue meetings, and health education materials (leaflet and app) on warning signs of severe pregnancy complications and how to respond for pregnant women. A mixed-methods approach was applied. Cross-sectional survey data and administrative data were used to assess intervention reach and dose. Qualitative data (records from dialogue meetings with midwives, participant observations and field notes from ANC visits, focus group interviews with midwives, and individual interviews with non-Western immigrant women) evaluated intervention fidelity, mechanisms, and contextual barriers. More than 80% of women received the MAMAACT leaflet and many found the content useful. The app was used more selectively. Midwives described being more aware and reflective in their communication with women from various cultural backgrounds. Organizational factors in ANC (time pressure, lack of flexibility in visits, poor interpreter services), barriers in women's everyday life (lack of social network, previous negative experiences/lack of trust and domestic responsibilities), and habitual interaction patterns among midwives served as contextual barriers. The reach of the intervention was high and it was evaluated positively by both pregnant women and midwives. Organizational factors hindered changes towards more needs-based communication in ANC potentially hindering the intended mechanisms of the intervention. When interpreting the intervention effects, attention should be drawn to both organizational and interpersonal factors in the clinic as well as the pregnant women's life situations.

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

In western countries, immigrant women have an increased risk of negative birth outcomes. Immigrant women's and maternity care system's delayed response to pregnancy complications contribute to ethnic inequities in reproductive health. The MAMAACT intervention was developed to improve midwives' and women's response to pregnancy complications in Denmark. The study examines the context of the implementation of the MAMAACT intervention and investigates how the intended intervention mechanisms regarding response to pregnancy complications were affected by barriers in non-Western immigrant women's everyday life situations. Twenty-one interviews with non-Western immigrant women were undertaken. Systematic text condensation and the situational-adaptation framework by Alonzo were used to analyze data. Four main categories were identified: 'Sources of knowledge during pregnancy', 'Containment of pregnancy warning signs', 'Barriers during the onset of acute illness' and 'Previous situations with maternity care providers'. Attention to potential pregnancy complications may conflict with immigrant women's everyday life situations and result in the containment of symptoms as well as causing delays in seeking medical assistance. It is probable that barriers in women's everyday life will impact the intended intervention mechanisms and thus the full potential of the intervention may not be reached.

"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.