Effectiveness evaluation of an antenatal care intervention addressing disparities to improve perinatal outcomes in Denmark: A nationwide register-based analysis of a cluster randomised controlled trial (MAMAACT).

OBJECTIVE: To evaluate whether MAMAACT, an antenatal care (ANC) intervention, aimed at reducing ethnic and social disparities in perinatal mortality, affected perinatal health outcomes. DESIGN: Cluster randomised controlled trial. SETTING: Nineteen of 20 maternity wards in Denmark. POPULATION: All newborn children within a pre-implementation period (2014-2017) or an implementation period (2018-2019) (n = 188 658). INTERVENTION: A 6-h training session for midwives in intercultural communication and cultural competence, two follow-up dialogue meetings, and health education materials for pregnant women on warning signs of pregnancy complications in six languages. METHODS: Nationwide register-based analysis of the MAMAACT cluster randomised controlled trial. Mixed-effects logistic regression models were used to estimate the change in outcomes from pre- to post-implementation in the intervention group relative to the control group. Results were obtained for the overall study population and for children born to immigrants from low- to middle-income countries, separately. Models were adjusted for confounders selected a priori. MAIN OUTCOME MEASURES: A composite perinatal mortality and morbidity outcome, including stillbirths, neonatal deaths, Apgar score <7, umbilical arterial pH < 7.0, admissions to a neonatal intensive care unit (NICU) >48 h, and NICU admissions for mechanical ventilation. Additional outcomes were the individual measures. RESULTS: The intervention increased the risk of the composite outcome (adjusted odds ratio [aOR] 1.16, 95% confidence interval [CI] 0.99-1.34), mainly driven by differences in NICU admission risk (composite outcome excluding NICU, aOR 0.98, 95% CI 0.84-1.14). The intervention slightly increased the risk of low Apgar score and decreased the risk of low arterial pH, reflecting, however, small differences in absolute numbers. Other outcomes were unchanged. CONCLUSIONS: Overall, the MAMAACT intervention did not improve the composite perinatal mortality and morbidity outcome (when excluding NICU admissions). The lack of effects may be due to contextual factors including organisational barriers in ANC hindering the midwives from changing practices.

Knowledge About How to Manage Warning Signs of Pregnancy Complications Among Immigrants and Their Descendants Compared to Women of Danish Origin.

OBJECTIVES: Ethnic differences in perinatal morbidity and mortality are starting points for social inequality in health. Increased incidence and severity of some pregnancy complications are found among immigrant women compared to ethnic majority women in high-income settings. However, little is known about immigrant women's assessment and management of warning signs. We aimed to assess women's knowledge about how to manage warning signs of pregnancy complications among immigrants and their descendants compared to women of Danish origin. METHODS: A cross-sectional study including phone-based interviews with 1899 women. Women were interviewed during gestational week 30-37 in one of six languages. Maternal ethnicity was categorized as; immigrants, their descendants and ethnic Danes. The outcomes were yes or no to; do you know what to do if you experience 1) sudden swelling, redness, and heat in one leg 2) severe headache and 3) vaginal bleeding. RESULTS: Immigrant women had lower levels of knowledge about how to manage all three types of warning signs of pregnancy complications compared to women of Danish origin. Adjusted OR for vaginal bleeding for women of European (4.33, 95% CI: 2.24-8.37), Asian (9.26, 95% CI: 5.10-16.83) and African (8.66, 95% CI: 3.26-23.05) origin. CONCLUSIONS FOR PRACTICE: Immigrant women had lower levels of knowledge about how to manage warning signs of pregnancy complications compared to women of Danish origin. Improved needs-based health education in pregnancy complications and body symptoms during antenatal care is needed to address delays in the management of complications and could potentially improve the health of women and children.

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.

Social and ethnic disparities in stillbirth and infant death in Denmark, 2005-2016.

Ethnic disparity in stillbirth and infant death has been demonstrated in Europe. As the relation between migration and health change over time, this population based register study investigated the recent figures and explored if potential differences could be explained by the well-known educational and income inequalities in stillbirth and infant death using a novel approach. Stillbirth and infant mortality varied considerably according to country of origin, with only immigrants from China, Norway, and Poland having an overall lower risk than Danish women. Women of Pakistani, Turkish, and Somali origin had a particularly high risk of both outcomes. Women from recent high conflict areas displayed a pattern with increased stillbirth risk. An observed excess risks across generations was found, which is disturbing and rule out factors related to language barriers or newness. Differences in educational level and household income explained only part of the observed inequalities. Strengthening of the maternity care system to better understand and meet the needs of immigrant women seems needed to mitigate the disparities.

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.