Abstract

Objective

To explore Southern European immigrant mothers and fathers' experiences of reproductive health services in Norway, and their perceptions of health providers' beliefs and attitudes regarding pregnancy and childbirth.

Method

We employed a qualitative research methodology with two focus group discussions and 11 in-depth interviews with 4 fathers and 11 mothers from Italy, Spain, Portugal, and Greece, whose children were born in Norway. Thematic Analysis was conducted to identify and analyze patterns across the data.

Results

We identified three themes as key elements in parents' experiences: experiences with the coverage and organization of the Reproductive Health Services; relational experiences with health providers; and pregnancy and delivery as a culturally-shaped event. The immigrant parents experienced a clash between their expectations and the procedures and health facility environment encountered in Norway regarding check-ups, diagnosis tests, childbirth preparation courses, and health facilities. Informants perceived that the maternity care practices of the host country were underpinned by the health care providers' cultural understandings of labor and pregnancy. Particularly, they experienced a less interventionist approach towards pregnancy and childbirth.

Conclusions

The experiences of immigrant parents provide relevant information to improve reproductive health services in a cross-cultural context. Inmigration brings new challenges that must be addressed from a perspective of cultural competence. These services should acknowledge diversity in cultural beliefs around childrearing and involve both fathers and mothers in decision-making.

Keywords:
Qualitative research; Reproductive health services; Emigrants and immigrants; Culture; Obstetric delivery; Maternity

Resumen

Objetivo

Explorar cómo fueron las experiencias de padres y madres inmigrantes procedentes del sur de Europa al utilizar los servicios de salud reproductiva en Noruega, así como sus percepciones sobre las actitudes y las creencias del personal de salud con respecto al embarazo y el parto.

Método

Estudio cualitativo, basado en dos grupos focales y 11 entrevistas en profundidad con 4 padres y 11 madres italianos, españoles, portugueses y griegos, quienes habían tenido algún/a hijo/a en Noruega. Los datos se analizaron usando análisis temático.

Resultados

Emergieron tres temas: experiencias con la cobertura y la organización de los servicios de salud reproductiva; experiencias con profesionales de salud; y embarazo y parto como eventos culturales. Los padres y las madres inmigrantes experimentaron un choque entre sus expectativas y las prácticas de los servicios de salud reproductiva noruegos, especialmente en cuanto a consultas, procedimientos, pruebas diagnósticas, preparación para el parto e infraestructura sanitaria. Los informantes percibieron que las prácticas de los/las profesionales de los servicios de salud reproductiva están influenciadas por creencias culturales relacionadas con el embarazo y el parto en Noruega. En concreto, los informantes experimentaron un enfoque menos intervencionista al recibir los cuidados perinatales del personal de salud en Noruega.

Conclusiones

Las experiencias de los padres y las madres inmigrantes ofrecen información relevante para contribuir a mejorar los servicios de salud reproductiva en un contexto intercultural. La inmigración supone nuevos retos que deben afrontarse desde una perspectiva de competencia cultural. Los servicios de salud reproductiva deben reconocer la diversidad cultural en el embarazo y el parto, e involucrar a ambos progenitores.

Palabras clave:
Investigación cualitativa; Servicios de salud reproductiva; Emigrantes e inmigrantes; Cultura; Parto obstétrico; Maternidades

Introduction

Immigrant women are at risk of poorer maternal outcomes and inadequate prenatal care due to vulnerabilities associated with immigration like isolation, language barriers, and economic challenges.¹1. Lyberg A, Viken B, Haruna M, et al. Diversity and challenges in the management of maternity care for migrant women. J Nurs Manag. 2012;20:287-95.^,22. Heaman M, Bayrampour H, Kingston D, et al. Migrant women's utilization of prenatal care: a systematic review. Matern Child Health J. 2013;17:816-36. When immigrant women navigate reproductive health services (RHS) in a new country, they deal with cultural beliefs concerning pregnancy and childbirth that are different from those of their home countries and lack of information about the services.³3. Fair F, Raben L, Watson H, et al. Migrant women's experiences of pregnancy, childbirth and maternity care in European countries: a systematic review. PloS One. 2020;15:e0228378. However, the risk of poor pregnancy outcomes is lower in countries with policies that offer immigrants new opportunities within the RHS.⁴4. Bollini P, Pampallona S, Wanner P, et al. Pregnancy outcome of migrant women and integration policy: a systematic review of the international literature. Soc Sci Med. 2009;68:452-61.

In Norway, the immigrant community has grown and now accounts for 14.7% of the population.⁵5. Statistics Norway. Population: Immigrants and Norwegian-born to immigrant parents; 2020 (Accessed September 2020). Available at: https://www.ssb.no/en/innvbef
https://www.ssb.no/en/innvbef... Despite having declined significantly, immigrants' fertility rate is higher than that of ethnic Norwegians, contributing to an increase of the total fertility rate.⁶6. Statistics Norway. Decline in fertility for immigrant women; 2019 (Accessed September 2020). Available at: https://www.ssb.no/en/befolkning/artikler-og-publikasjoner/decline-in-fertility-for-immigrant-women
https://www.ssb.no/en/befolkning/artikle... All pregnant women in Norway are entitled to free maternity care from the maternal and child health centers, which usually consist of eight antenatal appointments and an ultrasound between weeks 17-19. Birth preparation courses are arranged by maternal and child health centers or hospitals with local variations. Some municipalities offer free courses, whereas in others parents-to-be have to pay a course fee.

Few studies have explored immigrant women's experiences with the Norwegian RHS, most of which focus primarily on women from non-western countries, who have been found to have a greater risk of childbirth complications.⁷7. Vangen S, Johansen REB, Sundby J, et al. Qualitative study of perinatal care experiences among Somali women and local health care professionals in Norway. Eur J Obstet Gynecol Reprod Biol. 2004;112:29-35.^,88. Vangen S, Stoltenberg C, Stray-Pedersen B. Complaints and complications in pregnancy: a study of ethnic Norwegian and ethnic Pakistani women in Oslo. Ethnicity Health. 1999;4:19-28. The literature provides insight about the challenges of cross-cultural RHS in Norway, pointing at a lack of social support and knowledge about RHS as factors that reinforce immigrant women's insecurity about pregnancy and childbirth.¹1. Lyberg A, Viken B, Haruna M, et al. Diversity and challenges in the management of maternity care for migrant women. J Nurs Manag. 2012;20:287-95. These factors challenge also immigrant women's ability to assess the advice they receive from midwives, which reinforce unequal status between parties in the antenatal consultations.⁹9. Haaland MES. Demanding communication about pregnancy and childbirth - On the guidance of immigrant women at a Norwegian Maternity and Child Health Center. Norsk Antropologisk Tidsskrift. 2016;27:192-208.

Although the Norwegian authorities have developed policies and protocols regarding antenatal and postnatal care to ensure equal access to healthcare,¹⁰10. Norwegian Directorate of Health. Health Directorate. New life and safe maternity time for the family. National professional guidelines for maternity care. Norwegian Directorate of Health; 2014 (Accessed September 2020). Available at: https://bityli.com/dclegB
https://bityli.com/dclegB...

11. Lov om pasient- og brukerrettigheter (pasientrettighetsloven). [The Act of 2 July 1999 No. 63 relating to Patients' Rights (The Patients' Rights Act)]. 1999. (Accessed September 2020). Available at: http://www.lovdata.no/all/hl-19990702-063.html. (English version available at: http://www.ub.uio.no/ujur/ulovdata/lov-19990702-063-eng.pdf).
http://www.lovdata.no/all/hl-19990702-06... ^-1212. The Directorate for Health and Social Affairs. A national clinical guideline for antenatal care, Short Version; 2005 (Accessed September 2020). Available at: https://www.helsedirektoratet.no/publikasjoner/national-clinical-guideline-for-antenatal-care-short-version/Publikasjoner/Inational-clinical-guideline-for-antenatal-care-short-version.pdf
https://www.helsedirektoratet.no/publika... the Ministry of Health has stated that more knowledge is needed from immigrants' perspectives about their experiences and expectations on RHS.¹³13. Regjeringen.no. Likeverdige helse- og omsorgstjenester- god helse for alle. Nasjonal strategi om innvandreres helse 2013-2017. [Equal health and care services- good health for all. National strategy on immigrant health. From 2013 to 2017]. 2013. (Accessed September 2020). Available at: https://www.regjeringen.no/no/id4/.
https://www.regjeringen.no/no/id4... Moreover, despite the positive outcomes of fathers' involvement in RHS,¹⁴14. Sarkadi A, Kristiansson R, Oberklaid F, et al. Fathers' involvement and children's developmental outcomes: a systematic review of longitudinal studies. Acta Paediatr. 2008;97:153-8. research has neglected male experiences with RHS. Our study seeks to fill this gap by exploring the experiences of Southern European parents with the Norwegian RHS, and their perceptions of health providers' beliefs and attitudes regarding pregnancy and childbirth.

Methods

Study setting and sample

This study is part of a project on the experiences of Spanish, Italian, Greek and Portuguese immigrant parents of raising their children and encountering welfare institutions in Norway.¹⁵15. Herrero-Arias R, Ragnhild H, Haldis H. Self-legitimation and sense-making of Southern European parents' migration to Norway: the role of family aspirations. Population, Space and Place. 2020:e2362. Southern Europe was hardly hit by the 2008-financial recession that triggered South-to-North intra-European migration.¹⁶16. Lafleur JM, Stanek M, Veira A. South-North labour migration within the crisis-affected European Union: new patterns, new contexts and new challenges. South-North migration of EU citizens in times of crisis. Cham: Springer; 2017, p. 193-214. Spaniards comprise the largest Southern European group in Norway (6,211 people in 2018), followed by Italians (4,315), Portuguese (3,218) and Greeks (2,828).¹⁷17. Statistics Norway. Immigrants and Norwegian-born to immigrant parents; 2018 (Accessed September 2020). Available at https://www.ssb.no/en/befolkning/statistikker/innvbef
https://www.ssb.no/en/befolkning/statist...

Informants were recruited through the first author's attendance to events organized by the Southern European communities in Norway, snowballing,¹⁸18. Biernacki P, Waldorf D. Snowball sampling: problems and techniques of chain referral sampling. Sociol Meth Res. 1981;10:141-63. and advertising in Facebook groups used by immigrants. The sample consisted of 15 Southern European parents (11 mothers and 4 fathers; 4 of which were married) who had experiences with the Norwegian prenatal care (n=15), and childbirth and postnatal care (n=13) (Table 1).

Data collection and analysis

Data were collected in Norway in 2017. Two focus group discussions (FGD) were conducted at a university setting in west Norway. One FGD was conducted in English with six mothers (two Italians, two Spaniards and two Greeks) who had lived in Norway for more than 5 years. The second FGD was conducted in Spanish with four Spanish mothers who had migrated less than 5 years ago. The first author, a Spanish researcher, moderated the FGDs assisted by another Spanish doctoral candidate who took notes, audio-recorded each session, and helped facilitate the discussion. FGD participants were asked about experiences of mothering and their meeting with Norwegian institutions.

Eleven semi-structured interviews were conducted with eight Southern European mothers and four Southern European fathers. Most were one-on-one interviews (n=10), with one interview carried out with a couple (n=1). These were held in English (n=4) or Spanish (n=7) at a place of the interviewee's choosing, which included their workplaces, homes, a café, or the University. Five of the interviewees had participated in the FGDs and were invited to be interviewed because they were women with Norwegian partners, which was considered a factor shaping their experiences of mothering in a new country. The first author conducted all the interviews using an interview guide that contained exploratory questions around the themes of family backgrounds, life transitions, life in Norway, and parenthood. Interviews lasted between 75 and 120minutes and were digitally recorded. The first author transcribed the data verbatim.

Data were coded using NVivo12 software and analysed thematically following Braun and Clarke's model.¹⁹19. Braun V, Clarke V. Using thematic analysis in psychology. Qual Res Psychol. 2006;3:77-101. The first author became immersed in the data, and inductively coded the dataset. Next, codes were arranged into initial themes and subthemes. The initial themes were reviewed against the dataset and reformulated considering the literature. This resulted in the definition of the final themes and subthemes. Finally, a report narrating the themes including quotes was discussed with the co-authors.

Ethics

Ethical approval was obtained from the Norwegian Data Protection Official. Written informed consent was provided by informants prior to data collection. During the FGDs, the first author highlighted the importance of respecting others' opinions, and informants and co-moderator signed a non-disclosure agreement. To ensure confidentiality and anonymity, we have omitted details about informants' personal situations, and quotations are presented anonymously.

Results

Three themes related to parents' experiences with RHS emerged: 1) coverage and organization of RHS; 2) relational experiences with health providers; and 3) pregnancy and delivery as a culturally-shaped event. Within each theme, the following subthemes were identified:

Coverage and organization of RHS (Table 2)

1) Check-ups, tests, and courses

Informants shared that they received fewer antenatal checks and ultrasounds than they expected. Their perceptions that RHS had limited coverage were based on their comparisons between their experiences with these services and the experiences of friends or relatives who were pregnant in their countries of origin, who received more tests (Q4, Q5). Two informants also compared their own experiences with the Norwegian RHS and those from their countries of origin (Q5, Q6). Regarding childbirth preparation courses, informants shared their perceptions that these were not free of charge (Q3, Q7, Q8). Only one informant, who worked in healthcare and had an extended social network in Norway that included his in-law family, satisfactorily attended to a preparation course (Q7).

Informants' experiences of a mismatch between their expectations and the care received brought feelings of fear and dissatisfaction (Q1, Q2, Q3, Q9). They expressed feeling insecure about the fetus' health because the monitoring was not enough and it was not adequate. Among the reasons they gave to the limited monitoring were economic (Q3), moral (Q2), and cultural (last theme).

2) Professionals in charge

Informants expressed surprise at finding out that nurse-midwives were responsible for prenatal check-ups, unlike in their countries of origin where gynecologists are the main professional providing antenatal care (Q10). This was accompanied by insecurity towards the attention a midwife could provide (Q11).

3) Procedures and health facility environment

Informants perceived that the procedures and technology employed during prenatal check-ups were different from those used in Southern Europe. In Norway, immigrant parents encountered non-invasive medical devices that are used because they do not interfere as much with the physiological process of childbearing. However, informants perceived this was out-of-date technology unable to provide an accurate diagnosis (Q12-Q14).

The immigrant parents in our study described the facilities used for labor and delivery in Norway through comparisons with those of Southern Europe, where the mother-to-be is moved from a labor to a delivery room. To their surprise, once admitted in the hospital, they were placed in a birthing-room that was equipped with all that was needed to assist the labor (Q15, Q16). Negative assessments of postnatal facilities were more common in the accounts of mothers who recovered from a C-section in a shared room with limited visitation rights. Being alone in an unfamiliar place brought feelings of stress and fear (Q17, Q19). Parents who experienced a normal birth were admitted in the “birth-hotel”, a building connected to the hospital. Informants shared positive experiences with this facility that promotes closeness among the family (Q17, Q18).

Experiences with health providers (Table 3)

1) Decision-making

Informants' accounts regarding the degree of decision-making experienced in the context of RHS were diverse. Some highlighted that it was easy to engage in collaborative relationships with health providers. This was contrasted to Southern Europe, where parents-to-be are treated in a more paternalistic manner. This resulted in informants attributing the success of their childbirth experiences to health providers' attitudes, which were characterized by respect for the women's wishes (Q23, Q24). However, some perceived that the Norwegian health providers' favorable attitudes towards vaginal birth could be an obstacle for good communication. These informants agreed that vaginal delivery is better than a C-section. However, in case of childbirth complications, they were worried that health providers would not listen to their opinions about the need for an emergency C-section and the risks of prolonged labor (Q27).

Informants discussed their decision-making experiences around being admitted to the childbirth facilities. For them, it was a “shock” that when the woman was in labor, she was expected to call the hospital and be guided about the steps to take from home. Based on their experiences with healthcare services in Southern Europe, informants wanted to be admitted to the hospital and monitored from the beginning of the labor. Their experiences of being sent back home or told to stay at home brought fear and stress (Q25, 26). This extended to breastfeeding, where we found different accounts for the degree of decision-making experienced. While some mothers experienced health providers' focus on breastfeeding as pressure (Q20), others, who had always been willing to breastfeed, reported feeling supported by the health providers in their decision (Q20-Q22).

2) Quality of the care received

Informants positively assessed the treatment received from health providers during pregnancy, especially when professionals explained why there were not as many ultrasound scans as expected (Q35). Regarding their experiences of childbirth, the majority highlighted that health providers were caring and psychologically supportive (Q29-Q34). Mothers who had a C-section and were admitted in a shared room without their partners shared less positive experiences. They complained about health providers who approached them to check their milk production (Q28) and seemed to care more for the baby than for them (Q36).

Pregnancy and delivery as a culturally-shaped event (Table 4)

1) Pregnancy as a culturally-shaped event

To make sense of their experiences with Norwegian RHS, informants reflected on the cultural understandings around pregnancy they perceived as dominant in the country. The immigrant parents in our study discussed that fewer monitoring was the result of a less interventionistic healthcare system that understands pregnancy as a natural experience (Q37-Q40). They reflected on the more paternalistic and interventionistic approach towards pregnancy that characterises Southern European healthcare systems. Informants discussed that in these countries, pregnancy was understood as a life disruption (Q41, Q42). On the contrary, based on their experiences with employers and professionals, they perceived that pregnancy was constructed as a positive experience in Norway. Informants discussed that, framed by these cultural understandings, Norwegian health providers would guide, not monitor, the parents-to-be.

2) Delivery as culturally-shaped event

Informants discussed that childbirth in Norway was framed by a cultural understanding of delivery as a natural and beautiful experience to be shared with family (Q43-Q47). They shared that in the host country there is a belief in the capacity of the human body to recover from physical difficulties, which shapes RHS provision and organization.

Discussion

The findings identified main themes regarding how immigrant parents perceived and experienced childbirth in Norway. First, informants portrayed Norway as an unfamiliar place to give birth. In this regard, informants' immigrant-status can be a source of their vulnerability to experience environmental stressors. The lack of knowledge about the RHS and of social support might have hindered immigrant parents from feeling safe in the environment where they became parents. Particularly, informants' experiences were influenced by factors like support from social networks and partner presence during childbirth.²⁰20. Aune I, Marit Torvik H, Selboe ST, et al. Promoting a normal birth and a positive birth experience - Norwegian women's perspectives. Midwifery. 2015;31:721-7.^,2121. Dahlberg U, Aune I. The woman's birth experience - the effect of interpersonal relationships and continuity of care. Midwifery. 2013;29:407-15. Informants stressed how much they missed sharing their experiences with their families, which shows how social networks influenced their childbearing and childbirth experiences.³3. Fair F, Raben L, Watson H, et al. Migrant women's experiences of pregnancy, childbirth and maternity care in European countries: a systematic review. PloS One. 2020;15:e0228378.

Secondly, most informants did not take any birth preparation courses because they assumed these were not free of charge in Norway. This shows their lack of knowledge about the services, which may have been reinforced by their reported feelings of isolation. An extensive social network would have helped them to navigate the health system, including getting accurate information and the support that expecting parents need. Research shows that antenatal preparation and access to information about childbirth promote positive experiences.²⁰20. Aune I, Marit Torvik H, Selboe ST, et al. Promoting a normal birth and a positive birth experience - Norwegian women's perspectives. Midwifery. 2015;31:721-7. These courses help expecting parents to make friends,²²22. Nolan ML, Nolan V, Mason V, et al. Making friends at antenatal classes: a qualitative exploration of friendship across the transition to motherhood. J Perinat Educ. 2012;21:178-85. which can be especially valuable for immigrants' integration in a new country.

Thirdly, we found mixed experiences of satisfaction with RHS. Dissatisfaction was prompted by how informants' expectations of the services and the actual experience differed. This despite that Norwegian antenatal guidelines are in line with the World Health Organization's recommendation of a minimum of eight antenatal consultations.²³23. World Health Organization. WHO Recommendations on intrapartum care for a positive childbirth experience. World Health Organization; 2018 (Accessed September 2020). Available at: https://www.who.int/publications/i/item/9789241550215
https://www.who.int/publications/i/item/... Based mostly on experiences that their friends and family had in Southern Europe, informants formed their expectations about antenatal care.²⁴24. Fenwick J, Hauck I, Downie J, et al. The childbirth expectations of a self-selected cohort of Western Australian women. Midwifery. 2005;21:23-35. These expectations reinforced their dissatisfaction with the Norwegian RHS, which they assessed as deficient. Dissatisfaction with RHS was more common in the accounts of women who were afraid of long labor and had expectations about the possibility to have a C-section. When such expectations were not met by health providers, they felt abandoned and dissatisfied. This is consistent with research showing that powerlessness during childbirth is associated with negative experiences.²⁵25. Cheung W, Chan WY, Dominic H. Maternal anxiety and feelings of control during labour: a study of Chinese first-time pregnant women. Midwifery. 2007;23:123-30. On the contrary, a woman's acceptance of pain and positive perception of her ability to give birth promotes positive childbirth experiences.²⁶26. Berentson-Shaw J, Scott KM, Jose PE. Do self-efficacy beliefs predict the primiparous labour and birth experience? A longitudinal study. J Reprod Infant Psychol. 2009;27:357-73. A Norwegian study similarly found that women who understood pain as a natural component of childbirth were more likely to experience childbirth positively.²⁰20. Aune I, Marit Torvik H, Selboe ST, et al. Promoting a normal birth and a positive birth experience - Norwegian women's perspectives. Midwifery. 2015;31:721-7. Childbirth preparation should be thus available and incorporate a natural vision on childbirth that helps women to understand its physiology.

Regarding positive experiences with RHS, consistent with previous studies,²⁷27. Bylund CL. Mothers' involvement in decision making during the birthing process: a quantitative analysis of women's online birth stories. Health Commun. 2005;18:23-39. informants highly valued mothers' involvement in childbirth. Furthermore, they emphasized the caring attitude of health providers as a factor that brought satisfactory experiences. This shows how interpersonal relations that incorporate emotional needs foster satisfaction.²³23. World Health Organization. WHO Recommendations on intrapartum care for a positive childbirth experience. World Health Organization; 2018 (Accessed September 2020). Available at: https://www.who.int/publications/i/item/9789241550215
https://www.who.int/publications/i/item/... As for the health facilities, informants who were admitted to the birth-hotel shared positive opinions regarding the family-oriented and non-medicalized environment. This resonates with research that stressed the importance of a warm environment promoting humanized care in RHS.²⁸28. Santos de Oliveira P, Menezes Couto T, Pereira Gomes N, et al. Best practices in the delivery process: conceptions from nurse-midwives. Rev Bras Enferm. 2019;72:455-62.

Our informants' experiences with RHS were shaped by the dissonance between their expectations, which were bounded by their own culture, by the experiences of others back home, and by the services provided in Norway. The clashes that these immigrant parents felt reflect how cultural understandings of the body informs and shapes RHS, including the use of technology, the relationship between provider and patient, and the experience of giving birth in a health facility. Informants identified a predominant trust in the body's capacity to give birth in Norway. Based on this, they perceived that women receive the support they need to cope with the physiological process of childbirth through the midwifery system. This contrasts to the experiences that others from their countries of origin shared, where women are treated as patients who need an intervention.

Southern European societies hold a natural view on childbearing that has not been successfully reflected in their RHS.²⁹29. Emons JK, Luiten MIJ. Midwifery in Europe: an inventory in fifteen EU-member states. Deloitte & Touche; 2001 (Accessed September 2020). Available at: http://www.deloitte.nl/downloads/documents/websitedeloitte/GZpublVerloskundeinEuropaRapport.pdf
http://www.deloitte.nl/downloads/documen... This is manifested in the high numbers of C-sections, in the important place that gynecologists are awarded in the antenatal care process, and in the competition between these professionals and midwives.²⁹29. Emons JK, Luiten MIJ. Midwifery in Europe: an inventory in fifteen EU-member states. Deloitte & Touche; 2001 (Accessed September 2020). Available at: http://www.deloitte.nl/downloads/documents/websitedeloitte/GZpublVerloskundeinEuropaRapport.pdf
http://www.deloitte.nl/downloads/documen... This context influenced our informants' expectations of being assisted by gynecologists who would use state-of-the-art tests and machines. Informants expressed disdain for the ‘old-fashion' techniques prevalent in Norway and felt uneasy about the scarce use of tests. This is in line with a Spanish study that found that women see RHS technology as a source of security.³⁰30. Goberna-Tricas J, Banús-Giménez MR, Palacio-Tauste A, et al. Satisfaction with pregnancy and birth services: the quality of maternity care services as experienced by women. Midwifery. 2011;27:e231-7. However, changes have been implemented to Southern European RHS since our informants emigrated. Research shows that efforts towards the de-medicalisation of RHS have resulted in a transformation of attitudes and practices in Spain, and that these new policies were met with strong resistance, particularly in areas like decision-making and risk-management.³¹31. Benet M, Escuriet R, Alcaraz-Quevedo M, et al. The extent of the implementation of reproductive health strategies in Catalonia (Spain) (2008-2017). Gac Sanit. 2020;33:472-9.

The limitations of the study include that one FGD and seven interviews were conducted in English, which was not informants' native language. Moreover, fathers were underrepresented in the sample and we did not have a large enough number of informants from each country, which was a limitation for the analysis. Regarding data saturation, no new information related to experiences of RHS were observed after coding nine interviews. The first author's insider position facilitated the collection of rich data but it might have brought possible bias to the analysis. To minimize this, the co-authors, with different personal and professional backgrounds, participated in the formation and discussion of the themes.

A larger study would benefit from interviewing both immigrant parents and health providers about their experiences with RHS. Likewise, further research should include Southern European immigrants with recent experiences with the RHS from their countries of origin. The recent efforts to de-medicalize childbirth in these countries may result in fewer experiences of a cultural clash. In any case, our study provides relevant insights into immigrants' experiences with RHS in a new country and how these are shaped by experiences and expectations formed in a complex context.

Conclusion

The findings suggest that developing culturally competent healthcare systems and interventions is needed to address disparities in healthcare access and utilization between immigrants and nationals. Individuals experience and understand childbearing framed by cultural beliefs. Healthcare providers need to problematize their cultural understandings, the methods and organization of RHS to avoid taken-for-granted assumptions. Acknowledging differences in approaches towards childbearing would set the stage for collaboration between users and providers.

References

Publication Dates

History