Towards equitable maternity care : Exploring access to fetal movement care among migrant women in Sweden

In Sweden, women who have migrated to Sweden have, compared to women born in Sweden, higher risks of adverse birth outcomes related to decreased fetal movements, such as intrauterine growth restriction and stillbirth. Fetal movement information is integrated into the Swedish antenatal care programme and women are encouraged to seek care if they perceive that the movements decrease in strength or frequency. There are disparities regarding how often women seek care for decreased fetal movements based on their country of birth and level of education. Women born in Sweden and those with higher education levels are more likely to seek care compared to women born in Sub-Saharan Africa and those with lower education levels. This thesis aimed to explore access to fetal movement care among migrant women in Sweden, with a particular focus on Swedish-Somali migrant women. Study I explored Swedish-Somali migrant women’s experiences of fetal movement awareness through individual interviews (n=15). In Study II, interviews with midwives (n=15) about providing fetal movement information to migrant women were conducted. Study III, a retrospective cohort study based on registry data encompassing 18,791 women, examined the impact of the Covid-19 pandemic on women’s healthcare contacts for decreased fetal movements in Region Stockholm. Study IV, a non-randomised intervention study with a control group, including 2,806 women, used registry data to assess the effect of a modified Mindfetalness-based intervention specifically aimed at Swedish-Somali migrant women on birth outcomes. Study I and II found that migrant women encounter barriers on both individual and structural levels when accessing information and care related to fetal movements. Continuity of care was essential to building trust between the woman and midwife, overcoming communication gaps, and safeguarding maternal and fetal well-being. Study III showed that, overall, healthcare contacts for decreased fetal movements remained consistent before and after the onset of the Covid-19 pandemic. However, for women with a BMI ≥ 30.0, the rate of contacts declined following the onset of the pandemic, while for Swedish-born women, those with a university-level education, and students, the rate of healthcare contacts increased. Study IV did not find statistically significant differences in the primary outcome, Apgar score below10 at five minutes, between the intervention and control groups. However, women who participated in the intervention had significantly higher rates of spontaneous vaginal births compared to women in the control group. Migrant women’s awareness of fetal movements and their decision to contact healthcare for this complication are influenced by both individual, structural and contextual factors. The findings from this thesis highlight systemic inequities within the Swedish maternity healthcare system that create barriers for migrant women regarding access to fetal movement care. Addressing these barriers requires improved communication strategies and support for midwives to provide individualised care. When designing interventions aimed at improving birth outcomes, it is important to consider both demographic data and the prevalence of risk factors within the target population. To understand an intervention’s broader implications, it is essential to involve stakeholders throughout the study process, from designing the intervention to evaluating its outcomes.