The findings below illustrate how the women’s experiences of being refugees and their backgrounds and life situations impacted their pregnancy, birth and postpartum experiences, particularly in relation to their access to and use of maternal healthcare services. The cross-cutting issues of language, social support, and unfamiliarity with healthcare services were evident throughout pregnancy, birth and postpartum.
The role of intersecting identities in shaping maternal healthcare needs
The women came from different countries and had diverse migration experiences, life situations, and backgrounds which impacted their access and utilization of maternal healthcare services. Most were either pregnant upon arrival in Norway or within the first year. Some had formal education, while others were illiterate. Some had travelled with families, others arrived alone, or with their children. Many had prior pregnancy experiences, and a few had experienced stillbirths. Upon arrival in Norway, the women were required to participate in the Introduction Program for Refugees. Being pregnant during the introduction program and managing multiple roles in the household such as being the main caretaker of the children often resulted in the women having to take sick leave or to quit the course altogether. As one mother of seven children explained:
I was three months pregnant. I was so tired and exhausted. I just wanted to sleep. I did not manage to have control over my body. I was so tired. That is why I needed sick leave from the Introduction Course. It was just so heavy. Getting the children to school, getting myself ready, rushing home after classes, make dinner…So it was hard. (Participant 5).
It was crucial for the women who did not have any formal education to attend the courses during pregnancy despite lack of sleep and the double burden of household chores. They shared that although learning a new language was challenging, it is a necessity for managing daily life in Norway:
You are deaf without language. The first thing I tell women when I meet them here at the Women’s Organisation is, ‘do not get pregnant before you learn the language.’ When I look back at the time when the kids were young, I find it very challenging, like wow, it has not been easy to live in a new country. (Participant 8).
In contrast, the findings indicated that the women who had higher education before coming to Norway tended to become pregnant later, usually after a few years. They initially continued their education, and learnt Norwegian through education, job training and social networks. As most of the women did not have networks upon arriving in Norway, they expressed that being away from family during pregnancy added extra emotional strain:
Many get depressed and are very lonely. You do change a lot during a pregnancy. Maybe you have a lot of children at home also. It is tough. You need someone who can be with you and support you during pregnancy. Even though you have a husband, you do not necessarily have your family around you. I have no family here. (Participant 8).
For the ones who had stayed longer in Norway before getting pregnant, the dependency on social networks was important during pregnancy. However, despite having a social network, being pregnant and not having family around was still an emotional strain.
Experiences of structural inequities in maternal healthcare services
The women’s stories indicate that the maternal healthcare services did not consider the women’s different experiences and identities, leading to misconceptions, insecurities and trust issues when encountering the maternal healthcare system. Many of the women shared that their first point of contact during pregnancy was with a general practitioner, as they were unaware of the maternal healthcare clinics and the services they provide. Once referred to these clinics, the women generally expressed that the care provided by the midwives was good, and they valued being closely followed up during pregnancy. However, on sharing their experiences of the visits, they highlighted various barriers such as access and lack of interpreters during appointments:
My first challenge was that I did not have the language skills. When I had an appointment with a midwife, I could sometimes not go to the appointment. I had to call someone I knew to see if they could join me, or someone who knew English who could join. Going to the midwife was also very difficult. We do not know the area, so we were very dependent on a contact person who could drive us back and forth. (Participant 2).
The women expressed that not being able to communicate or receive information in their native language was difficult. Most of the women also shared that the information and support they sought during their pregnancies, was provided through informal networks, such as social media or people from their countries of origin.
If you do not have the language, you are unable to search online for information, travel to the healthcare facilities, call the midwife to get easier access to services. The knowledge the women have about the system is often not because they asked health personnel, but because friends told them. I tell them that they need to ask the midwife because that information is often better. (Participant 7).
Inconsistency in the use of interpreters was also an issue highlighted by the women, with some saying that they had an interpreter for some of the appointments, while others had none. However, they shared that they rarely had in person interpretation, it was mostly conducted remotely over the phone. Some of the women’s concerns when preparing for birth indicate inadequate support from the maternal healthcare services:
The fear… I started to dread giving birth. It has given me great worries. I thought about the consequences if something were to happen to me during birth. I also worried about who would take care of my children when I was giving birth. What happens after birth? So that time during pregnancy was mixed with stress, sadness, and worries. I had no one to talk to about these feelings. (Participant 5).
For some of the women, meeting a support person before birth was crucial and helped them to feel more secure during pregnancy and preparing for birth at the hospital. One woman met a person who worked as a Multicultural Doula at an Eid party and was eager to get this support. She was not aware that this support was free of charge and available but felt very relieved when she managed to get it:
I felt safe with this support. When the Multicultural Doula came with me to appointments, I then got the support I needed…I have told all my friends who are pregnant about this support, as they do not know about it. I have told them that they need to ask for it. (Participant 5).
When it came to giving birth, the women experienced similar challenges with maternal healthcare services as during pregnancy. Although the women came from countries where the maternal healthcare services might not have been as comprehensive as those in Norway, they had the security of family support during birth. Many of the women became pregnant within a year of arriving in Norway, they had not been in a Norwegian hospital before and felt insecure about the system. They recounted their previous birthing experiences and shared how they had missed having someone to support them:
I will never forget the day I was going to the hospital to give birth. We have as a tradition that your mother or mother in-law, sister or other relatives will come with you. I had to go to the hospital by myself as my husband had to stay at home with the children. (Participant 2).
It was painful for them to look back on those experiences:
When I think back at the time when I was going to give birth after arriving in Norway, I get back some of the feelings like the pain you know. Every time I meet someone who is pregnant, it reminds me of the painful experience I had. (Participant 2).
As one woman shared, having had difficult births experiences when she was very young in her home country, such as stillbirth, the support of someone she could trust during childbirth helped her feel more comfortable and safer:
One day I met a lady, she was from the same country as me, and she said, ‘does your mother live here?’ I said ‘no, I live alone’. She told me that if I needed help, I should call her. She was with me when I was about to give birth. I didn’t want to have a C-section. Only if she was there. (Participant 9).
Language was a significant issue for most of the women during birth as many of them did not speak Norwegian or English. Having an interpreter was important to help them express their needs, ask questions, and understand the information provided. However, what came through in many of the women’s stories was that they did not get this service, or it was inconsistent. This resulted in the women feeling nervous and anxious:
I was in the hospital for three days. They would come in and ask me things, but I didn’t understand anything. I got scared [woman shows with hand movements that her heart was beating] when the doctor came into the room. (Participant 9).
The lack of communication in their native language resulted in many of the women not knowing what was happening:
The day after giving birth, I thought there was something wrong with the baby since I had to go to the doctor for a check-up. I did not know what it was. No one was talking to me, so I did not know what was going on. (Participant 10).
While the birth experiences in Norway highlighted significant challenges related to social support and language, these challenges continued to influence the women’s postpartum care experiences. Home visits from a midwife are an important aspect of postpartum care in Norway, and yet many of the women were not aware of this service. Most of them were pleased with the home visits after giving birth. However, many did not know beforehand what the home visits entailed. They wished that this information had been communicated to them prior to giving birth especially as some of them were misinformed about the visits:
People told me beforehand something that was wrong. They said that those who come on the home visits will try to check what you have bought for the baby, what you have in your closet, and things like that… However, they did not come to check the cupboards and what I had bought. They were nice and respectful. (Participant 3).
In addition, the lack of an interpreter during the visits, made it difficult for the women to express their needs and concerns:
I had visitors for half an hour, maybe an hour. There was no interpreter, so it was not easy to talk about these (difficult) feelings that I experienced. It was not. (Participant 2).
In Norway, the maternal healthcare services offer postpartum groups as a support to mothers. Some of the women were offered the opportunity to participate in postpartum groups, but as they were only conducted in Norwegian or English, many of the women could not participate. Moreover, a few women also expressed that the postpartum groups were not appropriate for them, as they felt the sessions were time consuming considering their busy lives and involved too many questions.
Adaptation and its influence on pregnancy, birth and postpartum experiences
Adapting to a new country and new systems is a challenging process for most immigrants, and being pregnant, giving birth and going through postpartum further exacerbates this process.
The women shared that it was challenging to adapt to a new country, climate, adjust to new roles within the household, attend language courses, and simultaneously manage their children’s transitions into kindergarten or school. One of the women illustrated this by explaining the differences in her pregnancy experiences in Norway and her home country:
The last pregnancy was difficult because of the language, new country…I can say it another way, all the five previous pregnancies on one side, and the last one on the other side. (Participant 2).
Furthermore, navigating parenthood with limited extended family support was very stressful, and some of the women said they left the hospital earlier than recommended because they had to return home and take care of their children. In addition, they also had to face new roles and expectations outside the home because of the introduction program. For some, this resulted in quitting language courses and/or education after having children. One of the women who was currently on maternity leave was concerned about going back to school:
The best thing about our country is that we are always with our children. Now it is very difficult for me, and I just think about the fact that he will soon go to kindergarten when I finish my leave.
She expressed a wish to stay at home longer, but did not feel she had a choice because of the rules that regulate the monthly payments she received:
It is a lot of pressure. The people at the Introduction Center for Refugees are only saying that I need to start classes again and the baby needs to go to kindergarten. (Participant 5).
The variety of concerns many of the women were facing had an impact on their health and well-being:
I feel quite a mess. I have backache, many children at home, and soon I must start work practice. I miss my family. My father is ill. I haven’t seen them in 13 years. Things are not quite right…I have 6 children you know, and a lot of absences from the introduction program. It causes a lot of problems for me. (Participant 2).
Despite wanting to adapt, many felt overwhelmed. When asked if they had expressed their needs to healthcare personnel or staff at the introduction center, some of the women explained that they wanted to manage on their own. Limited information about the supportive role of the social services led to some women expressing fear of sharing their worries with the healthcare workers:
To be 100% honest, it is scary to contact the healthcare services. You know, they have an obligation to report to childcare services. Despite that you have not done anything to your child, but if you are saying that you are tired, or need some kind of support, that also means that someone else needs to take care of your child. And then the childcare services will enter. (Participant 1).
Moreover, many of the women expressed a desire to support other women in similar situations as they reflected on their own past experiences:
When I see someone who is pregnant here at the language course, I care a lot. I’m starting to think about them. How are they going to cope? The memories always come back to the experience I had, and I start to put myself in their situation and get worried about them. (Participant 2).
This reflection not only highlights a concern for others’ wellbeing, but also the ongoing challenges many of the women in our study continued to face, from language barriers to feeling isolated, as they navigated their path to settling in Norway throughout the pregnancy, birth, and postpartum period.