Community Based Doulas for Migrant Women in Labour and Birth in Sweden - a Randomised Controlled Trial

In Sweden, the proportion of births to migrant women has more than doubled over the last four decades, from 10% in 1973 to 28% in 2015. Migrant women are at increased risk of adverse pregnancy outcomes as low birth weight, infant small for gestational age , congenital malformations, stillbirth, neonatal morbidity and mortality and also obstetric interventions, such as induction of labour and caesarean section. Unfamiliarity with the health care system, language barriers, knowledge gaps and cultural issues are all obstacles that play a vital role in migrant women deprivation from achieving the standard maternal health care.

Migrant women have shown to consistently rate their maternity care more negatively in contrast with Swedish women, mainly due to lack of knowledge on how Swedish health care system is functioning and providing care which consequently cause communication difficulties, in addition to discrimination and prejudicial staff attitudes. Migrant women reported being left alone in labour, and feeling fearful, insecure and unsupported. Factors to be targeted to improve experiences of care and pregnancy outcomes include; breaking down language barriers and bridging cultural gaps, increasing familiarity with and enhancing understanding of Swedish maternity care, and empowering women's sense of safety and confidence in giving birth.

In Sweden, migration of women of childbearing age has increased most rapidly from Somalia and from a number of Arabic-speaking countries and also Eritrea and Russia. Somali women are known to be at highest risk of perinatal morbidity and mortality, they have problems engaging with Swedish antenatal care and because of communication and language barriers they reported to have the poorer experiences of care regarding labour and birth. Like Somali-women, many Arabic-speaking and Tigrinya-speaking women (from Eritrea) have relocated in Sweden after traumatic experiences of war and conflict. They, and the Russian women, constitute a growing group of women giving birth in Sweden with little knowledge of how Swedish maternity care operates and facing major communication barriers.

One initiative that has addressed communication problems between migrant women and the caregivers throughout childbirth was to provide language assistance and labour support , the Community Based Doula (Doula och kulturtolk) Project. CBDs are bilingual women from migrant communities trained by expert midwives to provide support for migrant women in labour and birth. CBDs meet twice with the migrant women prior to the birth, accompany her throughout the labour and provide emotional, physical support and communication; and language assistance; they meet again for follow up twice after the childbirth. Two small qualitative evaluations, conducted in the early years of the program, indicate high levels of satisfaction among supported women and midwives.

Current evidence supports the potential for CBDs to play an important role in improving continuity for migrant women during labour and birth, enhancing their experiences of birth and of care, as improving their pregnancy outcomes. Good physical and emotional support in labour is known to improve a range of outcomes; greater maternal satisfaction with care, less use of analgesia, shorter labours, lower rates of caesarean section and more spontaneous vaginal birth - with no adverse effects for women or infants.