In recent years, international migration has grown rapidly (Arcaya et al., 2015). Between 2000 and 2017, the migrant population increased by 85 million. In 2017, more than 90 million international migrants were residing in the World Health Organization (WHO) European region and 49% of these migrants were women, many of childbearing age (DeGrandeet et al. 2014, International Organization for Migration 2017- 2018, WHO 2018, Heslehurst et al 2018).

On average, the fertility rate in the migration population is relatively higher than in the native population. Pregnancy is a period of increased vulnerability for migrant women. Vulnerable pregnant women face barriers to accessing health care. Late access and poor-quality maternity care can lead to adverse perinatal outcomes. Several studies and many official reports have demonstrated an increased maternal and neonatal mortality risk among migrant women (DeGrande et al 2014, Heslehurst et al 2018, ORAMMA 2017, Fair et al 2020, van den Akker et al 2016, Balaam et al 2013).

Although the healthy population of each country usually migrates, over time, the health of immigrants gradually deteriorates. Immigrants are physically and mentally burdened due to socio-economic problems, social exclusion, chronic stress, miserable living conditions, difficulty accessing health care, language restrictions, etc. Especially for migrant women, the provision of prenatal care is suboptimal care, and the mental health of women is burdened. This means that migrant women need to be more vigilant during pregnancy and to significantly increase the health promotion and prevention of these groups of migrants (Heslehurst et al 2018, van den Akker et al 2016, Pedersen et al 2014, Urquia et al 2015).

In the European Union, there is a consensus and commitment to ensuring the availability, accessibility, affordability and quality of essential health services for migrants; European countries have a shared responsibility to address inequalities and to provide high-quality healthcare that meets the needs of migrant women who give birth. However, in the Member States of the European Union (EU), services provided to migrants are not the same and in some countries, inequalities have not been eliminated (Arcaya et al 2015, Fair et al 2020, Balaam et al 2013).

This study aimed to provide up-to-date evidence on migrant women’s experiences of pregnancy, childbirth, and maternity care in their destination country within Europe.

Material and Methods

The aim of qualitative research is to "discover the views of the researched population, focusing on the perspectives from which individuals experience and feel the events".

In the interview, the researcher needs to have the ability to build trust relationships and create a climate of trust that will enable participants to relax, open up and give honest and complete answers. To listen to his interlocutor with interest, to observe and react to what is being said in such a way as to urge him to reveal more information without losing his mind or escaping the matter or drifting in the direction he wishes the researcher.

The purpose of the interview is to reveal the respondent's views, perceptions, behaviours, attitudes, experiences, interpretations and experiences. The interview process, therefore, is designed to enable the respondent to move across the spectrum of possible answers rather than limiting or trapping him in a series of specific answers in the direction the researcher desires.

The methodology of this qualitative study is based on the experiences and satisfaction of migrants, refugees and asylum seekers women by providing perinatal care.

Sample of the Interview Respondents

The participants are five (5) women, all Arab-speaking, living in Skaramagas camp, and it was conducted in March 2018. The interviews were conducted during (1) or a few weeks after (4) the 6-week postpartum appointment. Five (5) individual interviews were conducted by a female midwifery researcher. All the interviews were carried out with the help of a female mediator, not related to the MPSs (Maternity Peer Supporters), so women's answers were objective. The questions were made in Greek. The answers were given in Arabic and translated into Greek by the mediator. All interviews lasted between 30-40 minutes. Finally, informed consent was obtained for all women, including permission for audio recording and participants were informed about the type and purpose of the interview.

The interviews ranged in four themes. As to theme 1 about their overall experience with the care according to the ORAMMA approach. As to theme 2 about their experience with the midwifery-led continuity. As to theme 3 about their experience with MPSs. Regarding theme 4 about their empowerment for health seeking- assessing to maternity services, care model.

The data of each interview were studied and analysed to draw conclusions regarding the recording of women's views and experiences regarding the provision of perinatal care.


Theme 1: Overall experience with the care according to the ORAMMA approach

  1. How satisfied were you with your care overall?

  2. Could you tell me about any parts you particularly liked during perinatal care? Why did you like those parts/ how were they beneficial?

  3. Could you tell me about any parts you did not liked during perinatal care? Why didn’t you like those parts?

“I was very happy every time I had an appointment. [...] The MPS was waiting for me at the hospital and we went together to the midwives.” (1803)

“The people there made me feel very comfortable. Sometimes they were trying to speak Arabic and they had a lot of fun!” (1801)

“I was very satisfied! [...] They did all my examinations in 1 day while they could send me to another center every day. [...] They explained me every time what these examinations were about, and they were let me be the one who will decide if I will do them or not!” (1805)

“For me it was very difficult to move in the town. There, they (the multidisciplinary team) were in all in the same place, the same date, so I had to take the bus only for that day.” (1805)

“...I didn’t want to do the ultrasound in the second trimester, because if there was an anomaly to the baby, we couldn’t do anything because of our religion. (Midwives) respect our choice. [...] (The MPS) had a lot of patience and helped me understand a lot about this situation.” (1802)

“I did not feel fear, I felt great security. The environment was friendly, and they were all pleasant.” (1804)

“I am generally satisfied. The only thing that bothered me was the long wait to know the baby's sex and that I had to go to many appointments throughout pregnancy. [...] In Syria, if we feel well, we usually go 2 or 3 times to the doctor.” (1801)

Theme 2: Experience with the midwifery-led continuity care model

  1. What was your experience of the care you received by midwives?

  2. Can you tell us two things you liked about the care by your midwife?

  3. Can you tell us two things that could have been improved in the care you received by your midwife?

“I was feeling very comfortable because (the midwives) were women. [...] My husband was feeling safe also and was waiting for me outside the examination room with our daughter.” (1801)

“It was very important that all they were all women because I could ask questions that I was shy to ask in front of a male doctor.” (1803)

“When I was about to have an ultrasound scan, (the midwife) gave me an apron to cover myself and closed the door of the examination room. [...] We were only me, the midwife and the MPS, all women! [...] I felt very relieved, because in the other hospital they were men in the room, and I was too embarrassed...” (1805)

“I felt like I was talking to a friend” (1804)

“...(the midwives) made me feel very comfortable and safe because I was very anxious due to diabetes. They showed the baby in the monitor and they told me that he (the baby) is fine. I felt very relieved!” (1802)

“They paid a lot of attention to me. I had a problem with my blood, and I had to make injections every day. [...] (Referring to the name of midwife) and (referring to the name of MPS) explained me very carefully how to do the injection to myself, like teachers!” (1803)

“It is my first time I became a mother. [...] My husband and I were very anxious with the baby care because (the baby) had to stay in hospital after birth. The midwives explained us everything and the social worker helped us to find an apartment. We are moving next week!” (1802)

“I loved that they gave a lot of attention to pregnant women and taking care of them more than they should.” (1801)

Theme 3: Experience with MPSs

  1. What was your experience of having a maternity peer supporter involved in your care?

  2. Did the maternity peer supporter increase your knowledge and confidence around pregnancy, childbirth and looking after your child?

  3. Was the maternity peer supporter the same ethnicity as you? What are your thoughts about this?

  4. Overall do you think there was a benefit in having a maternity peer supporter?

  5. What if anything do you think could be improved in the services you were offered during pregnancy, birth or after having our baby?

  6. Prior to this current baby had you previously accessed maternity services in Greece?

“When there was my MPS with me I felt I knew everything. In the previous pregnancy, this was not the case and I had many questions” (1801)

“I was very happy that (the MPS) waited for me at the hospital every time I had an appointment.” (1802)

“ is very important for us (the refugees) to have someone to translate in every service we go. We rely on him like he's king. Otherwise we are lost. [...] The MPS was better than anyone else; she knew all the things about pregnancy and where I had to go to do the medical test. [...] In every appointment was the same person; we knew her, and this made us (referring to her husband) fell comfortable to discuss about our questions” (1805)

“ is easier to talk about female issues and have a woman to translate to you.” (1804)

“(name of MPS) was a nurse in her country. She had also said that has made seminars about maternity care. [...] I am sure that she understands exactly what the doctors are talking about and explains me everything in details. I feel safe that way.” (1803)

“She inspires confidence because she knows exactly what the doctor is talking about and explains it very well” (1802)

“Here (in Greece) everything is different than Syria. The pregnant woman must do a lot of medical test and ultrasound in specific dates. [...] I had to go to different places for different reasons and I usually got lost. [...] It was helpful to have someone to help you. (The MPS) spoke Greek too, so she understood everything.” (1805)

“Sometimes I called her to her mobile phone. For example, I had pain in my belly, but it was not the time to give birth. I call (name of MPS) and she called the midwife. [...] I went directly to the emergency...” (1804)

“I had someone who understood me, standing next to me all the time. [...] I could share all my thoughts. She was a mother too and knew a lot about baby care. We were discussing altogether (with the midwives) like friends about our babies and how to take care of my baby. [...] They helped me a lot!” (1802)

“The MPS was not from Syria. She was from Libya. Does this matter? No! We are talking the same language, we are Arabs. All I care about is to understand each other.” (1805)

“Yes, the MPS was from a nearby village. But she had left Syria for a long time. [...] I felt even better that we were from the same place.” (1801).

Theme 4: Empowerment for health seeking- assessing to maternity services

  1. What were your experiences of accessing maternity services? If you got pregnant again would you know how to access maternity services?

  2. Did you shared any of the information you learned about perinatal care and how to handle the maternity services in Greece with other pregnant women (eg friends, relatives, etc.)

  3. Do you have any further comments you would like to make about your maternity care or the ORAMMA project?

“I think I will be able. Although... I don’t want to get pregnant again. I already have 3 children and now I have a boy too.” (1801)

“Yes, I have understood very well; so much that I think I can visit the hospital alone!” (1802)

“Υes, I'm talking to everyone. I explain them, I help them understand how important it is... They may have some trouble with all the services and medical test, but it is more important to give birth to a healthy baby and be well themselves too.” (1805)

“Sometimes I go together with my sister to the hospital. She will give birth to the same hospital as me. I know the place there and I help her to understand how the system works. [...] Yes, I am able to help her because they helped me too much when I was pregnant to understood how things work” (1801)

“I want to get pregnant again! I had a wonderful time with you! I really miss (name of the midwife) and (name of the MPS)...” (1803)


As to the results of the interviews to the five (5) women, according to the themes that they were analyzed, these are mentioned as follows.

In response to theme 1 about their overall experience with ORAMMA-based care, the women stated that the MPS was waiting for them at the hospital and that they went together to the midwives. They were made to feel very welcome by the people there. They had a lot of fun pretending to speak Arabic at times. They completed all of their examinations in one day and could send them to another center every day as well. They explained to them what these examinations were about each time and let them decide whether or not to take them. They were all pleasant, and the environment was friendly.

In response to theme 2, the women stated that they felt very comfortable with the midwifery-led continuity care model because (the midwives) were women. It was critical that they were all female because they could ask questions that they would be embarrassed to ask in front of a male doctor. When they were about to have an ultrasound scan, (the midwife) gave them an apron to wear and closed the examination room door. They felt as if they were conversing with a friend. They were very attentive to them. Finally, they appreciated that they paid special attention to pregnant women and cared for them more than they should.

In response to theme 3 about their experiences with MPSs, the women expressed gratitude that (the MPS) waited for them at the hospital every time they had an appointment. Furthermore, it is critical for them (the refugees) to have someone translate for every service they use. They look up to him as if he were king. Otherwise, they will perish. The MPS was superior to everyone else; she knew everything there was to know about pregnancy and where they needed to go for the medical test. Every appointment had the same person; they knew her, and this made them (referring to their husbands) feel at ease discussing our concerns. Everything is different in Greece than it is in Syria. The pregnant woman must do a lot of medical test and ultrasound in specific dates. Finally, they said that they had someone who understood them, standing next to them all the time. They could also share all their thoughts. They were discussing altogether (with the midwives) like friends about our babies and how to take care of their baby.

As to the theme 4 about their empowerment for healthseeking- assessing maternity services, the women said that they understood very well, so much so that they think they can visit the hospital alone. They are talking to everyone. They explain to them, they help them understand how important it is. They may have some trouble with all the services and medical tests, but it is more important to give birth to a healthy baby and be well themselves too. Sometimes they go together with their sister to the hospital. They give birth in the same hospital as them. They know the place there, and they help her to understand how the system works. Finally, they say that they had a wonderful time with the midwife.

The struggles of immigrant women with barriers to communication and language are issues that migrant women constantly face. Immigrant women report a poor understanding of medical terminology and yet there is insufficient use of interpreters in the healthcare system (Fair et al 2020, Lionis et al 2018).

Poor communication and the provision of insufficient information impact women’s ability to choose appropriate care options and provide informed consent. An inability to converse in the local language also means women find it difficult to establish a relationship with their care provider and this impact women accessing care. HCPs can help women to overcome language barriers by providing appropriate information, engaging professional interpreters more frequently and ensuring they give women the opportunity to ask the questions that they have (ORAMMA 2017, Fair et al 2021, Papadaki et al 2020).

According to studies, the lack of understanding between migrants and HCs about traditional customs and their expectations for maternity care affected their access to health services. The issues clearly point to a need for HCPs to receive education and training in culturally competent care to identify women’s expectations of care better and how to understand and appropriately respond to women’s needs related to their cultural background, to ensure effective maternity care and reduce barriers to accessing care (ORAMMA 2017, Fair et al 2021, Papadaki et al 2020).

An issue that emerged particularly strongly in this study is that to meet the unique needs of many immigrant women, there is a need for care that goes beyond traditional models. In addition, other studies have highlighted the unstable or inadequate living conditions of migrant women, their financial difficulties and the enormous burden of loneliness and the lack of a family network around them (Heslehurst et al 2018, Balaam et al 2021, Soltani et al, 2020).

Some migrant women described exemplary care, receiving treatment that was empathetic, caring, culturally sensitive and compassionate. However other migrants reported discrimination prevalent in the HCPs that they encountered. Care is seen to be impacted where women do not feel well treated or feel discriminated against, while unrushed, kind, empathetic HCPs are appreciated. Our findings suggest that continuity of care increases migrant women’s satisfaction with maternity care. This is in line with the Cochrane review which has found increased satisfaction reported by women receiving continuity by a known midwife, as well as reduced rates of preterm birth and perinatal death (Pedersen et al, 2014).

To address the social determinants of health and avoid discriminating against migrant women, it calls for personcentred, high-quality, continuity of care that incorporates aspects of cultural competency and trauma-aware care. The evidence within this review, alongside other evidence, led to the development of the ORAMMA integrated perinatal care model (ORAMMA 2017, ORAMMA 2017).

The women who received care under the ORAMMA program were very satisfied with the provision of antenatal care, they felt very comfortable with the providers talking, communicating and understanding the reason for their care. Finally, empowering them to become familiar with the healthcare system has proven useful for women.

A very important limitation of the qualitative study is that the sample is relatively small. The specific population is very difficult to locate due to the mobility of the population in different parts of Greece and Europe, so it is difficult to be included in the research. Also, these women find it very difficult to trust the structures and the purpose of this study easily. Through this study, important conclusions and useful benefits emerge from implementing the ORAMA project.

Finally, in the future, it would be useful for intercultural mediators to be women with special education in obstetric care. HCPs to be trained and experienced in the culture of the specific population but also to know the obstetric care they have in their country.


Regarding the conclusion of the above study, it is important for immigrant women to feel understood. Professional interpreters should listen to women and build a friendly relationship of trust with women. HCs should incorporate traditional or cultural practices related to the perinatal period and provide care for women. Therefore, the provision of the ORAMMA program to migrant and refugee women is vital.