Migrant women ’ s experiences of community-based doula support during labor and childbirth in Sweden. A mixed methods study

Objective: To describe migrant women ’ s experiences of bilingual community-based doulas (CBD) contribution to care in relation to labor and birth. Methods: Mixed methods study combining quantitative data from 82 women who received CBD-support within a randomized controlled trial and qualitative data from semi-structured interviews with a sub-sample of 12 women from the same study arm. Descriptive analyses were used for quantitative data and content analysis for the manifest and latent content of the qualitative data. Quantitative findings were categorized according to qualitative findings. Results: The women expressed how CBDs played an essential role in the response to their basic emotional, informational, and physical support needs, when no other female family member was available. Three main categories emerged from the analysis of interviews: The doulas help women feel safe and calm – providing support before, during and after childbirth ; The doulas ’ support role fills the void left by a deeply missed family, mother or sister; and The doulas assist women in achieving autonomy through communication support and advocacy. More than half of women reported feeling involved during labor and birth (56.8%), most valued CBD positively (such as being competent, calm, secure, considerate, respectful, encouraging, supportive) (40.8%-80.3%), that CBD had interpreted (75.6%), facilitated communication with the midwife (60,3%), comforted the woman (57.7%) and reduced anxiety (48,7%). Few reported negative CBD-characteristics (1.3 – 9.2%). Nevertheless, 61.7% of women felt frightened sometime during labor and birth, which made it even more important to them that the doula was there. Few women (21.8%) reported that the CBD had supported her partner but expressed so in the interviews. Conclusion: Through an essential contribution in responding to migrant women ’ s basic emotional, informational, and physical needs, bilingual community-based doulas have the potential to improve migrant women ’ s experience of care during labour and birth. However, more focus on the quality of CBD-support to partners seem necessary.


Introduction
Although the Swedish healthcare system provides high-quality maternity care, migrant women often have poorer pregnancy outcomes than Swedish-born women.The higher risk for maternal morbidity and mortality among migrant women compared to non-migrant women [1] may partly be attributed to physical health problems, obstetric history, and migration related issues and trauma [2].Additionally, a lack of knowledge about pregnancy and birth, the health care system, language barriers, and poorer quality of maternity care plays a role [3][4][5].
In general, migrant women rate their maternity care experience more negatively in comparison with non-migrant women [6,7].Systematic reviews indicate that migrant women report poorer communication with healthcare providers [6] and are more likely to report feeling lonely and scared or experience insufficient support during childbirth.Perceptions of disrespect or discrimination from caregivers contributed to the negative assessments [7].
Like non-migrant women, migrant women want respectful care that is personalized to their needs, information about the healthcare system in their new country, as well as help communicating [7].This includes continuous support during labor and birth, which has been linked to several positive outcomes, including more spontaneous vaginal births, more women reporting positive birth experiences, shorter labors, fewer cesarean sections, decreased use of intrapartum pharmacological analgesia, and decreased risk of low Apgar-scores among newborns [8].Supportive care during labor includes emotional support, comfort measures, information, and advocacy, such as doula support [9].A doula could, in addition to such labor support, provide women with a common cultural background, which may empower women to raise voices in having needs addressed [10,11].
In Sweden, a model of bilingual community-based doulas (CBD) was first introduced in Gothenburg, a large city with a high proportion of migrants.CBDs are bilingual women from migrant communities who are trained to provide physical, emotional and information support during pregnancy, labor and birth.They speak the woman's mother tongue and Swedish, they understand the Swedish culture and healthcare system, and often have personal experience giving birth in Sweden.CBDs usually meet women twice prior to birth and are present throughout the active phase of labor and birth and for two hours after the baby is born.After the birth, CBDs meet with the women for a follow-up [10].By providing continuous support during childbirth, the purpose is that CBDs will increase the chance that women's needs are responded to and promote more positive pregnancy and childbirth experiences [9,10].
This model of care has now also been introduced in Stockholm, Sweden, and simultaneously, the CBD intervention was evaluated for its effectiveness by means of a pragmatic randomized controlled trial (RCT) [10,11].For the primary outcomes, "happiness with care" and "emotional wellbeing 2 months postpartum", no statistically significant differences were identified between the group receiving support from a CBD and the standard care group [11].However, the findings suggested that CBDs have the potential to improve communication between laboring women and staff.To investigate mechanisms for the expected improvements of care (see below), a parallel process evaluation was conducted.One qualitative study on midwives' and obstetricians' experiences of working along-side the CBDs in the same trial, showed that they in general welcomed CBDs as new members of the team.They valued CBDs' contribution to improving communication; by providing language assistance and continuous emotional support and increasing cultural understanding [12].Interviews with the CBDs showed that they perceived their work as rewarding and significant despite financial and organizational constraints [13].This paper will contribute additional information to the trial process evaluation by elucidating the hypothesized mechanisms from the perspective of the migrant women themselves.
This study aimed to describe migrant women's experiences of community-based doulas contribution to care in relation to labor and birth.

Methods
This mixed methods study combined concurrent quantitative and qualitative data from women in the intervention-arm of the RCT that aimed to evaluate the effectiveness of CBDs for improving the intrapartum care experiences and postnatal wellbeing of migrant women.The study is described in detail previously [10,11].

Setting
All residents in Sweden are entitled to free care during labor and birth, and nearly all births take place in hospitals.Midwives are ordinarily responsible for labor and birth, although obstetricians are consulted when complications arise.While midwives generally care for two women in labor at a time, obstetricians are often responsible for far more patients.Swedish laws mandate that all patients have the right to information that is adapted to her language and experiences, that staff make sure that the patient has understood the meaning of the information and that health care is conducted in agreement with the patient [14].In the Stockholm region, about one third (34 %) of the women giving birth between 2017 and 2022 were migrant women, the majority were born in Eastern Europe, Central Asia or Sub-Saharan Africa [15].However, few women in Sweden have access to an interpreter during labor and birth, and if they do, this occurs mostly by telephone and only for explaining procedures or when serious complications occur [16].The CBD program studied was financed by the Stockholm Region and was run in cooperation with the non-profit organization Mira, which was responsible for training and organizing the CBDs.

Intervention -Community-based bilingual doula support
The intervention was based on core values for quality intrapartum care: respect, communication, and support [8,17,18].The program theory has been described in detail elsewhere [10].In short, we hypothesized that the following would improve migrant women's intrapartum care experience and emotional well-being postpartum: Improved communication and information support ¡ to increase mutual understanding about desires and needs, timely apprehension about signs and symptoms for understanding of progress and necessary interventions and strengthen women's empowerment and rights.
Common backgroundto improve cross-language/culture interactions and empower women to raise voices in having needs addressed.
Emotional support and being with the woman ¡ to reduce anxiety and increase the probability of a normal birth.
Instrumental supportto help women manage pain and to encourage a normal progress of labor by providing hands-on comfort measures/physical techniques, ensuring appropriate positions during labor and supporting energy and fluid intake.
The intervention followed the CBD program introduced in Stockholm described above.The twenty-three CBDs involved were fluent in one of five languages: Somali, Tigrinya, Polish, Russian, and Arabic.CBDs received eight full days of training in anatomy, physiology, and strategies for providing support and comfort during labor and birth.They were then required to assist in three births before being fully authorized and assigned to participants.Women were provided a CBD who spoke their language in addition to standard care.CBDs met with women twice prior to birth to get acquainted and discuss the woman's wishes and birth plan.They were then present throughout the active phase of labor and birth and for two hours after the baby was born.During this time, the CBD's role was to provide physical, emotional and information support.After the birth, CBDs met the woman once or twice for followup.

Sample
Recruited to the trial were nulliparous and multiparous pregnant women who spoke Somali, Arabic, Polish, Russian, or Tigrinya, who could not communicate fluently in Swedish, were 18 years or older, in gestational week 25-35, and had no contraindications for vaginal birth.Women who had a planned caesarean section or did not consent to giving access to the patient records were excluded.Participants were recruited from six antenatal care (ANC) clinics in Stockholm.Midwives identified women who met the inclusion criteria and those who were interested in participating were contacted by a research assistant who had not been involved at any time in the care of the woman.She provided additional information about the study, obtained informed consent, conducted baseline interviews, and informed women of which group they had been assigned to (using a computerized randomization schedule).The present study included women from the CBD arm of the R. Purandare et al.
trial only.For the semi-structured interviews, a subsample of 12 women who had been supported by a CBD in the last 12 months were asked to participate.To capture some of the diversity among the participants, our intention was to include two or three women from each language group.

Quantitative data and analysis
Baseline data were collected by the bilingual research assistants using a structured questionnaire with closed and open-ended questions.Two months after the birth, the same research assistant contacted the woman again to administer a follow-up questionnaire, which inquired about health, and emotional wellbeing, support during labor and birth, and the health of the baby.The present study focuses on three questions from the follow-up questionnaire: What did the doula do that was important to you? (open ended question); Could you tell me what feelings you experienced during labor and birth?offering 12 negative feelings (e.g.feeling worried, lonely, abandoned, disappointed) and 12 positive feelings (e.g.feeling safe, strong, focused, trust in own capacity) as response alternatives; and How was your impression of the doula?providing 12 negative characteristics (e.g.brusque, unkind, vague, insensitive to your preferences) and 12 positive characteristics (e.g.clear, encouraging, informative, warm).The research assistant carefully read all feelings and characteristics aloud and circled the ones that the woman found relevant for her.The frequencies of each response alternative for these three questions were calculated using Statistical Package for Social Science version 26 (IBM SPSS Inc, Chicago, IL, USA).The responses to these questions were then categorized according to the categories from the qualitative interviews (see below).The authors individually categorized the quantitative data (women's feelings, characteristics of doulas) into the categories created from the qualitative data [19].They then discussed the categorization until consensus was reached.

Qualitative data and analysis
Semi-structured interviews were conducted by co-authors KÅ and MS with the assistance of the research assistants working on the RCT who spoke the woman's language.The interviews were conducted in Stockholm between October 2019 and August 2020 in sites chosen by the women.Eight interviews were conducted in person and four over the phone.The interviews followed a semi-structured interview guide and included questions about women's experiences of the doula support received according to RCT study protocol.The interviews lasted between 30 and 75 min, they were digitally recorded, translated orally from the woman's language into Swedish (n = 9) or English (n = 3), and then, the interpreters' translations were transcribed verbatim.Analysis of the manifest content (the visible, obvious components) and latent content (the underlying meaning of the text) was conducted using content analyses [18].The transcribed material was read through several times to get an overview of the content.The text was extracted into content areas, meaning units were identified and marked with codes, which were then organized into subcategories and categories and repeated similarities and differences were identified and discussed among co-authors.Defining the categories was a dynamic process in which we went back and forth between the transcripts and the categories, to ensure the categories captured the essence of the data.An example of the analysis process is described in Table 1.
The study protocol was approved by the Regional Ethical Review Board in Stockholm (approval number: 2018/12---31/2).Written informed consent was retrieved from all women.

Results
In total, 82 women (93 %) in the intervention arm of the trial responded to the follow-up questions, constituting the sample for the quantitative analyses.The average age of women was 30.3 years.The vast majority (70 %) could not speak Swedish fluently or spoke it with difficulties.Additionally, 37 % had low level of education (nine years or less), and 12 % had paid employment at the time of recruitment.Furthermore, 72 % of the women lived with a partner and 41 % were nulliparous while 59 % were multiparous.
The subsample of 12 interviewed women spoke Somali (n = 2), Arabic (n = 3), Tigrinya (n = 4) and Russian (n = 3).They were 22-46 years old and had resided in Sweden for 2-14 years.Three women were living alone and none of them had their original families in Sweden.Moreover, the level of education varied, ranging from two years of Koran School to a PhD degree from the woman's country of birth.Six women had prior work experiences in Sweden.The women had between 1 and 4 children, with the last was born 2-14 months earlier by means of a normal vaginal birth (n = 10), a cesarean section (n = 1), or a vacuum extraction (n = 1).
Across the interviews and quantitative data, the women expressed how doulas played an essential role in responding to their basic emotional, information and physical needs.Women thought that isolation, lack of support and insufficient health literacy posed greater challenges for them compared to non-migrant women.Most of the women had no family in Sweden, and they had limited knowledge about the healthcare system and their patient rights, contributing to feelings of loneliness, vulnerability, lack of confidence, and powerlessness during pregnancy, labor and birth.The analysis of interviews and surveys revealed three main categories: The doulas help women feel safe and calm providing support before, during and after childbirth; The doulas' support role fills the void left by deeply missed family, mother or sister; and The doulas assist women in achieving autonomy through communication support and advocacy.Categories and subcategories are shown in Table 2 and are described narratively below.

Table 1
Example of analysis with meaning units, codes, subcategories and categories.

Meaning units Codes Subcategories Categories
She was very experienced and competent.
Informed me all about giving birth.

Increased women's understanding
Contributing important knowledge and information that enabled the women to prepare for labour and birth.
The doulas help women feel safe and calm − providing support before, during and after childbirth.She explained a lot to me that I didn't knew before Since we belong from another culture we miss out a lot of information and access to health care.
Guide to health care I knew I could call the doula when I needed help She brought with her a huge, big optimism.And all fears were gone.

Personal engagement
Building trust through accessibility, closeness and continuous support.She supported me from her whole heart.She was always with me, close by, and supported me.

Presence
She was humble and calm.
In the interviews, several women expressed feeling scared and unsafe due to a lack of knowledge about the Swedish healthcare system and uncertainties about what to expect during labor and birth.This was particularly true for women who had not given birth in Sweden before.Doulas played a crucial role in addressing these concerns by offering basic information about Swedish maternity care and the normal birth process.This knowledge helped women feel better prepared for labor and birth and reduced their anxiety.
At first, I was worried, I was sleepless.But when she explained things to me many of my questions were answered.And then I became calm.Interview 5 Women experienced a lack of comprehensive information about labor and birth, and hospital procedures.Some women emphasized the importance of obtaining details about how to manage labor pain and available pain relief options.
First, she informed me how to give birth, how the baby comes out and what kind of pain relief that is available.How to use the laughing-gas during contractions.I knew it all since I had given birth before, but when she explained, everything felt better […] She encouraged me not to be afraid and she said that if I had questions, I should ask them, and not be afraid.Interview 4 Most doulas, having experienced labor and birth in Sweden themselves, shared their experiences and knowledge with the women.This exchange of information reduced uncertainty and built trust.
The most valuable personal quality about my doula was the fact that she had her own experiences of giving birth in Sweden, and that she was calm and humble.She explained everything to me and guided and helped me to get the right health care.If I would have had doula support during my first pregnancy and birth it would have helped me a lot.Interview 2 The mere knowledge of having a doula by their side when going into labor was comforting for women, contributing to their confidence.They reported that the doula was calm, optimistic, and cheerful, creating a safe and empowering environment for giving birth.
She brought with her a huge, big optimism.And all fears were gone.At the delivery she was always with me, close by, and supported me […] She created this very safe place around me. Interview 1 Doulas actively addressed women's expectations and fears, encouraging them to process stressful feelings and thoughts.Women expressed how this support reduced fear and worries during pregnancy and when thinking about giving birth.This anxiety sometimes stemmed from a past traumatic birth experience or a general uncertainty about giving birth in a foreign country, where they were not able to make themselves understood and afraid that something might go wrong.

I was terrified, I must say, because I had a previous bad experience when I gave birth to my son. I am thinking about how I would have done this alone if I hadn't had the doula with me. How I would have coped with all of this? and I was also afraid of the physical pain and worried about what would happen to me. Interview 9
One participant, initially considering a cesarean section due to a previous traumatic birth experience, felt empowered to choose a vaginal birth with the doula's support.
I was always thinking about telling my midwife that I wanted a c-section.But the doula convinced me that everything would be fine.That I would deliver the baby by myself […] and every time she was saying that: We will deliver, don't be afraid.Interview 1 The women also emphasized the importance of being able to reach the doulas for support, both before and after giving birth.Knowing that the doula would be available and assist in contact with medical staff was crucial for them to feel safe.

I received a lot of help and information from my doula. I could ask her things I couldn't ask the midwife and the doula explained everything well. After giving birth I got stomach pain, the doula informed me that I was able to go back to the hospital within seven days, which I didn't know. I had an infection, and I called the doula several times and she helped me interpret the conversations with the medical staff. Interview 2 The doula's support role filling the void left by a deeply missed family, mother or sister
In the quantitative data, women expressed that they felt closeness to the doula by reporting that she was, such as being 'warm' (63,2%), 'clear' (59,2 %) and 'funny' (51,3%) and that she had contributed by being by the woman's side (67,9%) helped her with nutrition (44,9%) and to the toilet and to move around (41.0 %) (Supplementary Table 1).Few women reported feeling abandoned (7.4 %) or lonely (4.9 %) during labor and birth.Notably, 21.8 % of women said that the doula had supported their partner or other labor companion.
Qualitative data showed that living in a country, without family by one's side, where they did not speak or understand the language often left the women feeling vulnerable, lonely and isolated during pregnancy, labor and birth.

I wasn't exactly afraid, but worried, how will it go? I have no one, no one to turn to. I was worried. Interview 11
Women emphasized the significance of family during pregnancy and birth; to have family by one's side when giving birth was considered the norm.Having a doula substituted for family members, providing companionship and reducing feelings of emptiness and loneliness.
To start with, she spoke Tigrinya, and understood me, which was good.Others, they have their families and their husband when they give birth, but she became like my family.I hope all doulas are as good as her.Interview 3

Table 2
Categories and subcategories describing women's experiences of community-based doula support.
The doulas help women feel safe and calm ¡ providing support before, during and after childbirth.

The doulas assist women in achieving autonomy through communication support and advocacy.
Contributing important knowledge and information that enabled the women to prepare for labour and birth.
Replacing absent family.Bridging language and cultural barriers by interpreting and explaining things Helping the women feel calm and manage stress and anxiety.
Breaking sense of isolation and loneliness.
Offering guidance within health care system.Building trust through accessibility, closeness and continuous support.
Providing emotional and practical support that a mother or sister would have done.
Recognizing, communicating andadvocating women's needs and wishes.

R. Purandare et al.
Establishing contact with the doula before giving birth, combined with her personal commitment facilitated the development of the close relationship.Participants said that the doula became like mothers or sisters.They missed being able to ask their own mothers for support but could now turn to the doula instead.
It was the first time I gave birth in Sweden, and I was completely alone without my mother.But it turned out that the doula was like a mother to me, she was so caring in every way and I felt so safe with her.I was very lucky to have her.Interview 9 Women talked about how the doula stayed close, gave massage, tried to ease pain during contractions, and encouraged them to change positions to facilitate progress during labor and birth.All these forms of support that the doula provided were seen as tasks akin to those of a mother or sister during labor.
I can say that we were just like a mother and daughter.She took care of me in an amazing way.When I was in the hospital, she never left me.She gave me food, helped me get dressed, and walked with me.She even cried when she saw what situation I ended up in.She took care of me like a mother, and she never closed her eyes, never fell asleep.She was with me every single minute.Interview 9 The need for female support during labor and birth was especially crucial for women whose partners could not attend.However, even among women with their partners present, some expressed that the doulas' support was even more important than their husbands'.When the participants recounted what doulas had done that was important for them, they frequently mentioned the emotional and physical support that she offered.The role of the doula was distinct from midwives, doctors, or interpreters.Women perceived the dedication and commitment from the doula as strong, genuine, and personal.
There are people, the doula in this case, who help you, take care of you, not only as somebody who does their work like a doctor or a midwife.But somebody who supports you from her whole heart.Interview 8 Some women mentioned that their husband also felt afraid and insecure at the hospital, and that the support from the doula was important for him as well.

My partner needed support himself during the delivery, and if it hadn't been for the doula, and it would have been just him and me, then maybe it wouldn't have been such a positive experience … He was very scared when the doula left the room […] and always asked her when she would come back. Interview 1.
Two women expressed disappointment when the doula was not accessible or present.In one case the labor was induced and doula did not show up until after the baby was born.In another case the doula had another job and was not able to attend until after the delivery.

I would really have liked that the doula would have been there to help me. But it didnt turnout that way and I just have to accept it. Now I have my son and everything is alright… but it wasn't a good experience. Interview 7.
On the contrary, one participant described how she already had support from her partner and felt safe, which made her feel that the doulaś presence was unnecessary or even disturbing.
I felt safe, I wasn't afraid at all, since my husband is born here in Sweden, and his family is here.So I was not worried at all…If they would ask me if I want a doula for the next delivery I will say no, because there were so many people in there, which made me feel sort ofstressed.Interview 6.

The doula assisting the woman in achieving autonomy through communication support and advocacy
The quantitative data showed that 56.8 % of women felt involved during labor and birth, 33.3 % reported feeling self-confident or strong, however, only 19.8 % had trust in their own capacity (Table 1).Most women perceived that the doula had been considerate (80.0 %), respectful (77.6 %), encouraging (71.1 %), and supportive (64.5 %).While a majority of women said that their doula interpreted for them (75.6 %), facilitated communication between her and the midwife (60.3 %) and helped her to understand what was happening (52.6 %), 17.9 % said that the doula had also facilitated communication between the woman and her partner or companion.
In the interviews, several women expressed feeling vulnerable and unsafe within the Swedish healthcare system, highlighting communication difficulties and other challenges beyond language barriers that affected their ability to receive suitable care.A lack of knowledge about their options made it challenging for women to actively participate in their own care.Some women expressed that the doula empowered them to take a more active role by encouraging them to express their needs and wishes to healthcare staff and thus facilitating access to services.The women described feeling that the doula was always on their side.
Since I ḿ not that good in Swedish, I wouldn't have understood the in- formation from the medical staff and also wouldn't have asked any questions or told them what I wanted.So the doula became a good support to me in this situation.Interview 5 Language barriers emerged as a significant obstacle for the women to participate in their own care during labor and birth.They described past experiences of waiting silently for healthcare staff to act and make decisions, rather than actively engaging themselves.

When you dont understand things and cannot ask what you want to ask, then you become quiet and let them do their job…which they do − a good job. But you would like to know a little bit more, to understand what is happening inside you. Interview 2
The doula became a bridge to overcome such language and cultural gaps by interpreting and explaining things to the women with her understanding of both cultures.Women expressed that the doulas helped clarify the information they received from the midwife.Since it's my first child, the healthcare staff explained to me how to breastfeed and take care of the baby.But when the doula came, she explained it to me again, in Tigrinya, and then I really understood.That was a good explanation.I understood well, exactly what I should do.Interview 5 Women expressed that the doula did not just translate what they said but also recognized their needs, encouraged, and helped them communicate these needs.For instance, the doula noticed when a woman could not change position due to continuous surveillance with CTG and suggested a wireless device.Another example was when the doula observed that the woman needed more pain relief and supported her in communicating this to the medical staff.
When I was in the most pain I could tell the staff what I felt and it felt good that [the doula] was there and listened so that I got to talk with the doctors and got medicine for the labor pain, and she was on my side and she listened so that was good.Interview 5 In addition to helping the women communicate with midwives, doulas often served as advocates when the women could not stand up for themselves.Doulas helped women understand their rights and the recommendations in the Swedish healthcare system and present their cases to ensure their needs were met.For example, one woman had given birth in a taxi on the way to the hospital after being told to wait at home until her water broke, because the delivery ward was full.In this case, the doula became a spokesperson for her in seeking an explanation for what had gone wrong.

Discussion
The anticipated improvements in labor care that community-based doulas were expected to provide for migrant women seemed to materialize.In both the quantitative and qualitative data, women emphasized the crucial role played by the CBDs in addressing their basic emotional, informational, and physical support needs during labor and birth.Three main categories emerged from the analysis of interviews and surveys: The doulas help women feel safe and calmproviding support before, during and after childbirth; The doulas' support role fills the void left by a deeply missed family, mother or sister; and The doulas assist women in achieving autonomy through communication support and advocacy.However, few women reported that the CBD had also supported her partner or other labor companion, but expressed so in the interviews.
Migrant women in this study described highly positive experiences with a CBD who shared a common background.They perceived the CBD as filling support gaps, particularly in the context of giving birth in a new country.The women faced challenges due to their lack of knowledge about the healthcare system, the birthing process and hospital procedures.Feeling lonely and vulnerable without female family members, and hindered by language barriers, they found it challenging to advocate for themselves.Specifically, they highlighted the doula's role in providing comprehensible information and emotional support, stepping in for mothers and sisters by offering warmth, nurturing guidance throughout the labor and birth.Similarly, a qualitative study in Sweden [20] and one in Norway [21] showed that CBD formed close bonds with women, referred to as mothers and sisters, who provided a sense of security and trust [20,21].However, a recent paper by Essén and Eriksson [22] discussed the CBD-concept in relation to gender-inclusive care.The authors expressed concerns about introducing an intervention involving women unknown to the family, suggesting that interventions involving the partner or the woman's social network would align more with Swedish policies of gender equality and shared parenting.We agree with the authors that CBD should primarily serve the most vulnerable women, such as newly arrived individuals or those without a partner, even though Swedish laws mandate that all patients have the right to comprehendible information adapted to her language so that health care is conducted in agreement with the patient [14].Our study indicates that midwives are already inclined to prioritize accordingly.The selection of women for the CBD trial comprised the socioeconomically most vulnerable; the majority couldn't communicate fluently in Swedish, very few had paid jobs, and over a quarter of women lacked a partner.Similarly, our evaluation of the 10-year CBD services in Gothenburg, Sweden, demonstrated that midwives effectively selected women to receive a CBD [16].Moreover, migrant women with CBDs (n = 880) experienced similar pregnancy outcomes to those without a CBD (n = 16,789), despite higher rates of socio-economic and obstetrical risk factors for adverse outcomes.The findings suggested that the presence of a CBD improved communication and relaxation support, factors associated with a higher prevalence of non-instrumental vaginal births [8,23].In light of this, offering CBD services to selected migrant women could be seen as an intervention addressing both inequalities and inequities in care, a point highlighted by Essén et al [22] and others [2,24,25].For more advantaged women, other interventions that take gender aspects into account may be appropriate, subject to financial feasibility.
CBD significantly contributed to women experiencing continuity in the care provided from late pregnancy, throughout labor and birth and the initial postpartum weeks.The established relationship in late pregnancy reassured women who felt safer and less anxious about what was about to happen.The opportunity to meet and reflect on the childbirth with the CBD, who shared her experience, was equally important.In similarity, Akhavan et al [25] found that the continuity of care, along with the information that CBD provide, appeared to increase women's satisfaction with and trust in maternity healthcare.Primiparous women in this study were particularly eager to be provided a continuity in the maternity care.A Norwegian study highlighted that CBDs, through continuity of care, came to know the women well, fostering trust and preparing them for birth.The CBDs reported that a shared language and the continuity of care helped women feel more secure during birth [21].There is strong evidence that women who receive midwife-led continuity models of care are more likely to be satisfied with their care during labor and birth than women who are provided separate antenatal and inlabor care [26].In Sweden, most women do not have contact with the midwife who is responsible for their care in the labor ward before admission.Instead, the CBDs became the ones women felt close to and could trust, being at her side throughout the entire process.Through providing continuous support and maintaining continuity of care, the CBD could alleviate women's anxiety and enhance their sense of security.
Another finding was that the CBD enabled and empowered the migrant women to gain autonomy and take an active part in their own care.The CBD encouraged them to express their needs, wishes and concerns to healthcare staff, they facilitated access to services, and bridged language barriers.Midwives and obstetricians sometimes fail to meet migrant women's needs of an interpreter, which will result in uncertainty in individualizing care, or difficulties in conveying medical information to women with varying levels of health literacy [27].A qualitative study by Schytt et al. [12] found that midwives and obstetricians experienced that CBDs helped navigate language and cultural barriers between them and women, which increased the possibilities to provide high-quality and safe intrapartum care to migrant women.The CBDs' role as an advocate and facilitator has been described previously by Amram et al [28].In this study, the CBDs understood that it was within their role to create space for questions and ensure that the women were fully informed throughout the process.With very limited knowledge about the process of labor and birth, as well as the reasons for medical decisions and interventions, a CBD needs to be humble and sensitive to both the woman, her partner, and the staff when bridging communication gaps.Hunter [29] argues that representing the womenś interest during labor, ensuring the woman's needs and autonomy are respected, are still the crucial parts of the CBD's work.In practice it means speaking on the woman's behalf when the woman is not able to express her own wishes.Ultimately, the CBD and the women share one common voice in labor, and the CBD is with the woman in an intimate space, helping the woman gain control [29].Our findings suggest that most women experienced that the CBD in this Swedish setting succeeded in doing that, and very few women in the trial expressed any negative CBD-characteristics.

Strengths and limitations
In this study, only few participants (7.8 %) did not remain for followup.We believe that the active involvement of bilingual research assistants in the data collection significantly contributed to the high participation rate.Their contacts with women facilitated effective communication about the study details, instilling a sense of safety among women to take part.Most interviews were conducted in the women's mother tongue with research assistants who had been working within the project but not in the care of women during pregnancy, labor or birth.This approach allowed the participants to articulate their experiences in detail, unrestricted by the confines of a foreign language.The research assistants' deep knowledge about the project also decreased the risk of misunderstandings.However, the women's awareness of the research assistants' inclusion in the project team may have constrained their willingness to freely discuss negative experiences.We believe though that this has been a minor problem and not affected the conclusions of the study.The use of a mixed methods approach increased the integrity of findings by using both qualitative and quantitative data concurrently, as well as helping illustrate the results, putting 'meat on the bones' to the figures [19].

Conclusion and implications for practice
Through a shared background and continuity of trust, bilingual community-based doulas contributed emotional and information support to the migrant women.This support was crucial for overcoming fright and anxiety, for empowering women to attain autonomy, and for encouraging women's active participation in their own care.The involvement of CBDs within the maternity healthcare system could further improve maternity care for particularly vulnerable migrant women.

Declaration of competing interest
The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.