Facing systemic barriers to providing contraceptive counselling:

According to the midwives, midwifery clinics were mainly funded by antenatal care visits, leading to lower prioritisation of contraceptive counselling. Midwives working in public clinics described an ideological difference between public and private clinics. In public clinics, care was viewed as a community service, whereas private clinics were characterised by greater autonomy in service management, although both operated within the same regional agreements. However, since all clinics, including public ones, were profit-driven, the focus on community service was somehow undermined, leading to a reduction in contraceptive counselling appointments overall. Counselling appointments were frequently cancelled or rescheduled by the staff at the clinics during holidays and other periods of staff shortage. This was described as a persistent and long existing issue at all types of clinics. Consequently, women in urgent need of emergency contraception were sometimes not seen in time, leading to unintended pregnancies. Immigrant women, especially those with limited Swedish language skills or irregular contraceptive use, were disproportionately affected.

…”– Appointments go to pregnant women…– In the summer, we have no contraceptive visits, preferably none at all. Those appointments are cancelled. …– Yes, this is the core issue. It’s about the reimbursement” (FGD 11).

In addition to organisational limitations, accessibility was further constrained by language barriers and administrative inefficiencies. While the system encouraged online booking and interpreter services, many women and their accompanying partners preferred visiting in person. Often, interpreter services were not booked, only to be discovered at the appointment, leading to re-bookings and delays of several weeks. Although online contraceptive counselling was available at many clinics, it was rarely used by immigrant women due to language barriers and lower health literacy. Cost-saving measures also reduced valuable frontline staff, increasing midwives’ workloads and limiting timely contraceptive care.

…”– our clinic would not have functioned without our onsite interpreter … some women can´t speak any Swedish but they just say her name on the phone, and she can help immediately” (FGD 7).

Encountering challenges in availability and cost:

Midwives noted that pharmacies sometimes withheld prescribed contraceptives due to concerns about potential interactions with other medications, which further limited access. The midwives expressed frustration, feeling that their role as prescribers was sometimes questioned by pharmacy staff, and they called for better communication and collaboration with pharmacies to avoid delays.

…”– We’re somewhat at odds with pharmacies that still follow old guidelines…and won’t dispense the contraceptives we prescribe to breastfeeding women, which makes it hard to build trust when women return to try contraception again. ” (FGD 10).

Also, recurrent shortages of contraceptives made it difficult for women to access their preferred methods. Additionally, the cost of contraceptives, particularly hormonal IUDs, was a significant barrier, and their large, indiscrete packaging acted as a deterrent for some women. Midwives emphasised that equal access to all contraceptive methods could not be achieved unless all contraceptives were included in the cost-protection schemes, making them affordable regardless of the chosen method.

…” – like now, when the copper IUD is out of stock, there are no IUDs available. It’s insane… the only free contraceptive isn't even available. That could be an economic issue for women, and we can't offer it” (FGD 8).

Getting limited support from gynaecologist services:

Midwives viewed gynaecologists as essential collaborators in providing specialised contraceptive counselling, but staff shortages and limited access to gynaecologists hindered comprehensive support. The obstetricians at the midwifery clinics were often overextended and lacked specific contraceptive expertise. The midwives stated that during periods of declining birth rates, midwives were assigned additional tasks to enhance women's SRHR, for example offering gynaecological exams. However, without expanded gynaecological resources, reduced referral times to specialist care at the hospital and increased prescription rights for midwives, they felt constrained in their ability to meet women's needs. Additionally, introducing charges for gynaecological services exacerbated inequalities in care access and deprioritised contraceptive counselling in an already strained system.

…”– it is really frustrating…we have doctors who want to work with us but are restricted not to, and we have doctors who are overloaded with patients…and at the hospital there is also a lack of doctors and appointments… it is all about cost saving” (FGD 11).

Lacking continuity of care and contraceptive counselling in postpartum and abortion services:

The midwives highlighted the need for a more integrated approach to contraceptive counselling and care, emphasising the importance of reaching women both postpartum and after abortion. They stressed the value of offering contraceptive options during antenatal visits and immediately postpartum, rather than waiting 6–8 weeks for the first visit as is the current practice, particularly for women who wanted to avoid pregnancy soon after childbirth. Misconceptions about the protective benefits of breastfeeding made early contraceptive counselling even more essential.

…”-some women believe that they can´t become pregnant because they are lactating…however…it is too late waiting 8 weeks for counselling” (FGD 3).

Similarly, the midwives identified gaps in abortion care, noting that some immigrant women avoided hospitals out of fear of being discovered by husbands or relatives. Women often turned to their trusted midwives at the clinic for emotional support, information about abortion and post-abortion contraceptive counselling. The midwives believed that offering services like home abortion care and postpartum contraceptive counselling would provide continuity of care, prevent unintended pregnancies and better address the needs of vulnerable women.

…” – If they had an abortion or if they have a miscarriage and did not get contraceptive counselling at the hospital as they should…they should communicate it to us…so women don´t fall between the cracks” (FGD 6).

Missing access to education and counselling materials from trusted sources:

While the midwives acknowledged having a solid foundational knowledge of contraception, they expressed a need for ongoing education in contraceptive methods and also in counselling, noting that counselling had been neglected in both their training and daily work. The midwives described a tendency to merely prescribe familiar contraceptive methods and that they lacked a specific counselling method or communication technique aligned with official guidelines. The Motivational Interviewing (MI) method introduced years ago remained as the unofficial counselling approach, with many midwives being self-taught and relying on experience. Colleague discussions were crucial for support and knowledge sharing. Attending courses during work hours was difficult, leading many midwives to pursue education in their free time. Concerns were raised regarding midwifery students receiving insufficient training in contraception, as pregnancy visits were prioritised. Regionally organised continuing education courses were offered annually but required payment, making them inaccessible to all. Information about contraceptive methods from pharmaceutical sales representatives raised concerns about trust.

…” – We have a good education but too little opportunities to add knowledge…except for when the pharma reps come, but they don´t come as often anymore…– and there is that one course once a year…” (FGD 4).

They also stressed the need for education on global contraceptive practices to better serve women from diverse backgrounds. With short counselling sessions being stressful, especially for women with limited knowledge, midwives called for standardised and trusted materials such as anatomical models, multilingual materials and digital apps in minority languages.

…” – Everything today is online…but our apps for women are mainly in Swedish language… – yes, we should have apps in Arabic and Albanian for instance at our clinic …because now we are all improvising” (FGD 7).

Identifying gaps in sex education and reproductive misconceptions:

The midwives described that they encountered young immigrant women and women with immigrant background, born in Sweden, lacking SRHR knowledge and expressed frustration with the school sex education. They suggested midwives should take the lead in providing SRHR education across all age groups. Collaboration between midwifery clinics, Youth Guidance Centres (UMO) and schools was seen as key to improving contraceptive use and reducing unintended pregnancies.

…” – how can it be that growing up in Sweden and going through the Swedish school system women and girls do not have more knowledge about their own reproductive system…sometimes it is really shocking and heart-breaking” (FGD 3).

As most immigrant women seeking contraceptive counselling at midwifery clinics were married or in partnerships, midwives perceived that the counselling needs of younger immigrant women risked being neglected. The midwives with youth centre work experience emphasised longer (60-minute) counselling sessions addressing SRHR, partner violence and honour-related issues. They believed such sessions would benefit all women and stressed the need to focus more on sexual pleasure and group discussions, similar to youth clinics’ contraceptive information in groups.

Promoting direct communication strategy and dialogue:

The midwives described their communication style as more direct than that of other professions, which often helped address sensitive topics but could lead to misunderstandings. They emphasised the importance of discussing taboos but noted that midwives without immigrant backgrounds tended to use a more indirect, sometimes hesitant approach. Providing extensive information supported informed choice but could also make midwives appear uncertain. Colleagues from diverse backgrounds were valued for improving communication and trust and offered important insights into immigrant women’s needs. Midwives with immigrant backgrounds were appreciated for their cultural and linguistic competence, which could provide another pathway into patients’ trust rather than differences in competence, while those without immigrant backgrounds sometimes felt constrained, fearing their words could be misinterpreted or perceived as discriminatory.

Perceived cultural norms, such as marriage prerequisites before contraception, sometimes caused hesitation and superficial counselling. Fears about being accused of racism added complexity to the interaction. Conversely, some immigrant women were less tolerant toward Swedish midwives unfamiliar with their cultures. The midwives saw themselves as bridge builders between cultures but noted that bridging SRHR, gender, and cultural norms required time, resources, and stronger institutional support.

…” – Absolutely, racism does exist… it’s shown like you just don’t want to engage; just do the absolute basic things you have to do. You don't want to understand the patient and it's like... – Really cold treatment, absolutely…we really try to work with these things to treat all equally” (FGD 9).

Sharing interprofessional SRHR values and norms not self-evident:

The midwives emphasised the importance of interprofessional collaboration and communication, particularly with Family Centres and Children’s Health Clinics (BVC), in providing holistic care for immigrant women. Collaborating with social workers and other professionals helped midwives increase access to contraceptives and SRHR services while building trust with women. However, not all clinics could collaborate with Family Centres due to financial constraints and structural issues. Moreover, successful partnerships required a communication based on shared SRHR values and norms. Finding trusted partners was sometimes difficult, with local ethnic clinics advising against contraceptives or receiving conflicting advice from imams. Cooperation with cultural doulas and interpreters was also inconsistent, as differing values could hinder collaboration. Despite these challenges, midwives agreed that having staff with immigrant backgrounds was invaluable for better understanding women's situations without judgment, reinforcing the importance of shared SRHR values.

…” – It was with cultural doulas, and we found out from some of our women that some doulas were talking badly about contraceptives and having sex before marriage…– we were shocked…we had never thought of the possibility of us working together and not sharing the same core SRHR values” (FGD 1).

Educating and involving men not the main concern:

Midwives expressed concern that involving husbands too closely could undermine women’s autonomy and trust during contraceptive counselling. They were reluctant to view men as patients within their professional scope, fearing this might create insecurity for women. At the same time, they acknowledged the importance of engaging and educating men to reduce opposition to contraceptives and to increase understanding of women’s anatomy. Involving men was seen as potentially supportive for women and useful for promoting shared responsibility in SRHR, particularly in discussions on preconception health.

… “- It’s important when talking about contraceptives to not only talk about contraceptives but also about what reproductive plans they have… and you emphasise that it is not only the woman's responsibility but also the man's” (FGD 9).

Condom use and vasectomy were considered sensitive issues linked to masculinity norms and personal choice, which midwives felt they could not easily influence—nor did they view this as part of their professional role. Although many found it challenging to involve men without compromising women’s autonomy, they sought ways to include them in SRHR discussions. Outreach to immigrant groups through Swedish For Immigrants (SFI) classes and religious institutions was regarded as essential for raising awareness, but staffing shortages and limited funding had reduced these efforts, and some midwives described engaging in such work voluntarily.

…“– We really should discuss this thing with men… yes, but they should not be our responsibility area… we are midwives working for women, so… no, someone else could take on that assignment” (FGD 10).

Considering the complexity of existing gender norms:

The midwives with limited experience of working in immigrant-dense areas described that they were initially unprepared for the complexity of providing contraceptive counselling, particularly when balancing women’s autonomy with the influence of their partners or relatives. They described difficulties in understanding women’s choices, especially when women deferred decisions regarding their reproductive autonomy to their husbands or mothers-in-law. Despite receiving detailed information on contraceptive methods, many women returned saying they needed their husband's approval or opted not to use the recommended method. Midwives also encountered women unaware of their sexual and reproductive rights in Sweden, fearing that they needed a husband's consent for contraception or abortion.

…” – It is sometimes really difficult to understand after having informed about everything and you think that you meet in some kind of agreement and understanding…and then it all ends with “I need to go home and discuss with my husband” (FGD 11).

The involvement of relatives or mothers-in-law, including husbands controlling menstruation cycles, further complicated women´s abilities for decision-making. The midwives found it challenging to navigate these situations, unsure whether to interpret them as reproductive repression or voluntary involvement and struggled with how to know when to intervene being afraid of being perceived as judgmental.

…”– When I was a new midwife and new here in this neighbourhood, I wanted to make so much change for women …many years later I have realised that making change is not always what I thought it is going to be… it is more about reaching each individual making the best for her” (FGD 3).