Culture and values
Image: Plattform / Johnér
The culture and values domain of the WHO maternal well-being framework focus on how equity, justice, dignity, respect and culturally supportive practices shape perinatal experiences. The domain comprises five subdomains, including gender norms, human rights, cultural beliefs, social power relations and demographic elements, all of which are highlighted as essential determinants of maternal and parental well-being (Le Lez et al., 2025).
This chapter discusses factors affecting the psychosocial well-being of foreign-born parents, primarily immigrant and refugee families, and of sexual and gender minority families. It summarises key risks and protective factors identified in the research literature, as well as culturally and structurally mediated experiences that shape help‑seeking and access to services.
Migration in the Nordic Region
The Nordic Council of Ministers’ standardized definitions for migration statistics highlight regional differences revealed by these classifications. Since the 1990s, the share of foreign-born residents (individuals born abroad) has grown everywhere except Greenland, with Sweden consistently leading and Finland at the lower end. Smaller territories such as Åland and Iceland have high proportions relative to their populations, although absolute numbers remain modest (Berlina et al., 2025).
By 2025:
- Sweden hosted about 2.2 million foreign-born residents
- Norway: 1.06 million
- Denmark (including the Faroe Islands and Greenland): 877,000
- Finland and Åland: 589,000
- Iceland: 82,000
Policy Frameworks for Migrant Integration in the Nordic Countries (2025) offers detailed insights into the governance, coordination and implementation of integration policies, including responsibilities across ministries and local actors, strategic policy directions, recent legislation and key measures such as introduction programmes, settlement schemes and language training.
Accumulating stressors challenge the psychosocial well-being of immigrant and refugee families
Research has identified that immigrants face a significantly increased risk of various psychosocial challenges during the perinatal period. In addition to universal risk factors, immigrants encounter unique cultural and migration-related challenges and may carry substantial life-related burdens. Individuals with immigrant backgrounds often struggle to adapt to a new country and environment (Heslehurst et al., 2018; Klas et al., 2023), including adjusting to changed roles and parenting in the new recipient country (Aiyar et al., 2023). Living between two cultures may be difficult when individuals try to maintain their cultural identity while simultaneously adapting to a new society, service system and maternal identity (Pangas et al., 2019). An uncertain legal status, such as waiting for an asylum decision, can further undermine psychosocial well-being and may act as a barrier to seeking help (Balaam et al., 2022; Firth et al., 2022).
Women with refugee and immigrant backgrounds often carry burdens and trauma related to previous life experiences (Almeida et al., 2024; Heer et al., 2024). Prior mental health problems have been shown to increase the risk of the postpartum depression among immigrant women among social determinants (Nilaweera et al., 2014). The prevalence of postpartum depression is higher among women with immigrant backgrounds compared to the general population (Almeida et al., 2013; da Conceição et al., 2015). In a review by Winter, Due and Ziersch (2024), prevalence rates of depressive symptomology ranged from 22–43% during pregnancy and 25–57% postpartum. Among refugee and asylum-seeking women, the prevalence of postpartum depression has been reported to be as high as 22.5%, compared to 17.5% in other populations (Heer et al., 2024). Traumatic experiences and other risk factors contribute to higher rates of mental health disorders among refugee women, including PTSD, depression, sleep disorders, anxiety and schizophrenia (Klas et al., 2023).
Refugee and asylum-seeking parents have reported limited social support from family and the community, as well as experiences of isolation and loneliness (Aiyar et al., 2023; Almeida et al., 2024; Balaam et al., 2022). Separation from family and other close relationships often results in a lack of social support in the recipient country, a known risk factor for psychosocial challenges during the perinatal period. Social isolation, experiences of discrimination and relationship challenges are further identified risk factors for postpartum depression among immigrant women (Heer et al., 2024; Nilaweera et al., 2014). More broadly, inadequate social support is associated with an increased risk of mental health disorders and poorer perinatal well-being among immigrant parents (Heslehurst et al., 2018; Klas et al., 2023). Immigrant, refugee and asylum-seeking fathers have also reported insufficient social support (Aiyar et al., 2023; Vo et al., 2024.
Lower socioeconomic status
Refugee and asylum-seeking women also face various challenges related to housing and financial situations (Balaam et al., 2022). Financial pressures may make it difficult to cover basic living costs, transportation to appointments and costs of essential care. Many express concerns regarding living conditions (Fair et al., 2020). Men have reported concerns related to employment and financial security, which contribute to anxiety about supporting their wives (Aiyar et al., 2023). Financial limitations and related stress are recognised risk factors for postpartum depression (Heer et al., 2024; O’Mahony & Donnelly, 2010). A lower socioeconomic status also affects access to and the quality of services (Dela Cruz et al., 2023). In some regions, rates of intimate partner violence are higher than the global average and may constitute a particular risk to the safety and well-being of immigrant and refugee women (Winter et al., 2024, citing WHO, 2013).
Protective factors and cultural influences
Cultural and family influences play a significant role in shaping women’s experiences during the postnatal period. Supportive family networks and adequate health literacy can enhance well-being, while cultural beliefs, social norms and family pressures may create barriers to accessing professional care. These challenges can lead to disengagement from health services, underscoring the importance of culturally sensitive approaches (Walker et al., 2019).
Social support has constantly been identified as a key a protective factor for the psychosocial well-being of immigrant families. Support from a partner, family and the wider community is associated with increased help-seeking, better well-being outcomes and improved coping with psychological stress (Almeida et al., 2024; Dela Cruz et al., 2023; O’Mahony & Donnelly, 2010; Winter et al., 2024). Fair et al. (2020) found that women who had family members nearby benefited from assistance with domestic tasks and received guidance and support.
Developing new friendships, enrolling in education or employment, connecting with religion and using childcare to allow time for self-care were reported as beneficial coping strategies. Maintaining cultural practices, such as eating traditional foods and celebrating birth with the family, positively impacted emotional and physical well-being during pregnancy and postpartum (Aiyar et al., 2023). Women employ a variety of strategies to cope with perinatal mental health symptoms. Support from others with similar experiences is often particularly valuable. Spirituality and spiritual communities can also serve as meaningful sources of support (Aiyar et al., 2023; Watson et al., 2019).
Intersectional vulnerabilities
LGBTI people in the Nordic countries who belong to multiple minority groups face heightened vulnerability due to overlapping discrimination, such as racism, homophobia, and ableism, which often leads to violence, economic insecurity, and poor mental health. Particularly at risk are groups like LGBTI asylum seekers and Sámi LGBTI individuals, who encounter structural barriers, invisibility, and multiple minority stress. Further insights, including challenges, solutions, and outcomes from Nordic co-operation projects, can be found in the publication “Standing out even in groups to which you belong” Conditions and co-operation for LGBTI people who belong to multiple minority groups in the Nordic countries
Sexual and gender minorities in perinatal care
Another vulnerable group identified in the literature includes individuals belonging to LGBTQ minorities. People from sexual and gender minorities have reported higher levels of low mood and depression compared to the general population, and they often experience anxiety and stress related to fertility processes and gender identity (Kirubarajan et al., 2022).
LGBTQ individuals report multiple forms of exclusion, both within perinatal services and, at times, within their own LGBTQ communities. These experiences can exacerbate the challenges during the perinatal period and create LGBTQ barriers to seeking help. In addition to mental health concerns, LGBTQ individuals report difficulties accessing appropriate services and information, a lack of recognition of gender identity in health care, contradictory birth experiences and experiences of discrimination in perinatal care (Permezel et al., 2023). Same-sex parents have identified discrimination and homophobic attitudes in healthcare services (Adams et al., 2025).
These findings highlight the need to develop perinatal services that are genuinely equal and sensitive to sexual and gender minorities. Services must recognise diverse family and identity backgrounds, provide a safe space for sharing experiences and ensure that staff have the necessary competence to engage with LGBTQ individuals respectfully and without prejudice.
Findings from the psychosocial intervention review for the culture and values domain
The intervention portal mapping identified a significant gap in Nordic interventions: gender, language and cultural minorities were poorly addressed, despite being recognized as risk groups. Only one international intervention was evaluated as effective and explicitly targeted a cultural minority group (Family Spirit®, a culturally tailored home-visiting programme for Native American communities, designed to promote optimal health and well-being for parents and their children). None of these interventions aimed at refugee, asylum-seeking or immigrant mothers or parents were found to be assessed as effective or even at a promising level. Similarly, there were no interventions specifically designed for LGBTQ families.
Intervention | Culture & values* | |||
Immigrants, refugees, and asylum seekers | Sexual and gender minorities | Other minorities | ||
|---|---|---|---|---|
UK/USA | Family Spirit® | X | ||
Table 12. Identified effective psychosocial interventions in the psychosocial interventions in the Culture and values domain.
*) Reminder: The selected portals only include interventions that have been evaluated within the assessment systems according to specific criteria, with an emphasis on research-based evidence of effectiveness. The interventions that demonstrate at least some research-based evidence of effectiveness are presented. The assessment systems operate dynamically, and the information presented in this report may therefore be updated quite rapidly. Regular monitoring of the relevant portals of these assessment systems is recommended.
The checkmarks reflect what was indicated as the primary target group or objective in the portal descriptions of each intervention. Many interventions have multiple secondary goals and effects, so additional checkmarks could apply in practice.
There is a need for more interventions in the Nordic context. While some programmes have incorporated cultural background factors and acknowledged the importance of culturally sensitive approaches, systematic integration of these considerations into intervention design and delivery remains limited.
In the literature, several studies highlighted the need for culturally responsive maternity care, as well as attention to the continuity of care (for example Aiyar et al., 2023). Having the same care providers during pregnancy, birth and postpartum helps to build trust, improves communication and reduces the need for women to repeatedly share traumatic histories (Ayiar et al., 2023). Fair et al. (2020) have reported a need to increase the use of interpreter services and offer clear information as well as provide training in culturally competent and trauma-informed care. Postnatal practices also vary across cultures, influencing well-being and care experiences, and region-specific care approaches are necessary to ensure equitable, culturally sensitive maternity services (Ayiar et al., 2023).
In the study of Balaam, Kingdon & Haith-Cooper (2022), the interventions that were most valued by women themselves were those using a community-based befriending/peer support approach, as these provided the most holistic approach to addressing their needs. The impacts of the interventions were devided into five themes: alleviation of being alone, safety and trust, practical knowledge and learning, being cared for and emotional support, and increased confidence in and beyond the intervention.
Unrecognized perspectives of the Sámi people
The Sámi are the only recognized indigenous people in the European Union. Sápmi, the cultural region traditionally inhabited by the Sámi people, is assimilated by and spans parts of Norway, Sweden, Finland and Russian. The Sámi are the indigenous people inhabiting Sápmi, which is a cultural and geographic area significant to the Sámi people. It should be noted that a significant proportion of the Sámi population lives outside the Sámi homeland area (Saami council). No studies on Sámi families were found in the literature search for this report.
Sivertesen et al. (2025) identified a similar gap in their scoping review on indigenous women's dissatisfaction with birthing experiences. Research on the birthing experiences of the Sámi people is almost completely lacking. The authors note that this research gap perpetuates the invisibility of the Sámi in healthcare structures and prevents the development of culturally safe childbirth services, and there is therefore an urgent need for research based on the Sámi's own perspectives in the healthcare systems of Norway, Sweden and Finland (Sivertesen et al., 2025).
Key observations from Nordic expert discussions concerning the culture and values domain
Experts stressed the importance of recognising family diversity in service provision. Parents with limited literacy or language skills require tailored communication, interpretation services, additional time and trauma‑informed approaches. Immigrant families are diverse, and services must reflect this variability.
Trauma-, migration‑ and bereavement‑informed care remains insufficiently embedded in routine practice, including after stillbirth or neonatal loss. Experts noted that the focus on trauma can sometimes overshadow other significant experiences, such as cultural dislocation, value differences, helplessness and a lack of belonging. Large families may require different support approaches compared to first‑time parents. While the role of fathers and other caregivers is increasingly recognised, inclusive and targeted support for them must be strengthened.