Study sample characteristics and health insurance coverage

The 10 FGDs at three clinics included 64 participants of whom almost half were experienced (multi-gravid) mothers, with a variety of prior perinatal experiences including giving birth at home, at a migrant clinic or at a government hospital. All of our participants had previously visited or were visiting the migrant clinic to receive ANC and register for birth services. While clinics were on the Thailand side of the border, women came from both sides to receive care. Most of our participants were undocumented migrants who were not eligible for coverage under the Thai government’s Migrant Health Insurance Scheme. Nevertheless women could register to a local non-profit health insurance program known as the M-FUND which was developed with one of the premises to ensure coverage for emergency birth services [7, 18]. Women with M-FUND health insurance were assured that they would have coverage if advanced care at a Thai or Myanmar hospital was required. By registering for ANC, birth services and the M-FUND, women embarked on a pathway for utilizing care for complicated or uncomplicated births.

Pregnant women in our study described availability of maternal health services, accessibility of maternal health service and choice of appropriate care.

An informal network approach to learning about available maternal health services

When considering availability to maternal health services, some women drew from their past experiences of seeking other types of healthcare from migrant clinics as well as accompanying family members. One woman describes, “I used to follow my mother when I was young. My mother came to this clinic for delivery”.

Participants used their local informal networks to learn about availability and the location of maternal health services from family members, friends and community members including local health workers. Women spoke of following the advice of family members, “I heard it from my aunty that people come to register for their birth here, so that is why I come”. In some cases, they also accompanied a local contact as a woman explains, “One of my neighbors came here and I followed her”. Another woman with a first-time pregnancy followed a community member to the clinic and described how the person had encouraged her to come by asking “Are you not registering for your birth, are you not going?”.

One woman reported that she heard about maternal health services at the migrant clinic from a local health worker, “Before I had a pregnancy. When I came here, I was already 6 months pregnant. I didn’t know there was a clinic here. But the (healthcare worker) told me to come”. Positive reports of birth experiences and perceptions of quality care from other women in the community also shaped women’s desire to seek care at the clinic as, “people talked that the health care worker at (the clinic) takes very good care of the patients”.

Accessibility: travelling for antenatal and birth services

Women utilized multiple methods of transport to arrive at the clinics including: walking, motorcycle (taxi and personal), car (taxi), boat, bicycle, boat and tractor (taxi). There was a significant range in travel times ranging from 5 min to 4 h. Several women reported walking for up to 2 h to arrive at the clinic. The journeys of women who crossed the border to receive care were often lengthier with the longest being 4 h from home to the clinic, including half an hour at the bridge to apply for a border pass.

Women described how they had travelled to the clinic. For women living on the Thai side of the border, the journey was more straightforward and often required only a single mode of transport or the combination of walking and a taxi ride to arrive at the clinic. One woman described, “I came here by bicycle with my husband… I sat on the back while my husband pedalled”.

Women who lived on the Myanmar side had to make the international border crossing and then continue on to the clinic. The Thailand–Myanmar border is demarcated by the Moei river, a long narrow body of water (Fig. 1). There exists one official border crossing with a large bridge as well as multiple informal crossings where women can come across by boat. Often women used one mode of transport to reach the border, a second to cross it and a third to travel to the clinic. One woman explained that she walked from her home and then “I came across the river by boat. I then came here (to the clinic) by car which took me 15 min”.

When asked about accessibility and getting to care, women did not identify long walks as difficult, even those who walked for 2 h. When probed, participants maintained that it was normal to walk long distances for health services and were very matter of fact about physically navigating this environment to access care. Additionally, participants did not report any work or familial responsibilities that prevented them from coming to the ANC at the clinic.

Travel during the rainy season was sometimes more complex, and compounded challenges caused by the Thailand–Myanmar official bridge crossing. Several women who had previously given birth described the logistical cross-border transportation challenges that they experienced during their labour. One woman registered to give birth at a border clinic in Thailand but ended up going to Myawaddy hospital in Myanmar. She described, “It was the middle of the night and it was difficult to cross (the border) in the rainy season so I had to deliver at Myawaddy hospital”. The woman experienced labour onset in the evening for her first two children and could not cross the border to give birth. The large bridge crossing is closed at night.

Women also described how they would strategically assess where to go to give birth depending on where they were during the onset of labour and the weather conditions, “I think if I began to have labour pain in Myanmar, I would go to the place which is closest to me. We have difficulty with the roads during the rainy season. If not, it’s easy for us to come here with a motorbike”.

Given the challenge of transportation logistics, one woman delivered enroute, “I delivered on the way, in the tractor coming to the clinic. I couldn’t help it”. Other women acknowledged that not arriving at the clinic in time for delivery was a possibility and one expressed, “some people prefer to deliver at home. Some people are used to coming here so they come. For some they gave birth on the way (to the clinic).”

Choosing appropriate care

For many participants choice of alternative antenatal and birth care, beyond the migrant clinic, was constricted by limited options of care providers who have formal training. When asked about other places they could seek maternal healthcare many indicated that the clinic they were visiting is the only one they knew about. In the voice of some participants, “We have only this one”.

Some women weighed up the option of going to the migrant clinics instead of giving birth at home or in the community and cited higher levels of care in deciding to go to the clinics. One woman explained, “They have a good system of taking care of mother and child, if compared to the place where I live. So, instead of giving birth in the place where I live, I feel more secure to give birth here”. Another noted, “It is not a hundred percent reliable to cut off the umbilical cord at home. It is more reliable here. That’s why I decided to come”. Women expressed that the migrant clinic was better equipped to support them if they had any complications during birth. One participant explained, “I am afraid of some difficulties that would happen if I was there [at home]. But if I am in the hands of a health worker here, I know they have enough medicine. So that, I think is good for me”.

Several women noted that some limited maternal health services were available at the village level. A few women living in Myanmar villages indicated that health workers came to provide vaccinations. In Thailand, some women could also receive ANC from Thai community health centres.

On their respective sides of the border, Thai and Myanmar government hospitals exist which provide maternal healthcare. Depending on where migrant women are living these may be farther than the migrant clinics which are mostly located closely adjacent to the border. Research participants had multiple perspectives on hospital maternal health services. Some knew that additional maternal health services existed within their geographic area, including the local Thai and Myanmar government hospitals, but many had limited knowledge about these care options. For example, when asked about maternal healthcare availability in Myawaddy, the largest town in Myanmar that is close to the Thai border, some women responded, “We heard about it. But we have never been there”. Indeed the distance to this hospital from the clinic of the FGD is some 60 km away.

A few experienced mothers had previously given birth at Thailand and Myanmar government institutions and were thus more knowledgeable about the services. Most had positive birth experiences at government hospitals and a few reported disrespectful care compounded by communication difficulties. Conversations were sometimes rough and care providers appeared impatient amidst language barriers. One woman expressed, “It would be good if we have mutual understanding. We are delivering our babies in a foreign country and automatically feel small or sad.” Overarchingly women perceived that Thai and Myanmar health services were expensive (for those without migrant health insurance) and communication with care providers was sometimes difficult due to language differences and infrequent availability of interpreters. Participants understood that they could access government facilities through a referral from the migrant clinic and their M-FUND insurance but most did not see them as a first choice for accessing ANC and birth care independently.

Cultural appropriateness and affordability of care at migrant clinics helped to make care more accessible for migrant women. At the migrant clinics workers spoke two dialects of Karen language, Sgaw and Pwo as well as Burmese. For migrant patients, being able to get care in a language they understood increased their comfort and influenced their decision to come to the migrant clinic for maternal care. A participant explained, “As for me culturally we speak the same language which is comfortable for me”.

Maternal health care services were provided free of charge at the three migrant clinics we visited. Affordability factored into women’s choice on where to get maternal care and one person expressed, “I get free care here. On the other side (of the border), I had to give money to get care”. Another explained, “We have problems with money. This (service here) makes us happy. It is convenient for me coming here because it costs no money”.