In a small Victorian town, Liv, a mother of five, recalls the hopelessness she felt at her pregnancy check-ups.
Part of Myanmar's ethnic Karen community, she came to Australia in 2007 and does not speak English.
"The interpreter keeps changing, or sometimes I can’t understand the interpreter. So, at those times I felt so sad and hopeless," said Liv, who asked not to use her real name.
With her first Australian-born child, the now 39-year-old had no access to an interpreter, but with her subsequent pregnancies things improved.
However, there was no continuity of care when it came to interpreters, and some experts think that needs to change.
On one occasion she was offered a Burmese-speaking interpreter, but Burmese and the Karen language Liv speaks are different.
Only with her fifth pregnancy did she have a more stable relationship with an interpreter.
Her youngest child is now three years old.
Bid to empower women in early pregnancy
Liv is among the one-third of mothers in Australia who were born overseas.
Melbourne obstetrician Oliver Daly sees the barriers these women face on nearly a daily basis.
Working in a busy hospital in the city's west, one in five women he sees are from a migrant background.
"It's very challenging, because time constraints on busy wards put immense pressure on staff, with standard clinic appointments only 15 minutes long," Dr Daly said.
"You not only have to discuss how the woman is but do all of the screening tests to identify any potential problems and prepare women for some decisions that they need to make.
"And so, if you have an interpreter on top of that, then that makes it even more challenging."
Dr Daly said with the help of skilled interpreters, and adequate time for clinical consults, women can be more empowered in early pregnancy, which is key to overcoming some of the current shortfalls.
More than 80 per cent of women born in Australia had their pregnancy check-ups in their first trimester, compared to 76 per cent of migrant women, according to the latest data from the Australian Institute of Health and Welfare's (AIHW) National Women and Babies report.
The data does not differentiate between women born overseas who speak English, and those who do not.
Not attending antenatal visits early on can lead to worse outcomes for mothers and their babies.
Some risk factors might be missed, and women may miss out on crucial information they need for a healthy pregnancy.
More female interpreters needed
"Women from migrant backgrounds do have poorer maternal and child health outcomes than the general population," said Regina Torres-Quiazon, acting executive director at the Multicultural Centre for Women's Health in Melbourne.
"If you do come from a non-English speaking background, you're less likely to participate or access health services."
This group are more likely to develop gestational diabetes.
According to the AIHW figures, 12 per cent of Australian-born women compared to 21 per cent of overseas-born women develop the condition during pregnancy.
They are also more likely to have interventions such as caesareans or episiotomies during labour.
Dr Torres-Quiazon said language barriers were partly to blame, as there is limited availability of interpreters.
She said interpreters are not always skilled at understanding and properly translating pregnancy and antenatal care issues for migrant women, especially in rural and remote areas.
It is also a struggle building trusting relationships because these women rarely see the same interpreters or don't feel comfortable with who is available, added Dr Torres-Quiazon.
"We know also that there is a lack of female interpreters, and female interpreters are often the ones that migrant women would prefer to speak to about very sensitive topics," she said.
"There is also concern [that] some interpreters may be someone that they know in the community.
"So, together, these are issues that really put women's health at risk."
Interpreters face 'tenuous, insecure employment'
Many interpreters are contractors or casuals, so they can't easily access paid training that would support their work, Dr Torres-Quiazon said.
It's something Liana Papoutsis, who worked as an interpreter for 16 years and is now a consultant and academic, has experienced herself.
"There is the odd hospital here and there that may put on interpreters on an ongoing basis," she said, but "that's the exception, it's not the norm".
"Interpreters are … in tenuous, insecure employment."
She said interpreters need to be highly skilled to help women navigate their pregnancies and read non-verbal cues that might require intervention, such as in domestic violence cases.
Sonia Kalsi, the women's and families team leader at the SydWest multicultural centre in western Sydney, is familiar with such situations.
Ms Kalsi works with women from the diverse areas of Blacktown and Mount Druitt.
She said women from those communities needed continuity with interpreters to build trust to address issues beyond their pregnancy.
"If the woman is pregnant and there is another issue, for example, there is a domestic violence issue also added to it, they are not ready to speak of any of those concerns through an interpreter," she said.
Experts call for interpreters to be permanent hospital staff
Liana Papoutsis believes hospitals should employ interpreters directly on a set roster and book women in accordingly.
"So, hospitals can say, 'look, we want to have X amount of interpreters ongoing, because these languages are the ones we use – the top 10'."
Dr Torres-Quiazon also wants to see interpreters become permanent hospital staff members with "proper contracts" to create "stability in that profession".
She said they also needed access to professional development and paid training so they can better deal with the sensitive and technical issues discussed in appointments.
Back in rural Victoria, Liv's 48-year-old friend, a Karen mother-of-three, had no access to interpreting services when she was pregnant 15 years ago.
Even more than a decade on, the friend still feels anxious about visiting a doctor, and is in tears while talking about her experience.
"Whenever I have an appointment I don't want to go; I feel very heavy to go and also even now because of experiences with the pregnancy," she said.
Liv has one message for pregnant women.
"Whenever you suffer because you are unable to speak English, don't … suffer," she said.
"Just go [to the hospital] and try to communicate with a body gesture," she said.
"Be brave."
