Service design for improving pregnancy, childbirth, and childcare competency among North Korean refugee women in South Korea: a qualitative service-design study

Abstract

Purpose

North Korean refugee women face multiple vulnerabilities during pregnancy and early childrearing due to fragmented support and limited familiarity with Korea’s health and welfare systems. Existing research has examined isolated barriers. This study used a service design approach to explore their maternal–infant care experiences and identify structural discontinuities across the care pathway.

Methods

Data were collected from North Korean refugee mothers and service providers from April to August 2024. A service design approach using user journey mapping, thematic analysis, and service blueprinting was employed to examine user actions, emotional trajectories, frontline interactions, and backstage and interagency processes.

Results

Five structural issues were identified: fragmented information, cross-institutional access barriers, cultural and emotional isolation, discontinuity in interagency linkage, and provider resource constraints. These issues accumulated along the pathway, increasing emotional burden, delaying timely care, and reinforcing avoidance behaviors. Misalignment between user needs and multi-agency processes was also evident.

Conclusion

Maternal and infant care challenges among North Korean refugee women stem from structural fragmentation rather than individual factors. Based on these findings, the NK Mom Care Navigator—a pathway-based, culturally responsive service design model—is proposed to strengthen continuity of care and enhance equitable maternal–infant support for vulnerable refugee families.

INTRODUCTION

North Korean female defectors represent over 70% of all North Korean defectors [1], and many are entering life stages involving pregnancy, childbirth, and infant care. These women face significant vulnerabilities during pregnancy and childbirth due to overlapping factors, including traumatic experiences during defection, initial socioeconomic instability upon settlement, limited social support networks, and challenges in navigating medical and welfare systems [2]. Although institutional medical coverage and maternal support policies exist, substantial difficulties persist in actual utilization, underscoring the need to understand pregnancy and childbirth experiences among North Korean female defectors within their specific context.

Previous studies indicate that although South Korea’s medical and welfare services are formally accessible to defectors, difficulties in understanding procedures, communication barriers with medical staff, and complex terminology hinder effective healthcare access [3,4]. In routine healthcare settings, limited information access, complicated administrative processes, and low health literacy further exacerbate health inequalities and undermine continuity of care during pregnancy and childbirth [5,6]. In addition, Hanawon settlement education programs, which prioritize social adaptation, have been criticized for insufficient coverage of pregnancy- and childbirth-related education and for using materials with limited relevance to real-life contexts [7,8].

Compared with general Korean mothers or other migrant women, North Korean female defectors experience more severe structural, cultural, and emotional vulnerabilities. While migrant women from China and Southeast Asia may receive partial support from spouses’ families [9], many North Korean women endure solitary defection and prolonged family separation, resulting in fragile emotional support systems during prenatal and postnatal periods [2,10]. Furthermore, North Korea’s historically informal and intermittent prenatal care practices differ markedly from South Korea’s standardized medical system [11,12], creating cultural and communicative gaps often described as misunderstandings rooted in a “similar language but different meaning” dynamic [10,13,14]. Traumatic experiences during defection and settlement stress further exacerbate mental health vulnerabilities, including depression and anxiety, during pregnancy and childbirth [2,3,10,15,16].

Even in routine care settings, North Korean female defectors experience emotional isolation and cultural maladjustment during school events, parent participation activities, and public health center visits due to the absence of family networks, limited access to social resources, and differences in cultural symbolic systems [17]. These factors influence the entire care experience and extend beyond issues of institutional accessibility, yet they remain insufficiently addressed in existing research.

Most existing studies on North Korean defectors have adopted fragmented, single-domain approaches, focusing separately on healthcare utilization [3,6,15], initial adaptation [18], pregnancy-related health issues [7,19], or mental health and stress [5]. As a result, there is a notable lack of research that comprehensively analyzes the integrated care pathway from pregnancy awareness through childbirth to infant care, or that identifies structural pain points and discontinuities across the entire care continuum.

Service design offers a suitable methodological framework for addressing these gaps, as it enables systematic analysis of user experiences, emotions, provider operations, and institutional contexts to redesign structurally fragmented public and health services [17-19]. Experience-based and human-centered design approaches have also been recognized as effective strategies for improving maternal health services for refugee and migrant women by addressing service pathway disconnections [11,12,19,20].

This study applies a service design methodology to explore the pregnancy, childbirth, and infant care experiences of North Korean female defectors, aiming to derive a pathway-based service model for maternal and child health care. By identifying structural disconnections in the maternal care pathway, this study seeks to establish design principles for improving maternal and child health service. The goal is to generate user-centered implications to enhance maternal and child health among North Korean female defectors and expand the nursing evidence base for care design targeting vulnerable populations.

METHODS

Ethical statements: This study was approved by the Institutional Review Board of the University of Hannam (IRB No. 2023-03-03-0111). Informed consent was obtained from all participants (or their parent legal guardians).

1. Study Design

This study is a service design–based qualitative study [21] that examines the pregnancy, childbirth, and childcare experiences of North Korean female defectors. It aims to develop an integrated support service model grounded in the care pipeline. Focus group interviews (FGIs) and in-depth interviews (IDIs) were conducted concurrently to identify structural issues across the pregnancy, childbirth, and childcare pipeline, based on participants’ lived experiences. Through qualitative analysis, participants’ experiences, emotions, and environmental contexts were comprehensively examined to identify pain points within the service utilization flow. This study was conducted using a service design methodology, and the qualitative interview components were reported in accordance with the Consolidated Criteria for Reporting Qualitative Research (COREQ) guidelines [22].

2. Study Setting and Participants

1) Users (focus group interview participants)

Six North Korean female defectors with experience in pregnancy, childbirth, and infant care were selected for the study. The inclusion criteria were: residence in South Korea for no more than 10 years, having been pregnant or childbirth within the last 5 years, and the ability to communicate in Korean. Recruitment involved distributing research information leaflets in collaboration with Hana Centers and private support organizations in targeted areas, followed by voluntary participant enrollment. To protect personal identities, all participants were treated anonymously (P1–P6).

2) Providers (in-depth interview participants)

The providers consisted of five agency managers from Hana Centers, each with at least 3 years of experience in specific areas of Seoul. These participants voluntarily agreed to participate after receiving an explanation of the study’s purpose and methodology, all participants were treated anonymously (S1–S5).

In determining the sample size, this study followed the principle of thematic saturation commonly applied in qualitative service design research. Data collection and preliminary analysis were conducted concurrently, allowing the research team to continuously assess the emergence of new themes and insights. Saturation was considered to have been reached when no substantially new codes, concepts, or service-related pain points emerged from successive interviews, and when participants’ accounts showed recurring patterns and redundancy across the pregnancy, childbirth, and childcare service pipeline. In addition, convergence between user experiences (FGIs) and provider perspectives (IDIs) further supported the adequacy of the sample size for achieving analytical depth and contextual completeness.

3. Data Collection

Data collection was conducted following approval from the researcher’s university ethics committee. Prior to participation, the researcher explained the study’s purpose, procedures, potential risks and benefits, and principles of anonymity and confidentiality, and written informed consent was obtained. Participants were informed of their right to withdraw at any time without disadvantage and to request a summary of the findings. All audio files and transcripts were anonymized, encrypted, and securely stored with access restricted to the research team.

Data were collected through a FGI, individual IDIs, and field notes. One FGI with service users was conducted in April 2024, lasting 125 minutes, using a semi-structured questionnaire. Key topics included challenges related to pregnancy, childbirth, and childcare; experiences with South Korea’s medical, health, and welfare systems; use of support services from local governments and public health centers; information-seeking processes and difficulties; and cultural and emotional challenges.

IDIs with five service providers, including Hana Centre practitioners and organizational managers, were conducted between May and August 2024. Each interview lasted 60–90 minutes and was conducted individually by the same researcher using a semi-structured guide. Questions focused on administrative procedures, system linkage pathways, commonly observed difficulties, and perceived vulnerabilities in supporting pregnancy, childbirth, and childcare among North Korean female defectors.

During both the FGI and individual interviews, the researcher recorded non-verbal expressions, emotional responses, contextual factors, and preliminary analytical insights as field notes. These notes were used as supplementary data to support contextual interpretation during analysis. With participants’ consent, all interviews were audio-recorded and transcribed verbatim for analysis.

4. Data Analysis

The data analysis for this study was conducted using the Double Diamond model (Discover–Define–Develop–Deliver) of service design [21]. A service design-oriented analytic process was applied to synthesize user experiences into structured insights, including user journey mapping, contextual interpretation of experiences, identification of pain points, and iterative development of a service blueprint.

In this study, the term care pathway denotes the sequential continuum of service experiences from pregnancy awareness through childbirth and early childcare, serving as the primary analytical framework guiding the service design analysis. Transition refers to critical points between stages of this pathway where service discontinuity, informational gaps, and emotional burden tend to intensify. Accordingly, transition support denotes targeted design strategies aimed at reducing structural vulnerability during these high-friction periods.

The analysis followed the four-stage procedure outlined below.

1) Discover stage: collection of raw user experience data and extraction of insight units

All materials, including FGIs, IDIs, and field notes, were read repeatedly. These meaning units were subsequently organized and categorized during the analytic process, which later informed the identification of key experiential dimensions in the results stage. This stage secured “raw user experience data” by recording not only technical facts but also the flow of experience, inconveniences, and emotional changes.

2) Define stage: categorization based on the service journey (Customer Journey Map)

The derived meaning units were arranged chronologically along the care pipeline: pregnancy awareness → Hanawon → regional center → medical institution → childbirth → early childcare. This arrangement formed the Customer Journey Map. For each stage, touchpoints, actions, thoughts, feelings, needs, and barriers were organized, visually structuring discontinuities between stages and recurring difficulties. This process clearly identified high-friction moments and points where support continuity was disrupted (gaps in continuity). Barriers and recurring problems identified during this process were categorized according to the Pain Point analysis framework used in service design.

3) Develop stage: service development

The develop stage of this research involved designing a service concept to address the core Pain Points identified in the discover and define analysis, followed by the creation of a concrete prototype based on this concept. This stage integrated narrative data from North Korean female defectors, the operational context of providers, and institutional constraints to develop a service structure linking the pregnancy–childbirth–childcare pathway into a single continuous flow.

4) Deliver stage: service blueprint-based structural analysis

Finally, a service blueprint analysis was conducted to verify how the developed service model would function within the existing service system. Focusing on four layers—user actions, frontstage, backstage, and support process—we identified points of disconnection within the current system and analyzed how the service flow and backstage structure would be realigned upon introducing the Navigator model.

5. Methodological Rigor

To ensure methodological rigor, this study followed the criteria proposed by Lincoln and Guba: credibility, dependability, confirmability, and transferability [23]. The primary researcher conducted an in-depth analysis of transcribed interview data and field notes to generate and iteratively refine initial codes through constant analytic comparison. Reflexive memos, codebooks, and version-controlled service design artifacts, including journey maps and service blueprint drafts, were systematically documented to establish a clear audit trail, supporting dependability and confirmability.

The primary researcher has formal training and research experience in qualitative inquiry within nursing and health-related social research, including interview-based studies and thematic analysis. To minimize interpretive bias, reflexive engagement was maintained throughout the analytic process, with analytic decisions and emerging interpretations continuously documented and critically examined. Interview transcripts were not returned in full to participants. However, to support interpretive accuracy, key meanings and summarized interpretations were checked with participants to confirm they reflected their intended meanings. This process served as a form of meaning validation rather than full transcript verification.

To enhance credibility, key thematic structures and service model representations were periodically reviewed in consultation with an external service design expert. The expert contributed by reviewing evolving themes and service models from a service design perspective, supporting critical reflection rather than directly coding raw data. Additionally, analytic interpretations were compared across multiple data sources, including FGIs with service users and IDIs with service providers, to assess thematic convergence and divergence.

Participant characteristics were explicitly presented (Table 1), and care pathways were described in detail across analytic stages, facilitating assessment of applicability in similar contexts and enhancing transferability.

Table 1.

Characteristics of the research participants

Variable	Age group (yr)	Length of stay in South Korea (yr)	Position	No. of children	Position	Years working with North Korean refugees (yr)	Participation type
Service users
P1	Latea) 20s	5	NA	1	NA	NA	FGI
P2	Earlyb) 30s	7	NA	2	NA	NA	FGI
P3	Midc) 30s	10	NA	1	NA	NA	FGI
P4	Earlyb) 40s	15	NA	2	NA	NA	FGI
P5	Midc) 40s	12	NA	1	NA	NA	FGI
P6	Latea) 20s	12	NA	2	NA	NA	FGI
Service providers
S1 (W)	Earlyb) 50s	NA	Center director	NA	Center director	23	Individual IDI
S2 (W)	Latea) 40s	NA	Center director	NA	Center director	20	Individual IDI
S3 (M)	Earlyb) 40s	NA	Center director	NA	Center director	12	Individual IDI
S4 (W)	Earlyb) 30s	NA	Staff member	NA	Staff member	10	Individual IDI
S5 (M)	Latea) 40s	NA	Staff member	NA	Staff member	14	Individual IDI

FGI, focus group interview; IDI, in-depth interview; M, man; NA, not applicable; W, woman.

^a)7–9 yr. ^b)0–3 yr. ^c)4–6 yr.

RESULTS

This study presents findings from FGIs and IDIs with North Korean female defectors (n=6) and service providers (n=5), focusing on experiences related to pregnancy, childbirth, and early childcare. User experiences and provider contexts were analyzed separately and then synthesized, revealing patterns of service discontinuity, unmet needs, and transition-related vulnerabilities. The inductively derived meaning units were organized into four experiential dimensions—behavioral, emotional, contextual, and system-level factors—to structure the service design outputs. Based on these findings, core service design outputs—including journey maps, personas, service blueprints, and pain point analyses—were developed to inform a pathway-based service model and prototype, provisionally termed the NK Mom Care Navigator.

1. Key Themes from the User Perspective

Across the pregnancy–childcare continuum, users consistently experienced structural barriers, including discontinuous information, procedural complexity, cultural and emotional burdens, and fragmented inter-agency coordination.

1) Theme 1: Discontinuity in pregnancy and childbirth information and reliance on informal channels

Participants reported a lack of formal and consistent guidance from early pregnancy through childbirth, resulting in confusion about required procedures and service pathways.

• “I told them I was pregnant, but no one told me exactly where to go first. I had to search online and ask people to find out.” (P2)

Due to this absence of official guidance, participants increasingly relied on informal channels such as online communities and acquaintances, which often provided inconsistent or unreliable information.

• “I find myself trusting posts on cafes more than what the center tells me.” (P4)

Unfamiliar administrative and medical terminology further delayed or discouraged service utilization, leading some participants to avoid available support altogether.

2) Theme 2: Complexity of support scheme utilization and the management burden shifted to individuals

Although participants were generally aware of available support schemes, actual utilization remained low due to complex application processes, frequent documentation requirements, and insufficient procedural guidance.

“They say there are benefits, but the application is so complicated I just gave up.” (P1)

Responsibility for managing vouchers, expiration dates, and administrative procedures was largely shifted to individuals, causing psychological fatigue and avoidance. Participants also described regional disparities in guidance quality and the absence of family- or child-centered support structures.

3) Theme 3: Increased care stress due to cultural and emotional burdens

Cultural norms presuming extended family involvement intensified emotional withdrawal, particularly among single-parent households. Participants described feelings of isolation and self-consciousness in family-oriented settings.

• “Everyone else brings family... I go alone, so I feel like I have to do everything myself.” (P6)

Psychological barriers such as fear of stigma and self-blame delayed engagement with community services, while limited understanding during healthcare encounters heightened anxiety and emotional burden. The absence of informal support systems further concentrated caregiving responsibilities on individuals, particularly after childbirth.

4) Theme 4: Structural discontinuities across the pregnancy, childbirth, and parenting care pipeline

The care pathway was characterized by discontinuities across stages, including limited guidance during early pregnancy, weak linkage between Hanawon education and real-world procedures, poor inter-agency information sharing, and a sharp decline in support after childbirth.

• “After 3 to 6 months, the services suddenly almost disappear. That’s actually the hardest time.” (P1)

These discontinuities amplified vulnerability during critical transition periods rather than at isolated points in care.

2. Provider Themes: Key Insights from the Provider Perspective

Analysis of five providers (Hana Centre practitioners and agency managers) confirmed that difficulties in user experience stem from the system, operations, and backstage structure.

1) Theme 5: Information inconsistency due to non-standardized guidance and procedures

Providers acknowledged that guidance standards and explanation practices varied across institutions, resulting in inconsistent information delivery and user confusion.

• “Even for the same system, the explanation differs by center.” (S2)

Heavy administrative workloads further limited the time available for individualized guidance.

2) Theme 6: Limitations of personalized services due to staffing and resource constraints

Shortages of specialized staff and time constrained sustained case management and follow-up for high-risk individuals, despite providers’ recognition of their necessity.

• “We want to manage cases continuously, but realistically, there isn’t enough time.” (S4)

3) Theme 7: Lack of early vulnerability detection and crisis linkage systems

Providers identified the absence of standardized systems for early detection of high-risk pregnancies, mental health and parenting stress screening, and rapid inter-agency crisis linkage as major structural gaps.

• “There is no formal system to screen mental health or parenting stress.” (S5)

3. Integrated Service Design Analysis Results (Based on Analysis Tools)

User–provider data were integrated and organized into the four core structures of service design: journey, persona, blueprint, and pain points. Tables and figures were used as analytical devices to identify structural patterns, discontinuities, and interactional mismatches across the maternal care pathway rather than as descriptive illustrations.

1) (A) Journey stage (customer journey summary)

The care pathway—from pregnancy awareness through local government/centers, public health centers, medical institutions, childbirth, and childcare—revealed patterns of insufficient procedural understanding, inconsistent guidance, accessibility barriers, and disconnected information flows. These findings confirm that the care pathway is structurally discontinuous rather than integrated. The analysis summarized in Table 2 shows that procedural confusion and information discontinuity intensify at institutional transitions, indicating vulnerability accumulates across stages rather than occurring as isolated events.

Table 2.

Key experiences and barriers across care pipeline stages for North Korean refugee women

Stage	Key experiencesa)	Information/procedural barriersa)	Provider-side barriers
Pregnancy recognition	Increased uncertainty immediately after confirming pregnancy	Lack of basic guidance on required procedures and registration	Absence of an initial guidance protocol
Settlement education (Hanawon)	Theory-centered education; difficult to apply in real situations	Gap between educational content and actual procedures	Lack of standardized guidelines for educational staff
Local government/Hana Center	Initiation of administrative procedures	Difficulty understanding application methods and terminology	Limited counseling time due to workload
Public health center	Use of prenatal and postnatal examinations	Confusion regarding terms/procedures such as dental checkups and postpartum care	Insufficient information-sharing systems between institutions
Medical institutions	Anxiety during medical visits and examinations	Insufficient explanations; burden of repeatedly asking questions	Difficulty in early identification of high-risk conditions
Around childbirth	Availability of various benefits	Burden of managing voucher expiration periods	Weak linkage across support programs
Early childrearing (0–12 mo)	Lack of support networks; concentrated caregiving burden	Sharp decline in available services	Absence of continuous case management and referral systems

^a)Key experiences and barriers reported in this table refer to North Korean refugee women.

2) (B) Persona types

Four design personas (A–D) were constructed based on service usage characteristics, information utilization strategies, and emotional responses observed in participant narratives. These personas represent heterogeneous experience patterns rather than discrete user categories. The personas differed in their ability to navigate support systems, manage uncertainty, and respond to psychological and emotional burdens along the care pathway. These differences reflect variations in experiential configurations shaped by individual coping approaches and structural service conditions, which influenced divergent service usage experiences.

Table 3 presents the personas as heuristic profiles for service design, linking information-seeking behaviors, emotional responses, and patterns of system utilization. The table shows how recurring experiential patterns informed the structuring of service design outputs, rather than implying stable typologies or population-level classifications.

Table 3.

Persona types (A–D) derived from user and provider data

Persona type	Information-seeking pattern	Characteristics	Key barriers	Core needs	Support program utilization pattern	Representative statement (summary)
Type A: Independent information seeker	Actively uses search engines and social media	Higher education level; able to search and process information independently	Lack of clear entry points in early procedures	Accurate procedural guidance, terminology explanation, stage-specific checklists	Uses services consistently	“I was confused at the beginning because nobody explained the basic steps.”
Type B: Procedure-burdened, system-dependent user	Relies on offline guidance	Strong willingness to use support programs but struggles to understand procedures	Overwhelming terminology and document requirements	Step-by-step application guidance; assistance with voucher management	Frequent discontinuation or drop-off	“They keep asking for documents again and again.”
Type C: Emotionally burdened, anxiety-driven user	Depends on acquaintances or local centers	Limited family support; parenting alone; high emotional burden	Emotional barriers; fear of being judged	Emotional support; crisis-time linkage system	Low utilization rate	“I feel intimidated going to institutions, so I tend to avoid them.”
Type D: High-risk, avoidant user	Minimal information access	Hesitant to visit institutions; reluctant to ask for help	Multiple overlapping barriers (informational, emotional, financial)	Simple, low-threshold, remote guidance; streamlined administrative processes	Lowest utilization; frequent voucher/registration omission	“I didn’t even know I had to register for those services.”

3) (C) Service blueprint

The emotional burden and institutional disconnects identified were mapped to service blueprint layers. At the user actions layer, unfamiliar terminology, family-norm assumptions, and lack of early guidance inhibited service engagement. On the front stage, inconsistent explanations and verification heightened anxiety, while backstage, staffing constraints and fragmented systems produced service discontinuities. At the support process level, the absence of transition-focused case management led to breakdowns in guidance, linkage, and tracking during pre- and postnatal periods. Table 4 visualizes how misalignments across frontstage, backstage, and support processes generate user confusion and emotional burden.

Table 4.

Integrated service blueprint and user pain points across the care pipeline

Stage	User actions	Frontstage (service delivery)	Backstage (operational causes)	Support processes	Identified gaps	Dominant pain point type(s)a)	Frequency (participants/providers)	Observed outcome pattern
1. Early pregnancy	Confirms pregnancy; searches institutions; seeks information from online cafés or acquaintances	Limited or inconsistent initial guidance	No integrated early-stage information-sharing system	Distribution of general policy guidelines; basic registration systems	Mismatch in timing of information delivery	Information gaps	5/6 participants	Delayed prenatal registration; missed vouchers; initial confusion about where to go first
2. Hana center → local government	Visits Hana Center; begins registration/application; submits documents	Offline counseling; administrative explanations	Non-standardized manuals between institutions; inconsistent document requirements	Voucher issuance system; administrative workflow management	Repeated procedures; inconsistent instructions	Information gaps, lack of inter-agency coordination	5/6 participants; 5/5 providers (indirectly)	Repeated submission of identical information; procedural confusion; increased paperwork burden
3. Public health center use	Schedules visits; attends prenatal/postnatal exams; navigates terminology	Explanations during visits; program participation guidance	Shortage of specialized staff; lack of unified terminology and procedural protocols	Health data management systems; maternal–child program distribution	Difficulty understanding terminology and procedures	Accessibility barriers, provider resource constraints	4/6 participants; 5/5 providers	Delays in tests, vaccinations, and required checkups; discontinuation of public health center visits
4. Medical institutions (prenatal/delivery)	Attends checkups; receives clinical instructions; prepares for delivery	Clinical guidance; risk explanations	Limited time for personalized explanations; fragmented info flow from other agencies	Medical record systems; clinical reporting guidelines	Weak linkage with community services	Information gaps, cultural & emotional isolation	4/6 participants	Heightened anxiety during visits; repeated questioning; uncertainty about next steps; tendency to avoid asking for clarification
5. Immediately after birth	Navigates newborn care; attempts to apply for postpartum and infant-care services	Postpartum care guidance; benefit instructions	High administrative workload; delays in processing support applications	Postnatal voucher systems; newborn welfare service databases	Postpartum service delays; lack of automatic linkage	Accessibility barriers, lack of inter-agency coordination, provider resource constraints	4/6 participants; 5/5 providers	Gives up applying for some services; misses key support windows; partial or fragmented use of available benefits
6. Early childcare	Requests childcare services; searches for additional support	Counseling for childcare-related benefits; program referrals	Case information not shared across agencies; fragmented follow-up	Cross-agency welfare and health data systems (not fully integrated)	No automatic follow-up service linkage	Cultural & emotional isolation, lack of inter-agency coordination	4/6 participants; 6/6 (coordination-related)	Low continuity of care; avoidance of program participation; inconsistent service uptake over time

^a)Pain point type(s): information gaps, accessibility barriers, cultural & emotional isolation, lack of inter-agency coordination, and provider resource constraints.

4) Deliver stage: service delivery and structural integration

The deliver stage examines how the developed service model restructures existing care pathways. Based on blueprint analysis, the Navigator redesigns service flows to reduce fragmentation and improve coordination across users, providers, and support systems.

(1) Service blueprint analysis

The service blueprint comprises four layers—user actions, frontstage, backstage, and support processes—whose coordination determines service quality.

a. User actions

The existing system has independent care stages requiring self-navigation. The Navigator creates an auto-guided sequential flow reducing transition uncertainty.

b. Frontstage

Guidance was standardized through checklists, templates, and adapted language, reducing institutional variations.

c. Backstage operations

Issues like duplicated procedures and staffing shortages are addressed through shared datasets, automated schedules, and alert-based management.

d. Support processes

Policy updates and administrative schedules integrate into a pathway structure linking health centers, medical institutions, and agencies.

(2) Structural impact

The Navigator model enhances visibility, consistency, and safety during vulnerable transitions.

5) Key structures of pain points

Pain points were categorized (Table 4), showing service failures stem from user challenges, provider operations, and institutional frameworks. The problems in the care pathways for North Korean female defectors stem from three factors: individual challenges (user), provider operational processes (provider), and institutional or policy frameworks (system). Effective improvement requires a comprehensive, structural approach to redesign the overall service pathway instead of addressing issues within a single institution.

4. Developed Service Model

1) Service concept

The NK Mom Care Navigator integrates pregnancy, childbirth, and child care into a unified pathway. It addresses institutional fragmentation through guidance, language translation, automated notifications, support, and case management, improving access to and continuity of care.

2) Core functions

(1) Early navigation module

Upon pregnancy recognition, this module provides step-by-step guidance for prenatal registration, public health center linkage, medical institution selection, and identifying relevant support programs. Translations of medical and administrative terminology are embedded to reduce comprehension barriers.

(2) Transition support module (management of the pre- and postnatal transition period)

This module supports prenatal scheduling, birth preparation, postnatal care coordination, benefit reminders, and emergency linkage during the high-vulnerability period from 4 weeks pre-delivery to 8 weeks postpartum.

(3) Continued care module (early infant care continuity)

This module ensures continuity of infant care by automating the management of vaccinations, health screenings, home nursing visits, and developmental monitoring during the first year.

(4) Cultural–emotional support module

This module addresses social isolation and psychological burden through emotional self-assessment, counseling referral, community linkage, and supportive messaging to promote sustained service engagement.

3) Service flow architecture

During the development phase, the modules were rearranged according to their temporal flow and structured into a single pathway encompassing pregnancy, childbirth, and childcare (Figure 1).

Figure 1.

(A–G) Service prototype created by the author using Figma (non-artificial intelligence design tool).

(1) Pregnancy awareness → early navigation

This phase includes test registration, the selection of health centers/medical institutions, and automatic notification of support schemes.

(2) Immediately before birth → transition-period intensive support

This phase consists of a prenatal care checklist, birth preparation, and the automatic connection to postnatal services.

(3) After birth → transition to ongoing management module

This phase covers newborn registration, vaccinations, screening schedule, home nursing visits, and emotional support.

4) Prototype development

The primary deliverable of the develop phase is a low-fidelity prototype that visually represents the actual service architecture. Figure 1 represents a design translation of the analytical results, illustrating how identified structural pain points were operationalized into concrete service functions within the NK Mom Care Navigator: (1) post-conception guidance screen: “next-step” centered structure; (2) birth preparation screen: checklist-based interface; (3) early parenting service screen: vaccinations, checkups, and crisis response menu; and (4) emotional support screen: psychological self-assessment with link recommendation button.

This prototype was designed to address all identified pain points in the user journey and serves as the foundation for future high-fidelity user interface development and user testing.

DISCUSSION

This study analyzed the pregnancy–childbirth–infant care pathway experienced by North Korean female defectors using a service design methodology. It elucidate show vulnerabilities, previously discussed only fragmentarily in existing research, are structurally generated across the entire pathway. The findings indicate that information gaps, difficulties in understanding procedures, cultural and emotional burdens, lack of support systems, inadequate inter-agency coordination, and provider-side resource shortages are not isolated issues, but recurring structural vulnerabilities embedded throughout the pathway. This highlights a complex structure emerging at the intersections of multiple systems and agencies that cannot be explained solely by limited service accessibility.

These findings are consistent with previously reported barriers related to healthcare access, terminology complexity, and administrative procedures among North Korean defectors [2,3,5,6,15,24]. However, this study extends prior research by identifying when, through which pathways, and at which structural points these problems intensify through an analysis of the entire care continuum. Whereas earlier studies focused on users’ experiences at discrete points of contact—such as medical institutions, Hana Centers, or public health centers—this study demonstrates that the same problems recur and accumulate over time, from pregnancy awareness through childbirth, the postpartum period, and infancy. This pattern resembles pathway discontinuity reported in international studies of refugee and migrant women [11-15,19], but among North Korean female defectors it is compounded by the Hanawon settlement process, prior experiences within the socialist healthcare system, pseudo-linguistic misunderstandings, and family separation, resulting in more profound structural risk [10-14].

Although emotional withdrawal and cultural maladjustment have been documented among multicultural mothers [9,17], this study shows that these challenges are more deeply experienced by North Korean female defectors due to factors such as solitary defection, separated families, and family disconnection [2,10,11]. Traumatic experiences during defection and settlement stress, combined with tension arising from a nuclear family-centered culture, further intensify these structural burdens. Additionally, misunderstandings based on a shared language that fails to convey meaning represent a unique mechanism among North Korean female defectors that exacerbates communication mismatches with medical staff, a phenomenon not observed in other migrant populations. Previous studies have shown that despite formal insurance coverage, North Korean migrant women experience persistent barriers to sustained health care due to limited health literacy and the absence of sustained and transition-responsive health management [25]. Notably, national health insurance data indicate that North Korean women demonstrate higher utilization of mental health services than both male defectors and the general population, suggesting sustained mental health needs that are not adequately addressed through episodic or institution-centered care alone [6]. These findings reinforce the present study’s conclusion that vulnerability among North Korean female defectors is not transient but structurally embedded across life stages. Beyond individual and experiential vulnerability, these findings point to systemic limitations in how health and case management services are currently organized for North Korean women. From a service provision perspective, existing domestic case management systems for North Korean defectors—primarily delivered through Hanawon and regional Hana Centers—focus on early settlement and functional adaptation, with limited capacity for life-course–oriented health management. Although health checkups and medical referrals are formally available, prior policy analyses and empirical studies indicate that follow-up, coordination across institutions, and long-term health monitoring remain institutionally segmented, particularly for women navigating pregnancy, childbirth, and early parenting [3,26]. As a result, support during critical transition periods is often inconsistent, leaving users to independently bridge gaps between services.

Provider analysis revealed that backstage issues—such as staff shortages, non-standardized guidance, and lack of inter-agency information sharing—directly caused user confusion as structural factors. This aligns with the front stage–backstage misalignment problem identified in service design research [17,19,20], demonstrating that South Korea’s maternal and infant services operate with an agency-function focus rather than a user-centered pathway design. Importantly, this misalignment limits the effectiveness of existing case management frameworks, which lack mechanisms for tracking users across transitions or responding proactively to accumulating risk.

These findings strongly support the necessity of the NK Mom Care Navigator proposed in this study. The Navigator is not merely a tool providing individual functions, like existing voucher apps or support guidance services. Instead, it is a pathway-based service redesign model that integrates “next-step” guidance, intensive management during transition periods, continuous case management during infancy, and cultural and emotional support into a cohesive flow, covering the entire life pathway from pregnancy through birth to infancy. In contrast to current fragmented support structures, the Navigator directly addresses empirically documented gaps in continuity, coordination, and long-term health monitoring among North Korean women [3,6]. Its originality lies in its structural design, which reflects the characteristics of North Korean female defectors, including an emotional support module to alleviate cultural and emotional burdens. This aligns with international recommendations advocating for the application of user experience-based services to improve maternal and newborn care [17-19,27].

From a policy perspective, this also underscores the importance of transition-based case management. The World Health Organization similarly emphasizes continuity from pregnancy through childbirth to the neonatal period as crucial for maternal and infant health outcomes [28]. This study provides foundational evidence for applying such international guidelines within the Korean context, particularly for vulnerable mothers. Korea’s current system is fragmented by institution and function, failing to adequately provide transition-based case management for vulnerable mothers, such as North Korean female defectors. Instead, a pathway-oriented, service design–based model is required to translate policy intent into lived continuity of care. Accordingly, the NK Mom Care Navigator offers a structurally grounded framework that can strengthen health equity and care integration for North Korean female defectors within Korea’s existing health and welfare systems.

Although the NK Mom Care Navigator was developed in response to the distinctive structural and experiential vulnerabilities of North Korean female defectors, it is important to differentiate between elements that are context-specific and those that are conceptually transferable. Several components of the Navigator are explicitly grounded in the North Korean defector context, including the Hanawon settlement process, prior experiences within a socialist healthcare system, pseudo-linguistic misunderstandings arising from shared but semantically divergent language, and the compounded trauma associated with solitary defection and family separation. These factors reflect historical, political, and cultural conditions unique to this population and therefore constrain direct, unmodified application to other maternal groups.

At the same time, the core design logic underpinning the NK Mom Care Navigator—namely, pathway-based service integration, transition-focused guidance, and continuous case management across pregnancy, childbirth, and infancy—addresses structural problems that are not exclusive to North Korean female defectors. Institutionally segmented service delivery, poor inter-agency coordination, and discontinuities during critical transition periods have been widely documented among migrant women, refugee mothers, and other socially vulnerable caregivers. From this perspective, the Navigator should be understood not as a universally applicable intervention, but as an adaptable service framework whose broader relevance lies in its pathway-oriented approach. Any extension to other vulnerable maternal populations would require deliberate contextual adaptation, including cultural recalibration and alignment with local institutional arrangements, rather than direct replication.

In conclusion, this study confirmed that the barriers faced by North Korean female defectors during pregnancy, childbirth, and infant care are not isolated phenomena; they arise from the interaction of multi-layered structural factors related to information, procedures, emotions, culture, institutions, and operations. Given the structural nature of these issues, simple service expansion is unlikely to resolve them. Instead, a service design-based approach that restructures the entire care pathway is essential. The NK Mom Care Navigator proposed in this study offers a practical model for addressing these structural problems and can serve as a core foundation for enhancing the health rights and care equity of North Korean female defectors in future policy, practice, and academic domains. Several limitations should be recognized. This qualitative study focused on North Korean female defectors in a specific region, which limits the empirical scope of the findings beyond the studied context. Additionally, while the service design approach effectively reveals structural issues, it does not include quantitative verification of intervention effects. Future research should compare pathway differences across regions, utilize mixed-methods research to assess the effectiveness of integrated support models, and develop and experimentally evaluate actual intervention programs.

CONCLUSION

This study thoroughly analyzed the pregnancy, childbirth, and early parenting pathways experienced by North Korean female defectors from both user and provider perspectives. It confirmed the existence of structural problems, including a lack of initial guidance, absence of inter-agency coordination, transitional gaps, and insufficient long-term case management. By applying service design methodology, the flow of these issues was visually mapped, leading to the proposal of an integrated support model that progresses from initial guidance to transition management and long-term case management. This study can inform the design of health policies aimed at improving health equity not only for North Korean female defectors but also for various vulnerable maternal groups in South Korea. Future program development and effectiveness verification based on this model could enhance the maternal and infant care system.