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Objectives: To describe how Somali immigrant women in a Swedish county use the antenatal care and health services, their reported and observed health problems and the outcome of their pregnancies. Study design: Retrospective, case-control study, comparing data obtained from the records of antenatal and obstetric care for Somali born women with the same data for parity matched women born in Sweden giving birth between 2001 and 2009. Main outcome measures: Utilisation of antenatal health care (timing and number of visits), pregnancy complications (severe hyperemesis, anaemia, preeclampsia), mode of birth (normal vaginal, operative vaginal, caesarean), and infant outcomes (preterm birth, birth weight, and perinatal mortality). Results: Compared to the 523 Swedish-born women tM 262 Somali women booked later and made less visits for antenatal care. They were more likely to have anaemia, severe hyperemesis and a few patients were found to have very serious health conditions. Emergency caesarean section (OR 1.90, CI 1.16-3.10), especially before start of labour (OR 4.96, CI 1.73-14.22), high perinatal mortality with seven versus one perinatal deaths and small for date infants (OR 2.95, CI 1.49-5.82) was also more prevalent. Conclusion: Pregnant Somali immigrant women still constitute a vulnerable group, which implicates that there is a missing link in the surveillance system that needs attention. There is an increased risk for intrauterine foetal death, small for date and low birth weight infants as well as serious maternal morbidity.

BACKGROUND:

Political violence and war are push factors for migration and social determinants of health among migrants. Somali migration to Sweden has increased threefold since 2004, and now comprises refugees with more than 20 years of war experiences. Health is influenced by earlier life experiences with adverse sexual and reproductive health, violence, and mental distress being linked. Adverse pregnancy outcomes are reported among Somali born refugees in high-income countries. The aim of this study was to explore experiences and perceptions on war, violence, and reproductive health before migration among Somali born women in Sweden.

METHOD:

Qualitative semi-structured individual interviews were conducted with 17 Somali born refugee women of fertile age living in Sweden. Thematic analysis was applied.

RESULTS:

Before migration, widespread war-related violence in the community had created fear, separation, and interruption in daily life in Somalia, and power based restrictions limited access to reproductive health services. The lack of justice and support for women exposed to non-partner sexual violence or intimate partner violence reinforced the risk of shame, stigmatization, and silence. Social networks, stoicism, and faith constituted survival strategies in the context of war.

CONCLUSIONS:

Several factors reinforced non-disclosure of violence exposure among the Somali born women before migration. Therefore, violence-related illness might be overlooked in the health care system. Survival strategies shaped by war contain resources for resilience and enhancement of well-being and sexual and reproductive health and rights in receiving countries after migration.

Background: Somali-born women constitute one of the largest groups of childbearing refugee women in Sweden after more than two decades of political violence in Somalia. In Sweden, these women encounter a midwifery care system that includes antenatal care visits where routine questions on violence are asked. The aim of this study is to explore Somali-born women’s views on being approached with questions on violence in Swedish maternity care and how they understand and relate to violence and wellbeing.

Method: Qualitative interviews (22) with Somali-born women (17) living in Sweden were conducted and analysed using thematic analysis.

Findings: A balancing act between keeping private life private and the new welfare system was identified, where the midwife’s questions on violence were met with hesitance. The midwife was, however, considered a resource in gaining access to support services in the new society. A focus set on pragmatic strategies to move on in life, rather than dwelling on potential experiences of violence and related traumas, was prominent. Social networks, spiritual faith and motherhood were crucial for regaining coherence in the aftermath of war. Own experiences of intimate partner violence or non-partner sexual violence were not revealed. Dialogue and mutual adjustments were identified as strategies used to overcome power tensions in intimate relationships undergoing transition.

Conclusions: For beneficial violence prevention and identification, midwives’ questions on violence need to be justified in relevant ways and embedded in contexts of trustful relationships. Approaches of rationality and “moving on”, without focusing on violence or adversities, indicate strength and access to alternative resources, but need to be balanced against risks for hidden needs in care encounters. Collaborations between Somali communities, maternal health care and social service providers can support families in transition and bridge gaps to formal social and care services.

BACKGROUND:

Violence against women is associated with serious health problems, including adverse maternal and child health. Antenatal care (ANC) midwives are increasingly expected to implement the routine of identifying exposure to violence. An increase of Somali born refugee women in Sweden, their reported adverse childbearing health and possible links to violence pose a challenge to the Swedish maternity health care system. Thus, the aim was to explore ways ANC midwives in Sweden work with Somali born women and the questions of exposure to violence.

METHODS:

Qualitative individual interviews with 17 midwives working with Somali-born women in nine ANC clinics in Sweden were analyzed using thematic analysis.

RESULTS:

The midwives strived to focus on the individual woman beyond ethnicity and cultural differences. In relation to the Somali born women, they navigated between different definitions of violence, ways of handling adversities in life and social contexts, guided by experience based knowledge and collegial support. Seldom was ongoing violence encountered. The Somali-born women's' strengths and contentment were highlighted, however, language skills were considered central for a Somali-born woman's access to rights and support in the Swedish society. Shared language, trustful relationships, patience, and networking were important aspects in the work with violence among Somali-born women.

CONCLUSION:

Focus on the individual woman and skills in inter-cultural communication increases possibilities of overcoming social distances. This enhances midwives' ability to identify Somali born woman's resources and needs regarding violence disclosure and support. Although routine use of professional interpretation is implemented, it might not fully provide nuances and social safety needed for violence disclosure. Thus, patience and trusting relationships are fundamental in work with violence among Somali born women. In collaboration with social networks and other health care and social work professions, the midwife can be a bridge and contribute to increased awareness of rights and support for Somali-born women in a new society.