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Conceptualising the prevention of adverse obstetric outcomes among immigrants using the 'three delays' framework in a high-income context
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
Malmö University.
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
2012 (English)In: Social Science and Medicine, ISSN 0277-9536, E-ISSN 1873-5347, Vol. 75, no 11, 2028-2036 p.Article in journal (Refereed) Published
Abstract [en]

Women from high-mortality settings in sub-Saharan Africa can remain at risk for adverse maternal outcomes even after migrating to low-mortality settings. To conceptualise underlying socio-cultural factors, we assume a ‘maternal migration effect’ as pre-migration influences on pregnant women’s post-migration care-seeking and consistent utilisation of available care. We apply the ‘three delays’ framework, developed for low-income African contexts, to a high-income western scenario, and aim to identify delay-causing influences on the pathway to optimal facility treatment. We also compare factors influencing the expectations of women and maternal health providers during care encounters. In 2005–2006, we interviewed 54 immigrant African women and 62 maternal providers in greater London, United Kingdom. Participants were recruited by snowball and purposive sampling. We used a hermeneutic, naturalistic study design to create a qualitative proxy for medical anthropology. Data were triangulated to the framework and to the national health system maternity care guidelines. This maintained the original three phases of (1) care-seeking, (2) facility accessibility, and (3) receipt of optimal care, but modified the framework for a migration context. Delays to reciprocal care encounters in Phase 3 result from Phase 1 factors of ‘broken trust, which can be mutually held between women and providers. An additional factor is women’s ‘negative responses to future care’, which include rationalisations made during non-emergency situations about future late-booking, low-adherence or refusal of treatment. The greatest potential for delay was found during the care encounter, suggesting that perceived Phase 1 factors have stronger influence on Phase 3 than in the original framework. Phase 2 ‘language discordance’ can lead to a ‘reliance on interpreter service’, which can cause delays in Phase 3, when ‘reciprocal incongruent language ability’ is worsened by suboptimal interpreter systems. ‘Non-reciprocating care conceptualisations’, ‘limited system-level care guidelines’, and ‘low staff levels’ can additionally delay timely care in Phase 3.

Place, publisher, year, edition, pages
2012. Vol. 75, no 11, 2028-2036 p.
National Category
Medical and Health Sciences
Research subject
International Health
Identifiers
URN: urn:nbn:se:uu:diva-182860DOI: 10.1016/j.socscimed.2012.08.010ISI: 000310385200015OAI: oai:DiVA.org:uu-182860DiVA: diva2:561129
Available from: 2012-10-17 Created: 2012-10-17 Last updated: 2017-12-07Bibliographically approved
In thesis
1. The Maternal Migration Effect: Exploring Maternal Healthcare in Diaspora Using Qualitative Proxies for Medical Anthropology
Open this publication in new window or tab >>The Maternal Migration Effect: Exploring Maternal Healthcare in Diaspora Using Qualitative Proxies for Medical Anthropology
2012 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

This project explores the 'maternal migration effect'. Following migration to a high-income country with a low maternal mortality rate, we assume that some immigrant women’s reliance upon maternal practices that respond to a low-income, high-mortality context can adversely affect care-seeking and utilization of treatment facilities. At highest risk in the United Kingdom and Sweden are those from Africa's Horn, particularly Somali women who have experienced diasporic migration. By applying constructivist qualitative methods as proxies for medical anthropology, we propose a framework for identifying socio-cultural factors, and then we explore how these can influence the western facility-based maternity care encounter.

Study 1 proposes a conceptual framework to understand why sub-Saharan African immigrants might experience adverse childbirth outcomes in western settings. Analysis was guided by 'naturalistic inquiry method' to explore delay-causing socio-cultural factors to optimal maternity treatment. Delays can result from (a) broken trust underlying women’s late-booking or refusal of treatment interventions, and care provider frustration; (b) over-reliance on poorly-functioning interpreter services that deny women’s access to medical expertise; and (c) mutual broken trust and miscommunication, and limited development of guidelines for treatment avoidance. Limited coherence exists in the perspectives between women and providers about caesarean section and other interventions, refusal of treatment, and coping strategies following adverse birth outcomes. Care providers' held misconceptions about women’s preferences for gender- and ethnic-congruence. Women preferred competent care. Congruent language was identified as the key ingredient for optimal culture-sensitive care.

Study 2 applied 'grounded dimensional analysis' and 'functional narrative analysis' to explore pre-migration socio-cultural factors that influence Somali parents' childbearing in Sweden. Women’s delayed care-seeking continues, despite that childbearing is still perceived as life-threatening. Decision-making is shared between the couple. Men more than women trust care providers to fill gaps in their knowledge. The postpartum period showed that fathers play an important role. "Aftercare" concerns include unarticulated sexual aversion combined with loss of traditional kin support. Women's autonomy is enhanced but greater necessity exists for intimate partner communication and reliance upon professional care services.

Medical anthropology can provide a complementary instrument for developing qualitative evidence-based strategies that target prevention of adverse childbirth outcomes in European countries.

Place, publisher, year, edition, pages
Uppsala: Acta Universitatis Upsaliensis, 2012. 110 p.
Series
Digital Comprehensive Summaries of Uppsala Dissertations from the Faculty of Medicine, ISSN 1651-6206 ; 827
Keyword
caesarean section; care encounter; constructivist; interpreter use; migration; Somali; African immigrant; socio-cultural factors
National Category
Medical and Health Sciences
Research subject
International Health
Identifiers
urn:nbn:se:uu:diva-182870 (URN)978-91-554-8504-7 (ISBN)
Public defence
2012-12-01, Sal IX, Biskopsgatan 3, Uppsala, 09:15 (English)
Opponent
Supervisors
Available from: 2012-11-09 Created: 2012-10-17 Last updated: 2013-01-23Bibliographically approved

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Binder, PaulineEssén, Birgitta

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