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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, 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 [en]
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)oai:DiVA.org:uu-182870 (OAI)diva2:561154 (DiVA)
Public defence
2012-12-01, Sal IX, Biskopsgatan 3, Uppsala, 09:15 (English)
Opponent
Supervisors
Available from2012-11-09 Created:2012-10-17 Last updated:2013-01-23Bibliographically approved
List of papers
1. Conceptualising the prevention of adverse obstetric outcomes among immigrants using the 'three delays' framework in a high-income context
Open this publication in new window or tab >>Conceptualising the prevention of adverse obstetric outcomes among immigrants using the 'three delays' framework in a high-income context
2012 (English)In: Social Science and Medicine, ISSN 0277-9536, E-ISSN 1873-5347, Vol. 75, no 11, 2028-2036Article 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.

National Category
Medical and Health Sciences
Research subject
International Health
Identifiers
urn:nbn:se:uu:diva-182860 (URN)10.1016/j.socscimed.2012.08.010 (DOI)000310385200015 ()
Available from2012-10-17 Created:2012-10-17 Last updated:2013-01-23Bibliographically approved
2. An anthropological analysis of the perspectives of Somali women in the West and their obstetric care providers on caesarean birth
Open this publication in new window or tab >>An anthropological analysis of the perspectives of Somali women in the West and their obstetric care providers on caesarean birth
2011 (English)In: Journal of Psychosomatic Obstetrics and Gynaecology, ISSN 0167-482X, E-ISSN 1743-8942, Vol. 32, no 1, 10-18Article in journal (Refereed) Published
Abstract [en]

We explored the perceptions of 39 Somali women and 62 obstetric care providers in London in relation to caesarean birth, as borne out of a paradox we recognised from evidence-based information about the Somali group. Socio-cultural factors potentially leading to adverse obstetric outcome were identified using in-depth and focus group interviews with semi-structured, open-ended questions. A cultural anthropology model, the emic/etic model, was used for analysis. Somali women expressed fear and anxiety throughout the pregnancy and identified strategies to avoid caesarean section (CS). There was widespread, yet anecdotal, awareness among obstetric care providers about negative Somali attitudes. Caesarean avoidance and refusal were expressed as being highly stressful among providers, but also as being the responsibility of the women and families. For women, avoiding or refusing caesarean was based on a rational choice to avoid death and coping with adverse outcome relied on fatalistic attitudes. Motivation for the development of preventive actions among both groups was not described, which lends weight to the vast distinction and lack of correspondence in identified perspectives between Somali women and UK obstetric providers. Early booking and identification of women likely to avoid caesarean is proposed, as is the development of preventive strategies to address CS avoidance.

National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:uu:diva-153200 (URN)10.3109/0167482X.2010.547966 (DOI)000286993800003 ()21291343 (PubMedID)
Available from2011-05-06 Created:2011-05-06 Last updated:2013-01-23Bibliographically approved
3. Shared Language Is Essential
Open this publication in new window or tab >>Shared Language Is Essential : Communication in a Multiethnic Obstetric Care Setting
2012 (English)In: Journal of health communication, ISSN 1081-0730, E-ISSN 1087-0415, Vol. 17, no 10, 1171-1186Article in journal (Refereed) Published
Abstract [en]

This study focuses on communication and conceptions of obstetric care to address the postulates that immigrant women experience sensitive care through the use of an ethnically congruent interpreter and that such women prefer to meet health providers of the same ethnic and gender profile when in a multiethnic obstetrics care setting. During 2005–2006, we conducted in-depth interviews in Greater London with immigrant women of Somali and Ghanaian descent and with White British women, as well as with obstetric care providers representing a variety of ethnic profiles. Questions focused on communication and conceptions of maternity care, and they were analyzed using qualitative techniques inspired by naturalistic inquiry. Women and providers across all informant groups encountered difficulties in health communication. The women found professionalism and competence far more important than meeting providers from one's own ethnic group, while language congruence was considered a comfort. Despite length of time in the study setting, Somali women experienced miscommunication as a result of language barriers more than did other informants. An importance of the interpreter's role in health communication was acknowledged by all groups; however, interpreter use was limited by issues of quality, trust, and accessibility. The interpreter service seems to operate in a suboptimal way and has potential for improvement.

National Category
Medical and Health Sciences
Research subject
International Health
Identifiers
urn:nbn:se:uu:diva-182866 (URN)10.1080/10810730.2012.665421 (DOI)000311459200005 ()
Available from2012-10-17 Created:2012-10-17 Last updated:2013-01-23Bibliographically approved
4. The Maternal Migration Effect and Childbearing in Diaspora among Somali-Swedish Parents
Open this publication in new window or tab >>The Maternal Migration Effect and Childbearing in Diaspora among Somali-Swedish Parents
(English)Manuscript (preprint) (Other academic)
National Category
Medical and Health Sciences
Research subject
International Health
Identifiers
urn:nbn:se:uu:diva-182868 (URN)
Available from2012-10-17 Created:2012-10-17 Last updated:2013-01-23
5. More than re-establishing the partner relationship
Open this publication in new window or tab >>More than re-establishing the partner relationship : Intimate aftercare for Somali parents in diaspora
2013 (English)In: Midwifery, ISSN 0266-6138, E-ISSN 1532-3099, no 29, 863-70Article in journal (Refereed) Published
Abstract [en]

Objective

to explore the sexual relationship and couples' perceptions about intimate partner support following childbirth.

Design

a hermeneutic design using a naturalistic inquiry framework as a qualitative proxy for medical anthropology. Data were collected using a fictional and culturally-specific narrative during focus group discussions (FGDs) in early 2011. Analysis was conducted by ‘functional narrative analysis’ and interpreted for conceptual constructions. Recruitment was by snowball and purposive sampling.

Setting

a diasporic context among participants living in six urban centres across Sweden.

Participants

successful recruitment included 16 Somali-Swedish fathers and 27 mothers. Three FDGs were conducted with fathers (3–7 participants) and seven with mothers (3–6 participants).

Findings

within day 40 post partum, parents learn to rely on each other in the absence of traditional support networks. After the first 40 days, the re-introduction of sexual intimacy is likely to occur. Of the fathers experiencing postpartum sexual aversion, these seemed to experience ‘existential angst’ resulting from a combination of profound remorse over having put the partner into what they perceived as a life-threatening situation during childbirth and their perceived moral and ethical obligations to provide support in this setting. Mothers in general did not directly discuss their own sexuality. Women could imagine men's sexual aversion after witnessing childbirth. However, they seemed unaware of men's potential for angst. Mothers are situated between the loss of traditional postpartum support networks, comprised of close female kin, and their own newly-defined responsibilities in the host setting. Fathers embrace their new role. Both partners articulated the mother's new role as enhancing autonomy and independence in the host setting. However, women held mixed attitudes about fathers replacing traditional kin support.

Implications for practice

to date, late postpartum aftercare for immigrant African parents is anecdotally linked to evidence-based recommendations, which have been identified for parents who are ethnically-congruent to a western study setting. Our findings suggest that aftercare meant for Somali parents living in these settings requires an understanding of how traditional intimate support and the postpartum sexual relationship are re-negotiated in the diasporic context. This includes recognition of the father as a willing and supportive partner.

Keyword
postpartum, proxy for medical anthropology
National Category
Medical and Health Sciences
Research subject
International Health
Identifiers
urn:nbn:se:uu:diva-182867 (URN)10.1016/j.midw.2012.09.002 (DOI)000321431200008 ()
Available from2012-10-17 Created:2012-10-17 Last updated:2013-08-12Bibliographically approved

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