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’Moving On’ and Transitional Bridges: Studies on migration, violence and wellbeing in encounters with Somali-born women and the maternity health care in Sweden
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health.ORCID iD: Kittelfjall1
2015 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

During the latest decade Somali-born women with experiences of long-lasting war followed by migration have increasingly encountered Swedish maternity care, where antenatal care midwives are assigned to ask questions about exposure to violence. The overall aim in this thesis was to gain deeper understanding of Somali-born women’s wellbeing and needs during the parallel transitions of migration to Sweden and childbearing, focusing on maternity healthcare encounters and violence. Data were obtained from medical records (paper I), qualitative interviews with Somali-born women (II, III) and Swedish antenatal care midwives (IV). Descriptive statistics and thematic analysis were used. Compared to pregnancies of Swedish-born women, Somali-born women’s pregnancies demonstrated later booking and less visits to antenatal care, more maternal morbidity but less psychiatric treatment, less medical pain relief during delivery and more emergency caesarean sections and small-for-gestational-age infants (I). Political violence with broken societal structures before migration contributed to up-rootedness, limited healthcare and absent state-based support to women subjected to violence, which reinforced reliance on social networks, own endurance and faith in Somalia (II). After migration, sources of wellbeing were a pragmatic “moving-on” approach including faith and motherhood, combined with social coherence. Lawful rights for women were appreciated but could concurrently risk creating power tensions in partner relationships. Generally, the Somali-born women associated the midwife more with providing medical care than with overall wellbeing or concerns about violence, but new societal resources were parallel incorporated with known resources (III). Midwives strived for woman-centered approaches beyond ethnicity and culture in care encounters, with language, social gaps and divergent views on violence as potential barriers in violence inquiry. Somali-born women’s strength and contentment were highlighted, and ongoing violence seldom encountered according to the midwives experiences (IV). Pragmatism including “moving on” combined with support from family and social networks, indicate capability to cope with violence and migration-related stress. However, this must be balanced against potential unspoken needs at individual level in care encounters.With trustful relationships, optimized interaction and networking with local Somali communities and across professions, the antenatal midwife can have a “bridging-function” in balancing between dual societies and contribute to healthy transitions in the new society.

Place, publisher, year, edition, pages
Uppsala: Acta Universitatis Upsaliensis, 2015. , 92 p.
Series
Digital Comprehensive Summaries of Uppsala Dissertations from the Faculty of Medicine, ISSN 1651-6206 ; 1127
Keyword [en]
Somali-born women, violence, transition, migration, childbearing, midwife, maternal health, perinatal health, wellbeing, qualitative, case-control
National Category
Medical and Health Sciences
Research subject
International Health
Identifiers
URN: urn:nbn:se:uu:diva-259881ISBN: 978-91-554-9302-8 (print)OAI: oai:DiVA.org:uu-259881DiVA: diva2:845757
Public defence
2015-10-01, Universitetshuset Sal IX, Uppsala, 09:15 (English)
Opponent
Supervisors
Available from: 2015-09-09 Created: 2015-08-13 Last updated: 2015-10-01
List of papers
1. Somali women's use of maternity health services and the outcome of their pregnancies: A descriptive study comparing Somali immigrants with native-born Swedish women
Open this publication in new window or tab >>Somali women's use of maternity health services and the outcome of their pregnancies: A descriptive study comparing Somali immigrants with native-born Swedish women
2013 (English)In: Sexual & Reproductive HealthCare, ISSN 1877-5756, E-ISSN 1877-5764, Vol. 4, no 3, 99-106 p.Article in journal (Refereed) Published
Abstract [en]

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.

Keyword
Maternal morbidity, Perinatal outcome, Somali women, Health care utilisation, Case control study
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:uu:diva-210719 (URN)10.1016/j.srhc.2013.06.001 (DOI)000325387700004 ()
Available from: 2013-11-18 Created: 2013-11-14 Last updated: 2017-12-06Bibliographically approved
2. Violence and reproductive health preceding flight from war: accounts from Somali born women in Sweden
Open this publication in new window or tab >>Violence and reproductive health preceding flight from war: accounts from Somali born women in Sweden
2014 (English)In: BMC Public Health, ISSN 1471-2458, E-ISSN 1471-2458, Vol. 14, 892- p.Article in journal (Refereed) Published
Abstract [en]

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.

National Category
Public Health, Global Health, Social Medicine and Epidemiology
Identifiers
urn:nbn:se:uu:diva-232780 (URN)10.1186/1471-2458-14-892 (DOI)000341650800001 ()25174960 (PubMedID)
Available from: 2014-09-25 Created: 2014-09-25 Last updated: 2017-12-05Bibliographically approved
3. Violence, wellbeing, and being approached with questions about violence in maternity care encounters. A qualitative study with Somali-born women in the context of recent migration to Sweden.
Open this publication in new window or tab >>Violence, wellbeing, and being approached with questions about violence in maternity care encounters. A qualitative study with Somali-born women in the context of recent migration to Sweden.
(English)Article in journal (Refereed) Submitted
Abstract [en]

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.

Keyword
Somali-born women, maternity care, qualitative, thematic analysis, violence, wellbeing, Sweden
National Category
Medical and Health Sciences
Research subject
Caring Sciences
Identifiers
urn:nbn:se:uu:diva-259880 (URN)
Available from: 2015-08-13 Created: 2015-08-13 Last updated: 2015-10-01
4. Being a bridge: Swedish antenatal care midwives' encounters with Somali-born women and questions of violence; a qualitative study
Open this publication in new window or tab >>Being a bridge: Swedish antenatal care midwives' encounters with Somali-born women and questions of violence; a qualitative study
2015 (English)In: BMC Pregnancy and Childbirth, ISSN 1471-2393, E-ISSN 1471-2393, Vol. 15, no 1, 1- p.Article in journal (Refereed) Published
Abstract [en]

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.

National Category
Public Health, Global Health, Social Medicine and Epidemiology
Identifiers
urn:nbn:se:uu:diva-242885 (URN)10.1186/s12884-015-0429-z (DOI)000348469300001 ()25591791 (PubMedID)
Available from: 2015-02-02 Created: 2015-02-02 Last updated: 2017-12-05Bibliographically approved

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