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Objectives: Comparing language-supported group antenatal care (gANC) and standard antenatal care (sANC) for Somali-born women in Sweden, measuring overall ratings of care and emotional well-being, and testing the feasibility of the outcome measures.

Design: A quasi-experimental trial with one intervention and one historical control group, nested in an intervention development and feasibility study.

Setting: Midwifery-led antenatal care clinic in a mid-sized Swedish town.

Participants: Pregnant Somali-born women (<25 gestational weeks); 64women in gANC and 81 in sANC.

Intervention: Language-supported gANC (2017-2019). Participants were offered seven 60-minute group sessions with other Somali-born women led by one to two midwives, in addition to 15-30min individual appointments with their designated midwife.

Outcomes: Primary outcomes were women's overall ratings of antenatal care and emotional well-being (Edinburgh Postnatal Depression Scale (EPDS)) in gestational week >= 35and 2 months post partum. Secondary outcomes were specific care experiences, information received, social support, knowledge of pregnancy danger signs and obstetric outcomes.

Results: Recruitment and retention of participants were challenging. Of eligible women, 39.3% (n=106) declined to participate. No relevant differences regarding overall ratings of antenatal care between the groups were detected (late pregnancy OR 1.42, 95% CI 0.50 to 4.16 and 6-8 weeks post partum OR 2.71, 95% CI 0.88 to 9.41). The reduction in mean EPDS score was greater in the intervention group when adjusting for differences at baseline (mean difference -1.89; 95% CI -3.73 to -0.07). Women in gANC were happier with received pregnancy and birth information, for example, caesarean section where 94.9% (n=37) believed the information was sufficient compared with 17.5% (n=7) in standard care (p<0.001) in late pregnancy.

Conclusions: This evaluation suggests potential for language-supported gANC to improve knowledge acquisition among pregnant Somali-born women with residence in Sweden <10 years. An adequately powered randomised trial is needed to evaluate the effectiveness of the intervention.

Background Language supported group antenatal care (gANC) for Somali-born women was implemented in a Swedish public ANC clinic. The women were offered seven 60-min sessions, facilitated by midwives and starting with a presentation of a selected topic, with an additional 15-min individual appointment before or after. The aim of this study was to assess the feasibility for participants and midwives of implementing The Hooyo ("mother" in Somali) gANC intervention, including implementation, mechanisms of impact and contextual factors. Methods A process evaluation was performed, using The Medical Research Council (MRC) guidelines for evaluating complex interventions as a framework. A range of qualitative and quantitative data sources were used including observations (n = 9), complementary, in-depth and key-informant interviews (women n = 6, midwives n = 4, interpreters and research assistants n = 3) and questionnaire data (women n = 44; midwives n = 8). Results Language-supported gANC offered more comprehensive ANC that seemed to correspond to existing needs of the participants and could address knowledge gaps related to pregnancy, birth and the Swedish health care system. The majority of women thought listening to other pregnant women was valuable (91%), felt comfortable in the group (98%) and supported by the other women (79%), and they said that gANC suited them (79%). The intervention seemed to enhance knowledge and cultural understanding among midwives, thus contributing to more women-centred care. The intervention was not successful at involving partners in ANC. Conclusions The Hooyo gANC intervention was acceptable to the Somali women and to midwives, but did not lead to greater participation by fathers-to-be. The main mechanisms of impact were more comprehensive ANC and enhanced mutual cultural understanding. The position of women was strengthened in the groups, and the way in which the midwives expanded their understanding of the participants and their narratives was promising. To be feasible at a large scale, gANC might require further adaptations and the "othering" of women in risk groups should be avoided.

Objective:

To explore Somali-born parents' experiences of antenatal care in Sweden, antenatal care midwives' experiences of caring for Somali-born parents, and their respective ideas about group antenatal care for Somali-born parents.

Design:

Eight focus group discussions with 2-8 participants in each were conducted, three with Somaliborn mothers, two with fathers and three with antenatal care midwives. The transcribed text was analysed using Attride-Stirling's tool "Thematic networks".

Setting:

Two towns in mid-Sweden and a suburb of the capital city of Sweden. Participants: Mothers (n = 16), fathers (n = 13) and midwives (n = 7) were recruited using purposeful sampling.

Findings:

Somali-born mothers and fathers in Sweden were content with many aspects of antenatal care, but they also faced barriers. Challenges in the midwife-parent encounter related to tailoring of care to individual needs, dealing with stereotypes, addressing varied levels of health literacy, overcoming communication barriers and enabling partner involvement. Health system challenges related to accessibility of care, limited resources, and the need for clear, but flexible routines and supportive structures for parent education. Midwives confirmed these challenges and tried to address them but sometimes lacked the support, resources and tools to do so. Mothers, fathers and midwives thought that language-supported group antenatal care might help to improve communication, provide mutual support and enable better dialogue, but they were concerned that group care should still allow privacy when needed and not stereotype families according to their country of birth.

Key conclusions:

ANC interventions targeting inequalities between migrants and non-migrants may benefit from embracing a person-centred approach, as a means to counteract stereotypes, misunderstandings and prejudice. Group antenatal care has the potential to provide a platform for person-centred care and has other potential benefits in providing high-quality antenatal care for sub-groups that tend to receive less or poor quality care. Further research on how to address stereotypes and implicit bias in maternity care in the Swedish context is needed. (c) 2019 The Authors. Published by Elsevier Ltd.

Background:

A tremendous number of girls in Yemen are still subjected to female genital cutting (FGC), which carries an increased risk of health complications and violates children's rights. This study describes the prevalence of FGC in four Yemeni provinces and investigates the determinants of FGC.

Methods:

We analyzed data from women aged 15 to 49 years who responded to a sub-national household survey conducted in six rural districts of four Yemeni provinces in 2008-2009. Logistic regression was used to estimate the association between individual and household socioeconomic factors and FGC practices and attitudes.

Results:

The prevalence of women's FGC was 48% while daughters' FGC was 34%. Almost 45.8% of the women surveyed believe the FGC practice should discontinue. Higher odds of FGC practice and positive attitude towards it were associated with older age, family marriage, and lower tertiles of wealth and education indices. Early marriage was also associated with increased odds of FGC practice (p < 0.01).

Conclusions:

Socioeconomic indices and other individual factors associated with FGC are differing and complex. Younger generations of women are more likely to not have FGC and to express negative attitudes towards the tradition. Appropriate strategies to invest in girls' education and women's empowerment with effective engagement of religious and community leaders might support the change of attitudes and practice of FGC in the younger generation.

Background: Experiences from the COVID-19 pandemic may help to better understand resilience, competences and skills for healthcare providers and the healthcare system. Within sexual and reproductive health inequalities for migrants exist and it is an area where promoting both cultural competency and healthcare equity in the clinical encounter is expected of healthcare providers yet can create tension. The aim is to explore healthcare providers experiences of encounters with migrants in the context of the pandemic and the subsequent changes in routines and norms.

Methods: A qualitative study based on semi-structured interviews with 31 healthcare providers working in sexual and reproductive healthcare in southern Sweden. Interviews were conducted during the COVID-19 pandemic influencing how healthcare providers reflected on their experiences. Analysis was done using reflexive thematic data analysis.

Findings: Healthcare providers reflected on how changes in routines increased the understanding of challenges and enablers in the intercultural encounter including the impact on communication and role of relatives and male partners. They emphasized the dynamics of culture in the clinical encounter and healthcare system through highlighting the importance of structural awareness, self-reflection and the flexibility of conducts and norms, often given a cultural connotation.

Conclusion: The COVID-19 pandemic resulted in changes of previously established routines directly affecting clinical encounters, which provided a unique opportunity for healthcare providers to reflect, with communication and self-reflection being discussed as central in complex encounters. It highlighted the dynamics of presumed deeply rooted cultural norms and the interplay with social factors affecting healthcare providers and patients alike.

Background:

Sweden has one of the most liberal abortion laws in the world, granting women extensive rights to make autonomous reproductive decisions. At the same time, Swedish policy-makers are keen to protect society’s religious diversity. This ambition is reflected in decisions to grant religious leaders the possibility to provide ‘spiritual care’ in public hospitals. Through interviews with religious representatives in public healthcare institutions, we asked: In what ways would they counsel a religious woman who is seeking their advice about abortion? And how does this advice correspond with Swedish policies on, and provision of, abortion care?

Methods:

Individual interviews were conducted with religious representatives of the Swedish Church, the Catholic Church, and the Buddhist and Muslim communities. Interviews took place in 2016 and 2017.

Findings:

We found that informants saw it as their obligation to provide religious people with abortion advice according to religious norms, giving them limited opportunities to harmonise the content of their counselling with Swedish healthcare laws or regulations. Most informants argued that it was their responsibility to inform women about the wrongdoing of terminating a pregnancy, and to provide suggestions about how women could mitigate the sin in order to gain God’s forgiveness.

Conclusion:

Informants appeared inclined to deliver religious recommendations on abortion that were more conservative than what is established in the Swedish Abortion Act.

Main messages:

• ‘Spiritual care’ in the question of abortion favours the delivery of religious norms at the possible expense of women’s right to non-judgmental abortion counselling.

• ‘Spiritual care’ is now an integral part of Swedish healthcare institutions. A critical discussion is needed about the extent to which such services should be in compliance with Swedish laws and public health aims on abortion.

Objective: 'Low socioeconomic status' and 'religiousness' appear to have gained status as nearly universal explanatory models for why women in minority groups are less likely to use contraception than other women in the Scandinavian countries. Through interviews with pious Muslim women with immigrant background, living in Denmark and Sweden, we wanted to gain empirical insights that could inform a discussion about what 'low socioeconomic status' and 'religiousness' might mean with regard to women's reproductive decisions.

Design: Semi-structured interviews were conducted in Denmark and Sweden between 2013 and 2016.

Findings: We found that a low level of education and a low income were not necessarily obstacles for women's use of contraception; rather, these were strong imperatives for women to wait to have children until their life circumstances become more stable. Arguments grounded in Islamic dictates on contraception became powerful tools for women to substantiate how it is religiously appropriate to postpone having children, particularly when their financial and emotional resources were not yet established.

Conclusion: We have shown that the dominant theory that 'low socioeconomic status' and 'religiousness' are paramount barriers to women's use of contraception must be problematized. When formulating suggestions for how to provide contraceptive counseling to women in ethnic and religious minority groups in Denmark and Sweden, one must also take into account that factors such as low financial security as well as religious convictions can be strong imperatives for women to use contraception.

Implications for practice: This study can help inform a critical discussion about the difficulties of using broad group-categorizations for understanding individuals' health-related behavior, as well as the validity of targeted interventions towards large heterogeneous minority groups in Scandinavian contraceptive counseling.

The abortion discourse in Sweden is marked by historically liberal ideals about women’s inviolable right to make autonomous reproductive decisions. However, to respond to the increase in cultural and religious pluralism building up over several decades, religious organizations have been given opportunities to provide so-called spiritual care in affiliation with Swedish hospitals since the 1980s. In this study we asked: in what ways do religious counsellors, affiliated with Swedish hospitals, construct their ideas on abortion, and how well do their ideas comply with Sweden’s ‘women-friendly’ abortion policies? Through interviews with Protestant, Catho-lic, Muslim, and Buddhist religious counsellors, we wanted to empirically test the presumption underlying the decisions to grant space to religious actors in Swedish healthcare, i.e., that religious counselling serves to complement existing services. We found that it cannot be expected that religious advice on abortion will always comply with Swedish abortion law and with the women-friendly abortion policy that the Swedish state seeks to impose. When policy-makers open up possibilities for diverse norms on abortion to manifest in close affiliation with healthcare institutions, they must be aware that some religious counsellors argue that only God—and not the woman herself—can decide whether a woman can terminate a pregnancy. We argue that the findings in this study speaks to what researchers have referred to as the “diversity-equality paradox”, which highlights the tension between the promotion of religious ideas on abortion on the one hand and the promotion of liberal ideas about women’s reproductive freedom on the other.

In this article, we explore how reproductive health care providers in Sweden, a country often described as one of the most gender-equal countries in the world, incorporate gender equality ideals in multicultural contraceptive counseling. In the tension between gender equality promotion on one hand and respect for cultural diversity and individualized care on the other, we will demonstrate that values of gender equality were often given priority. This is not necessarily undesirable. Nevertheless, our proposal is that the gender equality ideology may inhibit providers' ability to think differently about issues at stake in contraceptive counseling, which may negatively influence women's possibilities to obtain adequate support. At the end of the article, we suggest how health care providers' reflexivity might be used as a working tool for increased awareness about the taken-for-granted cultural norms that exist in their clinical milieu.

There are probably few groups of patients in Sweden today that arouse as much associations and thoughts as do Muslims from the Middle East. The core dilemma in much of these discussions is whether healthcare providers should adjust the provision of care to Muslims’ divergent religious preferences, or if they would be better off to treat Muslims in the same way as other patients. These debates are often entangled with both a concern about politics of equality (i.e. ambitions to treat everyone the same) and politics of diversity (i.e. to treatpeople from ethnic and religious minority groups differently). Inspired by Foucault’s concept of governmentality, we in this study intended to explore the principles of ‘equality’ and 'diversity’ as governing tools for the shaping of healthcare providers and patients’ conduct. We found that although these governing tools are presented as non-conflicting in health policies, there seems to be an often-present trade-off between diversity and equality ideals in their practical implementation. When these policies are assigned meaning and implemented inpractice, they appear to generate unforeseeable consequences, both for healthcare providers and for the patients. It thus appears that the policies that were introduced with the intention of improving the structure of multicultural care encounters, in some cases, had an opposite effect.

Det finns få studier om hur socialarbetare handlägger ärenden som berör transnationellt surrogatmoderskap. Vår studie har för avsikt att bidra till att fylla detta tomrum. I Sverige är det inte tillåtet för sjukvården att utföra assisterad befruktning vid surrogatmoderskap. Detta har gjort att människor vänt sig utomlands för denna reproduktionsmetod, främst till Indien. Det finns inga lagar som reglerar surrogatmoderskap i Sverige, vilket har lett till svårigheter vid fastställande av rättsligt föräldraskap när föräldrarna återvänt med barnet. Denna kvalitativa intervjustudie med familjerättssekreterare har funnit att det finns rättslig osäkerhet och etiska frågeställningar som påverkar deras hantering av ärendet. Hur föräldraskap konstrueras i nuläget beror till stor del på enskilda familjerättssekreterares uppfattning om hur man bäst väger surrogatmammans intressen mot vad som är bäst för barnet. Avsaknad av riktlinjer och de etiska frågeställningarna har lett till osäker och olika hantering av ärendena, och en reglering behövs för att bättre skydda de inblandade och öka rättsäkerheten i handläggningen.

Transnational surrogacy, when people travel abroad for reproduction with the help of a surrogate mother, is a heavily debated phenomenon. One of the most salient discourses on surrogacy is the one affirming that Westerners, in their quest for having a child, exploit poor women in countries such as India. As surrogacy within the Swedish health care system is not permitted, Swedish commissioning parents have used transnational surrogacy, and the majority has turned to India. This interview study aimed to explore how commissioning parents negotiate the present discourses on surrogacy. Findings from the study suggest that the commissioning parents' views on using surrogacy are influenced by competing discourses on surrogacy represented by media and surrogacy agencies. The use of this reproductive method resulted, then, in some ambiguity. Although commissioning parents defy the exploitation discourse by referring to what they have learnt about the surrogate mother's life situation and by pointing at the significant benefits for her, they still had a request for regulation of surrogacy in Sweden, to better protect all parties involved. This study, then, gives a complex view on surrogacy, where the commissioning parents simultaneously argue against the exploitation discourse but at the same time are uncertain if the surrogate mothers are well protected in the surrogacy arrangements. Their responses to the situation endorse the need for regulation both in Sweden and India.

This study sought to explore how Swedish parents who had commissioned surrogacy abroad experienced the process ofparenthood recognition. The study consisted of in-depth interviews with five couples and 10 individuals representing 10 additionalcouples who had used surrogacy abroad, mainly in India. The construction of motherhood and fatherhood in the Swedish systemcontradicts how parenthood is defined in the surrogacy process. This study found that the formal recognition of parenthood involved acomplex and frustrating process where the presumption of fatherhood and step-child adoption as grounds for parenthood makepeople feel questioned as parents, negatively affecting parental welfare. Policy makers need to take into account the consequencesof an unregulated situation regarding surrogacy, and focus more on the child–parent relationship when regulating surrogacy.

BACKGROUND: Surrogacy is a reproductive practice that has been strongly marketed in India as a solution for childless couples. As a result, the number of surrogacy clinics is increasing. Meanwhile, a global discourse on surrogacy, originating from a Western perspective, has characterized surrogacy as being exploitative of women in low-income settings, where poverty drives them to become surrogate mothers.

OBJECTIVE: This study explored perspectives on surrogacy from men and women in Assam, an Indian state known to be a low-income setting. Surrogacy arrangements in Assam are still uncommon. It can be expected that the dominant global discourses on surrogacy will be unfamiliar to the general population, and the objective was also to position the results within the divergent global discourses of surrogacy.

METHODS:  In order to explore local views on surrogacy, we conducted individual interviews and focus group discussions with people from various socioeconomic groups in Assam.

RESULTS: Our findings reveal that people in Assam perceive surrogacy as a good option for a childless couple, as it would result in a child who is a 'blood' relation - something highly desirable for sociocultural reasons. However, the part played by the surrogate mother complicates local views on surrogacy. Most people consider payment to the surrogate mother contrary to societal norms. A surrogate mother is also often judged in a moral light, either as a 'bad mother' for selling her child, or as a 'noble woman' who has helped a childless couple and deserves payment for her services.

CONCLUSIONS: In order to decrease the stigmatization of women, a regulatory policy is needed that will take into account the complex understandings of surrogacy and perceptions of surrogate mothers in Indian society. In policy, the possible effect of the dominant exploitation discourse needs to be modulated by local understandings of this reproduction method.

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.

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.

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.

Unskilled traditional healers are widely blamed for complications to male circumcision performed in low- and middle-income settings. However, attributions of culpability are mostly anecdotal. We identify self-circumcision in adults that was performed during adolescence, hereby termed retrospective self circumcision, and unexpectedly discovered during interviews with Somali men in Sweden in 2010. This study explores the phenomenon with the aim to increase our understanding about the health needs of this group. Two focus group discussions (six and seven participants), one informal discussion with three participants, and 27 individual interviews were conducted in 2010 and 2011 with Somali-Swedish fathers, guided by a hermeneutic, comparative natural inquiry method. Eight participants had performed retrospective self-circumcision while living in rural Somalia. Actions were justified according to strong faith in Islam. Genital physiology was described as adequate for producing children, but physical sensation or characteristics were implied as less than optimal. Few had heard about penile reconstruction. There was hesitation to openly discuss concerns, but men nevertheless encouraged each other to seek care options. Presently no medical platform is available for retrospective self-circumcision. Further systematic exploration is recommended in sexual, reproductive and urological health to increase interest in this phenomenon. Our findings suggest approachability if health communication is enabled within an Islamic context.

Background: It is unclear which anthropometric measure is most useful for assessment of the cardiovascular risk. We investigated the association between different anthropometric measures and risk of heart failure (HF) hospitalization. Methods: BMI, waist-hip ratio (WHR), waist circumference (WC), body fat percentage (BF%), weight and height were measured among 26 653 subjects (aged 45-73 years) without history of myocardial infarction (MI), stroke or HF from the Malmo Diet and Cancer cohort at baseline in 1991-96. Incidence of HF hospitalizations was monitored during a mean follow-up of 15 years. Results: Seven hundred and twenty-seven subjects were hospitalized with HF as primary diagnosis, of whom 157 had an MI before or concurrent with the HF. After adjustment for potential confounding factors, the hazard ratios of HF hospitalization (fourth vs. first sex-specific quartile) were 1.80 (95% CI: 1.45-2.24) for BMI, 1.87 (1.50-2.34) for WC, 1.77 (1.43-2.19) for WHR, 1.35 (1.09-1.68) for BF%, 1.93 (1.57-2.39) for weight and 1.18 (0.96-1.44) for height. Significant interactions between BMI and WC and WHR, respectively, were observed, and the joint exposure of high BMI and high WC or high WHR further increased the risk. The results were similar in secondary analyses, i.e. excluding incident HF with previous MI during the follow-up. Conclusion: Our results support the view that raised BMI, WC, WHR or BF% increases the risk of HF hospitalization. The joint exposure of high BMI and high WHR or high WC further increased the risk in an additive way.

BACKGROUND:

Studies from Sweden have reported association between immigrant status and incidence of cardiovascular diseases. The nature of this relationship is unclear. We investigated the relationship between immigrant status and risk of heart failure (HF) hospitalization in a population-based cohort, and to what extent this is mediated by hypertension and life-style risk factors. We also explored whether immigrant status was related to case-fatality after HF.

METHODS:

26,559 subjects without history of myocardial infarction (MI), stroke or HF from the community-based Malmo Diet and Cancer (MDC) cohort underwent a baseline examination during 1991-1996. Incidence of HF hospitalizations was monitored during a mean follow-up of 15 years.

RESULTS:

3,129 (11.8%) subjects were born outside Sweden. During follow-up, 764 subjects were hospitalized with HF as primary diagnosis, of whom 166 had an MI before or concurrent with the HF. After adjustment for potential confounding factors, the hazard ratios (HR) for foreign-born were 1.37 (95% CI: 1.08-1.73, p = 0.009) compared to native Swedes, for HF without previous MI. The results were similar in a secondary analysis without censoring at incident MI. There was a significant interaction (p < 0.001) between immigrant status and waist circumference (WC), and the increased HF risk was limited to immigrants with high WC. Although not significant foreign-born tended to have lower one-month and one-year mortality after HF.

CONCLUSIONS:

Immigrant status was associated with long-term risk of HF hospitalization, independently of hypertension and several life-style risk factors. A significant interaction between WC and immigrant status on incident HF was observed.

To explore the relation between country of birth and risk of hospitalization due to heart failure (HF). All 40-89 year-old inhabitants in the city of Malmö, Sweden (n = 114,917, of whom 15.2% were born outside Sweden) were followed from November 1st, 1990 until December 31st, 2007. During a mean follow-up of 13.5 ± 5.3 years, a total of 7,640 individuals (47.4% men) were discharged from hospital with first-ever HF as primary diagnosis. Of them, 1,243 individuals had myocardial infarction (MI) before or concurrent with the HF hospitalization. The risk of HF was compared between immigrants from selected countries and Swedish natives. The overall analysis showed substantial differences among immigrant groups (P < 0.001). Compared to Swedish natives, significantly increased HF risk was found among immigrants from Finland (HR (hazard ratio): 1.40; 95% CI, 1.10-1.81), Former Yugoslavia (1.45: 1.23-1.72) and Hungary (1.48: 1.16-1.89), taking age, sex, marital status, annual income and housing condition into account. Analysis results were similar when cases with MI before or concurrent with the HF hospitalization were included in the analysis. In general, the risk of HF was significantly higher among immigrants from high-income and middle-income countries. Marital status, annual income and housing condition were also significant independent risk factors for HF in this population. There are substantial differences in risk of hospitalization due to HF among immigrants from different countries that can not be explained by socioeconomic factors. To what extent these differences could be explained by biological risk factors remains to be explored.

INTRODUCTION: Somali-born women comprise a large group of immigrant women of childbearing age in Sweden, with increased risks for perinatal morbidity and mortality and poor experiences of care, despite the goal of providing equitable healthcare for the entire population. Rethinking how care is provided may help to improve outcomes.

OVERALL AIM: To develop and test the acceptability, feasibility and immediate impacts of group antenatal care for Somali-born immigrant women, in an effort to improve experiences of antenatal care, knowledge about childbearing and the Swedish healthcare system, emotional well-being and ultimately, pregnancy outcomes. This protocol describes the rationale, planning and development of the study.

METHODS AND ANALYSIS: An intervention development and feasibility study. Phase I includes needs assessment and development of contextual understanding using focus group discussions. In phase II, the intervention and evaluation tools, based on core values for quality care and person-centred care, are developed. Phase III includes the historically controlled evaluation in which relevant outcome measures are compared for women receiving individual care (2016-2018) and women receiving group antenatal care (2018-2019): care satisfaction (Migrant Friendly Maternity Care Questionnaire), emotional well-being (Edinburgh Postnatal Depression Scale), social support, childbirth fear, knowledge of Swedish maternity care, delivery outcomes. Phase IV includes the process evaluation, investigate process, feasibility and mechanisms of impact using field notes, observations, interviews and questionnaires. All phases are conducted in collaboration with a stakeholder reference group.

ETHICS AND DISSEMINATION: The study is approved by the Regional Ethical Review Board, Stockholm, Sweden. Participants receive information about the study and their right to decline/withdraw without consequences. Consent is given prior to enrolment. Findings will be disseminated at antenatal care units, national/international conferences, through publications in peer-reviewed journals, seminars involving stakeholders, practitioners, community and via the project website. Participating women will receive a summary of results in their language.

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 antenatal care that includes routine questions about violence being asked. The aim of the study was to explore how Somali-born women understand and relate to violence and wellbeing during their migration transition and their views on being approached with questions about violence in Swedish antenatal care. 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 about violence were met with hesitance. The midwife was, however, considered a resource for access to support services in the new society. A focus 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. Dialogue and mutual adjustments were identified as strategies used to overcome power tensions in intimate relationships undergoing transition. Conclusions: If confidentiality and links between violence and health are explained and clarified during the care encounter, screening for violence can be more beneficial in relation to Somali-born women. The focus on "moving on" and rationality indicates strength and access to alternative resources, but needs to be balanced against risks for hidden needs in care encounters. A care environment with continuity of care and trustful relationships enhances possibilities for the midwife to balance these dual perspectives and identify potential needs. Collaborations between Somali communities, maternity care and social service providers can contribute with support to families in transition and bridge gaps to formal social and care services.

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:

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.

OBJECTIVE:

to investigate how to prevent transmission of HIV and Chlamydia trachomatis (CT) by exploring whether screening of men during pregnancy may be an innovative way to reach men, to increase detection, and to avoid the present gendered responsibility.

DESIGN:

an explorative research strategy with in-depth interviews and an analysis informed by grounded theory principles was used.

SETTING:

the northern part of Sweden.

PARTICIPANTS:

twenty men/becoming fathers in their twenties and early thirties were offered CT and HIV testing and were interviewed about their perceptions about being tested during pregnancy.

FINDINGS:

Six categories emerged that concerned the men's risk perceptions, reasons for not testing men, benefits and negative consequences associated with being tested, incentive measures for reaching men and the optional time for testing men during pregnancy. The majority of the men perceived their own risk for having CT or HIV to be close to zero, trusted their stable partner, and did not see men as transmitters. They did not understand how men could play a role in CT or HIV transmission or how these infections could negatively affect the child. However, few informants could see any logical reasons for excluding men from testing and the majority was positive towards screening men during the pregnancy.

KEY CONCLUSIONS:

men's sexual health and behaviour on social and biological grounds will affect the health of women and their children during pregnancy and childbirth. As long as expectant fathers do not count in this 'triad', there is a risk that CT and HIV infections in adults and infants will continue to be an unsolved problem.

IMPLICATIONS FOR PRACTICE:

knowledge from this research can contribute to influencing the attitudes among health-care providers positively, and inspiring policy changes.

Objectives: We used qualitative research design to discursively explore expectant fathers' perceptions of chlamydia and HIV, and their masculinity constructions about testing, and explored how they talked about their potential resistance towards testing and their pre-test emotions.

Study design: Twenty men were offered chlamydia and HIV testing at the beginning of their partner's pregnancy. Those who agreed to be tested were interviewed in-depth; those who declined testing were also interviewed. The interviews were tape recorded and transcribed verbatim. The analysis was inspired by discourse analysis on masculinity.

Main outcome: Three discursive themes: Men prefer to suppress their vulnerability to STIs, Body and biology differ between men and women and Men have mixed emotions around STI testing underscore the informants' conversations and sometimes conflicting thoughts about STI testing.

Conclusion: The majority of men talked about pregnancy as a feminine territory, raised uncertainties about men's roles in the transmission of STIs, and talked about women's and men's essentially different bodies and biology, where few men realised that they could infect both their partner and the unborn child. This knowledge gap that men have must become apparent to healthcare providers, and policy makers must give men equal access to the reproductive arena.

The objective of this study was to explore religious beliefs of Somali men residing in Finland that may influence their use of condoms and their perceptions of contraceptive use by women of their community. Both quantitative and qualitative methods were used to study 98 refugee Somali married men aged 30-65 years. Participants filled in self-administered questionnaires (in English or in Somali) but were also interviewed. The interviews were semi-structured, featuring thematically clustered open-ended questions; they were conducted in Somali or in English. Participants had arrived in Finland between 1990-1998. They had from 2-12 children. For religious reasons, 63% of the men avoided using condoms and were opposed to women's contraceptive use. The remaining 37% were not deterred by religious beliefs from using condoms and from approving women's contraceptive practices. In conclusion, for religious reasons, most Somali men assessed avoided using condoms and disapproved of the use of contraception by women.

Iranians are one of Finland's major immigrant groups. Like other asylum seekers in Finland, the Iranians brought with them their own cultural practices, attitudes and beliefs regarding marriage and family structure. The aim of this research was to study factors associated with married Iranian women's contraceptive use in Finland. A total of 120 married women with more than one child were interviewed in Turku, a costal city situated about 200km from Helsinki, the capital of Finland. The questionnaires gathered information about the respondents' socio-demographic status, knowledge and use of contraception, number of children, length of time in Finland, education level and other social characteristics. Our research shows that the social factors that are associated with the Iranian women's contraceptive use are mainly due to changes in their conditions of life and adaptation to the Finnish society.

Objective.

To explore immigrant Somali women's experiences of reproductive and maternity health care services (RMHCS) and their perceptions about the service providers.

Design.

Five focus group discussions were conducted from April 1999 to June 2000 using a purposeful sampling strategy in order to reach multiparous female Somali-born Immigrants with experiences from the maternity health care in Finland.

Participants.

A total of 70 married Somali women aged 18-50 and mother of 2-10 children were studied. Among them, 18 came from Kenya, 32 from Mogadishu and 20 from Hargeysa.

Settings.

Of the participants, 45 were living in the city of Vantaa, 22 in the city of Helsinki and 13 in the city of Turku.

Results.

Participants were satisfied with the RMHCS they received in Finland. Despite their satisfaction, the health care providers' social attitudes towards them were perceived as unfriendly, and communication as poor.

Conclusions.

The women's experiences revealed that they have access to good quality RMHCS in Finland. While their experiences are significant, their perceptions are important for physicians, nurses and midwives in order to achieve culturally competent care.

Communication problems due to language and cultural differences between health care professionals and patients are widely recognized. Finns are described as more silent whereas one concurrent large immigrant group, the Somalis, are described as more open in their communication. The aim of the study was to explore physicians-nurses/midwives' communication when providing reproductive and maternity health care to Somali women in Finland. Four individual and three focus group interviews were carried out with 10 gynecologists/obstetricians and 15 nurses/midwives from five selected clinics. The health care providers considered communication (including linguistic difficulties), cultural traditions, and religious beliefs to be problems when working with Somali women. Male and female physicians were generally more similar in communication style, interpersonal contacts, and cultural awareness than the nurses/midwives who were engaged in more partnership-building with the Somali women in the clinics. Despite the communication and cultural problems, there was a tentative mutual understanding between the Finnish reproductive health care professionals and the Somali women in the clinics.

BACKGROUND: The aims of this study were: (i) to investigate stillbirth risk in offspring to foreign-born women by region of birth; (ii) if disparities in risks can be explained by socio-economic factors, pregnancy complications or maternal morbidity; and (iii) if the risk varies by time since immigration.

METHODS: This was a population-based register study with data from the Swedish Medical Birth Register and socio-economic variables from national income and population registers. We studied single births from 1992 to 2005, and included 219 832 births to foreign-born women and 1 094 146 births to Swedish-born women. Logistic regression analysis was used to calculate odds ratios (ORs), using 95% confidence intervals (CIs).

RESULTS: In all, 4104 antepartal and 255 intrapartal stillbirths occurred. Compared with births to Swedish women, the OR of stillbirth was 2.27 (95% CI 1.84-2.80) for births to women from Africa and 1.41 (95% CI 1.22-1.64) for births to women from Middle East, after adjustment for confounding factors. The risk of stillbirth was higher in immigrants who had been in Sweden for a short time period (<5 years) compared with those who had been in Sweden for a longer period, OR 1.21 (95% CI 1.05-1.40).

CONCLUSIONS: The risk of stillbirth in immigrant women varies by region of birth and time since immigration, being highest in women from Africa and the Middle East, and the recently settled. Further studies are needed to identify the mechanisms behind these patterns.

Western countries have reported an increased risk of maternal mortality among African immigrants. This study aimed to identify cases of maternal mortality among immigrants from the Horn of Africa living in Sweden using snowball sampling, and verify whether they had been classified as maternal deaths in the Cause of Death Registry. Three “locators” contacted immigrants from Somalia, Eritrea, and Ethiopia to identify possible cases of maternal mortality. Suspected deaths were scrutinised through verbal autopsy and medical records. Confirmed instances, linked by country of birth, were compared with Registry statistics. We identified seven possible maternal deaths of which four were confirmed in medical records, yet only one case had been classified as such in the Cause of Death Registry. At least two cases, a significant number, seemed to be misclassified. The challenges of both cultural and medical competence for European midwives and obstetricians caring for non-European immigrant mothers should be given more attention, and the chain of information regarding maternal deaths should be strengthened. We propose a practice similar to the British confidential enquiry into maternal deaths. In Sweden, snowball sampling was valuable for contacting immigrant communities for research on maternal mortality; by strengthening statistical validity, it can contribute to better maternal health policy in a multi-ethnic society.

Men who have sex with men are a hidden population in India. This study explores the psychological violence such men are exposed to in Puducherry, India. Eleven in-depth interviews probe experiences of blackmail, discrimination, and rejection. Some informants modified their behaviors or appearances to avoid harassment and safeguard their families' reputations. Others told how Indian men accepted their behaviors, but rejected their identities. Social pressure to marry was also a recurring theme. Understanding the factors behind these violent experiences may facilitate their amelioration.

INTRODUCTION: The objective of this study was to compare ever-in life contraception use, use of contraception at current conception, and planned use of contraception after an induced abortion, among three groups of women: migrants, second-generation migrants and non-migrant women, and to compare the types of contraception methods used and intended for future use among the three groups of women.

METHODS: The cross-sectional study administered a questionnaire face-to-face to women aged 18 years and older who were seeking abortion care at one of six abortion clinics in Stockholm County from January to April 2015.

RESULTS: The analysis included 637 women. Migrants and second-generation migrants were less likely to have used contraception historically, at the time of the current conception, and to plan to use contraception after their induced abortion compared with non-migrant women. Historically, non-migrants had used pills (89%) and withdrawal (24%) while migrants had used the copper intrauterine device (24%) to a higher extent compared to the other two groups of women. Both the migrants (65%) and second-generation migrants (61%) were more likely than the non-migrants (48%) to be planning to use long-acting reversible contraception.

CONCLUSIONS: Lower proportions of contraception use were found in migrants and second-generation migrants than in non-migrants. In addition, there were significant differences in the types of contraception methods used historically and intended for future use.

Swedish healthcare providers must comply with the Patient Act's principles of equal and accessible care and account for patients’ religious backgrounds by offering culturally sensitive care. This chapter explores what characterizes patients’ and their relatives’ expectations in healthcare encounters perceived as religiously discriminatory in the diverse Swedish healthcare system. It analyses perceived religious discrimination in healthcare through the interpretative phenomenological analysis of complaints submitted to the Equality Ombudsman in Sweden from 2012 to 2021, which registered 92 complaints as religious discrimination in healthcare, 66 of which were included in this study's analytical sample. The complaints addressed unfulfilled expectations related to cultural and religious literacy, equal treatment in relation to religious symbols or medical records, affirmative action in medical treatment that takes beliefs into account, and a secular environment that forbids religious symbols in healthcare encounters. One-third of the complaints were submitted by Muslims or individuals presumed to be Muslim. Several complaints concerned healthcare providers’ reactions to patients wearing hijabs or other ethnic or religious attributes. The study indicates that healthcare providers face difficulties in conforming to the partially contradictory ideals of equal treatment and cultural sensitivity, whose relation to religious diversity has not yet been clearly defined.

Objectives: Women’s healthcare is a potential source of cross-cultural conflicts.Diverging values between healthcare providers and patients challenges the provision ofculturally sensitive care and meeting migrant women’s needs. The aim is to investigatehealthcare providers’ values in relation to sexual and reproductive rights, gender equality,migration and religion in Swedish sexual and reproductive healthcare.

Methods: A national cross-sectional study was carried out. The questionnaire wasdistributed through a non-probability sample to midwives or other nurses,gynaecologists and obstetricians, and hospital social workers (n = 1,041). Throughdescriptive statistics, we mapped their values, comparing healthcare provider data toexternal representative population survey data.

Results: Healthcare providers in sexual and reproductive healthcare displayedhomogeneous liberal social values, being permissive towards sexual and reproductiverights and restrictive against gender-based violence. They were for gender equality,expressed low anti-immigrant sentiments, and had even more liberal values than theSwedish population and a demographically comparative sub-population.

Conclusion: Individuals with very liberal values are selected to work in Swedish sexual andreproductive healthcare. Healthcare providers need self-reflexivity to avoid conflicts inclinical encounters in a diversified society.

Background: Several European countries report differences in risk of maternal mortality between immigrants from low- and middle-income countries and host country women. The present study identified suboptimal factors related to care-seeking, accessibility, and quality of care for maternal deaths that occurred in Sweden from 1988-2010. Methods: A subset of maternal death records (n = 75) among foreign-born women from low- and middle-income countries and Swedish-born women were audited using structured implicit review. One case of foreign-born maternal death was matched with two native born Swedish cases of maternal death. An assessment protocol was developed that applied both the 'migration three delays' framework and a modified version of the Confidential Enquiry from the United Kingdom. The main outcomes were major and minor suboptimal factors associated with maternal death in this high-income, low-maternal mortality context. Results: Major and minor suboptimal factors were associated with a majority of maternal deaths and significantly more often to foreign-born women (p = 0.01). The main delays to care-seeking were non-compliance among foreign-born women and communication barriers, such as incongruent language and suboptimal interpreter system or usage. Inadequate care occurred more often among the foreign-born (p = 0.04), whereas delays in consultation/referral and miscommunication between health care providers where equally common between the two groups. Conclusions: Suboptimal care factors, major and minor, were present in more than 2/3 of maternal deaths in this high-income setting. Those related to migration were associated to miscommunication, lack of professional interpreters, and limited knowledge about rare diseases and pregnancy complications. Increased insight into a migration perspective is advocated for maternity clinicians who provide care to foreign-born women.

Background

Although the incidence of suicide among women who havegiven birth during the past 12 months is lower than that ofwomen who have not given birth, suicide remains one of themost common causes of death during the year followingdelivery in high-income countries, such as Sweden.

Aims

To characterise women who died by suicide duringpregnancy and postpartum from a maternal careperspective.

Method

We traced deaths (n = 103) through linkage of the SwedishCause of Death Register with the Medical Birth and NationalPatient Registers. We analysed register data and obstetricmedical records.

Results

The maternal suicide ratio was 3.7 per 100 000 live births forthe period 1980–2007, with small magnitude variation overtime. The suicide ratio was higher in women born inlow-income countries (odds ratio 3.1 (95% CI 1.3–7.7)).Violent suicide methods were common, especially during thefirst 6 months postpartum. In all, 77 women had receivedpsychiatric care at some point, but 26 women had nodocumented psychiatric care. Antenatal documentationof psychiatric history was inconsistent. At postpartumdischarge, only 20 women had a plan for psychiatricfollow-up.

Conclusions

Suicide prevention calls for increased clinical awareness andcross-disciplinary maternal care approaches to identify and support women at risk.

Background: Cause-of-death statistics is widely used to monitor the health of a population. African immigrants have, in several European studies, shown to be at an increased risk of maternal death, but few studies have investigated cause-specific mortality rates in female immigrants. Methods: In this national study, based on the Swedish Cause of Death Register, we studied 27 957 women of reproductive age (aged 15-49 years) who died between 1988 and 2007. Age-standardized mortality rates per 100 000 person years and relative risks for death and underlying causes of death, grouped according to the International Statistical Classification of Diseases and Related Health Problems, 10th Revision, were calculated and compared between women born in Sweden and in low-, middle- and high-income countries. Results: The total age-standardized mortality rate per 100 000 person years was significantly higher for women born in low-income (84.4) and high-income countries (83.7), but lower for women born in middle-income countries (57.5), as compared with Swedish-born women (68.1). The relative risk of dying from infectious disease was 15.0 (95% confidence interval 10.8-20.7) and diseases related to pregnancy was 6.6 (95% confidence interval 2.6-16.5) for women born in low-income countries, as compared to Swedish-born women. Conclusions: Women born in low-income countries are at the highest risk of dying during reproductive age in Sweden, with the largest discrepancy in mortality rates seen for infectious diseases and diseases related to pregnancy, a cause of death pattern similar to the one in their countries of birth. The World Bank classification of economies may be a useful tool in migration research.

OBJECTIVE:

To obtain more accurate calculations of maternal and pregnancy-related mortality ratios in Sweden from 1988 to 2007 by using information from national registers and death certificates.

DESIGN:

A national register-based study, supplemented by a review of death certificates.

SETTING:

Sweden, 1988 to 2007.

POPULATION:

The deaths of 27 957 women of reproductive age (15 to 49 years).

METHODS:

The Swedish Cause of Death Register, Medical Birth Register, and National Patient Register were linked. All women with a diagnosis related to pregnancy in at least one of these registers within one year prior to death were identified. Death certificates were reviewed to ascertain maternal deaths. Maternal mortality ratio, the number of maternal deaths/100 000 live births (excluding and including suicides); and pregnancy-related mortality ratio (number of deaths within 42 days after termination of pregnancy, irrespective of cause of death/100 000 live births) were calculated.

MAIN OUTCOME MEASURES:

Direct and indirect maternal deaths and pregnancy-related deaths.

RESULTS:

The maternal mortality ratio in Sweden, based on the current method of identifying maternal deaths, was 3.6. After linking registers and reviewing death certificates, we identified 64% more maternal deaths, resulting in a ratio of 6.0 (or 6.5 if suicides are included). The pregnancy-related mortality ratio was 7.3. A total of 478 women died within a year after being recorded with a diagnosis related to pregnancy.

CONCLUSIONS:

By including the 123 cases of maternal death identified in this study, the mean maternal mortality ratio from 1988-2007 was 64% higher than reported to the World Health Organization.

It is well known that there is inter- as well as intra-individual differences between physicians doing genital examinations. Over the years, WHO has changed the form on how to classify FGM several times, with the latest typology from 2017. The interest in empirical exploration of different practices of gynaecological examination is emerging in order to keep a high standard of medical and juridical practice and to keep equality before the law. The question that will be discussed is: How to best safeguard a professional examination of the genitals in children and young women? How to best safeguard a legal procedure when professional practice of examinations given different classifications on the same individual? Comparative data from research by gynaecologist, surgeon, and paediatricians will be presented. Further, clinical cases will be discussed illustrating conflicting clinical practices as well as legal court cases. A structured model of best professional practices will be presented and discussed.