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This paper critically examines the disproportionate impact of Sweden's legal and policy measures aimed at detecting and prosecuting 'female genital mutilation' (FGM) within immigrant communities. Despite three criminal court cases related to FGM performed in African countries, forced genital examinations - central to many investigations - have not resulted in any prosecutions. This raises significant concerns about the effectiveness and proportionality of current practices. Drawing on an archive of police case files and interviews with professionals involved in FGM investigations, we explore how legal frameworks, while intended to protect children, apparently indicate a pattern of over-policing and structural injustice. Our analysis highlights the disconnect between policies rooted in suspicion and control and the cultural shifts occurring within affected communities, where attitudes toward the circumcision of girls have evolved due to migration. We argue that Sweden's reliance on invasive measures risks exacerbating the marginalisation of immigrant groups and underscores the need for more nuanced, trust-building approaches. The findings call for a re-evaluation of current strategies to ensure that interventions are proportionate and sensitive to evolving cultural contexts, while still protecting the rights and well-being of children.

BackgroundStereotypes about immigrant patients in healthcare can hinder effective communication, erode trust, and contribute to discrimination and poorer health outcomes. Culturally competent healthcare aims to improve communication and build trust by acknowledging patients' cultural backgrounds, but it also risks overemphasising cultural differences and reinforcing stereotypes. To address this tension, this study examines how healthcare providers in Sweden perceive the values of immigrant patients regarding sexual and reproductive rights and compares these perceptions with the actual values held by newly arrived immigrants.MethodsThe study draws on two large-scale surveys conducted in 2020-2021. The first survey was conducted among newly arrived immigrants in Sweden and included eighteen questions on moral issues related to sexual and reproductive rights, such as abortion, contraception, and sex before marriage. Responses from newly arrived immigrants originating from the Middle East, North Africa, and the Horn of Africa (N = 992) were used in this study. The second survey was conducted among healthcare providers working in sexual and reproductive healthcare (N = 1,041) and asked how they believed immigrant patients from corresponding regions would respond on the same set of issues. Results from the two surveys were compared using three complementary approaches: examining the distribution of healthcare providers' perceptions, assessing their accuracy relative to immigrants' self-reported values, and testing for systematic biases in the direction of these perceptions.ResultsOf the eighteen included issues, healthcare providers' perceptions aligned with immigrants' self-reported issue positions in only six cases. The greater the proportion of immigrants holding liberal rather than conservative positions, the more often providers' perceptions were incorrect (Pearson's r = -0.73). Healthcare providers often erroneously assumed that immigrant patients hold very conservative values, a pattern most pronounced on issues where immigrants held the most liberal views.ConclusionsTo avoid stereotypes and promote equitable, culturally competent healthcare, providers need to develop a better understanding of immigrants' values and how these are shaped. Our findings reveal a tendency to underestimate the liberal values of immigrant patients, particularly on issues related to sexual and reproductive rights, thereby reinforcing bias and contributing to essentialist thinking in clinical practice.

Background

It is widely recognized that migrant women from low-income countries are considered to be a group with increased obstetric challenges. To address these challenges, cultural doulas were introduced to provide continuous emotional and practical support during childbirth in Sweden. Leveraging their shared cultural background, language skills, and understanding, the idea behind these doulas was supposed to facilitate effective communication between the woman, her partner, and healthcare staff, with the assumption that this would lead to better maternity care for migrants. The aim of this study was to explore healthcare providers reflections on the role of cultural doulas and to explore their perceptions of cultural doulas’ impact on childbirth.

Methods

A qualitative study was conducted in 2022, involving semi-structured interviews with 18 healthcare providers; obstetricians and midwives from two Swedish counties. The data was analyzed using reflexive thematic analysis and discourse analysis, guided by Bacchi’s ‘What Is the Problem Represented to Be?’ approach.

Results

Using Bacchi’s ‘What Is the Problem Represented to Be?’ approach, the analysis highlights how healthcare providers interpreted cultural doulas as an asset in relation to problems in migrants’ maternity care. Three key discourses that emerged were: underlying social and cultural factors, assumptions of improved outcomes and integration, and cultural doulas as informal interpreters. Instead of emphasizing medical risks, healthcare providers focused on social risks and overlooked the importance of professional training.

Conclusions

Cultural doulas are recognized as valuable in addressing gaps in migrant maternity care, yet their role presents a paradox. Entrusting the care of high-risk migrant women to minimally trained non-medical professionals paradoxically risks miscommunication and compromised care quality. Insufficient training, unclear roles, and the overextension of cultural doulas further exacerbate this issue, underscoring the need for systemic reforms. To resolve this paradox and improve maternal outcomes, the maternity care system must redefine the role of cultural doulas, prioritize professional interpretation services, and implement integrated care models tailored to the evidence based medical needs of migrant women.

AIM: To analyse the occurrence and significance of complaints to the Equality Ombudsman (Diskrimineringsombudsmannen (DO)) of ethnic, religious and gender discrimination in Swedish healthcare in relation to discrimination as a social phenomenon.

METHODS: Through descriptive statistics and content analysis, we analysed complaints of discrimination on the grounds of ethnicity, religion and gender from 2012 to 2021 (N=431), and DO's case supervision decisions (n=23).

RESULTS: DO has legally reviewed or initiated a supervisory process for only 23 (5%) of 431 cases and filed two lawsuits in the sample. Two-thirds of complainants were patients (n=284, 66%), one-fourth relatives (n=109, 25%), two healthcare professionals (1%) and 36 unspecified (8%). The most frequently reported healthcare sectors were primary healthcare centres (n=133, 31%), emergency care (n=50, 12%), women's healthcare (n=47, 11%) and psychiatry/psychotherapy (n=40, 9%). Perceived discrimination concerned unfulfilled expectations of equal treatment (n=158, 37%), respectful treatment (n=151, 35%), different diagnosis or treatment (n=88, 20%), faster processing (n=15, 4%) and other (n=19, 4%).

CONCLUSIONS: Complaints of ethnic, religious and gender discrimination in Swedish healthcare often report subtle discrimination or unmet expectations, and the reported discrimination is rarely legally confirmed. The results suggest that many reported cases are likely based on misunderstandings and communication problems. The unfulfilled expectations were often related to miscommunication, distrust or perceptions of being neglected. Healthcare providers should recognise these perceptions earlier and clarify any misunderstandings. The findings point to a need for further analysis of perceived discrimination in healthcare, and that more cases should be investigated.

Background

Reducing maternal deaths is a critical public health concern. The Sustainable Development Goals (SDGs) aim to reduce maternal mortality globally to less than 70/100,000 live births by 2030. Mozambique has one of the highest maternal mortality rates in the world, at 233/100,000 live births. Of all maternal deaths, 11% are attributed to abortion. Mozambique decriminalized abortion in 2014 under certain conditions and approved clinical guidelines for service provision in 2016, aiming to reduce maternal deaths from unsafe abortion. This study assesses the availability, coverage, and utilization of facility-based voluntary termination of pregnancy (VTP) during the period 2016-2021 in Nampula province, northern Mozambique.

Methods

A descriptive quantitative study was performed, using secondary data analysis extracted from the national health monitoring information system (SIS-MA). Trends in the availability and utilization of VTP services were calculated from 2016 to 2021. The results were analysed while considering the geospatial distribution, coverage, and level of care of health facilities providing such services.

Results

Utilization of VTP services significantly increased by 77% (p < 0.001) and complications related to unsafe abortion decreased by 23.5% (p = 0.018) during 2016-2021.

Conclusions

Despite the significant improvement in service availability and utilization, the geographic distribution and population coverage of public health facilities providing services remains uneven and limited to semi-urban and urban areas, leaving unsafe abortion as the only option for women in rural areas. Despite these challenges, the results of this study reinforce scientific evidence that decriminalization of VTP and expansion of services may significantly improve access to and utilization of facility-based VTP, holding great potential for decreasing unsafe abortion-related complications and deaths.

Introduction: Despite the commitment of the Swedish government to ensuring equal access to Sexual Reproductive Health and Rights services for all citizens, shortcomings persist among the migrant population. In cases where healthcare providers lack sufficient knowledge or hold misconceptions and biases about these contentious issues, it can lead to the delivery of suboptimal care. Therefore, the objective of this study was to assess the level of knowledge of Swedish healthcare providers on global and Swedish migrant Sexual Reproductive Health and Rights.

Methods: A national cross-sectional study was conducted using a questionnaire consisting of seven questions related to global and Swedish migrant Sexual Reproductive Health and Rights. The questionnaire was distributed among midwives, nurses, gynecologists and obstetricians, and hospital social workers (N = 731). The analysis was guided by the Factfulness framework developed by Hans Rosling to identify disparities between healthcare providers’ viewpoints and evidence-based knowledge.

Results: There was an overall lack of knowledge among the health care providers on these issues. The highest correct responses were on the question on abandonment of female genital cutting/mutilation after migration (74%). The findings indicated that healthcare providers originating from Sweden, physicians, those with fewer years of clinical experience, and exhibiting more migrant-friendly attitudes, demonstrated a higher level of knowledge regarding global and Swedish migrant Sexual and Reproductive Health and Rights.

Conclusion: This study demonstrates that healthcare providers lacked knowledge of global and Swedish migrant Sexual Reproductive Health and Rights, which was almost uniformly distributed, except among those with more comprehensive and recent education. Contrary to expectations, healthcare professionals did not primarily rely on their education and experiences but were influenced by their personal values and opinions. The study underscores the importance of upgrading knowledge in Sexual Reproductive Health and Rights and encourages policymakers, professionals, and students to base their opinions on well-founded facts, particularly in the context of a diverse and globalized society.

Objective

This study aimed to explore young people’s perceptions and experiences on access to voluntary termination of pregnancy (VTP) in northern Mozambique.

Methods

A qualitative study of twelve focus group discussions was conducted from June to September 2021 in Nampula province, northern Mozambique. A total of 94 purposively selected 15–24-year-old males and females participated in the study. Data was inductively coded and reflexive thematic analysis inspired by Braun and Clarke was applied. Socio-Ecological theory was used to frame the discussion.

Results

Despite VTP being decriminalized and by law to be provided free of charge, unsafe abortion remains a common choice among young people towards unintended pregnancy. Barriers to help-seeking access to safe VTP include: 1) fear, 2) sociocultural gendered norms and power dynamics, 3) lack of VTP service provision at nearest health facilities, and 4) unaffordable services where available. Fear associated with early forced marriage, a parental corrective action towards premarital pregnancy coupled with lack of male financial autonomy to afford illicit charges, remain the most important factors preventing young people seeking for help at family and safe VTP services at facility level.

Conclusions

Amidst multiple barriers in accessing health services, unsafe abortion is viewed by young people as a better option than facing a lifetime punishment of early forced marriage, a common parental corrective action towards premarital pregnancy.

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.

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.

Ethnic disparities in stillbirth exist in Europe and suboptimal care due to miscommunication is one contributing cause. The MAMAACT intervention aimed to reduce ethnic disparity in stillbirth and newborns' health through improved management of pregnancy complications. The intervention encompassed training of antenatal care midwives in cultural competencies and intercultural communication combined with health education materials for the expecting parents about symptoms of pregnancy complications. The evaluation consisted of a qualitative in-depth implementation analysis and a process evaluation embedded in a cluster randomized trial including 19 of 20 maternity wards in Denmark. In this article, the findings from the different evaluation perspectives are integrated. The integration follows the principles of realist evaluation by analyzing to what extent the MAMAACT activities were generating mechanisms of change in interaction with the context. The integration analysis shows that the health education materials in the MAMAACT intervention contributed to heightened health literacy concerning pregnancy complications among pregnant women. Additionally, the training of midwives in cultural competency and intercultural communication raised awareness among midwives. Nonetheless, the exclusive emphasis on midwives and the inflexibility in care provision hindered them from changing their communication practices. To enhance the cultural competence in maternity care, it is essential to implement more comprehensive initiatives involving healthcare professionals in maternity care at all levels, from pregraduate to postgraduate. Adequate interpreter services and management support should also be ensured. Currently, the Danish antenatal care system faces challenges including inadequate information transfer between healthcare sectors, insufficient differentiation of care, and inflexibility in midwife scheduling. This results in a lack of responsiveness to the individual needs of women with immigrant backgrounds, potentially reproducing health inequities.