Antenatal care for Somali-born women in Sweden: Perspectives from mothers, fathers and midwives

Trends and disparities of disease burden in infections among pregnant women in 131 low-income and middle-income countries, 1990-2019

Background

In low- and middle-income countries (LMICs) and territories, maternal infections impose a non-negligible disease burden. We aimed to analyse the secular trends, age distribution, and associated factors of maternal sepsis and other maternal infections (MSMI) across 131 LMICs from 1990 to 2019.

Methods

We collected yearly data of incidences, deaths, and disability adjusted life years (DALYs) on MSMI in 131 LMICs from 1990 to 2019 from the Global Burden of Disease 2019 (GBD 2019). The sociodemographic index (SDI) and universal health coverage effective coverage index (UHCI) were also acquired. Relative percent change and estimated annual percentage change (EAPC) were used to assess the secular trends. Correlation analyses were also employed to explore the associations between the burden of MSMI with SDI and UHCI.

Results

Between 1990 and 2019, the age-standardised incident rates (ASIRs), age-standardised maternal mortality ratios (ASMMRs) and age-standardised DALYs rates of low-income countries (LICs) were much higher than that of lower-middle-income countries (LMCs) and upper-middle income countries (UMCs), although they all continued to decline. At least six of 131 LMICs had ASMMR greater than 70.00 per 100 000 live births in 2019. The incidences of MSMI increased first till 20-24 years and then decreased with age both in 1990 and 2019, while the ASMMRs were higher in the youngest and the oldest age group. With the growth of SDI and UHCI in 2109, the decreasing trend of ASIR, ASMMR, and age-standardised DALYs rates slowed down.

Conclusions

Although the progress has been made in reducing the burden of MSMI in 131 LMICs, the disease burden in LICs far exceeded that of LMCs and UMCs. Socio-economic status and universal health coverage were both associated with the MSMI burden, and further research is needed to explore the underlying factors contributing to these disparities and to identify effective strategies for reducing the burden of MSMI.

Migrant women's experiences of community-based doula support during labor and childbirth in Sweden. A mixed methods study

OBJECTIVE

To describe migrant women's experiences of bilingual community-based doulas (CBD) contribution to care in relation to labor and birth.

METHODS

Mixed methods study combining quantitative data from 82 women who received CBD-support within a randomized controlled trial and qualitative data from semi-structured interviews with a sub-sample of 12 women from the same study arm. Descriptive analyses were used for quantitative data and content analysis for the manifest and latent content of the qualitative data. Quantitative findings were categorized according to qualitative findings.

RESULTS

The women expressed how CBDs played an essential role in the response to their basic emotional, informational, and physical support needs, when no other female family member was available. Three main categories emerged from the analysis of interviews: The doulas help women feel safe and calm - providing support before, during and after childbirth; The doulas' support role fills the void left by a deeply missed family, mother or sister; and The doulas assist women in achieving autonomy through communication support and advocacy. More than half of women reported feeling involved during labor and birth (56.8%), most valued CBD positively (such as being competent, calm, secure, considerate, respectful, encouraging, supportive) (40.8%-80.3%), that CBD had interpreted (75.6%), facilitated communication with the midwife (60,3%), comforted the woman (57.7%) and reduced anxiety (48,7%). Few reported negative CBD-characteristics (1.3-9.2%). Nevertheless, 61.7% of women felt frightened sometime during labor and birth, which made it even more important to them that the doula was there. Few women (21.8%) reported that the CBD had supported her partner but expressed so in the interviews.

CONCLUSION

Through an essential contribution in responding to migrant women's basic emotional, informational, and physical needs, bilingual community-based doulas have the potential to improve migrant women's experience of care during labour and birth. However, more focus on the quality of CBD-support to partners seem necessary.

Interaction Processes between Health Professionals and Moroccan Immigrant Women in Reproductive Healthcare: The Disagreement in the Encounter-A Qualitative Study

INTRODUCTION

Spain is a multicultural society and has been defined by several authors as an immigrant-receiving country. Moroccan women of childbearing age constitute 28.20% of Moroccan immigrants.

OBJECTIVES

describe the interaction processes that occur between health professionals and Moroccan immigrant women in reproductive healthcare.

METHODS

Qualitative descriptive study based on Grounded Theory. Thirty immigrant women from Morocco and thirty-five health professionals participated in the study. Specific dimensions of analysis were defined and used to design the interview guide and focus groups.

RESULTS

In the healthcare encounter, the construction of an effective communicative space between the people involved in it is essential; however, the language barrier and the interpersonal relationships characterized by silence in the encounter make a meaningful healthcare relationship difficult for those who participate in it.

CONCLUSIONS

There are communication and relationship problems that alter healthcare and the professional-patient relationship which require the use of translation programs, the incorporation of intercultural meters, and the development of cultural competence in health professionals.

Comparing healthcare needs by language: interpreted Arabic and Somali telehealth calls in two regions of Sweden, 2014-18

BACKGROUND

Limited language fluency can impede healthcare system navigation. In Sweden, the national telehealth line (Healthcare Guide 1177) offers interpretation in Arabic and Somali. We compared calls by language to identify differences in healthcare use for immigrant populations, focusing on three contact causes: pregnancy; vomiting or nausea in children; and worry/anxiety.

METHODS

We conducted a cross-sectional analysis of 3.9 million (n = 18 351 Arabic, n = 7199 Somali) telehealth calls (2014-18). Using multivariable logistic regression, we investigated associations between language of the call (Arabic, Somali, non-interpreted) and each contact cause. Potential confounders (age, region, year, and additionally for vomiting or nausea, month) and an interaction between age and language were considered.

RESULTS

Compared with non-interpreted calls, interpreted calls were associated with increased odds of being for pregnancy, especially for 19 to 29-year-olds [adjusted odds ratio (aOR) (95% CI) = 4.04 (3.66-4.46) and 4.60 (4.05-5.23), for Arabic and Somali calls, respectively]. Vomiting or nausea showed similar results, with aOR increasing with age: from 0.90 (0.75-1.07) (Arabic, <1 year) to 3.79 (2.86-5.01) (Somali, 5-9 years). In contrast, in unadjusted analyses, Arabic and Somali calls were associated with decreased odds of being for worry/anxiety [OR = 0.47 (0.38-0.58) and 0.34 (0.21-0.50)], respectively, compared with non-interpreted calls.

CONCLUSION

Our results suggest callers to the interpreted lines may need additional assistance navigating the healthcare system for pregnancy and for vomiting or nausea among children. These findings can inform healthcare services planning for immigrants to Sweden and highlight a novel use of telehealth data as a way to uncover disparities in healthcare use within a multi-linguistic population.

Experiences of gender-based violence among Somali refugee women: a socio-ecological model approach

Gender-based violence (GBV) is an all-encompassing term that speaks to acts or threats that may lead to physical, sexual or emotional harm to an individual based on their gender. This paper provides a scoping review of research on gender-based violence among Somali refugee women in different parts of the world. Using the socio-ecological model as a framework, we reviewed 30 empirical studies focusing on some form of GBV among Somali refugee women. We identified societal, community and individual factors contributing to the experience of GBV. We also discuss how these factors influence women's willingness to access care, especially healthcare and social services. The review reveals that oftentimes, institutions that work closely with this population have a limited understanding of how closely culture affects the willingness and ability to seek help about GBV. Based on our analysis, we suggest ways in which social institutions and healthcare providers can provide culturally-safe support to Somali refugee women who have experienced some form of GBV.

Somali immigrant women's knowledge of and experiences with folic acid supplement use before and during pregnancy: A qualitative study from Norway

INTRODUCTION

Health authorities in many countries recommend that women should take folic acid supplements before and during pregnancy to prevent having babies with neural tube defects. Somali immigrant women in Norway use less folic acid supplements than the recommended amount and subsequently, less than Norwegian-born women.

OBJECTIVES

To explore Somali immigrant women's knowledge of and experiences with using folic acid supplements before and during pregnancy.

METHODS

Data were collected through semi-structured individual interviews with ten Somali immigrant women in Norway. The participants were recruited and interviewed between September and November 2019. Graneheim and Lundmańs qualitative content analysis was used for data analysis.

RESULTS

Two main themes were developed through the process of analysing the data: 1) Attitudes to life and pregnancy affect how health care advice is met; 2) Understanding the benefits of folic acid is crucial.

CONCLUSIONS

The women in this study had varied knowledge about, and experiences with the use of folic acid supplements before and during pregnancy. The findings suggest that the healthcare system needs to adapt the information it provides on folic acid supplementation to target the needs of Somali immigrant women. In line with suggestions from the study participants, information needs to be given in a timely manner, by someone they trust, in their first language, include visual aids, and be offered to all women of childbearing age before their first pregnancy.

Approaches for enhancing patient-reported experience measurement with ethnically diverse communities: a rapid evidence synthesis

BACKGROUND

Patient-reported experience measures (PREMs) are used to drive and evaluate unit and organisational-level healthcare improvement, but also at a population level, these measures can be key indicators of healthcare quality. Current evidence indicates that ethnically diverse communities frequently experience poorer care quality and outcomes, with PREMs data required from this population to direct service improvement efforts. This review synthesises evidence of the methods and approaches used to promote participation in PREMs among ethnically diverse populations.

METHODS

A rapid evidence appraisal (REA) methodology was utilised to identify the disparate literature on this topic. A search strategy was developed and applied to three major electronic databases in July 2022 (Medline; PsycINFO and CINAHL), in addition to websites of health agencies in Organisation for Economic Co-operation and Development countries via grey literature searches. A narrative evidence synthesis was undertaken to address the review question.

RESULTS

The review resulted in 97 included studies, comprised 86 articles from electronic database searches and 11 articles from the grey literature. Data extraction and synthesis identified five strategies used in PREM instruments and processes to enhance participation among ethnically diverse communities. Strategies applied sought to better inform communities about PREMs, to create accessible PREMs instruments, to support PREMs completion and to include culturally relevant topics. Several methods were used, predominantly drawing upon bicultural workers, translation, and community outreach to access and support communities at one or more stages of design or administration of PREMs. Limited evidence was available of the effectiveness of the identified methods and strategies. PREMs topics of trust, cultural responsiveness, care navigation and coordination were identified as pertinent to and frequently explored with this population.

CONCLUSIONS

The findings provide a basis for a maturity model that may guide change to increase participation of ethnically diverse communities in PREMs. In the short-medium term, health systems and services must be able to recognise and respond to cultural and linguistic diversity in the population when applying existing PREMs. In the longer-term, by working in collaboration with ethnically diverse communities, systems and services may co-create adapted or novel PREMs that tackle the factors that currently inhibit uptake and completion among ethnically diverse communities.

Perspectives of women and partners from migrant and refugee backgrounds accessing the Cross Cultural Worker Service in maternity and early childhood services-a survey study

BACKGROUND

Women from migrant and refugee backgrounds living in high-income countries have increased risk of adverse perinatal outcomes and report lower satisfaction with perinatal healthcare. In Sydney, Australia, a new service known as the Cross Cultural Workers (CCWs) in Maternity and Child and Family Health Service (the CCW Service) was implemented to support such women and families from pregnancy to the early parenting period. This study aimed to ascertain the experiences of women and their partners engaging with the CCW Service.

METHODS

A survey study was undertaken. Women accessing the CCW Service were recruited during pregnancy and were asked to complete surveys at three time points: in the third trimester of pregnancy, at 6 and 12 months postpartum. Their partners were invited to complete a survey at 6 months postpartum. Survey data were analysed to compare satisfaction, usefulness, number of CCW interactions, cultural sensitivity, and service improvement recommendations across all three survey timepoints.

RESULTS

A total of 231 surveys were received: 113 during pregnancy, 50 at 6-months postpartum, 44 at 12-months postpartum, and 24 partner surveys. Participants in all surveys reported the CCW Service to be useful (84-94%), stating that it increased their understanding of pregnancy, birth and parenting (95-100%), and that they would recommend the CCW Service (92-98%). Participants experienced a high level of satisfaction (88-95%) irrespective of the number of CCW interactions (p = 0.42). Thoughts on becoming a mother or parent were more positive after meeting the CCW than before for both women (p = 0.01) and partners (p = 0.12). Suggestions for CCW Service improvement were to 1) increase the provision of information, specifically financial entitlements, postnatal depression, and support services, 2) increase involvement of partners in care, 3) increase the CCW workforce/or number of CCWs.

CONCLUSION

The CCW Service was associated with positive experiences and high rates of satisfaction at all timepoints. This service has the potential to inform the implementation of similar models of care that improve accessibility, the perinatal experience, and respond to the unique needs of women and families from migrant and refugee backgrounds.

Miscommunication influences how women act when fetal movements decrease an interview study with Swedish Somali migrant women

OBJECTIVE

To explore how Swedish Somali migrant women perceive fetal movements, process information about fetal movements, and take actions if decreased fetal activity occurs.

DESIGN

A qualitative study based on individual semi-structured interviews. The interviews were analysed using content analysis.

SETTING

The study was conducted in Sweden.

PARTICIPANTS

Swedish Somali migrant women (n=15) pregnant in their third trimester or recently given birth.

FINDINGS

The analysis led to the main category: tailored information about fetal movements enhances the possibility to seek care if the movements decrease. The results are described in the generic categories: explanatory models determine action; and understand and interpret information.

KEY CONCLUSIONS

Miscommunication on fetal movements can be a hurdle for Swedish Somali migrant women that may have impact on stillbirth prevention and the quality of care. Improved communication and information tailored to individual needs is essential to achieve equality for women and their newborns.

IMPLICATIONS FOR PRACTICE

The midwife can be used as a hub for reassuring that adequate information about fetal movements reaches each individual woman in antenatal care. Individualised information on fetal movements based on the women's own understanding is suggested to increase the possibility that the pregnant woman will seek care if the movements decrease. Somali women's verbal communication can be used to spread accurate information in the Somali community on the importance of seeking care if fetal movements decrease.

Migrant-Native Disparities in Obstetric Neuraxial Analgesia Use: The Role of Host-Country Language Proficiency

BACKGROUND

Neuraxial analgesia (NA) is the most effective modality in managing labor pain with widespread availability in high-income countries. Previous research has reported a differential obstetric NA use among migrant and native women, but the contribution of language barriers is not well understood. We aimed to investigate whether host-country language proficiency among migrant women influences NA use and satisfaction with pain management during labor, when compared to natives.

METHODS

We conducted a secondary analysis of data collected from 1024 native and 1111 migrant women who had singleton vaginal deliveries between 2017 and 2019 and were enrolled in the nationwide Portuguese baMBINO prospective cohort study. Obstetric NA use, satisfaction with labor pain management, and migrants' Portuguese language proficiency were self-reported. Data were analyzed using robust multilevel Poisson regression, adjusted for maternal region of birth (characterized by the Human Development Index), age, and education.

RESULTS

Overall, 84.4% of native women gave birth with NA, compared to 81.6%, 71.3%, and 56.9% of migrant women with full, intermediate, and limited language proficiency, respectively. Compared to native women, migrants with intermediate (adjusted risk ratio [aRR] = 0.91 [95% confidence interval {CI}, 0.82-0.99]) and limited (aRR = 0.73 [95% CI, 0.56-0.94]) proficiency were less likely to receive NA. However, no significant differences were observed in pain management satisfaction by language proficiency level.

CONCLUSIONS

Compared to native women, we observed a differential obstetric NA use across migrant women with different host-country language proficiency levels in Portugal, without affecting satisfaction with labor pain management. Although defining the mechanisms underlying NA use discrepancies requires further research, our findings support systematically evaluating pregnant migrant women's linguistic skills and ensuring their access to adequate obstetric analgesia-related information and interpretation services.

Barriers and facilitators of access to sexual and reproductive health services among migrant, internally displaced, asylum seeking and refugee women: A scoping review

INTRODUCTION

Migrant, internally displaced, asylum seeking and refugee women experience ongoing risks of having their reproductive healthcare rights violated. This ever-increasing population also has limited access to sexual and reproductive health services. We conducted a scoping review to identify the barriers and facilitating factors when accessing sexual and reproductive health services for this specific population.

METHODS

We searched the grey literature and queried eight bibliographic databases (Embase, Medline, Cinahl, Scopus, Science Direct, Web of Science, Hinari, and Cochrane Library) to extract articles published between January, 2000, and October, 2021. The extracted data were organized in a framework adapted from Peters et al. and then categorized as facilitators or barriers. We followed the Arksey and O'Malley framework and wrote the report according to the PRISMA-Scr recommendations.

RESULTS

The search identified 4,722 records of which forty-two (42) met eligibility criteria and were retained for analysis. Ten (10) groups of factors facilitating and/or limiting access to sexual and reproductive health care emerged from the synthesis of the retained articles. The main barriers were lack of knowledge about services, cultural unacceptability of services, financial inaccessibility, and language barriers between patients and healthcare providers. Facilitators included mobile applications for translation and telehealth consultations, patients having a wide availability of information sources, the availability health promotion representatives, and healthcare providers being trained in cultural sensitivity, communication and person-centered care.

CONCLUSION

Ensuring the sexual and reproductive rights of migrant, internally displaced, asylum-seeking and refugee women requires that policymakers and health authorities develop intervention strategies based on barriers and facilitators identified in this scoping review. Therefore, considering their mental health in future studies would enable a better understanding of the barriers and facilitators of access to sexual and reproductive health services.

Ethnic minority women's experiences of accessing antenatal care in high income European countries: a systematic review

BACKGROUND

Women from ethnic minority backgrounds are at greater risk of adverse maternal outcomes. Antenatal care plays a crucial role in reducing risks of poor outcomes. The aim of this study was to identify, appraise, and synthesise the recent qualitative evidence on ethnic minority women's experiences of accessing antenatal care in high-income European countries, and to develop a novel conceptual framework for access based on women's perspectives.

METHODS

We conducted a comprehensive search of seven electronic databases in addition to manual searches to identify all qualitative studies published between January 2010 and May 2021. Identified articles were screened in two stages against the inclusion criteria with titles and abstracts screened first followed by full-text screening. Included studies were quality appraised using the Critical Appraisal Skills Programme checklist and extracted data were synthesised using a 'best fit' framework, based on an existing theoretical model of health care access.

RESULTS

A total of 30 studies were included in this review. Women's experiences covered two overarching themes: 'provision of antenatal care' and 'women's uptake of antenatal care'. The 'provision of antenatal care' theme included five sub-themes: promotion of antenatal care importance, making contact and getting to antenatal care, costs of antenatal care, interactions with antenatal care providers and models of antenatal care provision. The 'women's uptake of antenatal care' theme included seven sub-themes: delaying initiation of antenatal care, seeking antenatal care, help from others in accessing antenatal care, engaging with antenatal care, previous experiences of interacting with maternity services, ability to communicate, and immigration status. A novel conceptual model was developed from these themes.

CONCLUSION

The findings demonstrated the multifaceted and cyclical nature of initial and ongoing access to antenatal care for ethnic minority women. Structural and organisational factors played a significant role in women's ability to access antenatal care. Participants in majority of the included studies were women newly arrived in the host country, highlighting the need for research to be conducted across different generations of ethnic minority women taking into account the duration of stay in the host country where they accessed antenatal care.

PROTOCOL AND REGISTRATION

The review protocol was registered on PROSPERO (reference number CRD42021238115).

Is there a relation between stillbirth and low levels of vitamin D in the population? A bi-national follow-up study of vitamin D fortification

BACKGROUND

Stillbirth has been associated with low plasma vitamin D. Both Sweden and Finland have a high proportion of low plasma vitamin D levels (< 50 nmol/L). We aimed to assess the odds of stillbirth in relation to changes in national vitamin D fortification.

METHODS

We surveyed all pregnancies in Finland between 1994 and 2021 (n = 1,569,739) and Sweden (n = 2,800,730) with live or stillbirth registered in the Medical Birth Registries. The mean incidences before and after changes in the vitamin D food fortification programs in Finland (2003 and 2009) and Sweden (2018) were compared with cross-tabulation with 95% confidence intervals (CI).

RESULTS

In Finland, the stillbirth rate declined from ~ 4.1/1000 prior to 2003, to 3.4/1000 between 2004 and 2009 (odds ratio [OR] 0.87, 95% CI 0.81-0.93), and to 2.8/1000 after 2010 (OR 0.84, 95% CI 0.78-0.91). In Sweden, the stillbirth rate decreased from 3.9/1000 between 2008 and 2017 to 3.2/1000 after 2018 (OR 0.83, 95% CI 0.78-0.89). When the level of the dose-dependent difference in Finland in a large sample with correct temporal associations decreased, it remained steady in Sweden, and vice versa, indicating that the effect may be due to vitamin D. These are observational findings that may not be causal.

CONCLUSION

Each increment of vitamin D fortification was associated with a 15% drop in stillbirths on a national level. If true, and if fortification reaches the entire population, it may represent a milestone in preventing stillbirths and reducing health inequalities.

Syrian women's experiences of being pregnant and receiving care at antenatal clinics in Sweden for the first time after migration

OBJECTIVE

To describe Syrian women's experiences of being pregnant and receiving care at antenatal clinics for the first time after migration.

METHODS

A phenomenological lifeworld approach was used. Eleven women from Syria enrolled at antenatal clinics, who were experiencing their first pregnancy in Sweden but who may have given birth before in other countries, were interviewed in 2020. The interviews were open and based on one initial question. Data were inductively analysed using a phenomenological method.

RESULTS

The essence of Syrian women's experiences of being pregnant and receiving care at antenatal clinics for the first time after migration was the importance of being met with understanding to create trust to build a sense of confidence. The following four constituents capture the essence of the women's experiences: "It was important to feel welcomed and to be treated like an equal"; "A good relationship with the midwife strengthened self-confidence and trust"; "Good communication despite language difficulties and cultural differences was important"; and "Previous experience of pregnancy and care influenced the experience of the care received".

CONCLUSION

Syrian women's experiences reveal a heterogeneous group with different experiences and background. The study highlights the first visit and emphasises the importance of this visit for future quality of care. It also points out the negative occurrence of the transferring guilt from the midwife to the migrant woman in case of cultural insensitivity and clashing norm systems.

Group antenatal care compared with standard antenatal care for Somali-Swedish women: a historically controlled evaluation of the Hooyo Project

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); 64 women 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 15-30 min 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 ≥35 and 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.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov Registry (NCT03879200).

The silent shot: An analysis of the origin, sustenance and implications of the MMR vaccine - autism rumour in the Somali diaspora in Sweden and beyond

This article traces the origin, sustenance and implications of a persistent rumour that is responsible for low measles mumps and rubella (MMR) vaccination uptake in the Somali diaspora in a number of countries across the globe. The rumour stipulates that the MMR vaccine - the silent shot - causes autism spectrum disorder (ASD). Although the association between MMR and ASD is non-causal, and various public health initiatives have promoted health information campaigns, the rumour continues to circulate in the Somali diaspora in many countries, including Sweden. This paper shows that there are valid reasons for this. The findings from this paper draw on a systematic scoping review and qualitative interview data from Sweden. The results show that the Somali community experiences higher than average rates of ASD compared to the general population. Moreover, ASD does not exist in the Somali language or their home country, is considered a Western disease that only affects Somali children in the diaspora, and is a highly stigmatised disease. Also, the Somali diaspora has had negative experiences with ASD diagnosis and care. The rumour has been sustained by the absence of an answer to their ASD fear and through active diaspora networks on social media. The network that surrounds the rumour has arguably further helped to create an epistemic community for a community whose concerns have been silenced.

Application to promote communication between midwives and Arabic-speaking women at antenatal care: Challenges met by researchers when developing content

INTRODUCTION

Providing good communication is at the core of recent international guidelines for improving women's outcomes at birth. Communication barriers are identified as major obstacles to providing effective and equal care among foreign-born women. There is a need for accurate communication tools in antenatal care. The aim of this study was to describe challenges met by researchers when developing culturally sensitive content in a Swedish-Arabic application for communication support at antenatal care in Sweden.

METHODS

A co-design methodology was used for the development of the application, entailing collaboration between users and researchers in five different phases: users' needs and preferences, development, field testing I, refinement, and field testing II.

RESULTS

Five challenges emerged: evidence-based information, time frame, realistic photographs, norm-critical perspective, and cultural issues. One challenge was to meet the needs of the users and combine it with information following evidence-based obstetric welfare guidelines. It was also challenging to produce short informational videos that could be adjusted for the duration of the visit with the midwife without omitting important information and to produce photographs which can become outdated. It was also a challenge to portray a less clinical environment and to maintain parents' integrity. It was also challenging to produce norm-critical content from the women's perspective.

CONCLUSIONS

When developing content of an application for antenatal care, converting content proposals into a finished product is challenging. Collaboration between a cross-disciplinary research team, midwives and target-language women is essential to ensure that the content is usable and reliable.

Group antenatal care (gANC) for Somali-speaking women in Sweden - a process evaluation

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.

TRIAL REGISTRATION

The study was registered in ClinicalTrials.gov (Identifier: NCT03879200).

Migrant Somali women’s experiences with their first contact with the labor ward prior to admission: A qualitative study

INTRODUCTION

The first contact with the labor ward is a crucial moment in any birth and can be especially challenging when the woman has a migrant background. The aim of the study was to explore migrant Somali women’s experiences with their first contact with the labor ward prior to admission, in Norway.

METHODS

In this qualitative study, data were collected through semi-structured individual interviews and Systematic Text Condensation was the method used to analyze the data. Ten Somali-born women who had given birth in Norway were included.

RESULTS

The migrant Somali women’s first contact with the labor ward prior to admission was challenging, due to one-way communication, poor health literacy, and a fear of interventions or adverse outcomes. To improve care, the migrant Somali women highlighted a need for: 1) flexibility, tailored information and practical guidance before birth; and 2) face-to-face assessment in early labor.

CONCLUSIONS

The findings in this study indicate that the needs of laboring migrant Somali women are not fully met by antenatal or pre-hospital maternity care services. To improve the critical first contact with the labor ward for migrant Somali women, this study suggests that antenatal care services offer practical guidance on whom to contact and what to expect at the hospital in early labor. Face-to-face assessment of maternal and fetal well-being should be the first choice of care for Somali women in early labor who are unfamiliar with the healthcare system after immigration. Interpretation services need strengthening and our findings support a need for increased continuity of care.

Counselling for prenatal anomaly screening to migrant women in the Netherlands: An interview study of primary care midwives’ perceived barriers with client–midwife communication

INTRODUCTION

Large ethnic inequalities exist in the prenatal screening offer, counselling, informed decision-making, and uptake of prenatal anomaly tests. More insight into midwives’ experiences with offering prenatal counselling to migrant women may provide better insight into the origins and consequences of these ethnic inequalities.

METHODS

We conducted interviews with 12 midwives certified as counsellors for prenatal anomaly screening for women they identified as migrants. Interviews were analyzed using thematic analysis.

RESULTS

Midwives reported most difficulties in communicating with women of ‘non-western migrant background’, which include first- and second-generation migrants from Africa, Latin-America, Asia, and Turkey. They experienced barriers in communication related to linguistics, health literacy, sociocultural and religious differences, with midwife stereotyping affecting all three aspects of counselling: health education, decision-making support, and the client–midwife relation. Health education was difficult because of language barriers and low health-literacy of clients, decision-making support was hampered by sociocultural and religious midwife–client differences, and client–midwife relations were under pressure due to sociocultural and religious midwife–client differences and midwife stereotyping.

CONCLUSIONS

Barriers to optimal communication seem to contribute to suboptimal counselling, especially for women of ‘non-western migrant background’. Client–midwife communication thus potentially adds to the ethnic disparities observed in the offer of and informed decision-making about prenatal anomaly screening in the Netherlands. The quality of prenatal counselling for women from all ethnic backgrounds might be improved by addressing linguistic, health literacy, sociocultural and religious barriers in future training and continuing education of prenatal counsellors.

Experiences of accessing maternity care in the UK: Perspectives from Somali migrant women in Leicester

INTRODUCTION

Migrant women born in Somalia often have poorer pregnancy outcomes. Access to care around pregnancy is vital to improve outcomes. The views and experiences of Somali migrant women accessing maternity care in the UK have not been extensively explored. This study therefore explores and describes these with regard to accessing maternity care in the UK, with the hope of gaining a better understanding of perceptions and factors that influence their access to care around pregnancy.

METHODS

A qualitative approach was used to investigate the views and experiences of women born in Somalia who had migrated to Leicester. Data collected were transcribed and analyzed using a constant comparison method. The software package Nvivo 10 was used to organize themes, and verbatim quotes were used to support their interpretation.

RESULTS

Main finings included: 1) positive attitudes of community midwives and availability lead to positive and meaningful experiences; 2) language difficulties and ineffective communication are barriers to effective access; 3) lack of cultural awareness and preconceived ideas by some hospital caregivers makes them unsupportive and insensitive; 4) need for continuity of care and the provision of resources are needed to build important trusting relationships with care providers; and 5) personal, community and religious factors impact access to care.

CONCLUSIONS

The results highlight a number of important potential barriers to accessing care around pregnancy for migrant women born in Somalia and how these could be addressed to improve pregnancy outcomes.

Parents' Perceptions About Future Digital Parental Support-A Phenomenographic Interview Study

Background: Parents use digital sources (such as the internet or online forums and applications) during pregnancy and after childbirth to receive informative support. Research shows that there is further need for innovation development in digital parental support despite informative support available in digital form. Purpose: To explore parents' perceptions of future digital parental support concerning pregnancy and the first 18 months of parenthood. Method: A phenomenographic interview study with an inductive approach including 15 semi-structured interviews was conducted. Results: The analysis process resulted in three descriptive categories: Opportunities for virtual and in-person meetings, Individualized digital parental support, and Professional knowledge and trustworthiness concerning future digital parental support. Conclusion: The results broaden the knowledge about how future digital parental support can be designed to facilitate the functional, interactive, and critical digital health literacy of new and would-be parents. To succeed, healthcare organizations should allow healthcare professionals to assume an active role in developing digital parental support, both as health educators (i.e., providing parents with knowledge) and facilitators (i.e., facilitating parents' use of digital parental support). However, parents perceived that future digital parental support should complement standard care instead of replacing in-person meetings with healthcare professionals.

Strengthening Antenatal Care towards a Salutogenic Approach: A Meta-Ethnography

The aim was to explore how midwives, public health nurses and nurses view caring in antenatal care (ANC) as provided for mothers and fathers/partners. Based on Noblit and Hare (1988), meta-ethnography was used to address meaning by synthesizing knowledge and understanding inductively through selected qualitative studies (n = 16). Four core themes were identified: (1) supporting the parents to awaken to parenthood and creating a firm foundation for early parenting and their new life situation; (2) guiding parents on the path to parenthood and new responsibility; (3) ensuring normality and the bond between baby and parents while protecting life; and (4) promoting the health and wellbeing of the family today and in the future. The overarching theme can be expressed as "helping the woman and her partner prepare for their new life with the child by providing individualized, shared care, firmly grounded and with a view of the future". Caring in antenatal care (ANC) is being totally present, listening and using multidimensional professional competence but also being open-minded to new aspects and knowledge. The health promotion and positive health aspects should be considered an important part of supporting parents and the whole family now and in the future. A more conscious salutogenic approach to ANC would lead to more favorable results and could be a fruitful research topic in the future. There is a need to provide midwives/nurses with enough time to allow them to concentrate on specific needs and support for different kind of families in ANC but also training for midwives to make them more familiar with online and other options.

Social and ethnic disparities in stillbirth and infant death in Denmark, 2005-2016

Ethnic disparity in stillbirth and infant death has been demonstrated in Europe. As the relation between migration and health change over time, this population based register study investigated the recent figures and explored if potential differences could be explained by the well-known educational and income inequalities in stillbirth and infant death using a novel approach. Stillbirth and infant mortality varied considerably according to country of origin, with only immigrants from China, Norway, and Poland having an overall lower risk than Danish women. Women of Pakistani, Turkish, and Somali origin had a particularly high risk of both outcomes. Women from recent high conflict areas displayed a pattern with increased stillbirth risk. An observed excess risks across generations was found, which is disturbing and rule out factors related to language barriers or newness. Differences in educational level and household income explained only part of the observed inequalities. Strengthening of the maternity care system to better understand and meet the needs of immigrant women seems needed to mitigate the disparities.

Swedish and Australian midwives' experiences of providing antenatal care for Somali-born women: A qualitative study

BACKGROUND

Women from Somalia have increased risks of adverse pregnancy outcomes compared with destination country populations, but little is known about midwives' experiences of caring for Somali women in pregnancy, knowledge which might help to improve care and outcomes. This study aimed to explore how midwives in Melbourne and Stockholm experienced caring for Somali women.

METHOD

Eight midwives in Stockholm and ten midwives in Melbourne, all working in antenatal care clinics, were interviewed about caring for Somali women and the interviews were analysed using thematic analysis.

FINDINGS

Both the Swedish and Australian midwives highlighted lack of time and challenges in communication as impacting on their capacity to provide good care; and all wished they had a better understanding of Somali culture. Some differences in midwife attitudes and approaches to care were apparent in the two settings, particularly in how accepting of Somali women the midwives were and the flexibility with which care could be provided in order to meet the needs of the women. The Australian midwives appeared both more accepting and also more flexible.

CONCLUSION

Differences in the culture of care were apparent between midwives in Sweden and Australia, particularly in how flexible care could be in order to meet the needs of migrant women and how accepting and responsive the midwives were. More attention in antenatal care on developing mutual understanding between midwives and Somali women would improve their care, and possibly also their outcomes.

Epidural analgesia for labour pain in nulliparous women in Norway in relation to maternal country of birth and migration related factors

OBJECTIVE

To investigate associations between maternal country of birth and other migration related factors (length of residence, reason for migration, paternal origin) and epidural analgesia for labour pain in nulliparous women in Norway.

DESIGN

Population-based register study including nulliparous migrant women (n = 75,922) and non-migrant women (n = 444,496) with spontaneous or induced labour. Data were retrieved from the Medical Birth Registry and Statistics Norway, 1990-2013. Odds ratios (OR) with 95% confidence intervals (CI) were estimated by logistic regression, and adjusted for maternal age, marital status, maternal education, gross income, birth year, hospital size and health region.

MAIN OUTCOME

Epidural analgesia for labour pain.

RESULTS

Epidural analgesia was administered to 38% of migrant women and 31% of non-migrant women. Compared with non-migrants, the odds of having epidural analgesia were lowest in women from Vietnam (adjOR 0.54; CI 0.50-0.59) and Somalia (adjOR 0.63; CI 0.58-0.68) and highest in women from Iran (adjOR 1.32; CI 1.19-1.46) and India (adjOR 1.19; CI 1.06-1.33). Refugees (adjOR 0.83; CI 0.79-0.87) and newly arrived migrants (adjOR 0.92; CI 0.89-0.94) had lower odds of epidural analgesia. Migrant women with a non-migrant partner (adjOR 1.14; CI 1.11-1.17) and those with length of residence ≥10 years (adjOR 1.06; CI 1.02-1.10) had higher odds.

CONCLUSION

The use of epidural analgesia varied by maternal country of birth, reason for migration, paternal origin and length of residence. Midwives and obstetricians should pay extra attention to the provision of adequate information about pain relief options for refugees and newly arrived migrants, who had the lowest use.

Community-based doula support for migrant women during labour and birth: study protocol for a randomised controlled trial in Stockholm, Sweden (NCT03461640)

INTRODUCTION

Migrant women consistently rate their care during labour and birth more negatively than non-migrant women, due to communication difficulties, lack of familiarity with how care is provided, and discrimination and prejudicial staff attitudes. They also report being left alone, feeling fearful, unsafe and unsupported, and have poorer birth outcomes than non-migrant women. Community-based doulas (CBDs) are bilingual women from migrant communities who are trained in childbirth and labour support, and who facilitate communication between woman-partner-staff during childbirth. This study protocol describes the design, rationale and methods of a randomised controlled trial that aims to evaluate the effectiveness of CBD support for improving the intrapartum care experiences and postnatal well-being of migrant women giving birth in Sweden.

METHODS AND ANALYSIS

A randomised controlled trial. From six antenatal care clinics in Stockholm, Sweden, we aim to recruit 200 pregnant Somali, Arabic, Polish, Russian and Tigrinya-speaking women who cannot communicate fluently in Swedish, are 18 years or older and with no contraindications for vaginal birth. In addition to standard labour support, women are randomised to CBD support (n=100) or no such support during labour (n=100). Trained CBDs meet with women once or twice before the birth, provide emotional, physical and communication support to women throughout labour and birth in hospital, and then meet with women once or twice after the birth. Women's ratings of the intrapartum care experiences and postnatal well-being are assessed at 6-8 weeks after the birth using selected questions from the Migrant Friendly Maternity Care Questionnaire and by the Edinburgh Postnatal Depression Scale. The intervention group will be compared with the control group using intention-to-treat analyses. ORs and 95% CIs will be estimated and adjustments made if key participant characteristics differ between trial arms.

ETHICS AND DISSEMINATION

The study was approved by the Regional Ethical Review Board in Stockholm (approval number: 2018/12 - 31/2).

TRIAL REGISTRATION NUMBER

NCT03461640; Pre-results.

Somali women's experiences of antenatal care: A qualitative interview study

OBJECTIVE

To explore Somali women's experiences of antenatal care in Norway.

DESIGN

A qualitative study based on individual semi-structured interviews conducted either face-to-face or over the phone.

SETTING

Norway.

PARTICIPANTS

Eight Somali-born women living in Norway.

KEY FINDINGS

Four themes were generated from the analysis. From their experiences of antenatal care in Norway, the Somali women described: 1) when care was provided in a way that gained their trust, they made better use of the available health services, 2) the importance of continuity of care and of sharing commonalities with the caregiver, 3) a need for accessible information, specifically tailored to the needs of Somali women and 4) how culturally insensitive caregivers had a negative impact on the quality of care.

CONCLUSION AND IMPLICATIONS FOR PRACTICE

The Somali women in this study were grateful for the care provided, although the quality of antenatal care did not always meet their needs. This study should serve as a reminder of the importance of establishing trust between the pregnant woman and the caregiver, strengthening interpretation services and assuring tailored information is available to Somali women at an early stage. The findings further suggest that antenatal care for Somali women may be improved by offering continuity of care and improving clinical and cultural skills in clinicians. Suggestions for practice, and future research, include initiating group antenatal care especially tailored to Somali women.

Rationale, development and feasibility of group antenatal care for immigrant women in Sweden: a study protocol for the Hooyo Project

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.