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Somalis in Sweden

Sweden is one of the most affluent nations in Western Europe with a sophisticated system of health care; Somalia one of the poorest nations in sub-Saharan Africa with an undeveloped system of health care. Why is that, despite this sophisticated system of health care, perinatal mortality should be higher in Somali immigrants in Sweden than in native-born Swedish women, even after adjustment for social and obstetric risk factors? Birgitta Essen and her colleagues (pages 1507-15 12) explored this phenomenon, by conducting qualitative research in fifteen Somali women, many of whom had experienced childbirth in both Somalia and Sweden. The women were similar as regards culture and religion, but different as regards age, parity and social background; thus the results of this qualitative research can be generalized to any group of Somali immigrants in a similar setting. The success of this study depended on the trust between the researchers and the Somali women; this was achieved by the relationship which one of the authors, an anthropologist, had already developed in Somali groups living in Sweden. She conducted detailed interviews in the fifteen women, with the help of an interpreter so that no woman was excluded and ambiguities could be resolved immediately. The interviews were semi-structured with open-ended questions. The transcripts were analysed independently by the two principal investigators who identified four themes: the experience of pregnancy and childbirth in Somalia and in Sweden; nutrition; social network; and female genital mutilation. Although the Somali women thought well of their antenatal care and their care in labour, their knowledge of the medical aspects of this care was scanty; in particular few women could remember receiving any advice about pain relief in labour. The most startling finding, however, was that many Somali women deliberately reduced their intake of food during pregnancy in order to have a smaller baby and so reduce their risk of a caesarean section. This strategy is understandable in Somalia, where maternal mortality is high and obstructed labour is common, and where caesarean section itself carries a high risk of maternal death; these beliefs were carried over to Sweden. The women took a more fatalistic view of infant mortality, being a predetermined act of God. They were less concerned about female genital mutilation causing obstructed labour than about a large baby causing obstructed labour. The authors conclude that the relationship between the nutritional habits of Somali women in Sweden, the birthweight of their infants and perinatal mortality should be further explored by quantitative research. The results of this study are humbling to obstetricians, for it suggests that the Somali women were little interested in our concepts of good antenatal care. We are educated in a tradition of physical medicine, the diagnosis and treatment of disease. Because pathology in pregnancy in Western countries is now rare, obstetricians’ perceptions of antenatal care and care in labour has become subsumed into a vast array of screening tests of greater or lesser reliability in order to predict rare adverse outcomes. But pregnant women’s perceptions of antenatal care may differ from our own; the experience of the Somali women is an extreme example of how much these perceptions may differ. Of course it is important as far as possible to avoid adverse outcomes in pregnancy, but the content of antenatal care should also take into account women’s perceptions of their antenatal care, determined by qualitative research. Qualitative methods of determining the content of antenatal care should be used not just in well-defined groups of women, but in all populations, and in all societies.