Birgitta Essén | Uppsala University (original) (raw)

Papers by Birgitta Essén

Shifting norms and conventions: Female genital cutting and the applicability of social convention... more Shifting norms and conventions: Female genital cutting and the applicability of social convention theory in a migration context

International journal of gynaecology and obstetrics, Jan 15, 2016

The effects of previous cesarean deliveries on severe maternal and adverse perinatal outcomes at ... more The effects of previous cesarean deliveries on severe maternal and adverse perinatal outcomes at a university hospital in Tanzania.

International journal of gynaecology and obstetrics, Oct 1, 2012

Reproductive Biomedicine & Society Online, Jun 1, 2019

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

PLOS ONE, Dec 4, 2019

Background The aim of this paper was to investigate correlations between Somali Swedish own attit... more Background The aim of this paper was to investigate correlations between Somali Swedish own attitudes towards female genital cutting (FGC) and their perceptions about other Swedish Somalis attitudes. Methods In 2015, a cross-sectional study was conducted in four Swedish municipalities with 648 Somali men and women. To assess the level of agreement between the participants' approval of FGC and their perceptions about approval among other Swedish Somalis, Bangdiwala's B-statistic and Welch's t-test were used. Results We found a substantial agreement between an individual's own approval of FGC and their perceived approval of FGC among most other Swedish Somali men (B-statistic = 0.85) and women (B-statistic = 0.76). However, we also found a tendency for participants to report that other Swedish Somalis-and especially other Swedish Somali women-approved of FGC, while they themselves did not. Perceived percentage of Somali girls being circumcised in Sweden was significantly higher among Swedish Somalis who said they wanted tissue to be removed on their own daughter (mean 23%, 95% CI: 18.3-27.9) compared to those who said they opposed removal of tissue on their own daughter (mean 8%, 95% CI: 6.4-9.1). The majority of Swedish Somali men (92%) stated a preference to marry someone without FGC or with pricking, which was also the view of most of the Swedish Somali women (90%). Conclusions Swedish Somalis motivation to continue or discontinue with the practice of FGC may be influenced by perceptions of what other Swedish Somalis prefer. How FGC is being portrayed, in for example media reports, could therefore have an impact on attitudes towards FGC.

Introduction. Substandard intrapartum care contributes to maternal and perinatal morbidity in low... more Introduction. Substandard intrapartum care contributes to maternal and perinatal morbidity in low-resource settings. The aim was to estimate the impact of a criteria-based audit (CBA) of obstructed ...

Sexual & Reproductive Healthcare, 2020

Background: Use of vacuum extraction (VE) has been declining in low and middle income countries. ... more Background: Use of vacuum extraction (VE) has been declining in low and middle income countries. At the highest referral hospital Tanzania, 54% of deliveries are performed by caesarean section (CS) and only 0.8% by VE. Use of VE has the potential to reduce CS rates and improve maternal and neonatal outcomes but causes for its low use is not fully explored. Method: During November and December of 2017 participatory observations, semi-structured in-depth interviews (n = 29) and focus group discussions (n = 2) were held with midwives, residents and specialists working at the highest referral hospital in Tanzania. Thematic analysis was used to identify rationales for low VE use. Findings: Unstructured and inconsistent clinical teaching structure, interdependent on a fear and blame culture, as well as financial incentives and a lack of structured, adhered to and updated guidelines were identified as rationales for CS instead of VE use. Although all informants showed positivity towards clinical teaching of VE, a subpar communication between clinics and academia was stated as resulting in absent clinical teachers and unaccountable students. Conclusion: This study draws connections between the low use of VE and the inconsistent and unstructured clinical training of VE expressed through the health care providers' points of view. However, clinical teaching in VE was highly welcomed by the informers which may serve as a good starting point for future interventions. Background Prolonged and obstructed labour is one of the five major causes of maternal mortality in most low income countries [1] and is a risk factor for postpartum haemorrhage, chorioamnionitis, uterine rupture, obstetric fistula, perineal injury, birth asphyxia and overall neonatal morbidity [2-4]. In Tanzania, prolonged labour is present in a majority of perinatal deaths [2,5,6] and 9% of all maternal deaths are caused by complications of prolonged and obstructed labour [7], which can be prevented by timely diagnosis and relief by either caesarean section (CS) or assisted vaginal delivery including vacuum extraction (VE). Foetal distress, dystocia and maternal factors such as exhaustion, illhealth or medical conditions that call for measures to prevent of cardiorespiratory hyper function such as heart failure, respiratory distress or severe anaemia are included among the major indications for the use of VE [8-11]. VE, also referred to as "ventouse", is an evidence-based technique of assisted vaginal delivery aimed at shortening the length of the second stage of labour [8]. At Muhimbili National Hospital (MNH) in Dar es Salaam, the Malmström design is the most common method of VE. This consists of a metal cup connected to a vacuum pump which adheres the cup to the foetal head such that when traction is applied, the head is flexed and delivery is assisted by traction during the second stage of labour. However, the Malmström design is not the recommended design by the World Health Organization standards. High rates of CS at MNH [12] have been strongly associated with

International Journal of Gynecology & Obstetrics, 2018

Criteria-based audit and the Robson classification were useful tools for monitoring and optimizin... more Criteria-based audit and the Robson classification were useful tools for monitoring and optimizing the uptake of cesarean delivery in a low-resource setting.

Culture, Health & Sexuality, 2018

In every society where non-therapeutic female circumcision (FC) occurs, so too does non-therapeut... more In every society where non-therapeutic female circumcision (FC) occurs, so too does non-therapeutic male circumcision (MC). In the past few decades, the norm in Euro-American societies has been to distinguish between the practices: FC is banned, while MC is condoned or encouraged. We explored Somalis' post-migration perceptions of FC and MC, while considering that they once lived in a society where both practices were widely accepted and now live in a society where there is a legal ban on FC alongside acceptance of MC. Eighteen individual interviews and seven focus group discussions were conducted with Somali men and women in three Swedish cities. There seemed to be a continuity of values across male and female forms of genital cutting concerning being a good Muslim, not inflicting harm and upholding respectability. Following migration, however, a renegotiation of how these values relate to MC and FC resulted in a conceptual split between the two: MC was perceived as an unquestionably required practice, but FC was viewed as a practice that can be adapted or abandoned. In a new cultural context after migration, perceptions of ideal male and female genitals, and what kinds of inscriptions on the body are desired, seem to have changed.

BMC Pregnancy and Childbirth, 2017

Background: Women from low-income settings have higher risk of maternal near miss (MNM) and subop... more Background: Women from low-income settings have higher risk of maternal near miss (MNM) and suboptimal care than natives in high-income countries. Iran is the second largest host country for Afghan refugees in the world. Our aim was to investigate whether care quality for MNM differed between Iranians and Afghans and identify potential preventable attributes of MNM. Methods: An MNM audit study was conducted from 2012 to 2014 at three university hospitals in Tehran. Auditors evaluated the quality of care by reviewing the hospital records of 76 MNM cases (54 Iranians, 22 Afghans) and considering additional input from interviews with patients and professionals. Main outcomes were frequency of suboptimal care and the preventable attributes of MNM. Crude and adjusted odds ratios with confidence intervals for the independent predictors were examined. Results: Afghan MNM faced suboptimal care more frequently than Iranians after adjusting for educational level, family income, and insurance status. Above two-thirds (71%, 54/76) of MNM cases were potentially avoidable. Preventable factors were mostly provider-related (85%, 46/54), but patient-(31%, 17/54) and health systemrelated factors (26%, 14/54) were also important. Delayed recognition, misdiagnosis, inappropriate care plan, delays in care-seeking, and costly care services were the main potentially preventable attributes of MNM. Conclusions: Afghan mothers faced inequality in obstetric care. Suboptimal care was provided in a majority of preventable near-miss events. Improving obstetric practice and targeting migrants' specific needs during pregnancy may avert near-miss outcomes.

International Journal for Equity in Health, 2017

Background: Providing equitable maternal care to migrants is a seriously challenging task for hos... more Background: Providing equitable maternal care to migrants is a seriously challenging task for hosting countries. Iran, the second-most accessed country for refugees from Afghanistan, has achieved maternal health improvement. However, Afghan women with near-miss morbidity faced pre-hospital delays and disparity in maternal care at hospitals. This study explores experiences of maternal care among Afghan women surviving near-miss morbidity to increase insight into healthcare improvements for migrants. Methods: A qualitative study was conducted at university hospitals in Tehran, from April 2013 to May 2014. A total of 11 Afghan women and 4 husbands were interviewed when women recovered from near-miss morbidity that occurred around the childbirth period. Mothers were identified prospectively using the WHO maternal near-miss approach. Thematic analysis was used along with a data-driven approach to organize data guided by the 'three delays model' theoretical framework. Results: Mistreatment in the form of discrimination and insufficient medical attention were key experiences. Participants commonly perceived poor women-professional communication and delays in recognizing obstetric complications despite repeated care-seeking. Financial constraints, costly care, lack of health insurance, and low literacy were experienced barriers to accessing care to a lesser extent. Non-somatic consequences of near-miss morbidity affected mothers and families for extended periods. Conclusions: Near-miss survivors' experiences provided remarkable insights into maternal care of Afghans in Iran. The challenge for the health system and professionals is to provide equitable care with dignity and improve communication skills with caring attitudes toward ethnic minorities. Antenatal visits provide the best and most appropriate opportunities to tackle health illiteracy in Afghan women.

Reproductive health, Jan 8, 2017

Pricking, classified as female genital cutting (FGC) type IV by the World Health Organization, is... more Pricking, classified as female genital cutting (FGC) type IV by the World Health Organization, is an under-researched area gaining momentum among diaspora communities. Our aim was to explore factors associated with being supportive of pricking among Somalis in Sweden. In a cross-sectional design, attitudes and knowledge regarding FGC, and measures of socioeconomic status, acculturation, and social capital, were assessed by a 49-item questionnaire in four municipalities in Sweden. Data were collected in 2015 from 648 Somali men and women, ≥ 18 years old, of which 113 supported the continuation of pricking. Logistic regression was used for the analysis. Those more likely to support the continuation of pricking were older, originally from rural areas, and newly arrived in Sweden. Further, those who reported that they thought pricking was: acceptable, according to their religion (aOR: 10.59, 95% CI: 5.44-20.62); not a violation of children's rights (aOR: 2.86, 95% CI: 1.46-5.61); an...

BMC pregnancy and childbirth, Nov 8, 2016

In Tanzania, substandard intrapartum management of foetal distress contributes to a third of peri... more In Tanzania, substandard intrapartum management of foetal distress contributes to a third of perinatal deaths, and the majority are term deliveries. We conducted a criteria-based audit with feedback to determine whether standards of diagnosis and management of foetal distress would be improved in a low-resource setting. During 2013-2015, a criteria-based audit was performed at the national referral hospital in Dar es Salaam. Case files of deliveries with a diagnosis of foetal distress were identified and audited. Two registered nurses under supervision of a nurse midwife, a specialist obstetrician and a consultant obstetrician, reviewed the case files. Criteria for standard diagnosis and management of foetal distress were developed based on international and national guidelines, and literature reviews, and then, stepwise applied, in an audit cycle. During the baseline audit, substandard care was identified, and recommendations for improvement of care were proposed and implemented. T...

PloS one, 2016

In low-resource settings, obstructed labour is strongly associated with severe maternal morbidity... more In low-resource settings, obstructed labour is strongly associated with severe maternal morbidity and intrapartum asphyxia, and consequently maternal and perinatal deaths. This study evaluated the impact of a criteria-based audit of the diagnosis and management of obstructed labour in a low-resource setting. A baseline criteria-based audit was conducted from October 2013 to March 2014, followed by a workshop in which stakeholders gave feedback on interventions agreed upon to improve obstetric care. The implemented interventions included but were not limited to introducing standard guidelines for diagnosis and management of obstructed labour, agreeing on mandatory review by specialist for cases that are assigned caesarean section, re-training and supervision on use and interpretation of partograph and, strengthening team work between doctors, mid-wives and theatre staff. After implementing these interventions in March, a re-audit was performed from July 2015 to November, 2015, and th...

European Journal of Social Work, 2016

There are few studies on how social workers deal with cases regarding transnational surrogacy. Ou... more There are few studies on how social workers deal with cases regarding transnational surrogacy. Our study intends to contribute to filling this gap. In Sweden, surrogacy as an assisted reproductive technology method is not permitted. As a result, many prospective parents have turned abroad, mainly to India, for surrogacy. There are no laws regulating surrogacy in Sweden, and difficulties have arisen in establishing legal parenthood when the parents return with the child. This qualitative interview study with social workers found that legal uncertainty and ethical issues surrounded their handling. With no guidelines, the constructions of parenthood will continue to depend on individual social workers' conflicting views on how to best meet the surrogate mother's interest and the best interest of the child. Regulation is thus needed to better protect those involved and minimize the contingent aspects of legal handling by individual officials.

International Journal of Gynecology & Obstetrics, 2016

Violence against women, Jan 8, 2016

Violence against women is an increasing public health concern, with assault leading to death as t... more Violence against women is an increasing public health concern, with assault leading to death as the most extreme outcome. Previous findings indicate that foreign-born women living in Sweden are more exposed to interpersonal violence than Swedish-born women. The current study investigates mortality due to interpersonal violence in comparison with other external causes of death among women of reproductive age in Sweden, with focus on country of birth. Foreign-born women and especially those from countries with low and very low gender equity levels had increased risk of mortality due to interpersonal violence, thus implicating lack of empowerment as a contributing factor.

Social Science & Medicine, 2015

In recent decades, there has been growing attention to the overuse of caesarean section (CS) glob... more In recent decades, there has been growing attention to the overuse of caesarean section (CS) globally. In light of a high CS rate at a university hospital in Tanzania, we aimed to explore obstetric caregivers' rationales for their hospital's CS rate to identify factors that might cause CS overuse. After participant observations, we performed 22 semi-structured individual in-depth interviews and 2 focus group discussions with 5e6 caregivers in each. Respondents were consultants, specialists, residents, and midwives. The study relied on a framework of naturalistic inquiry and we analyzed data using thematic analysis. As a conceptual framework, we situated our findings in the discussion of how transparency and auditing can induce behavioral change and have unintended effects. Caregivers had divergent opinions on whether the hospital's CS rate was a problem or not, but most thought that there was an overuse of CS. All caregivers rationalized the high CS rate by referring to circumstances outside their control. In private practice, some stated they were affected by the economic compensation for CS, while others argued that unnecessary CSs were due to maternal demand. Residents often missed support from their senior colleagues when making decisions, and felt that midwives pushed them to perform CSs. Many caregivers stated that their fear of blame from colleagues and management in case of poor outcomes made them advocate for, or perform, CSs on doubtful indications. In order to lower CS rates, caregivers must acknowledge their roles as decision-makers, and strive to minimize unnecessary CSs. Although auditing and transparency are important to improve patient safety, they must be used with sensitivity regarding any unintended or counterproductive effects they might have.

International journal of gynaecology and obstetrics, Jan 15, 2016

International journal of gynaecology and obstetrics, Oct 1, 2012

Reproductive Biomedicine & Society Online, Jun 1, 2019

PLOS ONE, Dec 4, 2019

Sexual & Reproductive Healthcare, 2020

International Journal of Gynecology & Obstetrics, 2018

Culture, Health & Sexuality, 2018

BMC Pregnancy and Childbirth, 2017

International Journal for Equity in Health, 2017

Reproductive health, Jan 8, 2017

BMC pregnancy and childbirth, Nov 8, 2016

PloS one, 2016

European Journal of Social Work, 2016

International Journal of Gynecology & Obstetrics, 2016

Violence against women, Jan 8, 2016

Social Science & Medicine, 2015

Paper presented at the conference "Advancing Knowledge on Psycho-Sexual Effects of FGM/C: Assessi... more Paper presented at the conference "Advancing Knowledge on Psycho-Sexual Effects of FGM/C: Assessing the Evidence", Alexandria, Egypt. 10-12 October, 2004.

In discussions about sexuality in relation to circumcision, one often finds a kind of lip service... more In discussions about sexuality in relation to circumcision, one often finds a kind of lip service, where it is declared that sexuality is multifaceted and relies on all kinds of psychological and social dimensions. Yet few authors discuss, in depth, the implications of a sexual-pleasure research approach that moves beyond the state of the genitalia. We would like to discuss exactly this: Sexual pleasure cannot be reduced to a question of genital tissue – sexuality is a more complex phenomenon than that. It is obvious that current quantitative approaches to investigating sexuality after FGC are inadequate. Generally speaking, they place too much weight on that which has been done to a woman’s genital tissue. We call such assumptions the fallacy of genital determinism (Johnsdotter 2013).
Western understandings of sex rely heavily on ideas emanating from researchers that created the model of the Human Sexual Response Cycle (Masters and Johnson 1966), which has been criticized for its simplistic focus on genitals (and not on people). Physiological aspects are thus over-emphasized at the expense of psychological, social and cultural aspects of importance for outcome.
Sexual scripting theory, introduced by sociologists in the 1970s (e.g. Gagnon and Simon 1973), highlights the cultural and social dimensions of lived sexuality, demonstrates how sexuality is embedded in social and cultural contexts and how people learn how to enact their sexuality. In addition, anthropological research on sensations (e.g. Hinton et al. 2008) suggests that culturally based learning also takes place when it comes to how we perceive bodily sensations, whether we notice bodily signals or not, and how we interpret and give meaning to sensations. Based on these findings, we will discuss possible implications of current campaigning for immigrant women and girls, who have to deal with these public expectations about erased possibilities to feel sexual pleasure after genital cutting.
In summary, we suggest that research, preventive work and rehabilitation care better take into consideration that sexuality is a complex phenomenon, and we stress the need to avoid reductionist one-track approaches that may be more harmful than helpful.

References
Gagnon, J.H. and Simon, W. (1973). Sexual conduct. The social sources of human sexuality. London: Aldine.
Hinton, D. E., Howes, D. & Kirmayer, L.J. (2008). “Toward a medical anthropology of sensations: Definitions and research agenda.” Transcultural Psychiatry, 45(2),142–162.
Johnsdotter, S. (2013). “Discourses on sexual pleasure after genital modifications: The fallacy of genital determinism (a response to J. Steven Svoboda).” Global Discourse, DOI 10.1080/23269995.2013.805530 (e-pub ahead of print).
Masters, W. H. and Johnson, V. E. (1966). Human sexual response. Boston: Little, Brown.

Iranians are one of Finland's major immigrant groups. Eike other asylum seekers in Finland, the I... more Iranians are one of Finland's major immigrant groups. Eike 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. For centuries, Lutheran Christianity had a strong impact on Finnish culture, life and customs.1 It has been said that, during the 1700s and 1800s, sexual pleasure and intercourse outside marriage were perceived as sinful; sexual morality was absolute, with the requirement of monogamy and no extramarital relationships, and the Church represented the main educator in the sexual life of the Finnish population. Conditions changed radically in more recent times and a 1951 study argued that by the eve of the First World War a hedonistic view of sexuality and relative sexual morality had developed.2 However, it has been reported that the first generation copper-related IUD were introduced in Finland in 1972 and

Background Studies evaluating acceptability of simplified follow-up after medical abortion have f... more Background Studies evaluating acceptability of simplified follow-up after medical abortion have focused on high-resource or urban settings where telephones, road connections, and modes of transport are available and where women have formal education. Conclusion Home-assessment is highly acceptable among women in low-resource, and rural, settings. The choice to follow-up an early medical abortion according to women's preference should be offered to foster women's reproductive autonomy.

Background: Post-abortion contraceptive use in India is low and the use of modern methods of cont... more Background: Post-abortion contraceptive use in India is low and the use of modern methods of contraception is rare, especially in rural areas. This study primarily compares contraceptive use among women whose abortion outcome was assessed in-clinic with women who assessed their abortion outcome at home, in a low-resource, primary health care setting. Moreover, it investigates how background characteristics and abortion service provision influences contraceptive use post-abortion. Methods: A randomized controlled, non-inferiority, trial (RCT) compared clinic follow-up with home-assessment of abortion outcome at 2 weeks post-abortion. Additionally, contraceptive-use at 3 months post-abortion was investigated through a cross-sectional follow-up interview with a largely urban sub-sample of women from the RCT. Women seeking abortion with a gestational age of up to 9 weeks and who agreed to a 2-week follow-up were included (n = 731). Women with known contraindications to medical abortions, Hb < 85 mg/l and aged below 18 were excluded. Data were collected between April 2013 and August 2014 in six primary health-care clinics in Rajasthan. A computerised random number generator created the randomisation sequence (1:1) in blocks of six. Contraceptive use was measured at 2 weeks among women successfully followed-up (n = 623) and 3 months in the subset of women who were included if they were recruited at one of the urban study sites, owned a phone and agreed to a 3-month follow-up (n = 114). Results: There were no differences between contraceptive use and continuation between study groups at 3 months (76 % clinic follow-up, 77 % home-assessment), however women in the clinic follow-up group were most likely to adopt a contraceptive method at 2 weeks (62 ± 12 %), while women in the home-assessment group were most likely to adopt a method after next menstruation (60 ± 13 %). Fifty-two per cent of women who initiated a method at 2 weeks chose the 3-month injection or the copper intrauterine device. Only 4 % of women preferred sterilization. Caste, educational attainment, or type of residence did not influence contraceptive use.

The societal changes in India and the available variety of reproductive health services call for ... more The societal changes in India and the available variety of reproductive health services call for evidence to inform health systems how to satisfy young women's reproductive health needs. Inspired by Foucault's power idiom and Bandura's agency framework, we explore young women's opportunities to practice reproductive agency in the context of collective social expectations. We carried out in-depth interviews with 19 young women in rural Rajasthan. Our findings highlight how changes in notions of agency across generations enable young women's reproductive intentions and desires, and call for effective means of reproductive control. However, the taboo around sex without the intention to reproduce made contraceptive use unfeasible. Instead, abortions were the preferred method for reproductive control. In conclusion, safe abortion is key, along with the need to address the taboo around sex to enable use of "modern" contraception. This approach could prevent unintended pregnancies and expand young women's agency.

Iraqi refugees face considerable challenges when migrating to countries where individual freedom ... more Iraqi refugees face considerable challenges when migrating to countries where individual freedom has greater priority than the group-oriented honor culture. In-depth qualitative interviews were conducted with Iraqi male and female refugees residing in Sweden regarding honor, current well-being, and experiences of intimate partner violence. Feelings of psychological distress and worry about the future were frequently expressed. Men feared loss of status and unemployment, whereas women had more positive expectations regarding increased autonomy. Upholding honor norms and power shifts within the relationship could potentially lead to family conflicts and/or violence, with increased risk for adverse mental and somatic health consequences.

Background: Violence against women is associated with serious health problems, including adverse ... more 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.

Palabras clave Circuncisió n femenina/efectos adversos; Complicaciones del trabajo de parto/etiol... more Palabras clave Circuncisió n femenina/efectos adversos; Complicaciones del trabajo de parto/etiología;Mortalidad infantil; Transeú ntes y migrantes; Estudios de cohortes; Á frica Oriental; Suecia (fuente: DeCS, BIREME).

How to deal with female circumcision as a health issue in the Nordic countries.

This article intends to present the Scandinavian legislation on female genital mutilation and exp... more This article intends to present the Scandinavian legislation on female genital mutilation and explore the implications of the laws. Juxtaposing trends of plastic genital surgery in the West with claims that female circumcision may be a practice generally abandoned in Scandinavia, we highlight the double morality inherent in current public discussions. Finally, we pose the question: Is the legal principle of equality before the law regarded when it comes to alterations of the female genitals?

Background: Pricking, classified as female genital cutting (FGC) type IV by the World Health Orga... more Background: Pricking, classified as female genital cutting (FGC) type IV by the World Health Organization, is an under-researched area gaining momentum among diaspora communities. Our aim was to explore factors associated with being supportive of pricking among Somalis in Sweden. Methods: In a cross-sectional design, attitudes and knowledge regarding FGC, and measures of socioeconomic status, acculturation, and social capital, were assessed by a 49-item questionnaire in four municipalities in Sweden. Data were collected in 2015 from 648 Somali men and women, ≥ 18 years old, of which 113 supported the continuation of pricking. Logistic regression was used for the analysis. Results: Those more likely to support the continuation of pricking were older, originally from rural areas, and newly arrived in Sweden. Further, those who reported that they thought pricking was: acceptable, according to their religion (aOR: 10.59, 95% CI: 5.44-20.62); not a violation of children's rights (aOR: 2.86, 95% CI: 1.46-5.61); and did not cause long-term health complications (aOR: 5.52, 95% CI: 2.25-13.52) had higher odds of supporting pricking. Religion was strongly associated with the support of pricking among both genders. However, for men, children's rights and the definition of pricking as FGC or not were important aspects in how they viewed pricking, while, for women, health complications and respectability were important. Conclusions: Values known to be associated with FGC in general are also related to pricking. Hence, there seems to be a change in what types of FGC are supported rather than in their perceived values.

A meta-synthesis of the birth experiences of african immigrant women affected by female genital c... more A meta-synthesis of the birth experiences of african immigrant women affected by female genital cutting.

The abortion discourse in Sweden is marked by historically liberal ideals about women's inviolabl... more 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, Catholic, 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.

Background: Migration from Thailand to Sweden has increased threefold over the last 10 years. Tod... more Background: Migration from Thailand to Sweden has increased threefold over the last 10 years. Today Thailand is one of the most common countries of origin among immigrants in Sweden. Since the year 2000, new HIV cases are also more prevalent among Thai immigrants compared to other immigrant nationalities in Sweden. The purpose of this study was to investigate the association between knowledge and utilization of sexual and reproductive healthcare services, contraceptive knowledge and socio-demographic characteristics and social capital among Thai immigrant women in Sweden. Methods: This is a cross-sectional study using a postal questionnaire to all Thai women (18-64) in two Swedish regions, who immigrated to the country between 2006 and 2011. The questionnaire was answered by 804 women (response rate 62.3 %). Bivariate and multivariate logistic regression analyses were used. Results: The majority (52.1 %) of Thai women had poor knowledge of where they should turn when they need sexual and reproductive healthcare services. After controlling for potential confounders, living without a partner (OR = 2.02, CI: 1.16-3.54), having low trust in others (OR = 1.61, CI: 1.10-2.35), having predominantly bonding social capital (OR = 1.50, CI: 1.02-2.23) and belonging to the oldest age group (OR = 2.65, CI: 1.32-5.29) were identified as risk factors for having poor knowledge. The majority (56.7 %) had never been in contact with healthcare services to get advice on contraception, and about 75 % had never been HIV/STI tested in Sweden. Low utilization of healthcare was associated with poor knowledge about healthcare services (OR = 6.07, CI: 3.94-9.34) and living without a partner (OR = 2.53, CI: 1.30-4.90). Most Thai women had knowledge of how to prevent an unwanted pregnancy (91.6 %) and infection with HIV/STI (91.1 %). Conclusions: The findings indicate that social capital factors such as high trust in others and predominantly bridging social capital promote access to knowledge about healthcare services. However, only one-fourth of the women had been HIV/STI tested, and due to the HIV prevalence among Thai immigrants in Sweden, policy makers and health professionals need to include Thai immigrants in planning health promotion efforts and healthcare interventions.

Poor sexual and reproductive health (SRH) among immigrant women is often related to limited acces... more Poor sexual and reproductive health (SRH) among immigrant women is often related to limited access, or suboptimal use of healthcare services. This study investigates the knowledge about and use of sexual and reproductive healthcare services among immigrant women in Sweden. Method: A cross-sectional study of 288 immigrant women. A structured questionnaire was distributed among immigrants speaking Arabic, Dari, Somali or English registered at Swedish language schools for immigrants. Data collection took place in 19 strategically selected schools in Sweden. Descriptive statistics, chi-square tests, and logistic regressions were used for the analysis. Results: About one-third of the immigrant women reported lack of knowledge of where to go for contraceptive counselling. Experiencing lack of emotional social support and not having had children was associated with this lack of knowledge. An even higher proportion (56%) lacked knowledge of where to go to be HIV tested, and this was associated with not having participated in a health examination. Almost 25% stated that their culture kept them back from using contraception. Conclusion: Lack of knowledge of where to turn for contraceptive counselling and HIV testing among immigrant women participating in Swedish language schools for immigrants could be considered as a missed opportunity, as all citizens in Sweden have free access to these services. New health policies and strategies should aim to increase knowledge of SRH services among immigrants. Swedish language schools could play an important role in increasing knowledge of SRH-related information as many new immigrants become students during their first years in Sweden.

Objective: in light of the rising caesarean section rates in many developing countries, we sought... more Objective: in light of the rising caesarean section rates in many developing countries, we sought to explore women's and caregivers' experiences, perceptions, attitudes, and beliefs in relation to caesarean section. Design: qualitative study using semi-structured individual in-depth interviews, focus group discussions, and participant observations. The study relied on a framework of naturalistic inquiry and data were analysed using thematic analysis. Setting: a public university hospital in Dar es Salaam, Tanzania. Participants: we conducted a total of 29 individual interviews, 13 with women and 16 with caregivers, and two focus group discussions comprising five to six caregivers each. Women had undergone a caesarean section within two months preceding the interview and were interviewed in their homes. Caregivers were consultants, specialists, residents, and midwives. Findings: both women and caregivers preferred vaginal birth, but caregivers also had a favourable attitude towards caesarean section. While caregivers emphasised their efforts to counsel women on caesarean section, women had often reacted with fear and shock to the caesarean section decision and perceived that there was a lack of indications. Although caesarean section was perceived as involving higher maternal risks than vaginal birth, both women and caregivers justified these risks by the need to 'secure' a healthy baby. Religious beliefs and community members seemed to influence women's caesarean section attitudes, which often made caregivers frustrated as it diminished their role as decision-makers. Undergoing caesarean section had negative socioeconomic consequences for women and their families; however, caregivers seldom took these factors into account when making decisions. Key conclusions and implications for practice: we raise a concern that women and caregivers might overlook maternal risks with caesarean section for the benefit of the baby, a shift in focus that can have serious consequences on women's health in low-resource settings. Caregivers need to reflect on how they counsel women on caesarean section, as many women perceived a lack of indication for their operations. Supportive attendance by a relative during birth and more comprehensive antenatal care counselling about caesarean section indications and complications might enhance women's autonomy and birth preparedness.