Perinatal mortality among immigrants from Africa´s Horn: The importance of experience, rationality, and tradition for risk assessment in pregnancy and childbirth

This thesis is an exploration of the possible effects of maternal country of origin on the risk of perinatal mortality (PNM). Increased risk of PNM was found among infants of foreign-born women delivering in a Swedish hospital between 1990-1995. After adjustment for risk factors, however, the finding only held true for a subgroup of women from Ethiopia and Somalia (ES). In searching for the mechanism behind this observation, an anthropological study of Somali women was undertaken, yielding the hypothesis that experiences and notions of childbirth brought from their country of origin resulted in certain beliefs and pregnancy strategies of which Swedish caregivers were unaware. These factors, combined with miscommunication, may have occasioned sub-optimal care and heightened the risk of PNM. In order to test this hypothesis, an audit of all perinatal deaths to ES mothers in Sweden was compared to a matched cohort of Swedish women. Sub-optimal factors associated with PNM were noted with significantly greater frequency among the ES mothers. The audit showed that potentially avoidable deaths (e.g., intrapartal and neonatal deaths, as well as SGA stillbirths) could be related to maternal pregnancy strategies (such as avoiding C/S or not seeking perinatal care when needed), deficiencies in medical care (inadequate surveillance of IUGR or intrapartal CTG), and verbal miscommunication. However, no association was found between female circumcision and PNM. Circumcised women had in fact a lower risk of prolonged labour, and had a significantly shorter second stage of labour, as compared to non-circumcised women. It was concluded that the higher incidence of PNM appears partly to be due to an unfortunate interaction between certain pregnancy strategies practices by ES women and the performance of Swedish perinatal care services. The pregnancy strategies in question were related to poor health care experience, rationality, and tradition regarding childbirth in their countries of origin. Lack of awareness of these circumstances could be linked to sub-optimal perinatal care in the many of the instances studied. A greater familiarity among clinicians in the Swedish perinatal health care services with this background may decrease the risk of PNM in ES women by focusing on patient education, interpersonal communication, and improved foetal surveillance. The assertion made in the past linking PNM to prolonged labour due to circumcision in a high resource country like Sweden, found little support in this study

Sexual Health among Young Somali Women in Sweden: Living with Conflicting Culturally Determined Sexual Ideologies

Young Somali women in Sweden are affected by two conflicting ideologies on sexuality: on the one hand, the traditional values demanding chastity and modesty in women and, on the other hand, the public sexual ideology in Sweden, emphasising sexual liberty and the dismissal of sexual taboos. In addition, they have to deal with national campaigns condemning “female genital mutilation”. Some of these young women arrived in Sweden already circumcised. The public message to them is that they are “mutilated” and, consequently, deprived of their ability to enjoy sex. A planned project, Sexual Health among Young Somali Women in Sweden, aims at a deeper understanding of the sexual experiences among older Somali women in Sweden, and intends to map the internal discourse in this field. The study also intends to find methods of transferring a positive self-image of sexuality, prevalent among older Somali women, to the younger women.1 Discussing sexual matters is traditionally taboo among Somalis. Even if this situation is changing in exile, many young Swedish Somali women have to make their sexual débuts with only limited knowledge about the possibilities of their own sexuality

Förhöjd förekomst av akuta kejsarsnitt bland kvinnor med ursprung i Somalia: Patientens eller vårdens ansvar?

Afrikanska kvinnor är överrepresenterade när det gäller både mödra- och barnadödlighet i västliga länder. Vidare löper de större risk att få genomgå akut kejsarsnitt, trots att studier visar att det finns en utbredd rädsla för kejsarsnitt bland kvinnor med ursprung i Somalia som migrerat till väst. I artikeln diskuteras hur denna situation kan motverkas genom att man lyfter fram konsultationen som arena inom graviditets- och förlossningsvården. Konsultationen – i motsats till behandlingen i sig – är ett sammanhang som tillåter en mer kritisk hållning till ett strikt biomedicinskt synsätt på sjukdom och kropp, och en större öppenhet för alternativa förståelsemodeller. En konsultationsmodell som är öppen för somaliska kvinnors speciella erfarenheter, men samtidigt lägger vikt vid varje patients individuella livssituation, ökar möjligheterna för en respektfull vård som i  förlängningen också kan leda till ett bättre utfall (lägre mödra- och barnadödlighet, färre akuta kejsarsnitt) för den somaliska invandrargruppen inom förlossningsvården

A qualitative study of conceptions and attitudes regarding maternal mortality among traditional birth attendants in rural Guatemala.

OBJECTIVE: To explore conceptions of obstetric emergency care among traditional birth attendants in rural Guatemala, elucidating social and cultural factors. STUDY: design Qualitative in-depth interview study. SETTING: Rural Guatemala. SAMPLE: Thirteen traditional birth attendants from 11 villages around San Miguel Ixtahuacán, Guatemala. METHOD: Interviews with semi-structured, thematic, open-ended questions. Interview topics were: traditional birth attendants' experiences and conceptions as to the causes of complications, attitudes towards hospital care and referral of obstetric complications. MAIN OUTCOME MEASURES: Conceptions of obstetric complications, hospital referrals and maternal mortality among traditional birth attendants. RESULTS: Pregnant women rather than traditional birth attendants appear to make the decision on how to handle a complication, based on moralistically and fatalistically influenced thoughts about the nature of complications, in combination with a fear of caesarean section, maltreatment and discrimination at a hospital level. There is a discrepancy between what traditional birth attendants consider appropriate in cases of complications, and the actions they implement to handle them. CONCLUSION: Parameters in the referral system, such as logistics and socio-economic factors, are sometimes subordinated to cultural values by the target group. To have an impact on maternal mortality, bilateral culture-sensitive education should be included in maternal health programs

Improving Standards of Care in Obstructed Labour: A Criteria-Based Audit at a Referral Hospital in a Low-Resource Setting in Tanzania

Objective 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. Methods 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 the results were compared to those of the baseline audit. Results Two hundred and sixty deliveries in the baseline survey and 250 deliveries in the follow-up survey were audited. Implementing the new criteria improved the diagnosis from 74% to 81% (p = 0.049) and also the management of obstructed labour from 4.2% at baseline audit to 9.2% at re-audit (p = 0.025). Improved detection of prolonged labour through heightened observation of regular contractions, protracted cervical dilatation, protracted descent of presenting part, arrested cervical dilation, and severe moulding contributed to improved standards of diagnosis (all p \u3c 0.04). Patient reviews by senior obstetricians increased from 34% to 43% (p = 0.045) and reduced time for caesarean section intervention from the median time of 120 to 90 minutes (p = 0.001) improved management (all p \u3c 0.05). Perinatal outcomes, neonatal distress and fresh stillbirths, were reduced from 16% to. 8.8% (p = 0.01). Conclusion A criteria-based audit proved to be a feasible and useful tool in improving diagnosis and management of obstructed labour using available resources. Some of the observed changes in practice were of modest magnitude implying demand for further improvements, while sustaining those already put in place

On the carbohydrate metabolic response to an experimental infection with Brachyspira hyodysenteriae (swine dysentery) in pigs

The carbohydrate metabolic response to experimentally induced swine dysentery was studied in crossbreed pigs. Twelve pigs, with a mean weight of ~20 kg, were orally inoculated with Brachyspira hyodysenteriae strain B204. After an incubation period of 6-20 days, five animals developed swine dysentery with haemorrhagic diarrhoea and two animals developed non-haemorrhagic diarrhoea. Five animals remained healthy throughout the study. Blood samples from the animals with clinical signs of disease were collected before inoculation, several times during the course of the dysentery and finally after recovery. Blood samples from animals that remained healthy were obtained before inoculation and at slaughter four weeks later. Glucose, lactate and cortisol concentrations did not differ between sampling occasions in the healthy animals. In the sick animals, higher concentrations were observed when haemorrhagic diarrhoea occurred (mean peak value ± SD: glucose 7.6 ± 0.7 mmol/L; lactate 4.5 ± 1.7 mmol/L; cortisol 278 ± 86 nmol/L) compared to before inoculation (mean value ± SD: glucose 5.1 ± 1.2 mmol/L; lactate 1.3 ± 0.5 mmol/L; cortisol 24 ± 11 nmol/L). At slaughter, tissue samples from m. biceps femoris, m. longissimus dorsi, myocardium and liver were collected from 10 pigs and glycogen analysis was performed. Glycogen concentrations did not differ between the healthy pigs and those that developed swine dysentery: concentrations were highest in the liver and lowest in the heart. In conclusion, experimental infection with B. hyodysenteriae results in alteration of the carbohydrate metabolism, which is characterised by a transient increase in blood glucose and lactate concentrations during the initial phase of the haemorrhagic period of the disease

Maternal near-miss and death and their association with caesarean section complications: a cross-sectional study at a university hospital and a regional hospital in Tanzania

Background The maternal near-miss (MNM) concept has been developed to assess life-threatening conditions during pregnancy, childhood, and puerperium. In recent years, caesarean section (CS) rates have increased rapidly in many low- and middle-income countries, a trend which might have serious effects on maternal health. Our aim was to describe the occurrence and panorama of maternal near-miss and death in two low-resource settings, and explore their association with CS complications. Methods We performed a cross-sectional study, including all women who fulfilled the WHO criteria for MNM or death between February and June 2012 at a university hospital and a regional hospital in Dar es Salaam, Tanzania. Cases were assessed individually to determine their association with CS. Main outcome measures included MNM ratio; maternal mortality ratio; proportion of MNM and death associated with CS complications; and the risk for such outcomes per 1,000 operations. The risk ratio of life-threatening CS complications at the university hospital compared to the regional hospital was calculated. Results We identified 467 MNM events and 77 maternal deaths. The MNM ratio was 36 per 1,000 live births (95% CI 33–39) and the maternal mortality ratio was 587 per 100,000 live births (95% CI 460–730). Major causes were eclampsia and postpartum haemorrhage, but we also detected nine MNM events and five deaths from iatrogenic complications. CS complications accounted for 7.9% (95% CI 5.6–11) of the MNM events and 13% (95% CI 6.4–23) of the maternal deaths. The risk of experiencing a life-threatening CS complication was three times higher at the regional hospital (22/1,000 operations, 95% CI 12–37) compared to the university hospital (7.0/1,000 operations, 95% CI 3.8–12) (risk ratio 3.2, 95% CI 1.5–6.6). Conclusions The occurrence of MNM and death at the two hospitals was high, and many cases were associated with CS complications. The maternal risks of CS in low-resource settings must not be overlooked, and measures should be taken to avoid unnecessary CSs. More comprehensive training of staff, improved postoperative surveillance, and a more even distribution of resources within the health care system might reduce the risks of CS