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.