Migration projects

International comparisons show that Swedes' values are more liberal, individualistic, and pro-equality than those of other populations. These values are reflected in Swedish laws and institutions, such as the right to deny sex between spouses and youth clinics where minors can receive sexual counseling and contraception without parental consent. Sweden is multicultural, with many residents from the Middle East and Somalia, where values can sharply contrast with Swedish norms. Migrant women from these areas often have poorer delivery outcomes, lower contraceptive use, and more abortions than Swedish women.

Healthcare providers are encouraged to incorporate gender equality perspectives while providing culturally sensitive care, but tensions and misunderstandings can arise in clinical encounters. Research on handling these challenges is scarce due to the complex nature of the topics, requiring knowledge from both medical and social sciences.

The project aims to improve care for migrants from the Middle East and Somalia by understanding how value conflicts and cultural changes can be managed in the healthcare sector. Key research questions include: how and when gender-related values change among newly arrived Middle East and Somali migrants, how SRH care can be tailored to address value conflicts in clinical encounters with migrants, and whether a participatory community-based intervention involving the Swedish Somali diaspora can change attitudes towards FGC among practicing families in Somalia.

Using both quantitative and qualitative methods, data will be collected via surveys and focus group discussions between healthcare providers and migrants. The interdisciplinary project involves researchers from Reproductive Health, Anthropology, Social Work, and Norm Research, with collaboration between healthcare providers and migrants from the Middle East and Somalia.

Research questions:

• How and when do gender-related values change among newly arrived Middle East and Somali migrants?
• How could sexual and reproductive health (SRH) care be tailored, involving all relevant stakeholders, to best address value conflicts in clinical encounters with migrants?
• Can a participatory community based intervention involving the Swedish Somali diaspora change attitudes towards FGC among practicing families in Somalia?

This study investigates tensions in health care relating to cultural diversity, religious diversity, and gender equality by analyzing complaints about discrimination on the grounds of ethnicity, religion, and gender in Swedish healthcare, which have been submitted to the Swedish Equality Ombudsman (Diskrimineringsombudsmannen, DO). The study employs quantitative and qualitative methods to explore perceived discrimination in healthcare through an intersectional approach in relation to religion, ethnicity, and gender. The data consists of complaints about ethnic, religious and gender discrimination in healthcare submitted from 2012 to 2021, and the Equality Ombudsman’s case supervision decisions. The different grounds of discrimination are analyzed both separately and in combination. Through descriptive statistics and content analysis, we provide an overview of the complaints, and identify healthcare sectors, in which discrimination has been reported to higher extent. We also explore to what extent the Equality Ombudsman has legally investigated the reported discrimination in healthcare. Through qualitative analysis of the complainants’ narratives, we analyze what characterizes patients’ and their relatives’ expectations in healthcare encounters that are perceived as discriminatory. The methods are interpretive phenomenological analysis (IPA) and concept analysis. In dealing with the narratives, we analyze individual experiences through their social roles within a broader organizational process with inspiration by the theoretical framework of Institutional Ethnography (IE). The research focus is on the coordination between an individual’s experience and the institutional relations with which they engage. In that sense, we analyze the narratives as an entry point into the complex institutional field of health care, which includes norms, laws, rules, guidelines, formal competence, administrative skills, risk management, quality management, time management, etc. Furthermore, attention will be directed towards the concepts ‘cultural competence’, ‘cultural sensitivity’, and ‘cultural awareness’, and their use in the health care context. Knowledge generated by this study can develop increased reflexivity among health care providers in dealing with tensions that may arise between values, norms, and silent assumptions in the culturally and religiously diverse Swedish healthcare system.

Research questions:

• In which healthcare sectors has the reported discrimination on the grounds of ethnicity, religion and gender taken place?
• To what extent and on what grounds have the complaints of perceived discrimination been investigated by the Equality Ombudsman?
• How do complainants express that they are discriminated against in relation to their ethnicity, religion, beliefs, or gender?
• How does the reported discrimination relate to patients’ rights according to the Swedish Patient Act?
• How do narratives in discrimination complaints relate to the complainants’ social roles and the institutional field of health care?

This study, conducted by an anthropologist and a gynaecologist, aims at reaching an understanding of societal views of the relation between ’sex’, ’gender’ and genitals, through analysing the political positions that have given rise to decisions to advocate, accept or criminalise certain surgical genital modifications. The phenomena analysed are male and female circumcision, cosmetic genital surgery, hymenoplasty and operations on transsexual adults/intersexual infants. Society’s views of these procedures have their own social, medical and political history, and as yet there is no systematic analysis juxtaposing them. The theoretical approach is social constructivist, inspired by gender theory and critical medical anthropology. Empirical data include legislative texts and qualitative interviews with professionals in medicine and with key activists. Through discourse analysis we will explore the social values about ’sex’ and ’gender’ that are conveyed in legal decisions and medical practice in this field, and in alternative discourses. The study adds to our research about female genital cutting and cosmetic genital surgery. Procedures involving the genitals provide an arena where medicine and culture converge. Understandings of ‘sex’ are interwoven with politicized socio-cultural constructions of ‘gender’. What is ‘given by nature’ can be modified through surgery, but medical practice itself develops within a norm structure that is time- and culture-bound.

This study therefore sought to explore the factors associated with the approval of symbolic female genital pricking and male circumcision among new immigrants in Sweden and answer the following questions:

• Which individual and country-of-origin factors are associated with the approval of female genital pricking among new immigrants in Sweden?
• Which individual and country-of-origin factors are associated with the approval of male circumcision among new immigrants in Sweden?

The overarching aim is to study the utilization of Swedish postnatal care by foreign-born women and to understand their and their partners' perspectives on postnatal care. Additionally, the goal is to investigate the experiences, thoughts, and ideas of midwives, doctors, and policymakers on how postnatal care can be planned to effectively reach foreign-born women and meet their needs.

Postnatal care needs to be evaluated and developed as the population's composition changes, with more than a quarter of childbearing women being born outside Sweden. New working methods are requested by midwives to meet the needs of foreign-born women and offer equitable care. Foreign-born women are a heterogeneous group with both higher and lower risks for pregnancy and childbirth complications. To develop postnatal care for those who need it most, we will identify risk groups and examine their views on postnatal care. We will also interview midwives, doctors, and policymakers about their perspectives on how postnatal care for foreign-born women can be improved in a sustainable and cost-effective manner. The results will form the basis for intervention development and evaluation within the framework of the EMMA research program (Enhanced Maternity Care for Migrant Women - Research to Action).

The research will address several key questions to better understand and improve postnatal care for foreign-born women in Sweden. First, we will examine the extent to which foreign-born women participate in postnatal care. Additionally, we will identify the risk factors that contribute to foreign-born women missing their postnatal check-up with the midwife approximately 4-16 weeks after birth. The study will also explore the thoughts and experiences of foreign-born women and their partners regarding postnatal care, focusing on their expectations and what they wish the care would include. Furthermore, we will investigate how postnatal care for foreign-born families can be enhanced in a sustainable and cost-effective manner. These insights will be crucial for developing interventions and improving postnatal care services to meet the diverse needs of this population.

Migrant women from low-income countries have been reported to have an increased risk regarding both maternal and perinatal mortality and morbidity. In response to the health needs of migrant women at high risk of adverse obstetric outcomes, cultural doulas (or community-based doulas) have been implemented in Sweden despite little evidence of improved obstetric or perinatal effects. This interview study investigates embedded paradoxes in the cultural doula concept in relation to Swedish policies on gender mainstreaming and multiculturalism. The first aim is to investigate tensions in the cultural doula concept in relation to gender equality and diversity. The second aim is to investigate discrepancies between migrant maternal outcomes and researched effects of the cultural doula, as well as to expand the knowledge of the role and boundaries of cultural doulas in migrant maternity care. Hence, challenges in the distribution of roles and duties between cultural doulas, midwives, obstetricians, and authorized interpreters are investigated. Through semi-structured interviews (n=18) conducted with midwives and obstetricians in two Swedish counties in 2022, we examine healthcare providers’ perceptions of the cultural doula concept and their experiences of collaborating with cultural doulas in a clinical or administrative setting. Data is analyzed through thematic analysis and Bacchi’s WPR-approach What’s the Problem Represented to be? The research will expand the knowledge on the implementation of cultural doulas in relation to cultural sensitivity and gender equality. In the context of providing maternal care to migrant women at high risk, it is important to ensure that the right interventions are being implemented, and that these are evidence-based.

Research question:

• In what way is the cultural doula concept in line with the policies of gender equality and culturally sensitive care?
• What is the role of the cultural doulas according to health care providers, and what is left unproblematic?
• Are there any unintended consequences of the concept of cultural doulas?
• How do health care providers reflect on problems and risks in migrant women’s maternity care and on the effects of the cultural doula concept with regards to their knowledge about migrant women’s obstetric outcomes?
• How do health care providers reflect on the role of the cultural doula in relation to the professional duties of midwives, obstetricians, and authorized interpreters respectively?

Group antenatal care (gANC) aims to empower women and improve outcomes, particularly for those with poorer reproductive health. This thesis developed and tested the impact of language-supported gANC for Somali-born women in Sweden to improve their antenatal care experiences, emotional well-being, knowledge about childbearing, and pregnancy outcomes.

Results showed no significant differences in overall ANC ratings but indicated greater reductions in EPDS scores and higher satisfaction with pregnancy and birth information among gANC participants. Women in gANC reported positive experiences and better relationships with midwives, though partner involvement remained limited.

The findings suggest that language-supported gANC can improve information provision and knowledge for Somali–Swedish women, provided there is an adequate number of women sharing a common language in the area. Caution is needed to avoid reinforcing stereotypes or reducing privacy. Enhanced person-centering in gANC highlights the need for culturally sensitive, individualized care to address inequalities and counteract biases.

In Sweden, the study investigated the medical and non-medical factors behind maternal mortality among migrants. It was identified that migrant women born in low-income countries are at higher risk of maternal mortality due to suboptimal care and miscommunication, despite giving birth in a high-income country. Additionally, maternal mortality among immigrants was related to broken trust in care providers, influencing the women’s late booking or refusal of treatment. Somali-born childbearing women need targeted attention in the maternity healthcare system due to lower antenatal care attendance and adverse maternal health outcomes.

In Sweden, the study sought to explain the paradox that Somali migrants have the highest rate of CS but still express a very negative attitude towards caesarean delivery. It was observed that non-medical reasons, such as fear of blame and lack of senior support, play a role in the unnecessary use of CS. Additionally, medical anthropology was found to be a useful approach to understanding adverse obstetric outcomes among migrants. Socioeconomic factors seem to be more important than cultural factors per se, and shared language was identified as one of the most important factors for optimal care for migrants.

This project delves into the complex cultural dynamics surrounding female genital cutting (FGC) in communities affected by migration. It examines how these dynamics intersect with cultural beliefs about gender, sexuality, and bodily integrity. The study focuses on exploring the discourses around FGC and its implications for sexuality among young women from practicing communities. Additionally, it investigates the challenges faced by professionals in providing support and care to these women, navigating the intersection of universal rights frameworks with local cultural contexts.

The research aims to shed light on how differing cultural perspectives on harm, identity, and sexual health can be reconciled within national and international frameworks. It seeks to inform strategies for providing culturally sensitive sexual health services to women affected by FGC, particularly those who have migrated to Sweden. By addressing these complexities, the project aims to contribute to discussions and practices that promote sexual well-being and rights in diverse cultural contexts.

Research questions include understanding how Somali-born women perceive wellbeing, violence, and their Swedish maternity care encounters in light of long-lasting war. The study also explores the challenges immigrant women face in obtaining sufficient reproductive health in secular healthcare settings and the role of religion, specifically Islam, in these health disparities. It aims to identify risk factors, attitudes, and prevention strategies regarding female circumcision among Somalis in Sweden and examines what happens to traditions like female genital cutting after migration. Additionally, the study investigates the prevalence of induced abortion and barriers to equitable abortion care among different groups of migrants and non-migrants, as well as patterns of accessibility to contraception.

Major findings reveal that a significant portion of the Somali diaspora opposes female circumcision, supporting the social convention theory and indicating changing attitudes. Islam provides reproductive health norms, though not always observed by Muslims, and some use Islamic edicts to argue for contraception use. Strategies related to maternity healthcare, wellbeing, and violence disclosure in Sweden are influenced by experiences of political violence, with a focus on inner resources and social networks.

Most Somali-born women in Sweden have experienced war-related violence pre-migration, using social networks to cope in the new society. Partner violence was not a central theme post-migration. Communication is crucial in encounters at antenatal and reproductive care clinics, but Swedish midwives often lack familiarity with the fundamental differences between individualistic and collective life systems in Sweden versus Somalia. Migrants have lower accessibility to contraception compared to non-migrants, and second-generation immigrant women face even greater challenges. The organization of abortion care may hinder equitable access.