Birgitta Essén: “We mustn’t treat Muslim women as collective victims”

“In describing Somali and Afghan women’s interface with the care sector, western commentators often give disproportionate importance to honour-related violence, female genital cutting, forced marriage and other extremes. Unfortunately, this steals the limelight from the quantitatively big challenges: that these women often have their roots in cultures with a relatively risky view of, for example, obstetrics; and the severe generational clashes that arise when their daughters behave like young Swedes of their own age, rather than following their parents’ traditions.”

Birgitta Essén, Professor of International Maternal & Reproductive Health at Uppsala University, has been carrying out ground-breaking scientific work of major importance since the 1990s. It was then that, as a newly recruited doctor in Malmö, she began examining why immigrant women from low-resource African countries were, in conjunction with childbirth, at a substantially elevated risk. Among newborn Somali babies, mortality was four times higher than average; among their mothers, the mortality risk was as high as sixfold. In her thesis, Birgitta Essén showed that this stemmed largely from social factors. It was a conclusion that aroused heated emotions in Swedish health care at the time.

“When I presented my research at the Swedish Society of Medicine conference in 1997, an almost hostile atmosphere spread through the room. Who was I to drag cultural and socioeconomic aspects into a biomedical context? It took a while before academic weight was assigned to my results, but over time the ground rules have been rewritten, and today ‘medical humanities’ is an established concept.”

In 2008, Birgitta Essén arrived at Uppsala University and took up a lectureship in international women’s and maternal health care. Parallel to her position as senior consultant at the Department of Obstetrics and Gynaecology at Uppsala University Hospital, she started setting up a scientific network that soon expanded far beyond disciplines and national borders.

“I brought with me from Skåne the contact I’d already established with Sara Jonsdotter, a Malmö University anthropologist. Collaborating with her helped me, early on, to think outside the biomedical box. My professorship included a focus on global and migration-related reproductive health, and this gave me more key connections. I’d venture to say that our present-day research environment is unique nationwide in its multidisciplinary, long-term work in our multifaceted field.”

The group’s prominent position was further consolidated in autumn 2018, when the Swedish Research Council emphasised Uppsala University in a survey ahead of the drawing-up of a national research programme on migration and integration. This recognition was accompanied by a government grant of SEK 18 million for a six-year project (‘Migration and equal opportunities in sexual and reproductive health: Importance of the dynamics and joint creation of cultural values for improved practice’).

“The Government’s contribution comes at an extremely opportune time. Today, we have good knowledge of the causes underlying the current challenges. The new programme gives us a platform for continuing to develop the forms of our collaboration, so that we can join forces in adopting a more solution-oriented way of working,” Essén states.

At the Department of Obstetrics and Gynaecology at Uppsala University Hospital, several of the research group’s many findings have already been put into practice. At one clinic focusing specifically on pregnant immigrant women from the Middle East and African cultures, for example, the concept of “two experts in the room” – a consultation technique based on the perspective that doctors and patients alike possess relevant knowledge – is applied.

”Our studies show how midwives, in meeting Muslim women, often assume that they are victims of oppressive husbands, and therefore try to educate them according to Swedish ideals of gender equality. If, instead, our premise is that these women are both rational and capable of taking wise decisions, and if we listen to how they describe their problems, it’s simpler to give them the tools they need to understand and follow the treatments that Swedish care services provide.”

The model, which draws on knowledge from both medicine and anthropology, lays great emphasis on professionalism – the requirement that care staff disregard their own feelings – and communication. Every advisory session must take the time that is needed; interpreters are always available, and cultural sensitivity applies as long as it does not impair medical safety.

“This doesn’t take place completely without friction, of course,” admits Essén.

“On the one hand, health care is intended to be equal for all, with a clear gender perspective. On the other, we live in a multicultural society where cultural sensitivity is expected to prevail. Clashes do arise, but we must dare to ask our questions and rely on the patients’ replies instead of guessing. For those most in need of care to get it, we have to identify who they are and acquire the understanding required to provide it correctly.”

The areas in which Birgitta Essén sees clear needs of further knowledge include female genital mutilation (FGM). The challenge, in her view, consists less in how care services should deal with the range of interventions involved in ritual female “circumcision” or FGM as such than in the western world’s incorrect perception of their long-term complications. Somali women’s poor childbirth outcome is believed to be due to FGM as such, but according to Essén this is an enduring myth. Swedish health professionals are now undergoing in-service training in the social problems and unusual diseases – often diagnosed too late – that some immigrants bring with them to Sweden. Moreover, Essén says, research indicates that illegal “circumcision” is not practised in Europe; judging from the few cases that have been taken to court, the majority took place nearly 30 years ago in France or in the victims’ home countries. Similarly, rumours of “FGM parties” regularly reach as far as Sweden.

“Decision-makers and care providers are served ‘facts’ by activists whose information often lacks scientific support. So society needs more empirical data, and in particular the doctors who come into contact with suspected female genital cutting must have greater knowledge. We already see far too many examples of how incorrect assessments cause great legal damage.”

Birgitta Essén relates how she has repeatedly been called in as an expert in American and Danish courts, where doctors have incorrectly stated that genital cutting has taken place among Muslim girls. Sometimes, the professionals who have issued the statements have proved to possess no experience of what the interventions entail. Essén has now been awarded funding to safeguard legal security in future cases.

“We know that most Somalis who reach Sweden drop the custom. But as long as parents are at risk of imprisonment and families of being torn apart on false grounds, we must carry on with our work. The hope is that the migrants themselves will make a contribution by transferring their newly acquired knowledge and values to relatives and friends who still live in the country of origin. As in all international health work and research, we’ve got to think globally and work locally if we’re going to succeed.”