and Research areas

"Near miss" and maternal mortality in a globalized world

Research questions

  • What are the factors that impedes utilization of emergency obstetric care in Bolivia and Guatemala?
  • What are the factors that impede utilization of emergency obstetric care in Bolivia and Guatemala?
  • What are the characteristics of severe maternal morbidity in a middle income country like Iran with a high influx of refugees from Afghanistan?
  • What are the potential barriers to preventable maternal mortality and partner involvement during pregnancy in a setting like Rwanda, with a strong policy program for achieving gender equity?
  • What are the medical and non-medical factors behind maternal mortality among migrants in Sweden?

Location: Bolivia, Iran, Guatemala, Rwanda, Sweden

Major findings

  • In Iran, Afghan mothers face more suboptimal obstetric care than their Iranian counterparts through unequal access to insurance coverage.
  • Traditional birth attendants in Guatemala are unfamiliar with emergency obstetric care and there is a lack of collaboration with formal care providers.
  • In Bolivia, most women with near-miss arrived at hospital in critical condition.
  • Poor patient-provider interaction at care-encounter increases the risk of preventable complications, and decreases trust in facility based maternal care.
  • Even though men wish to participate during antenatal care and labour to ensure quality of care, they feel excluded from the maternal health system in Rwanda.
  • Migrant women born in low-income countries were identified as being at higher risk of maternal mortality due to suboptimal care and miscommunication despite giving birth in a high income country like Sweden.
  • Maternal mortality among immigrants in Sweden were related to broken trust  in relation to the 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 less antenatal care attendance and adverse maternal health.

Too many caesarean deliveries challenging Safe Motherhood?

Research questions

  • What are the effects and reasons for a high caesarean section rate in a low-resource setting like Tanzania?
  • Can criteria based audit of obstructed labor improve accuracy of the decision of caesarean section and standard of care in a setting with high maternal and perinatal mortality?
  • What are the characteristics of ”near-miss” in a setting with very high rate of caesarean section like Teheran and Dar-es-Salaam?
  • What is the explanation behind the paradox that Somali migrants have the highest rate of caesarean sections but still express a very negative attitude towards a caesarean delivery?

Location: Iran, Tanzania, Sweden

Major findings

  • Caesarean section (CS) is being overused also in some low-resource settings.
  • Despite improved safety, CS still entails high risks of severe maternal complications.
  • There is a tendency to justify maternal risks with CS by referring to a need to “secure” the baby.
  • Transparency, auditing, and dysfunctional team-work can contribute to CS overuse.
  • Placenta previa due to earlier CS is associated with maternal near-miss morbidity.
  • Non-medical reasons for unnecessary caesarean section include lack of support for junior clinicians from seniors and pressure from midwives during decision making, and fear of blame from colleagues and management in case of poor perinatal outcome.
  • Medical anthropology is a useful approach to understand adverse obstetric outcome among migrants. Socioeconomic factors seem to be more important than cultural factors per se. Shared language was found to be one of the most important factors for optimal care for migrants.

Genitals, gender and ethnicity: The Politics of Genital Modifications

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 politicised 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.

Birgitta Essén, Professor
Sara Johnsdotter, PI, Professor, Malmö University
Anna Arvidsson, Doctoral student

Improving reproductive choice and health for women and men

Research questions

  • How can we create a patient-centered health system that caters to reproductive health needs and increase access to medical abortion and contraception services among Indian women living in low-resource settings?
  • What are the potential barriers to preventable severe maternal morbidity and partner involvement during early pregnancy in a low-resource setting like Rwanda with a very strong policy program of improving women’s health.
  • How does the construction of parenthood and surrogate motherhood relate to the use of transnational surrogates in Sweden and India?
  • How to understand the dynamics of the HIV epidemic by estimating prevalence and exploring the relationship between HIV-related knowledge, attitudes, behavior and HIV status and stigma in Nicaragua.

Location: India, Rwanda, Sweden

Major findings

  • Despite the MDG agenda, inadequate care options force life-threatening solutions to unwanted pregnancy in Rwanda.
  • Indian women do not desire sterilization, but prefer reversible contraceptive methods post-abortion.
  • Simplified follow-up using a low-sensitivity pregnancy test two weeks post early medical abortion is as effective, acceptable and feasible as in-clinic follow-up by a doctor.
  • Surrogacy in India is a reproduction method that fulfills the cultural expectations of parenthood, as having an “own child”, while it is also attached with complex views of the surrogate mother.
  • Transnational surrogacy in India involves moral qualms but the exploitation of surrogate mothers is defied.
  • Although seven out of ten Men who have Sex with Men (MSM) and six out of ten women were concerned about becoming infected with HIV, inconsistent condom use was common in Nicaragua
  • MSM have a better understanding of HIV transmission than men and women of the general population.

Sexuality & reproductive health in a migratory context

Research questions

  • How do Somali-born women perceive wellbeing, violence and their Swedish maternity care encounters in the light of long-lasting war?
  • Why is that immigrant women face considerable challenges in obtaining sufficient level of reproductive health in secular healthcare settings?
  • What does religion – and Islam specifically – got to do with these disparities in health?
  • What are the risk factors, magnitude, attitudes, and prevention strategies regarding female circumcision among Somalis in Sweden?
  • What happened with the ”deeply rooted” traditions, like female genital cutting, after migration to Sweden?
  • What is the prevalence of induced abortion in different groups of migrants and non-migrants, and what are the barriers to equitable abortion care?
  • What are the patterns of accessibility to contraception in different groups of migrants and non-migrants?

Location: Sweden, EU

Major findings

  • A large part of the Somalis in diaspora, including the newly arrived, are opponents of female circumcision, supporting social convention theory and proving that attitudes towards this practice can change.
  • Islam offers a system of norms on reproductive health matters; yet not always observed by Muslims.
  • Several informants use Islamic edicts to argue positively for use of contraception.
  • Strategies related to maternity healthcare encounters, wellbeing and violence disclosure are upon arrival in Sweden shaped by political violence, with focus on inner resources and social networks for support and strength.
  • Most Somali born women in Sweden have a pre-migrational experience from war-related violence. In the new context of Sweden a ”moving on” strategy  and social networks are instruments used to cope in the new society. Partner-violence was, however, not seen as a central theme after migration.
  • Communication was a key role in encounters, at the antenatal and reproductive care clinics. Swedish midwives are not yet familiar with the fundamental differences between individualistic and the collective life systems in Sweden vs Somalia.
  • Migrants have lower accessibility to contraception as compared to non-migrants.
  • Second generation immigrant women have lower accessibility to contraception as compared to foreign-born and non- immigrant women.
  • The organization of abortion care might hinder equitable abortion care.

Health of unaccompanied minors and immigrant detainees

Research questions

  • What aspects are important for unaccompanied minors coming to Sweden to succeed and integrate in the Swedish society?
  • What are the factors that could mitigate the negative effect of immigration detention on the health and wellbeing of immigrants?

Location:  Sweden, EU

Major findings

  • Immigrant detainees in Sweden have low Quality of Life.
  • Health care, especially mental healthcare, provisions at the Swedish detention centers are suboptimal.
  • Among various factors, support received from detention staff was the factor positively associated with detainees’ quality of life in detention.
  • The unaccompanied minors, who are now adults, considered themselves to be adapted to the Swedish society and believe to have a good life.
  • Having support from a individuals who believed in the abilities of unaccompanied minors was very important for their successful adaptation in their new country.
  • Staff working with unaccompanied minors need to be trained to increase awareness of the children’s lives in Somalia.

Maternal mortality and severe obstetric morbidity in a globalised world

Maternal mortality is a well-known quality indicator of obstetric care, and maternal near miss is fast gaining interest as a complementary indicator, particularly among vulnerable groups with a lack of social networks in situations of general instability or poverty in low-income settings (Rwanda and Tanzania), or after migration to high resource settings (Sweden, UK). Our current research activities include analyses of maternal and perinatal ill-health in low-, middle- and high-income settings from a migration perspective. Partner’s role in the provision of support during antenatal and obstetric decision-making is also explored as an influence on birth outcome barriers. The overall aim is to develop tools for comprehensive maternal health services to women living in underprivileged situations. The research program is interdisciplinary and uses multiple mixed methods, including epidemiological, audit, as well as anthropological methods to define the social and cultural aspects of these medical phenomena.

The significance of these findings yields improved medical and culturally relevant ways to understand and prevent the tragic incidence of maternal or perinatal loss of life. The multidisciplinary group has previously shown effects of ethnic background, suboptimal care and socio-cultural factors, such as female circumcision, on the risk of perinatal mortality and maternal morbidity and results have been implemented in health care practices among ethnic groups in Latin America and in Sweden. The findings have contributed to theoretical knowledge, but have also been implemented through guidelines in order to reduce health inequalities in an ethnic perspective.

Sri Lankan Males Perspective of Gender

‘Gender’ is defined by WHO as ‘the socially constructed roles, behaviour, activities and attributes that a particular society considers appropriate for men and women’. The distinct roles and behavior may give rise to gender inequality, which are differences between men and women that systematically favor one group. Such inequalities build up the foundation for gender related issues such as gender based violence (GBV), social, economic and health inequalities between men and women. Partner violence is the most frequent form of GBV in societies, and efforts are made to get evidence based interventions. The Government in Sri Lanka has adopted several policies around GBV and calls for service points to provide care to abused women. GBV among ever married women and intimate partner violence (IPV) in Sri Lanka is estimated to be between 20 - 60 percent.

The Aim of the present study is to investigate in collaboration with University of Sri Jayawardenapura in Colombo, male university student’s perception on GBV, as it is the young generation that will have to make a change.                       

Objectives are to explore young men’s perceptions on GBV, on male dominance and female subordination and to investigate their willingness to actively engage in prevention of GBV in their future occupations. 

The study design is qualitative, using focus group discussion (FGD). An experienced Sri Lankan moderator on qualitative research will lead the discussions and an additional research assistant will observe and take notes. The study will contribute to build capacity at the University of Sri Jayawardenapura on sexual and intimate partner violence.

Expected outcomes are to get a deeper understanding of the new generation of men and their understandings on GBV and primary prevention to reduce partner violence. The results will strengthen the evidence base for prevention of sexual and intimate partner violence in South East Asia. This is a pilot study, which will serve as the base of a later application for funding of an intervention study.

Finansierad av ALF-medel.

Elisabeth Darj, Professor
Pia Axemo, PhD
Gunilla Lindmark, Professor emirita
Kumudu Wijwardena, Professor, University of Sri Jayewardenepura, Colombo, Sri Lanka

Intervention to increase university students’ knowledge on Gender Based Violence (GBV)

Pilot study to plan and test an educational program on GBV at the University Sri Jayewardenepura, Colombo, Sri Lanka. Studies in Sri Lanka has shown that university students have poor understanding of gender, GBV, its´ prevalence, contributing factors and possible preventive measures.

An educational program will be pilot-tested and evaluated in order to later introduce a computerized program accessible to all students and teachers at the University Sri Jayewardenepura.

Questionnaires before and after finalizing the program will be analysed, as well as Focus Group discussions with teachers and students.

Elisabeth Darj, Professor
Pia Axemo, PhD

Daily life and wellbeing of irregular immigrants detained in Sweden and other EU member states

Sweden receives a major share of asylum seekers in the world. In year 2007 the EU member states had together about 3,8 million irregular migrants form countries outside EU. Most of the European countries use detention centres in order to facilitate deportation of irregular migrants who have been captured.

The time spent in the detention unit is important for a detainee as it affects his/her present and future life. The health situation of the detainees, which is already deteriorated, is worsened when they are detained at the detention centres. They need support to handle the stressful situation in the detention. In order to provide this support, an understanding of the detainee’s daily life is required. The detention systems in Sweden, Belgium, the Netherlands and Luxembourg will be compared to identify good practicies.

The overall aim of the project is to create a knowledge base for the development of the care of detainees in the EU. The main focus will be on the Swedish system. The objectives are to: describe how the detainees experience the daily life, well-being and received care: describe the detention staff's perspectives on the care provided for the detainees; compare detention systems in various EU member states; identify factors which support or prevent the well-being of the detainees. Qualitative and quantitative methods are used for the data collection in the project, which is a PhD project in the area of International health with the PhD student Soorej Jose Puthoopparambil. The Swedish Migration Agency, the Swedish Border police, national NGOs and the International Organization for migration (IOM) are collaborating partners in the project.

Magdalena Bjerneld, PhD
Soorej Jose Puthoopparambil, PhD

Unaccompanied Somali refugee girls in Sweden, a follow up study

Sweden has received unaccompanied children since the end of 1980ths. During the period 1980 - 2010 around 11000 unaccompanied children arrived in Sweden. The tendency is that this group of children will increase in the future. In the beginning of 1990th the Somali children was the largest group and they still are, together with children from Afghanistan. The majority are boys but one third are girls. The majority of the children have received asylum and have therefore lived their fist years as young adults in Sweden. During 1998-1999 we performed a study in Sweden where unaccompanied girls from Somalia were interviewed. They experienced great cultural differences concerning the expectations on girls. They had difficulties to learn Swedish and lack of trust in new people.

The overall aim with this study is to document and to analyse how a group of unaccompanied girls from Somalia look back on their first years in Sweden as young adults. The objectives are to document how they have experienced the reception of the authorities, how they have been received by the Swedish health care system, how they self-rate their own health and how they have developed their social network in Sweden. Their experiences will identify factors important for a good reception and integration. This knowledge can be useful for authorities and caretakers when they plan for other groups of unaccompanied children today and in the future.

Magdalena Bjerneld, PhD

Infertility and assisted reproductive technology (ART), with focus on surrogacy in Assam, India

Infertility often creates social and financial problems because of the importance of having children to secure the support in old age and ensure the continuation of the lineage. Especially women suffer from not being able to bear children and childlessness carries social stigma. Even though infertility treatment can be found within the public health care system in India it is in a very small scale and difficult to access. ART is mainly provided to a high cost in private clinics, and there has been a rapid increase of clinics. Many clinics also provide surrogacy but the service is in large part used by childless couples outside of India. The enormous increase in ART clinics providing surrogacy also means that they are no longer located only in big cities, but have spread all over India even to places where they lack basic health care facilities.

Assam is one of seven North-East states in India and borders Bhutan and Bangladesh. Assam is considered to be one of the poorest states in India. Reproductive health care is in many ways insufficient and no government hospital has a department for In-vitro-fertilization (IVF). The study has a qualitative approach and is focusing on different perspectives of the issues on options to parenthood in Assam. Special emphasize is on surrogacy as a solution to childlessness. The study is carried out in collaboration with Gauhati University, Assam, The Department of Women´s studies.

Accessibility and Acceptability of Medical Abortion and Contraception in Low-resource India

Maternal mortality is high in India (178/100000 LB), especially in Rajasthan (255/100000 LB), one of the government’s priority states due to its poor health outcomes. Although abortion was legalized in 1971, access to safe abortion services is still inadequate. Unsafe abortions are estimated to account for 8-18% of maternal deaths in India, in addition to substantial morbidity. Contraceptive use is low and so is women’s general awareness of their reproductive health and available reproductive health services. This project aims to simplify medical abortion and make it more acceptable to women as well as to health care providers. Simplifying and demedicalising medical abortion can decrease service costs and make services more affordable to women in low-resource settings. Moreover, combining medical abortion with contraceptive counseling and health promotion may enhance women’s motivation to adapt a contraceptive method post-abortion. In addition, making abortion services more acceptable to women may motivate women to seek future reproductive health care services from the public health system, something that is not widely seen today.

A randomized control trial is carried out to investigate the efficacy, safety and acceptability of a simplified medical abortion regime in a rural and urban low-resource setting in Rajasthan, India. Studies in Europe and USA have shown an increased acceptability among both women and providers when fewer clinical visits are required for a medical abortion, however, these studies do neither take the low-resource setting, the lack of mobile phones and infrastructure, and the low literacy level into account. This study aims to fill the knowledge gap and investigate the feasibility of simplified follow-up in low-resource settings. Additionally, the contraceptive use among women post-abortion will be investigated, and barriers to access to safe abortion services and contraceptive use will be explored. Furthermore young women’s reproductive choices and partner involvement in the reproductive decision-making process among rural youth will also be explored outside of the randomized control trial.

Marie Klingberg Allvin, PhD
Birgitta Essén
, Professor

Kristina Gemzell, Karolinska Institutet
Mandira Paul, PhD