Methods
The author discussed the subject of perinatal care of women from Somalia with two physicians who care for them at Harborview Medical Center and the University of Washington Medical Center. Key informant interviews were conducted with Harborview’s Somali caseworker / cultural mediator and a Somali medical interpreter. In addition, the author reviewed and incorporated published literature.
The author, a labor and delivery nurse, has worked with Somali women for 11 years and has served on Seattle’s Somali Perinatal Taskforce.
Introduction
Providers can improve obstetrical outcomes and provide culturally appropriate care to women from Somalia if familiar with the cultural values and historical experiences of women and their families. It is important not to simply generalize. Be aware of some of the overall cultural values of the community and then explore the pertinent themes as they relate to providing health care for individual patients from Somalia. There is diversity within the Somali community. The experiences of Somali community members will vary greatly depending on whether they lived in rural or urban communities in Somalia, how long they have been in the United States, their former occupation and level of education.
When working with diverse communities in health care it has been customary to look at the non-dominant culture as a barrier to care (Tripp-Reimer, Choi, Skemp Kelley, & Enslein, 2001). Considering the culture of biomedicine as potentially having barriers to care may provide direction for practice (Tripp-Reimer et al., 2001). Cultural competency requires the provider to be cognizant of the role of privilege and power in the health care context (Drevdahl, Canales, & Dorcy, 2008; Wear, 2003). Many people from Somalia have endured incredible losses. Despite these losses, persistent difficulties and discrimination, people from Somalia continue to greatly value family and parenting. The health care provider is encouraged to be cognizant of the contextual background of both the vulnerability and strength of the Somali client or community and to consider the structures of privilege and power in health care institutions and providers that affect the relationship.
Migration patterns and census methodology make it difficult to know for certain the size of the local Somali immigrant population. Community leaders estimate that 15,000 to 20,000 Somalis live in the greater Seattle area, making it one of the largest Somali communities in the United States. This is a result of the migration of the thousands of Somalis who left the war-torn and impoverished country of Somalia as refugees in the 1990s. Health issues for refugees are further complicated by lack of adequate health care in resettlement camps, mental health issues because of many losses sustained, and ongoing discrimination and difficulty after arrival in this country. This is the context that many Somali immigrants bring to the health care encounter. It is helpful to review the cultural, social, and political background of Somalia to understand what is happening in the health care setting.
Role of Faith
Faith has a highly significant role in Somali culture. Almost all Somalis are Sunni Muslims. For those who practice Islam, religion has a much more comprehensive role in life than is typical in the Americas or Europe. Islam is a belief system, a culture, a structure for government, and a way of life. In Somalia, attitudes, social customs, and gender roles are primarily based on Islamic tradition (EthnoMed, 1996). The word “Inshallah” is an expression meaning “God willing” and this concept guides Somali people through life.
The Impact of Recent History on Women from Somalia
Civil War
In the early 1990s the government of General Mohammed Siad Barre was overthrown and civil war ensued. The civil war in Somalia had numerous implications for Somali women. Thousands of Somali women and girls experienced interpersonal violence between 1991 and 1994 (Musse 2004; Robertson, Halcon, Savik, Johnson, Spring, Westermeyer, & Jaranson, 2006; WomenWarPeace.com; Byrne, Marcus, & Power-Stevens, 1996). Often these attacks were clan related. (For more information about clans, see Family and Kinship Structure section below.)
Gender-specific violence, such as rape and kidnapping, has been used as a weapon of war in Somalia as it has been used in many war-torn areas. Women from Somalia have been profoundly affected by the sexual assaults that occurred during the civil war. It can be expected that many of these women are of childbearing age and present for care in Western settings.
Interpersonal Violence
As in many places of the world, the dominant Somali culture conceptualizes a woman’s honor and status on her sexual history (Musse, 2004). The sexual assault of a woman has traditionally required retribution by the male relatives of her family, which often leads to further inter-clan fighting. A strong cultural stigma is associated with rape in Somalia (Musse, 2004). If a woman is known to have been sexually assaulted, the possibility of marriage is greatly decreased. Socially, her prospects are bleak and this may be one of the reasons there is little reporting of sexual assault in Somalia. The stigmatization of sexually assaulted women has caused many of these women to withdraw from social and economic activities in the community. Musse (2004) believes that women from Somalia who have been sexually assaulted would benefit from counseling, reconstruction of social and economic networks, and restoration of their social status.
Resulting Impact on Health and Pregnancy
Mental health issues loom large for refugees because of their traumatic experiences. The most common disorder seen in refugee women is Post Traumatic Stress Disorder (PTSD) (Kemp & Rasbridge, 2004). Many refugees experience PTSD. Typical symptoms of PTSD include avoidance of the offending stimuli, emotional numbing, inability to remember significant memories around the trauma, hyper vigilance, irritability, difficulty sleeping, and poor concentration (Kemp & Rasbridge, 2004). Because of poor access to health and social services and continued experiences of discrimination after arrival in the U.S., PTSD may be chronic for the refugee (Byng, 1998; 2008). Many women and girls from Somalia experienced interpersonal violence during the civil war (Jaranson, Butcher, Halcon, Johnson, Robertson, Savik, Spring, & Westermeyer, 2004). It is conceivable that the mothers we are caring for are women suffering from the sequelae of these war crimes (Gardner, El Bushra, & Catholic Institute for International Relations, 2004).
Women who have a history of sexual trauma often have pregnancies that are complicated by the sequelae of the trauma, such as anxiety disorders, depression, PTSD, and personality disorders. These women have a higher incidence of somatic complaints, such as gastrointestinal complaints and chronic pain (Rodgers, Lang, Twamley, & Stein, 2003).
Women with a history of trauma may have better birth outcomes if they have prenatal care that addresses not only basic health issues related to pregnancy but also interventions targeted to the sequelae of sexual trauma (Rodgers et al., 2003). Because a large number of immigrants from Somalia are refugees and victims of violence, torture, and loss, it is important to be cognizant of the impact of these things on health care (Adams & Assefi, 2002). Many refugee women have lost family and partners to the war and subsequently have impaired support systems.
Providers should be familiar with culturally appropriate community resources that can assist the refugee and should provide referrals to services that may assist the individual in adapting to immigration and coping with the aftermath of violence and personal loss. (For information about treatment, see article about Somali Mental Health .) Recovery from the effects of conflict and trauma occurs within the social context (Robertson et al., 2006). Additional research is indicated in providing care for refugee women who have a history of interpersonal violence.
Reproduction
Childbearing and Family Size
For Somali women, childbearing usually begins at a relatively young age, shortly after marriage (American Public Health Association). (For more information, see Somali Cultural Profile section about Marriage .) In general, it is important for many women from Somalia to be able to have numerous children throughout their childbearing years, and Somali families may be large. Birth control and family planning are not widely practiced because of this preference. Women may especially want to avoid cesarean births because this procedure can limit the number of children a woman may be able to safely carry.
Children are highly valued in Somali culture and are considered gifts from Allah (God). In addition, mothers may desire many children because of high childhood mortality in Somalia, need for help in the household, security in old age, and for the social valuation of parenthood and love for children. A woman’s status is enhanced by having more children (Dybdahl & Hundeide, 1998).
Preconception Care
Preconception care is highly relevant to the Somali population because as refugees they may have compromised health status. Improving health before and between pregnancies can improve outcomes. It is important to be sure that any ongoing medical problems such as high blood pressure or diabetes are well-controlled before conception.
Family Planning
Because many women from Somalia place a high value on having many children, care providers who offer contraception may be turned down. Many women from Somalia feel that they are not asked or listened to about what their wishes are regarding family planning. The provider should be careful not to impose his or her beliefs about contraception, or to judge the patient’s perspective. For instance, it may not be appropriate to say to the patient, “Be realistic, in the U.S. it is not practical to have so many children.” (Minnesota International Health Volunteers, 2007).
The provider may ask, “Are you interested in birth control?” Birth control is considered appropriate in Islamic belief when there is a serious health problem or risk to the mother’s health. Framing contraception as a way to build up a woman’s health reserve and improve reproductive outcomes may be a more culturally congruent way to approach contraception and child spacing (Minnesota International Health Volunteers, 2007).
Child spacing was more easily maintained in Somalia since lactation often has a contraceptive effect. Children in Somalia are typically breastfed for 2 years. However, in the United States, increased supplementation with formula has interrupted the hormonal cascade that naturally maintains child spacing. Materials about child spacing are available in the Somali language for patients through the Minnesota International Health Volunteers. (See Patient Education Materials below for more information.)
Obstetrical Care of Women from Somalia
Prenatal Care
Many women not used to Western health care may need clear instructions as to why prenatal care is important. There is a perception among some women from Somalia that prenatal care is not needed as long as everything seems to be going well in the pregnancy (Essen, Johnsdotter, Hovelius, Gudmundsson, Sjoberg, Friedman, & Ostergren, 2000). The benefit of screening for potential problems is not always apparent, perhaps due to the lack of health care infrastructures and preventative care in rural Somalia.
Some women avoid going to an obstetrical provider, family doctor or midwife for fear that unnecessary tests or interventions will interfere with natural delivery and result in adverse birth outcomes. Some women from Somalia feel that doctors dictate to them. It is important to discuss risks and benefits and listen to and respect the patient’s decisions. Providers should encourage patients to ask questions and develop a birth plan so that it is clearly understood before labor what the patient’s wishes are regarding induction, pain medication, and epidural anesthesia.
Women from Somalia have identified a need for more information on the delivery room experience, pain medications, the rationale for prenatal care, use of interpreters, and services they can expect nurses and medical staff to provide (Herrel, Olevitch, Dubois, Terry, Thorp, Kind, & Said, 2004). Many women from Somalia have limited literacy or speak dialects that are not dominant, so careful assessment of the ease of utility by the client should be assessed when giving handouts in the Somali language.
Women from Somalia in general prefer to receive health education in the format of videotape for home viewing, tours of the birth unit given in the Somali language, audiotapes, printed materials, home visits by a Somali speaking educator, education for the partner/husband, web based programs, and one-on-one childbirth education (Herrel et al., 2004). Explanations can also be facilitated by informal drawings.
Research indicates that there are several strategies to improve attendance of women from Somalia at prenatal care appointments (Herrel et al., 2004). These include the following: reminder phone call the day before appointments; transportation to the appointment; childcare; education about the purpose of prenatal doctor visits; a drop-in clinic for Somali women only (no appointment needed); and printed calendars with date and time of next appointment.
First Appointment
Typically, health care providers ask clients at the first obstetrical appointment if the pregnancy is a wanted one. This may seem inappropriate and offensive since Somali families view children as gifts from Allah and would be opposed to the idea of terminating a pregnancy. For women who are unfamiliar with health care in the U.S., it may be appropriate to ask the patient if she would like to use the first prenatal visit to discuss pregnancy and prenatal care and have the pelvic examination on the next visit.
Subsequent visits should provide education about fetal monitoring and the significance of fetal monitoring, options regarding comfort measures, provider call systems, and information on teaching hospitals.
Gender Concordance and On-Call Providers
Gender concordance between the health care provider and the patient is a value for many women, and this may be especially true for obstetrical care for women from Somalia. It is important that the possibility of having a male provider on-call for delivery be discussed with the Somali mother during the prenatal time period and when the patient presents in labor. It is not possible to generalize about patient preferences. Some Somali women may choose a male provider to provide prenatal care; others may prefer a female provider but accept care easily from a male provider; others may accept care from a male provider only in an emergency; and, some may refuse care by a male provider. Every effort should be made to comply with a Somali mother’s wishes regarding preference for having female providers during labor. Strategies when the on-call provider is male have included having the obstetrical nurse do exams or asking available female providers to conduct exams.
Discuss Cesarean Delivery during Prenatal Care
Providers should be aware of the apprehension that women from Somalia have in regards to cesarean delivery. Fear of severe complications, even death, compels some Somali women to avoid seeking medical care or to refuse intervention that could involve cesarean delivery. The reasons for recommending a cesarean delivery should be carefully discussed in the prenatal time period (Herrel et al., 2004). (For more information, see Medical Technology and Fear of Cesarean Delivery below.)
Discuss Circumcision Care in the Prenatal Time Period
The lack of knowledge regarding the perinatal care of circumcised Somali women has a significant impact on the health care and relationship between the Somali mother and health care provider (Strauss, McEwen, & Hussein, 2007). Provider judgment or negative reactions regarding female circumcision are inappropriate. Some Somali women believe that cesarean births are encouraged due to the provider’s unfamiliarity with female circumcision. A thorough history and assessment of the mother’s wishes should be done in the prenatal time period after a trusting relationship has been established. (For more information, see Circumcision Care below.)
Identify and Document Decision-Makers
Decision-making in the Somali culture is much more communal than is typical of Western societies. Health care decisions affect not only the individual community member and her family but the whole community. In the acute situation of labor, assessing who is responsible for decision-making can be difficult. One approach is to ask the mother who will be assisting her in decision-making during labor. This should be clearly documented on the prenatal chart so that during labor or emergent situations this information can be easily accessed.
Labor and Delivery
Disparate Perinatal Outcomes in Somali Women in Washington State
In the Somali community in Seattle, there is a perception that there are too many technological interventions (such as induction of labor and cesarean births), which contrasts with the desire for natural childbirth. Fears of being practiced on, mistrust, and declinations of proposed obstetrical interventions have resulted from these cultural misunderstandings (Turnbull, 2004). Many women of Somali heritage have coped with this by declining proposed medical interventions in order to birth in ways that are more culturally appropriate. Research that examined maternal and infant outcomes in this community has confirmed some of these perceptions.
Researchers have linked disparate perinatal deaths with suboptimal perinatal care in Somali immigrants. Factors such as sociocultural differences in pregnancy strategies and suboptimal performance of certain health care routines in the perinatal care system have contributed to disparate perinatal deaths in the Somali community (Essen, Bodker, Sjoberg, Langhoff-Roos, Greisen, Gudmundsson, & Ostergren, 2002). Women may voluntarily reduce food intake in the prenatal time period in order to have a small baby, which will then facilitate vaginal delivery (Essen et al., 2000).
Avoidable perinatal deaths related to maternal pregnancy strategies include the Somali woman’s failure to report the absence of fetal movement, the lack of participation in routine perinatal surveillance such as ultrasound to determine dating, and late initiation of prenatal care (Essen et al., 2002). Other findings include incidence of delayed or declined emergent cesarean section even when experiencing grave symptoms such as hemorrhage. These findings suggest that it is imperative to build a rapport with the Somali family and to provide prenatal education that is culturally appropriate. If prenatal care is inaccessible or judgmental, and patients are not coming in for care it, is a failure of the health care system.
Disparate maternal-neonatal outcomes among Somali women in Washington State have been documented by Johnson, Reed, Hitti, & Batra (2005). The motivation for this research was to examine misunderstandings between health care providers and the Somali community. Somali community members have been telling providers that they were concerned that biomedical technical interventions were occurring too often, rapidly, and unnecessarily. The purpose of the study was to evaluate obstetrical and neonatal outcomes for Somali immigrant women in this geographical area and to discern whether this cohort represented a high risk sub population.
These researchers compared maternal and neonatal morbidity among Somali immigrants, U.S.-born blacks and whites in Washington State. This was done by comparing Washington State birth certificate data among these three groups between 1993 and 2001. The results indicated that first-time Somali mothers were more likely to have a cesarean delivery than the black or white control group. Among all women who had cesarean delivery, Somali women were more likely to have a cesarean delivery associated with fetal distress and failed induction of labor. They found that Somali women were:
- Nine times more likely than both whites and blacks to deliver past 42-weeks gestation
- Four times more likely to have oligohydraminos (low amniotic fluid volume)
- More likely to have gestational diabetes
- More likely to have significant perineal lacerations
- Less likely to smoke then either control group
The newborns of Somali women were at increased risk of prolonged hospitalization, having lower 5-minute Apgar scores, and requiring assisted ventilation and meconium aspiration.
This research suggests that the pregnancy outcomes need to be evaluated by addressing cultural factors that may contribute to poorer reproductive outcomes. The finding of prolonged gestation requires further research especially because it is in contradistinction to high prematurity rates in native-born black women (Baker & Hellerstedt, 2006). Postdatism (pregnancy continuing past 42 weeks) most likely plays a role in disparate outcomes in this cohort (Johnson et al., 2005). Female circumcision does not explain the identified adverse outcomes. Researchers suggest there is a need to address the concerns of this community and to use cultural ambassadors to bridge the gap between biomedicine and the needs of this community.
Perception of Labor and Delivery
Labor and Delivery in Somalia
Based on experiences in Somalia, women of Somali descent often have the perception that labor is a vulnerable time. Childbirth in Somalia is often fraught with the risk of maternal or neonatal mortality. The maternal mortality rate is 1,600 per 100,000 live births (UNICEF, 1998) which contrasts to a maternal mortality rate of 12 per 100,000 in the United States (UNICEF, 1998). The rates of child morbidity and mortality in Somalia remain among the highest in the world.
A survey undertaken in 2006, the Multiple Indicator Cluster Survey (MICS), estimates the infant mortality rate (IMR) at 86 per 1000 and under five child mortality rate (U-5MR) at 135 per 1000 (UNICEF, 2008). Hemorrhage, prolonged and obstructed labor, infections, and eclampsia are the major causes of death at childbirth. Anemia and female circumcision (infibulation) may aggravate these conditions. Inadequate antenatal and postnatal care, with the almost complete lack of emergency obstetric referral care for birth complications, further contribute to these high rates of mortality and disability. In Somalia it is estimated that only 2% of births take place in a health care facility accompanied by a skilled attendant (Herrel et al., 2004).
Medical Technology and Fear of Cesarean Delivery
The use of technology in childbirth has been an ongoing debate within Western culture over the past generation. For women from Somalia, procedures which may seem routine to many women (induction of labor, monitoring during labor, and cesarean delivery) can be problematic. Cesarean birth is thought of by some Somali women with fear and apprehension (Herrel et al., 2004). This may be related to the dismal rates of maternal mortality in Somalia, and the fact that in Somalia, cesarean deliveries take place under dire circumstances in which survival is already at risk. It is believed that women who have cesarean births are at risk of suffering in post-delivery life. The perception that cesarean birth is dangerous and limits parity compels some Somali women to decline cesarean delivery in emergent situations (Essen et al., 2000).
In Somalia, and in refugee camps, the cesarean incision was most often done vertically. It is important to discuss with the Somali mother the difference between vertical and horizontal uterine incisions. Horizontal incisions are less risky to subsequent pregnancies and a vaginal birth after a cesarean delivery is often possible.
Providers should be aware of the apprehension that Somali women have in regards to cesarean delivery. Somali people value medical care; therefore, presenting care in culturally appropriate ways may facilitate the decision-making process. When cesarean delivery is presented as an intervention, include those individuals designated by the patient to assist in the decision-making process. In the U.S., use of a Somali doula has been shown to improve outcomes such as decreased cesarean delivery rates in the Somali community and should be considered if possible (Shelp, 2004; Dundek, 2006). Establishing good rapport and trust, addressing fears in the prenatal time period, and minimizing the use of optional medical technology may be ways of dealing with concerns.
Community’s Role During Labor and Postpartum
Members of Somali social groups can expect help from the community during labor (Finnstrom & Soderhamn, 2006). Somali women often receive social support from community members in the form of hospital visitation, foods from home, and prayer. Having family and community members close by is important to Somali women when in pain (Finnstrom & Soderhamn, 2006). This value is sometimes complicated by the necessity of more stringent work schedules and obligations in Western industrialized nations than is typical in Somalia. Traditional birth attendants were used in Somalia. Using a traditional birth attendant or doula in the hospital may be one way of providing support for the Somali mother (Shelp, 2004).
Conceptualization of Pain During Childbirth
The concept of pain and pain behaviors are culturally construed. Research indicates that disparities in pain treatment sometimes result from difficulties with pain assessment and communication and is sometimes related to race and ethnicity. Health care providers can assess pain and tailor interventions more effectively if they consider cultural norms.
In the Somali language the word for pain is the same as the word used for illness . The various meanings can obfuscate pain assessment. Emotional explanations of pain such as sadness and worry, discrimination, stress, and anger are increasingly used by Somali women to explain pain (Finnstrom & Soderhamn, 2006). Somali women tend to be stoic about pain; moaning and crying are viewed as weakness, since life contains a great deal of suffering (Finnstrom & Soderhamn, 2006).
Cultural norms that value endurance are seen in how Somali women conceptualize pain (Finnstrom & Soderhamn, 2006). Many Somali women fear that the use of an epidural will lead to stalled labor and possibly a cesarean birth; therefore, the patient may decline the use of an epidural to cope with labor pains. Ways of dealing with pain include rest, being with family and friends, and analgesics. Traditional methods include herbs, hot needles, and reading the Quran (Finnstrom & Soderhamn, 2006). Some Somali women opt for natural pain relievers such as warm compresses, massage, and position changes, instead of interventions such as medication or epidural anesthesia. The use of a doula is a culturally appropriate way to cope with labor and has been shown to improve outcomes (Shelp, 2004; Dundek, 2006).
Circumcision Care
Cultural needs of Somali women include the informed and respectful care of circumcision during childbirth. Approximately 98% of Somali women have female circumcision, usually the pharaonic type. Qualitative data from Somali women in respect to birthing in a Western setting is replete with Somali women’s perception of discrimination and this is especially evident around the cultural practice of female circumcision (Arbesman, Kahler, & Buck, 1993; Beine, Fullerton, Palinkas, & Anders, 1995; Chalmers & Omer-Hashi, 2000, 2002; Vangen, Johansen, Sundby, Traeen, & Stray-Pedersen, 2004).
The health care provider needs to be cognizant of both the technical and cultural aspects of caring for childbearing women with female circumcision. (See 1997 manuscript by Horowitz and Jackson for recommendations, and 2013 article by Hearst and Molnar: Female Genital Cutting: An Evidence-Based Approach to Clinical Management for the Primary Care Physician.)
A thorough history and assessment of the mother’s wishes should be done in the prenatal time period after a trusting relationship has been established. The mismanaged care of circumcised Somali women has a significant impact on the health care and relationship between the Somali mother and health care provider (Strauss et al., 2007).
Postpartum Care
Somali women receive esteem for their roles as mothers. The mother’s need for recuperation in the post-partum period is recognized and facilitated. During this time the woman is expected to rest and her primary responsibility is breastfeeding the newborn. Traditionally, family and community members take care of the other children, the house, and meal preparation. The mother is given special foods to help her recuperate. When the newborn is awake but not breastfeeding, other women take care of the baby so the mother can rest.
Because of changes in roles due to changes in lifestyle in the U.S., many family members who would have been available for help in Somalia are now obligated to care for children or to work outside the home. This usual source of postpartum support has been curtailed. Some Somali mothers are perplexed that there is not more assistance in the hospital, where staff typically expects mothers to provide care for their newborns from birth. Acknowledging the difference in cultural practices may validate the mother’s perception that there is little of the type of help in the hospital that Somali women are accustomed to. The use of a Somali postpartum doula may be a way of promoting this cultural practice (Shelp, 2004; Dundek, 2006). Encouraging family members and community members to participate in the postpartum care of the mother may help support her.
Perinatal Loss
Incidence
People from Somalia have been exposed to multiple stressors and losses in their lives through their experiences of being from a war-torn and impoverished nation, being refugees, and having high maternal and child mortality rates in Somalia (UNICEF , 2008; Ibrahim, Omar, Persson, & Wall, 1996 ). Research indicates that the mean number of births was 5.2 in Somali women but the surviving number of children was 3.7 (Omar, Hogberg, & Bergstrom, 1994). Almost 66% of women over the age of 45 years had six or more births, 33% had at least one miscarriage, and 20% had at least one stillbirth. Eighty-percent of Somali women have experienced the death of at least one child (Omar et al., 1994).
Intrauterine fetal demise and neonatal mortality are sometimes viewed as the will of Allah. Somali women are often encouraged to accept their loss with strength. Accepting Allah’s will is a religiously appropriate way of dealing with loss. To the Western provider it may look like denial or apathy; however, Somali people are often encouraged to accept loss stoically. To accept loss is to reinforce one’s faith in Allah. This may be an adaptive mechanism in view of the multiple losses Somali people have endured. Health care providers can be cognizant of this when caring for Somali mothers who are experiencing loss.
Communication and Rapport in the Health Care Setting
Because Somali culture is oriented much more toward community interdependence than is typical of Western cultures (Finnstrom & Soderhamn, 2006), people from Somalia tend to be more concerned about relational aspects of care (Finnstrom & Soderhamn, 2006). As with obstetrical care in general, the provider can facilitate the care of the woman if time is spent on establishing rapport and trust, which in turn will facilitate communication in the acute situations that often arise during childbirth.
One of the recurrent themes in the qualitative literature on Somali women and childbirth in Western settings is a perception of disrespect on behalf of health care professionals (Beine et al., 1995; Chalmers & Omer-Hashi, 2000, 2002; Essen et al., 2002; Herrel, et al., 2004; Strauss et al., 2007; Vangen et al., 2004). Providers who spend the energy and time to understand individual and community values will find shared decision-making in acute health situations easier to navigate.
To promote rapport (Strauss et al., 2007):
• Use a trained interpreter
• Explain proposed interventions
• Acknowledge importance of community and family in decision-making
• Provide continuity of care
• Be aware of the accumulated pressures immigrant women face
• Ensure gender concordance when important to the patient
• Respect modesty
Patient Education Materials in Somali
Child Spacing & U.S. Obstetrical Health Care System
WellShare International (formerly Minnesota International Health Volunteers (MIHV)) has published videos and pamphlets on the subject of child spacing and the U.S. obstetrical health care system. Contact WellShare International for these free materials.
Other Resources
A resource for health care workers providing health care to Somali women is the article Primary Care Refugee Medicine: General Principles in the Post-Immigration Care of Somali Women published by Adams & Assefi (2002) which details the context of Somali refugee immigrant health and important components in history taking of this population, as well as pertinent exams, diagnostic labs, and issues of concern.
The article “Islam and Family Planning: A Somali Family Planning Case Study” (Dubois, D., Burkland, H., Kluznik, J., Jama, S., & Pasha, M.K.) can be accessed online at Research Gate.
Somali Health Board (Seattle) Centering Pregnancy
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