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Between two lives - reproduction and health in a new country
For people who have recently arrived in Sweden, life can change how they think about their next pregnancy. With concrete language support, counselling for couples about contraception at midwifery clinics becomes easier and more equitable.
Illustration: Hans von Corswant
Women born abroad use effective contraceptive methods less often, despite a desire not to become pregnant. Knowledge, language and cultural norms affect women’s ability to make informed decisions, and contraceptive counselling therefore needs to be adapted to individual needs.
To address this, researchers at Karolinska Institutet launched IMPROVE-it, a Forte-funded project aimed at improving and strengthening equity in contraceptive counselling. The project included several components. In the first phase, 101 Arabic- and Somali-speaking women and men contributed by describing their experiences of meeting with midwives.
Their perspectives formed the basis for improvement proposals that were tested in the next step, where 14 midwifery clinics took part in seminars, competence-building initiatives and new ways of working – while the women continuously provided feedback.
– We used a co-creation approach in which the women were able to give input to ensure that the care would be as good as possible for them, says Elin Larsson, senior researcher at Karolinska Institutet.
We wanted to use a co-creation approach in which the women could provide input, so that the care would be as good as possible for them.
Elin Larsson
Senior researcher at Karolinska Institutet
Focus on recovery between pregnancies
The study showed that life in Sweden had changed how the participating women and men think about their next pregnancy. Language studies, establishing themselves in the labour market and having a weaker social network increased the need for recovery between pregnancies.
Counselling must take into account varying levels of knowledge about the body and contraception – sometimes conveyed through an interpreter. Differences between advice from people in the country of origin and Swedish healthcare professionals sometimes created confusion and uncertainty.
– If midwives are aware of this, they can address it and explain how the Swedish healthcare system works, says Elin.
Many of the women appreciated it when the midwife asked during pregnancy whether it was okay to talk about contraception.
– At that moment, they may have wanted to focus on the baby being born healthy, but still felt it was desirable that contraception was mentioned, Elin explains.
Others said that the conversation was easier when the focus was on recovery between pregnancies.
– They expressed that instead of talking about preventing pregnancy, it was better to talk about increasing the time between pregnancies.
The man is important in the conversation
While the women emphasised that the decision about contraception is theirs, they felt that their partner’s understanding and involvement are important. Many of the men also asked for more knowledge.
Trust in healthcare varied. Several described receiving good support, while others – particularly Somali-speaking women – reported experiences of discrimination in healthcare.
SRHR stands for sexual and reproductive health and rights. Mika Fogelberg is an analyst at the unit for sexual health and HIV prevention at the Public Health Agency of Sweden. She explains why women born abroad should be prioritised at the national level.
– People with migration experience often have poorer conditions for achieving good and equitable health, she says.
The Public Health Agency of Sweden particularly emphasises the importance of access to knowledge and information about SRHR for those who are young and newly arrived in Sweden.
We have tried to adapt the information so that no values related to culture, religion or sexual orientation are reflected in the content.
Dima Bitar
Doktorand på Linnéuniversitetet samt barnmorska
Language support for the dialogue
Language can be a barrier for those who are newly arrived. A concrete tool developed to strengthen contraceptive counselling is SADIMA, a multilingual dialogue support available in Arabic, Swedish and English. The tool was developed by midwife and doctoral student Dima Bitar together with research colleagues at Linnaeus University, in close collaboration with practising midwives.
SADIMA is web-based and includes short, easy-to-access videos about contraception and rights in several languages.
No values reflected in the content
Dima emphasises that a norm-critical perspective has also been central.
– We have tried to adapt the information so that no values related to culture, religion or sexual orientation are reflected in the content, she says.
Dima believes that achieving more equitable sexual and reproductive health requires both new ways of thinking and flexibility:
– You need to think outside the box and adapt care to women’s circumstances – and communication is extremely important.
Elin Larsson shares this view.
– If you adapt care to the individual in front of you, each person receives the care they need rather than everyone receiving the same.
To achieve sexual and reproductive health, all individuals must:
- have their bodily integrity, privacy and personal autonomy respected
- be free to define their own sexuality, sexual orientation, gender identity and gender expression
- decide if and when they want to be sexually active
- have the right to choose their sexual partners
- have safe and pleasurable sexual experiences
- choose if, when and with whom to enter into marriage
- decide if, when and how they want to have children, and how many children they want
- have access throughout life to the information, resources, services and support needed to achieve the above, without the risk of discrimination, coercion, exploitation or violence
Sweden works globally for equitable SRHR
SRHR stands for sexual and reproductive health and rights and refers to physical, emotional, mental and social well-being in relation to all aspects of sexuality and reproduction. Everyone should have the right to decide over their own body and have access to healthcare and other health-promoting services.
Sexual and reproductive health has improved globally, but major challenges remain in low- and lower-middle-income countries. Every eleven seconds, a woman or a newborn dies in connection with childbirth.
Many unintended pregnancies and deaths could be prevented with better healthcare, comprehensive sexuality education, knowledge about maternal and childbirth care, and access to safe abortion.
Through development assistance from Sida, more girls and women are able to decide over their own bodies, access to contraception is improved, and maternal health is strengthened.
Sweden is one of the largest international donors.
Source: Sida
TEXT: Johanna Aggestam (english translation by Forte)
