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Perinatal Experiences of Somali Couples in the United States Danuta M. Wojnar

Correspondence Danuta M. Wojnar, PhD, RN, IBCLC, FAAN, Seattle University College of Nursing, 901 12th Avenue, PO Box 222000, Seattle, WA 98122-1090. [email protected] Keywords immigrants childbirth phenomenology health care disparities

ABSTRACT Objective: To explore the perspectives of Somali couples on care and support received during the perinatal period in the United States. Design: Descriptive phenomenology. Setting: A private room at the participants’ homes or community center. Participants: Forty-eight immigrant women and men from Somalia (26 women and 22 men) who arrived in the United States within the past 5 years and had a child or children born in their homelands or refugee camps and at least one child born in the United States. All of the participants resided in the Pacific Northwest. Methods: Semistructured individual interviews, interviews with couples, and a follow-up phone interview. Colaizzi’s method guided the research process. Results: Data analysis revealed an overarching theme of Navigating through the conflicting values, beliefs, understandings and expectations that infiltrated the experiences captured by the three subthemes: (a) Feeling vulnerable, uninformed, and misunderstood, (b) Longing for unconditional respect and acceptance and (c) Surviving and thriving as the recipients of health care. Conclusions: Integration of new Somali immigrant couples into the Western health care system can present many challenges. The perinatal experience for new Somali immigrant couples is complicated by cultural and language barriers, limited access to resources, and commonly, an exclusion of husbands from prenatal education and care. Nurses and other health care providers can play an important role in the provision of services that integrate Somali women and men into the plan of care and consider their culture-based expectations to improve childbirth outcomes.

JOGNN, 44, 358-369; 2015. DOI: 10.1111/1552-6909.12574 Accepted January 2015

Danuta M. Wojnar, PhD, RN, IBCLC, FAAN, is an associate professor and chair of the Department of Maternal/Child and Family Nursing, Seattle University, College of Nursing, Seattle, WA.

The author reports no conflict of interest or relevant financial relationships.

uring the past few decades, Somalia has been plagued by war, famine, and instability (Wojnar & Narruhn, in press). There has been no effective central government in Somalia for more than 20 years (Narruhn & Schellenberg, 2013). In its absence, ongoing violence and lack of infrastructure have taken a devastating toll on the Somali people (Ethnomed, 2012). It has been estimated that more than a million Somalis have fled their war torn country, and more than 1.3 million are internally displaced (Refugees International, 2013). These cumulative stressors make Somalia one of the largest and most longstanding humanitarian crises in the world (Refugees International, 2013). The United States granted residency status to more than 100,000 Somalis who quickly became the largest African-born Muslim population in the country (Cultural Orientation Resource Center, 2008). Currently, roughly 20,000 Somalis reside in the Minneapolis Metropolitan area, 12,000 to 13,000 in the Seattle, Washington, area,

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and 10,000 to 12,000 in Chicago, Illinois, and Columbus, Ohio. Other Somali immigrants are scattered in smaller settlements throughout the country (Cultural Orientation Resource Center, 2008). Integration of new Somali immigrants in the United States and other host countries may be a long and complex process compounded by the vast cultural differences, the terror of witnessing war, and prolonged living in refugee camps that typically lacked access to formal education, health care, and other conveniences of modern-day life (Scuglik & Alarcon, 2005). The acculturative stress in the form of language difficulties, social isolation, financial pressures, and unquestionable beliefs in the effectiveness of traditional healers and related health practices has been an added tension for Somali immigrants that requires exploration of the Somali peoples’ perspective when offering essential services, such as the

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Western model of health care (Kirmayer et al., 2011).

Somali men want to be included in the provision of perinatal care of their wives.

Literature Review The majority of health care services currently offered in the United States and other host countries are linked to evidence-based recommendations identified for clients who are culturally congruent with the Western biomedical model of care. Integration of new Somali immigrants into the Western model of care may present challenges given that many Somalis are more familiar with traditional healers and folk remedies than Western medicine (Wojnar & Narruhn, in press). The situation is of particular concern for Somali women’s reproductive health as health disparities have been identified between the Somali and mainstream female populations in the United States (Johnson, Reed, Hitti, & Batra, 2005; Narruhn & Schellenberg, 2013), Canada (Chalmers & Hashi, 2000), and European countries (Akhavan & Lundgren, 2012; Rassj ˚ o, ¨ Byrskog, Samir, & Klingberg-Allvin, 2013; Warfa et al., 2012). In recent years, several investigators set out to identify the barriers to health care facing Somali immigrants in the United States as the first step to alleviating reproductive health disparities. Hill, Hunt, and Hyrkas ¨ (2012) using focus group approach (N = 4) and Pavlish, Noor, and Brandt (2010) using descriptive exploratory approach (N = 57) found that many Somali women avoid prenatal care because they distrust Western health care system. In a descriptive study of Somali women (N = 123) Dundek (2006) found that the majority of women were dissatisfied with inadequate public transportation to get to prenatal appointments and with the limited access to interpretation services. Based on the findings of a qualitative study conducted with Somali women (N = 23), Ameresekere et al. (2011) reported that the majority feared providers’ lack of knowledge about assisting vaginal birth for those with female genital cut (FGC) (also known as female circumcision), a procedure performed on most Somali women in their childhood (Wojnar & Narruhn, in press). Moreover, qualitative investigation conducted with Somali women (N = 34) by Brown, Carroll, Fogarty, and Holt (2010) showed that the majority of study participants feared cesarean section. Findings obtained using quantitative methodologies supported qualitative research findings. As

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a result of clinical records review of nearly 2,500 women, Johnson et al. (2005) reported poorer obstetrical outcomes for Somali women than the general population in Washington State, United States. Likewise, in a systematic review of the literature, Merry, Small, Blondel, and Gagnon (2013) reported higher cesarean section rates for SubSaharan African, Somali, and South Asian women than women from the host countries even after considering protective factors, such as healthy immigrant effect, preference for a vaginal birth, a healthier lifestyle, younger mothers, and preference to use fewer interventions in labor than women in the host countries (Merry et al., 2013). A combination of acculturative stress, social disparities, limited access to health care, and language barriers were identified as the main contributing factors to poorer obstetrical outcomes. Research conducted to identify the short term outcomes of supportive interventions designed for Somali women produced encouraging findings. Several studies investigated the Somali women’s involvement with doulas (also known as lay pregnancy and labor couches). Shelp (2004), in a study of doulas (N = 9), found that doula support program developed for Somali women resulted in women’s overall improved satisfaction with care, decreased use of pain medications in labor, and decreased cesarean section rate. Shelp (2004) also reported that trusted doulas successfully acted as cultural brokers between the Somali women and providers. Consistent findings were reported by Dundek (2006) who collected data from (N = 123) Somali women to evaluate satisfaction with services of doula program established at a large metropolitan hospital in the United States. Likewise, Akhavan and Edge (2012) reported improved patient satisfaction with the continuity of care and the quality of health information afforded by doula support in a community-based doula intervention pilot study for Somali women (N = 10) in Sweden. There are no published studies, however, in which investigators evaluated long term outcomes of supportive interventions offered to Somali childbearing women. Khaja, Lay, and Boys (2010) argued that before culturally appropriate supportive interventions can be designed and

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lead to elimination of childbirth disparities for Somali women, a broader perspective of Somali communities on their interaction with the Western health care systems is needed. The purpose of this study was to expand the existing knowledge by exploring the Somali couples’ perspectives on care and support they received during the perinatal period in the United States.

Methods Ethical approval was granted by the Institutional Review Board (IRB) for protection of human subjects at Seattle University. Descriptive phenomenological design was used to guide the investigation. Descriptive phenomenology emphasizes discovering knowledge about the phenomena that are not well understood, from the perspective of people who live through them and, in contrast to other phenomenological approaches; it seeks to unravel universal truths about the phenomenon under study (Wojnar & Swanson, 2007). Because the goal of this study was to identify common perspectives of Somali couples on pregnancy and childbirth, descriptive phenomenological approach was selected to guide the inquiry. Congruent with the descriptive phenomenological approach, research participants are considered experts on the phenomenon under investigation (Gearing, 2004; Wojnar & Swanson, 2007). Bracketing helps the investigators to set aside their prior knowledge and biases. Consistent with Wojnar and Swanson’s (2007) recommendations, the investigator engaged in the bracketing process. This was accomplished by completing self-reflective diary after each interview to clarify the points that seemed ambiguous and thus, allowing for various interpretations. The ambiguities were clarified during the telephone follow up interviews with study participants and postinterview conversations with the study interpreter who was an expert on Somali culture and customs. These strategies ensured accuracy of interpretation and thus, presenting the phenomenon under study from the participants’ perspective (Husserl, 1965).

Procedure Couples expressed interest in the study by calling a Somali interpreter hired to assist with the investigation. The interpreter explained the study purpose and procedures, answered questions, obtained a verbal consent to meet for an interview, and determined which families would require interpretation services to conduct the interviews. Subsequently, the interpreter made arrangements between the investigator and the prospective participants for an in-person interview. The women and men were interviewed separately and then a couple-together interview was conducted. All interviews were conducted at locations convenient for the study participants. The majority of interviews were conducted in the participants’ homes. Four interviews were conducted at a community center that allowed for complete privacy. The interviews with each individual lasted from approximately 30 to 60 minutes and the couple together interviews were about 30 minutes each. The interpreter was present at the interviews with 14 couples who lacked or had low knowledge of written and/or spoken English. Of those, interviews with eight couples were conducted in Somali language and six were conducted in Bantu (a dialect spoken by Somali Bantus).

Twenty six couples (26 women and 26 men) were recruited from the Pacific Northwest from Spring 2011 through 2012. Four men who initially agreed to participate in the study were subsequently not available for interview. Of those, three changed their mind for unknown reasons and one declined an interview because he separated from his wife.

The investigator’s questions were live translated to Somali or Bantu language as appropriate, and the participants’ answers were then live translated to English. The accuracy of translation was verified by a second individual fluent in both languages. Variations in the translation to English were resolved through verbal agreement between the two interpreters. All interviews, with the exception of two, were audio-recorded and transcribed verbatim for analysis. Two couples refused to be audiorecorded in fear of negative consequences should

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Sample

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In all four cases, data obtained from the women were included in the analysis. Several recruitment strategies were used: personal solicitation through a community partner agency that offers educational and social programs to new immigrants, provider referrals, and snow-balling technique. Inclusion criteria were (a) first-generation immigrant couples from Somalia who have arrived in the United States within the past 5 years, (b) Somali couples with or without the knowledge of English language, (c) Somali couples who had a child or children born in their homeland or refugee camp and at least one child born in the United States, (d) able to consent to participation verbally or in writing, (e) willing to participate in the study.

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Table 1: Examples of Interview Questions Questions Pregnancy What are some special customs observed by Somalis in pregnancy? What was is like for you as expectant parents in the USA? What assistance did you receive to access health care during pregnancy? Tell me about getting to the doctor/midwife appointments? How was the prenatal care different from your homeland/the refugee camp? How was the prenatal care similar in your homeland/refugee camp? Childbirth

family’s presence, and personal insights/biases that were later discussed and with the study interpreter and clarified during phone follow-up interviews to eliminate misinterpretation of data and solicit feedback on the outcomes of preliminary analysis. A follow-up phone interview was conducted with each couple within 2 weeks of the inperson interviews (with the interpreter’s assistance where needed) to clarify any ambiguities. The multifaceted data collection process (in person interviews with women and men separately then a couple together interviews, follow-up phone interviews, and fieldnotes taken to attempt bracketing) enhanced the credibility and trustworthiness of findings (Houghton, Casey, Shaw, & Murphy, 2013). The participants received $50.00 honorarium as a token of appreciation for their time and participation in the study.

What are some special customs observed by Somalis during childbirth? Tell me about the circumstances when you sought hospitalization for childbirth? What was the childbirth process like for you as a couple? How was it different from your homeland/refugee camp experience? How was it similar to your experience in your homeland/refugee camp? Postpartum What are some special customs observed by Somalis in postpartum period? What was the postpartum hospital stay like for you? What health care services would you find particularly helpful that were not offered? Why was it important to you?

the audiotapes be lost or stolen. Information gathered from these couples was recorded via hand-written notes taken by the investigator and verbally verified for accuracy at the completion of the interview. In-person interviews typically began with an opening question, “Tell me about your life after you settled in the United States?” and continued with questions more specific to pregnancy, childbirth, and postpartum period. A summary of research questions is presented in Table 1. Fieldnotes were generated after each interview to ensure bracketing took place. They included comments offered by women and men outside of the audio-recorded interviews, descriptions of environment while in

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Analysis The transcripts were read, reread, hand coded, and analyzed using steps outlined by Colaizzi (1978). To avoid preliminary foreclosure on the essence of emerging phenomenon, two research assistants coded data separately and then discussed it with the investigator to verify the interpretations. Additionally, the interpreter, who participated in the majority of interviews, was consulted because of their personal knowledge of Somali culture and customs. This approach to data analysis helped to enhance understanding of the contextual factors such as the culture, religion, and social context that influenced participants’ perinatal experiences with health care in the United States, before the final themes and exemplar quotes were selected by the interpretive team. The findings were then offered to study participants for final feedback regarding accuracy of interpretation. The participants agreed that their personal experiences mirrored the collective experience presented in the Findings section. Hence, there was no need to revise the description of the phenomenon as a result of follow-up interviews.

Results Sample The final sample consisted of 48 individuals, (n = 26) women and (n = 22) men. The length of the participants’ stay in the United States ranged from one to 5 years with the majority living in the United States for 3 to 4 years. All study participants lived in the Pacific Northwest at the time of data collection with some families (n = 7) who relocated there from other cities within the past year.

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The broader Somali community must be included in the planning of programs aimed at improving perinatal health disparities of Somali women.

The majority of families (n = 19) resided within the city limits whereas a few (n = 7) resided in the suburbs. The number of children participants had ranged from four to nine. Three women were pregnant at the time of data collection and one had a hysterectomy with her last childbirth due to a ruptured uterus. A summary of participants’ age, marital status, education, and employment is presented in Table 2.

Women

Men

(n = 26)

(n = 22)

n

n

3

1

Age 16–20 years 21–25 years

8

5

26–30 years

12

10

30–35 years

3

4

Older than 35 years

0

2

Married

25

22

Separated

1

0

4

0

7 years of elementary school

6

5

High school

12

15

Some college

4

2

20

4

Marital status

Education 1–2 years of elementary school

a

Employment/Annual income No paid employment Less than 5,000K

3

0

$10,000–20,000

0

10

$20,000–30,000

2

8

On unemployment benefits

1

0

Note. a None of the Somali Bantu women or men had paid employment at the time of data collection.

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An overarching theme—Navigating through the conflicting values, beliefs, understandings and expectations—and three subthemes, (a) Feeling vulnerable, uninformed, and misunderstood; (b) Longing for unconditional respect and acceptance; and (c) Surviving and thriving as the recipients of health care, constituted the common experience of study participants’ pregnancy, childbirth, and postpartum periods. The narrative exemplars presented in this section were selected by the interpretive team and confirmed as the key messages by study participants during follow up phone interviews. They illustrate the diverse ways in which the overarching theme and subthemes were experienced and enacted.

Navigating through the conflicting values, beliefs, understandings, and expectations

Table 2: Sample Characteristics

Characteristic

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Soon after arrival in the United States all study participants became acutely aware of the differences between their own cultural values, beliefs, and customs and what they considered “the American culture” around various aspects of life but especially, family size. All of the couples expressed a desire to have “as many children as God is willing to give” and felt troubled that so many American couples had one to two children or no children at all. To reduce the cultural gap regarding the desired number of children, study participants focused their energy on identifying similarities between the host country and their own belief system to help them better interact with others at the community level and with the obstetric care teams during pregnancy and hospitalization for childbirth. The desire for unconditional respect and understanding of the Somali belief system regarding family size was the key narrative that permeated the overarching theme and the three subthemes. The participants focused on what mattered most to them as couples though being acutely aware that the divergent beliefs were likely to create at least some dissonance in their interactions with non-Somalis. All couples stressed a desire to be accepted just as they are and spent a great deal of time explaining their stance on pregnancy and children. One male participant summarized: Children are very important in our culture. When a man cannot have the kids he wanted from his wife, he can look for another woman to fulfill his role in life as a man and

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the God’s expectation from marriage. You know, that traditional expectation of many kids meaning much wealth. But, it is hard to keep that kind of attitude here (in the USA); I find many doctors and nurses and people in general are judgmental about Somalians having many kids. They may or may not say it out loud but you can feel it and it creates tension. And so, I am trying to focus on similarities, like showing I love my many kids just like the Americans who have only one or two kids. The majority of couples felt discomfort with what they referred to as “the American lifestyle,” especially regarding marriage and children. They missed the social order congruent with the Somali culture and expressed that the difference felt uncomfortable. They also expressed a desire for unconditional respect of Somali customs. A female participant explained: One good example I can give you is when a Somalian woman falls in love and dates. It is considered disrespectful in our culture. Back home it is all about having an arranged marriage and then having kids. In the US, as far as I can see, it is all about dating and having a relationship. And so, it feels uncomfortable to go about marriage and kids differently than most Americans but we do what is right. Maybe if Americans saw a movie about Somali culture they would judge less. Although couples were aware of the prenatal care and government sponsored community resources, many believed they could not solely depend on health care professionals for pregnancy and childbirth care either because it wasn’t delivered in a culturally sensitive manner or because they simply didn’t trust that the interventions would be of any benefit. By weighing medical advice against their own life experiences and the opinions of healers and elders in the Somali community, the women and men felt they could navigate the health care system easier. For example, the majority of study participants believed that routine pregnancy tests and dietary adjustments are not necessary because pregnancy is a “normal” state. Like other women, one study participant shared: Back home women have babies without taking any pills when pregnant. I had three kids in Kenyan refugee camp, all vaginal births; I had no problems. With my fourth

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kid, in the US, my midwife advised: “eat this and eat that; take this medicine and that medicine.” I didn’t argue but when I came home I told other women in my community. They all said: “medicines are for sick people and you are not sick; you are just pregnant.” I decided to not take the pills and the baby was born normal like my other kids. Experiencing pregnancy and childbirth within the framework of traditional Somali beliefs was of paramount importance to all couples in the study and was one of the most prevalent narratives throughout the interview process. All of the couples highlighted the importance of vaginal birth to prevent setting up a limit on the number of pregnancies and to avoid the potential complications of surgery. Many participants readily described strategies to accomplish just that. One woman shared: I think no woman should come to hospital too early to have a baby. When you arrive too early you get medicine in your arm and then end up with a c-section. I would rather give birth on the highway than arrive too early and have a c-section. With my last kid I waited at home until I was pretty close to delivery and when I arrived, I think it was too late for any medicines and I had a vaginal birth. Many women I know have done the same. Feeling vulnerable, uninformed, and misunderstood. The majority of couples felt uniformed and wished more time was spent on explaining things and verifying wishes and understandings. Most couples didn’t ask any questions because they didn’t know what to ask. They hoped the caregivers would somehow know when to provide them with information without making assumptions. Because the participants often didn’t understand what was going on, they missed opportunities that were important to them for religious and cultural reasons. One father recalled: When our last son was born, I went to hospital with her because there were no women to go with her. I knew some English but my she didn’t and we had a computer translation. But, when the baby came out, they turned it off. They took my baby away and gave him shots. I thought something was wrong with him and I started crying. When the nurse saw it she asked: “Are you crying because you are happy?” and I said

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“No, what is wrong with my baby?” and she said “Nothing, he is getting normal care.” I wanted to hold the baby first and say a blessing like I did back home but I didn’t know how to ask or if I could. I wish I had the opportunity to do it my way. I just want them to accept and respect us just as we are, but I didn’t know how to say it. . . . Moreover, during individual interviews, a number of female participants expressed sorrow for the pain they suffered as a result of FGC performed on them in the childhood. Still, they stressed the importance of having had the procedure done as part of their religious and cultural heritage. The majority of women also expressed feelings of shame and fear of being ridiculed by health care professionals because of “looking different down there.” They were equally afraid of getting a provider without the skills necessary to perform the “right kind of cut” (episiotomy) to open the birth passage. Similar to others, one woman explained: In our culture it is very important to get a circumcision. It had been done to me when I was four or five. I remember they took me somewhere and promised something special. I was excited that I would get a candy but instead I got the cut and I suffered terrible pain that I can still remember. Then I got stitched up until I had my first baby. They open you up for the baby and close you up again after. When the time came for me to have my fifth kid, I was already in the US. I asked the nurse to open me up to prepare myself for the baby. She called the doctor and not one but three of them came. But, I don’t think they knew what they were doing. They cut me all wrong . . . . It was a real disaster. For three months I couldn’t sit down.

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nal delivery again and not be a complete woman. And, she won’t have the number of kids her husband wanted. But if the American doctor told me that my wife needs a c-section, I wouldn’t oppose if I was sure there was no other way to deliver. But, I would question how does he know there is no way she can deliver vaginally after four kids? Many Somalians who ask the doctor feel judged and misunderstood. Many couples described situations during labor and delivery when there were breakdowns in communication between them and health care professionals. They talked at length about the confusion and fears caused by the lack of mutual understanding at any point. Some couples felt pressured to agree to treatments whereas others felt that few providers took time to explain the informed consent to their full satisfaction and understanding. One woman recalled a miscommunication that may have led to her getting a hysterectomy. At my last prenatal visit my doctor pressured me to get an induction. I said “I don’t feel my body is ready; it is my fourth kid, I would know,” but I felt I had to agree. While getting the IV medicine, I was like, screaming: “something is terribly wrong, I have too much pain.” It turned out my uterus broke (ruptured). I had to have an emergency c-section. After surgery I was told they took out my uterus. I was devastated and I begged them: “give me back my uterus; in my culture we must bury all body parts.” But, I never got my uterus back. I was really, really mad, hurt, and depressed for a long time.

Male participants tended to be less concerned about their wife getting the “right” episiotomy and more concerned about them not having the cesarean birth. They consistently indicated that the memories of “women all the time dying in surgery back home” was one of the key reasons they opposed cesarean birth. Some also expressed concerns that cesarean section would limit the number of children they wanted. One man stated:

Longing for unconditional respect and acceptance. All study participants expressed a desire for unconditional acceptance of their otherness as childbearing couples. Some participants felt that because they had different expectations from pregnancy and childbirth than the Americans, the providers broke their promises or disregarded wishes. Such situations led the study participants to feeling disrespected, lonely, and longing for a better relationship with health care professionals. Similar to others, one man recalled:

I oppose the c-section. I witnessed some young women dying of complications back home after they had a c-section. Like most Somalian people I also believe, if a woman has a c-section, she will never have vagi-

I don’t think the doctors and nurses really understand some of the things that are very important to us. With our last baby, I completed a form to say we didn’t want any men in the delivery room unless absolutely

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necessary. I know no man is going to be ugh . . . aroused by the delivery, but still, I wanted no men around. I stayed at my wife’s head out of respect for her and I was glad that only a nurse was taking care of her for most of the day. But at one point, a young male doctor came in without checking first with us. He wasn’t doing anything, just stared at my wife’s bottom. I felt insulted and thought: “I want him out!” But, I didn’t say anything because I feared they would refuse to care for my wife if I said anything. Although prenatal education was commonly viewed by the study participants as a window to understanding the pregnancy and childbirth process in the American health care system, no couples took the prenatal classes. Many male participants believed that the providers ignored them likely because they did not think of them as willing or interested partners in learning about pregnancy and childbirth while they were. Men in the study talked at length about the prenatal classes as a missed opportunity to overcome the knowledge barrier. Similar to others, one man recalled: My wife’s doctor mentioned prenatal classes but we didn’t attend after we Checked them out. Our religion doesn’t allow us to attend classes with the women learning in the same room as men. And, we are not allowed to look at naked figures and so on. I think many Somalian men would definitely go if the setting was respectful of our beliefs. I know I would go to better advocate for my wife. Doctors and nurses think we don’t care but we do. For example, after we arrived in the hospital to have the last baby I was asked to complete some forms. Under the prenatal classes I checked “none.” The nurse remarked: “not interested, huh?” Well, I was, but I felt it wasn’t a good time to educate the nurse why I didn’t go. And so, I didn’t. Although some women were open to their husbands’ participation in the pregnancy and birth processes, others felt stuck in the “Somali ways” of life and somewhat troubled by the idea of men’s involvement. One woman explained: My husband went with me to the clinic and then to hospital to have a baby because he knows English better. I have no family here and no female friends yet. But, I

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wish women I know were there with me, not him; like back home. Somalian women know what you need when your baby is coming. If there was something for him to learn from about baby coming maybe it would be better. Surviving and thriving as the users of health care. As time went on, similar to other first-generation immigrants from other parts of the world, the study participants, but in particular men reported that they were more aware of their rights when it comes to health care. Although many felt unprepared to handle all cultural differences surrounding pregnancy and childbirth, those who had more than one infant born in the United States were more likely to request the care they wanted. Those without or little knowledge of English language were more likely to distrust the American health care system and to trust the advice of elders and healers within the Somali community. Moreover, the participants, in particular men with some knowledge of English sought additional knowledge on the internet. Hence, the Somali men felt more empowered to ask questions and advocate for their wives in health care than the women themselves. Although misunderstandings continued and were a source of considerable emotional distress to study participants, with time the couples felt more empowered. One man summarized: The longer you are in this country, the smarter you become about the differences between you and the Americans and about your rights. You begin to understand that you have to be your own advocate in health care because nobody else will. It is very true when you go to hospital to have a baby. If you don’t ask the right questions they will assume you understand and agree to everything while you don’t. Another man provided an example of when he felt particularly proud for asking the right question about medication administered to his wife: After our last baby, my wife got a pill for avoid constipation. The pill was red. It reminded me of gel and so I asked: “Is this pill made of gelatin?” The nurse didn’t know but went to check and it turned out it was made of pork gelatin. Because our religion doesn’t permit us to eat any pork products, my wife didn’t take the pill and got something else. In this case, I was happy with

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care because the nurse went out of her way to find out. As in the preceding example, other interactions with health care professionals were positive especially when the providers were consistently supportive, informative, and provided opportunities for the study participants to make the decisions that were right for them. One woman recalled: I felt really cared for by my nurses after my last baby even though I ended up with an emergency c-section. After the baby was born, the nurses checked on me, gave me choices about rest, helped me to get up from bed, and ordered porridge for breakfast. One nurse even asked if I wanted a binder for my tummy. I was really surprised she knew that Somalian women like to wear a binder to have their tummies tucked in.

My wife had a cut (FGC) as a child; a very bad cut. After she had the last baby in the US, the doctor took me aside, explained how bad it was and suggested we should consider having it repaired. He didn’t pressure me, just had a conversation. I was open to the idea because my wife had health problems because of it but my she was against it at first. We talked about it more after coming home and then went back to see that doctor in strictest confidence. Nobody knows she had the surgery, only me. It is the most taboo topic in our culture.

Discussion

A number of study participants shared in strictest confidence about one of the most taboo topics in the Somali community: a plastic reconstructive surgery for women with FGC. The surgery aims to restore women’s clitorial and perineal anatomy and function, and it has reduced pain and increased sexual pleasure for many women (Abduclair, Boulvain, & Petignat, 2012). Interestingly, the topic was brought up exclusively by men. One man recalled how a compassionate provider approached him about reconstructive surgery for his wife. It was apparent from the men’s narratives that the women were more resistant to the idea. Regardless, according to few male informants their wives ended up consenting to the surgery and were since pleased with the results. The in-

The results of this study suggest that traditional customs and beliefs are an important point of reference for Somali immigrants after they arrive in the United States. The stories of participants illustrated a variety of adjustments and losses they had in their encounters with health care teams during the perinatal period. Cultural beliefs, values, and customs shaped how the participants interpreted, responded to, and judged health care professionals’ actions and words. The need for unconditional respect of the Somali “otherness” was one of the most common narratives that permeated the overarching theme and all subthemes. Although doctors, midwives, and nurses brought to the Somali couples’ perinatal experiences deep knowledge of Western medical care, the couples brought deeply rooted beliefs about what the right course for pregnancy and childbirth should be. Collectively, the lack of understanding of Somali culture by health care professionals and subsequently, unmet expectations of Somali clients, often created an atmosphere of doubt and mistrust among the study participants. This finding is consistent with Straus, McEwen, and Hussein’s (2009) finding that cultural differences may lead to misunderstandings, distrust, and insecurity among Somali clients across the perinatal continuum. Interestingly, the couples reported that they were more aware of the differences between their own beliefs and those of Western health care system than the providers. They wished that the members of the health care team were better educated about and respectful of Somali customs, regardless of how different they might be, a finding reported by several prior investigations conducted

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The male participants felt particularly cared for when their presence was acknowledged, things were explained to them as if they were the patient, and they were invited to participate in care “without any pressure.” One man recalled: Back home, birthing baby is a woman’s work. And, the (birthing) woman is surrounded by other women. Here, it was my responsibility to help. I felt really awkward. Before we went home, the nurse asked me how I was doing. I was relieved she asked because I wasn’t doing well at all. She then explained and showed me how to do different things. It helped me realize how much help my wife will need after we get home because she had a c-section.

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formants remarked that it is culturally important for Somali men to be included in conversations and decision making process about the procedure. One man recalled:

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to explore the effects of cultural dissonance on the immigrant patients’ perceptions of care in different health care environments (Liamputtong & Watson, 2006; Vangen, Johansen, Sundby, Traeen, & Stray-Pedersen, 2004). Enang, Wojnar, and Harper (2002) suggested that one important factor for positive childbirth experience across different cultures is delivery of compassionate, respectful, and unconditional care and support. Participants acknowledged that some providers already had considerable knowledge of Somali culture and customs or showed interest in learning about the differences, such as when the nurses were aware of Somali women’s dietary preferences or desire for abdominal wall support after birth. The study participants expressed deep gratitude for that kind of effort and support. On the other hand, the couples in this study felt particularly uncomfortable in culturally unacceptable or awkward situations, such as when an unessential care team member would enter the delivery room without clear purpose or permission, a finding consistent with that of Ameresekere et al. (2011). Well-intentioned but inadequately explained treatments or procedures added to the study participants’ anxiety and distrust in the health care system and to feeling burdened and vulnerable. In those situations, study participants typically passively agreed to the recommended course of care in fear of retaliation, a finding consistent with those of Bischoff et al. (2003) and Heaman et al. (2013). Such situations could have been prevented through staff education, personal curiosity of health care professionals, and culturally appropriate prenatal education opportunities for the Somali couples. A growing body of literature suggests that sociocultural factors play an important role in people’s decision-making process about important life events, such as pregnancy and childbirth, and that these factors may create barriers to access or full utilization of available health care services without an extra effort by health care professionals to overcome these barriers (Kusow, 2006; Warfa et al., 2012). In this study, it was apparent that the majority of study participants disregarded providers’ advice, based on the community’s endorsement of the prescribed treatments. As a result, some women in the study may have not benefited from preventative interventions, such as taking prenatal vitamins or iron supplements to treat anemia (U.S. De-

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The social-cultural context of Somali families must be considered when providing care throughout the perinatal period.

partment of Health and Human Services, 2010). It is therefore important, that health care professionals become educated about Somali culture, explore the Somali clients’ traditional beliefs and practices, and take time to negotiate Western medical treatments or remedies before prescribing. A unique finding of this study is the new knowledge about the Somali men’s perspective on pregnancy and childbirth a finding consistent with the Binder, Johnsdotter, and Essen ´ (2013) report. Male participants readily admitted that the lack of culturally appropriate resources, such as the lack of prenatal classes offered in separate rooms for males and females, was an important barrier to gaining new knowledge about the pregnancy and childbirth process. This finding suggests, in contrast to popular belief that Somali men are not interested in the topic, that culturally appropriate education resources for both genders would attract Somali men to become fully informed and active participants in their wives’ care. Another unique finding of this study is that, in spite the current efforts of World Health Organization to educate health care practitioners in Western countries about the care of women with FGC in childbirth (Khaja et al., 2010), more targeted education is needed for all providers (Ahmed & Abushama, 2005; Berggren, Bergstrom, & ¨ Edberg, 2006; Essen & Wilken-Jenssen, 2003). For example, in this study, the female participants believed that well-meaning but uneducated providers contributed to their undue pain and prolonged healing, a situation that could have been avoided by proper education and training. Moreover, while all participants generally considered the topic of FGC taboo, male participants wanted to talk about it during their individual interviews to explore new ways of alleviating their wives’ pain and discomfort or admitted their wives had reconstructive surgery of the perineum. Culturally appropriate prenatal programs and individual supportive interventions offered to Somali couples in the perinatal period may help more women to seek reconstructive surgery. Lastly, it is important to note that, consistent with prior reports regarding acculturation processes

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(Scuglik & Alarcon, 2005), the study participants residing in the United States longest (closest to 5 years) were able to understand and navigate the health care system considerably better than the newcomers. Hence, though supportive services are warranted for all Somali clients, special attention should be paid to the most recent immigrants to help them overcome the multiple barriers to seeking and accessing health care services.

Limitations Because the study participants came from two Somali clans (main stream Somalis and Somali Bantus), this may have affected the picture of the social–cultural context from which the narratives were told in the study. Moreover, all study participants reported to have at least a few years of elementary school education from their home country or refugee camp. Findings should therefore be used cautiously when applying to other Somali immigrants. Because some couples had better command of English language than others, one might argue that the findings are biased toward the faction of participants that were better able to articulate their experiences in English. Conversely, it can also be argued that the clan (Bantu and mainstream Somalis), language, socioeconomic, educational, and gender diversity of the participants was the greatest strength of this study. Regardless, consistent with the spirit of descriptive phenomenology, every effort was made to identify the common experiences for all study participants.

Community-based participatory research, conducted in partnership with a broader Somali community is needed to design prenatal programs in which Somali couples’ fundamental beliefs about childbearing and childbirth are upheld and supported. Community-based programs offered to both genders can help improve health care utilization and, subsequently, result in better longterm outcomes of care for Somali population in the perinatal period. Further, research into the roles of Somali fathers across the perinatal continuum is needed. Moreover, policy makers, researchers, and providers must consider the extent to which the educational level, knowledge of English language, and clan label placed on the individuals within the Somali community result in socially constructed reactions in the American health care.

Acknowledgment Funded by Sigma Theta Tau International and J. Sinegal Foundation. The author thanks research assistants Fadumo Aden, RN, BSN and Jenna Cuneo, RN, BSN for assistance with data collection and analysis.

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Conclusions and Implications Somali couples’ narratives suggest that better knowledge and understanding of cultural beliefs, customs, and expectations for pregnancy and childbirth among Somali immigrant couples can have immediate and long-term implications for practice. In contrast to the popular belief about the Somali men’s lack of interest in pregnancy and childbirth, men in this study desired to be active participants in their wives’ perinatal care and offered specific, unsolicited ideas on how to best facilitate their involvement in prenatal education and care. Findings also suggest that designing prenatal intervention programs can create an opportunity for a new, positive dynamic in the caregiver–patient relationship and pregnancy outcomes for this population. Access to trusted interpreters and health care providers who understand and accept traditional Somali beliefs about pregnancy and childbirth is imperative.

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