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Objective To explore the attitudes, strategies and habits of Somalian immigrant women related to pregnancy and childbirth, in order to gain an understanding as to how cultural factors might affect perinatal outcome.Interpreter assisted qualitative in depth interviews around topics such as attitudes and strategies regarding childbirth.Fifteen women from the Somalian community in a city in Sweden, between the ages of 20 and 55 years with delivery experience in Somalia and Sweden.The interviews describe how the women themselves perceived their experiences of childbirth in the migrant situation. Many voluntarily decreased food intake in order to have a smaller fetus, an easier delivery and to avoid caesarean section. The participants considered a safe delivery to be the same as a normal vaginal delivery They reduced food intake in order to diminish the growth of the fetus, thereby avoiding caesarean section and mortality. The practice of food intake reduction, while rational for the participants when in Somalia, was found less rational in Sweden and may lead to suboptimal obstetric surveillance.Somalian women have childbirth strategies that differ from those of Swedish women. These strategies should be seen as 'survival behaviours' related to their background in an environment with high maternal mortality. The hypothesis generated is that there is a relationship between the strategies during pregnancy and adverse perinatal outcome among Somalian immigrants. Considering the strong association of the habits to safe birth, it seems doubtful whether the women will change their habits as long as health care providers are unaware of their motives. We suggest a more culturally sensitive perinatal surveillance. Methods Participants Results Conclusions

Study objective -To test the stress hypothesis by characterising women during their first pregnancy who continue to smoke in early pregnancy in comparison with women who quit smoking, with special reference to psychosocial factors like social network, social support, demands, and control in work and daily life. Design -The study is based on a cohort of primigravidas followed during pregnancy. Data were collected by self administered questionnaires during the pregnant womens' first antenatal visit at about 12 weeks.Setting -The study was performed in the antenatal clinics in the city ofMalmo, Sweden.Participants -The participants were all primigravidas living in the city of Malmo, Sweden, over a one year period, 1991-92.A total of 872 (87.7%) of the 994 invited women agreed to participate. The population of this study on smoking includes all primigravidas who at the time of conception were smoking (n=404, 46.3%).Main results -At the first antenatal visit (63-6% (n =257) of the prepregnancy smokers were still smoking (a total smoking prevalence of 29-5%). The pregnant smokers were on average younger and had a lower educational level. The highest relative risk (RR) of continued smoking was found among unmarried women RR 2-7 (95% confidence interval) (1.5, 4.8), women having unplanned pregnancies RR 2-2 (1-2, 4.0) and those with a low social participation RR 1-6 (1.0, 2-7), low instrumental support RR 2-6 (1.2, 6.0), low support from the child's father RR 2-1 (1.0, 4.2) and those exposed to job strain RR= 2-3 (1.1,4-8). The In recent years great attention has been paid to the dangers of smoking during pregnancy. In spite ofthis, many pregnant women continue to smoke. In Sweden the prevalence of smoking among all pregnant women was 21 8% in 1992 (Swedish Medical Birth Registry -personal communication). A study from two big cities in Denmark showed a prevalence of 44% in 1987, and 81% ofthese women were still smoking at the end of pregnancy.9 One Norwegian study in 1989 showed a smoking prevalence of 46% 3 months before pregnancy, and 84% of the women were still smoking at the time of the first medical check up. '0 In a Swedish study, 32% of the pregnant women in one big city were daily smokers at the time of conception and by the time oftheir antenatal visit, 2 months later, 77% reported that they were still smoking."1 Women's smoking has been seen as related to social deprivation, stress, and disadvantage.2 13 Persistent smoking during pregnancy is found to be related to low household incomes, living in rented accommodation, being unmarried, and having a husband or partner in manual employment.'4 High parity number, not living with the infant's father, and daily passive smoking at home are also associated with an increased risk for continued smoking.'5 Other important predictors of unsuccessful smoking cessation are a high level of smoking before pregnancy and high coffee consumption.9Women experiencing depression and those with psychosocial difficulties in daily domestic roles also have higher rates of pe...

Objective To test the hypothesis that suboptimal factors in perinatal care services resulting in perinatal deaths were more common among immigrant mothers from the Horn of Africa, when compared with Swedish mothers. Design A perinatal audit, comparing cases of perinatal deaths among children of African immigrants residing in Sweden, with a stratified sample of cases among native Swedish women. Population and setting Sixty‐three cases of perinatal deaths among immigrant east African women delivered in Swedish hospitals in 1990–1996, and 126 cases of perinatal deaths among native Swedish women. Time of death and type of hospital were stratified. Main outcome measures Suboptimal factors in perinatal care services, categorised as maternal, medical care and communication. Results The rate of suboptimal factors likely to result in potentially avoidable perinatal death was significantly higher among African immigrants. In the group of antenatal deaths, the odds ratio (OR) was 6.2 (95% CI 1.9–20); the OR for intrapartal deaths was 13 (95% CI 1.1–166); and the OR for neonatal deaths was 18 (95% CI 3.3–100), when compared with Swedish mothers. The most common factors were delay in seeking health care, mothers refusing caesarean sections, insufficient surveillance of intrauterine growth restriction (IUGR), inadequate medication, misinterpretation of cardiotocography (CTG) and interpersonal miscommunication. Conclusions Suboptimal factors in perinatal care likely to result in perinatal death were significantly more common among east African than native Swedish mothers, affording insight into socio‐cultural differences in pregnancy strategies, but also the suboptimal performance of certain health care routines in the Swedish perinatal care system.

Estrogen metabolism in the human intestine was studied in two ways. Firstly, by measuring the excretion of 12 estrogens in pooled human late pregnancy feces before and during the administration of ampicillin (2 g/day). Secondly, by administering 5.4 and 20 mg of 16alpha-hydroxyestrone orally to two postmenopausal women and analyzing the estrogens in simultaneously drawn portal and peripheral venous blood samples at time intervals from 0 to 150 min after steroid administration. The majority of the estrogens in normal pregnancy feces were unconjugated. The amounts of estradiol, estreon and 16-epiestriol excreted, relative to the principal estrogen estriol, were greater than in pregnancy bile or urine and 16alpha-hydroxyestrone, an important biliary estrogen, was only present in trace amounts. Considerable quantities of 15alpha-hydroxyestradiol-17beta were also found. Ampicillin administration, which decreases intestinal bacterial steroid metabolism, caused a huge increase in the fecal excretion of conjugated estrogens. In particular it caused very striking increases in the excretion of both unconjugated and conjugated, estriol, 15alpha-hydroxyestrone, 15alpha-hydroxyestradiol and 2-methoxyestrone. These findings emphasize the active role played by the intestinal microflora in estrogen metabolism under normal conditions. Administration of 16alpha-hydroxyestrone resulted in increases in portal venous unconjugated and conjugated 16alpha-hydroxyestrone, 16-oxoestradiol-17beta, 15alpha-hydroxyestrone, 16-epiestriol and conjugated estriol levels. The most significant finding in both subjects was the large increase in portal venous unconjugated 15alpha-hydroxyestrone. This would suggest that the human intestine (or intestinal contents) has the ability to carry out the transformation, 16alpha-hydroxyestrone leads to 15alpha-hydroxyestrone. Increases in the same estrogens were found in peripheral plasma, with the increase in conjugated estriol occurring in peripheral blood before it was seen in portal blood. The largest elevations in peripheral plasma values were seen in unconjugated estriol and conjugated 16alpha-hydroxyestrone in the subject who received the 20 mg dose and in unconjugated 16alpha-hydroxyestrone and 16-oxoestradiol-17beta in the subject who had the 5.4 mg dose. The intestinal and enterohepatic metabolism of estrogens is discussed in relation to these findings.