Perinatal Cultural Aspects of African Refugee Women Resettled in Greece: Providing Culturally-sensitive Midwifery Care.

INTRODUCTION: African refugee women constitute a growing group of maternity service users in Greece. Being a refugee is considered a risk factor in itself for poorer maternal and neonatal health outcomes. These women additionally, are at high risk of perinatal complications, often due to misconceptions or absence of interpretation between providers and patients through different cultural concepts. Consequently, midwives may feel uncertainly experienced when provide perinatal care for a culturally diverse patient population. AIM: The aim of the study was to investigate perinatal cultural aspects and practices of African refugee pregnant women in Greece, in order to increase cultural awareness and improve midwifery care in a culturally-sensitive way.
METHODS: Forty-two (n=42) African pregnant women who lived in a "Reception and Identification Center" on a greek island named "Samos", were included in the study. Women were selected by "simple random sampling" and asked to complete anonymously, with assistance of interpreters, a questionnaire that was devised by the authors with open-ended and closed-ended questions.
RESULTS: Women were aged between 19-38 years old. The 50% (n=21) of them were from the Democratic Republic of the Congo, 28.6% (n=12) from Ghana and 21.4% (n=9) from Cameroon. Major themes emerging from the data analysis were: presence of antenatal care in African countries, potentiality of abortions, complications in previous pregnancy, supplement receipt in previous pregnancy after healthcarers' consultation, decision of birth place, support of traditional birth attendants' during pregnancy and birth, consumption of culturally acceptable food during pregnancy and birth, culturally accepted disposal of placenta, postpartum ceremonies for the baby and newborn's navel care.
CONCLUSION: Increased understanding of the pluralistic African perinatal cultural aspects is essential. Inclusion of cultural insight and/or family members in decision making and implementation of training programmes culturally-oriented for midwives, can fulfil women's health, social needs and expectations.

INTRODUCTION

African refugee women constitute a growing group of maternity service users in Greece. Being a refugee can be considered a risk factor in itself for poorer maternal and neonatal health outcomes. These women additionally, are perceived to be at high risk of perinatal complications, based on coexisting illnesses, unusual medical conditions, higher burden of disease in countries of origin or transit, complex physical / psychological / mental state of health, societal factors, lack of access and finally, misconceptions or absence of interpretation between providers and patients through different cultural concepts (1, 2). Because of these concerns, midwives may feel uncertainly experienced when provide perinatal care for a culturally diverse patient population (3).

Considering the latest data (January-November 2020), a total of 84.340 refugees and migrants arrived at Mediterranean countries (Greece, Italy, Spain, Malta and Cyprus), of which the 14.600 resettled in Greece, either through sea or land. Specifically, in Greece, the 40.3% are men, 36.1% children and 23.5% women. Democratic Republic of the Congo and Algeria are among the most common nationalities (4).

On the basis of these statistics, it is understandable that midwives, having a crucial role in perinatal multidisciplinary teams, should act promptly, coordinately and effectively to promote safe motherhood, access and delivery to perinatal healthcare and to improve as well, perinatal outcomes of all refugee pregnant and lactating women with newborn babies. Alongside with culturally-sensitive midwifery approach, the goal of providing an optimal start in life for all newborns and families can be potentially reached.

The International Code of Ethics for Midwives defines, inter alia, that midwives should “respect cultural diversity”, “maintain competence in safe midwifery practices in all environments and cultures” and be persons of “moral worth” (5). In other words, a midwife should be aware of the beliefs, values and moral points of view of a mother in order to respect her. Thus, providing culturally-sensitive midwifery care has become vital if the code of professional conduct is to be sustained (6). Indeed, the provision of midwifery care for a woman from a different nationality and culture is a major challenge that midwifery profession should focus on the future.

AIM

The aim of the study was to investigate the cultural aspects and practices, during the perinatal period, of African refugee pregnant women in Greece, in order to increase cultural awareness and improve midwifery care in a culturally-sensitive way.

PATIENTS AND METHODS

This is a cross-sectional study which was conducted between May-August 2020. Forty-two (n=42) African pregnant women who lived in a “Reception and Identification Center” (RIC) on the Greek island of Samos, were included in the study. Women were selected by “simple random sampling” technique and asked to complete anonymously a questionnaire that was devised by the authors with open-ended and closed-ended (“yes” or “no”) questions.

As women spoke French, English or Lingala (a language spoken in the Democratic Republic of the Congo) assistance of interpreters who worked at the RIC facilities was essential. The questionnaire was answered in the form of a face to face interview. All participants gave their written consent. Confidentiality of the collected data was assured. The questionnaire was distributed in a quiet environment, without external interventions and honest in the answers was asked kindly as a prerequisite. Each questionnaire, immediately after its completion, was enclosed in an envelope and placed in a special area so as to be anonymity preserved. Data were assigned to a numerical code that was used for data analysis.

RESULTS

Descriptive Characteristics

Women were aged between 19-38 years old, with the biggest percentage (33,3%) being between 24-26 years old. The 50% (n=21) of the women were from the Democratic Republic of the Congo, 28.6% (n=12) from Ghana and 21.4% (n=9) from Cameroon.

Obstetric History and Maternal Healthcare

The 33.3% (n=14) of the women were nulliparous, 35.7% (n=15) had one child, 21.5% (n=9) had two children and the 9.5% (n=4) had three children. The 73.8% (n=31) reported the presence of antenatal care in their country, provided by hospital, health center, maternity home, private doctor, organization or “other”, while the 26.2% (n=11) reported its absence. Services provided by maternity homes were social, antenatal counseling, midwifery care, medicine administration, postpartum and neonatal clinical examination. Access to them whenever limited was due to lack of money or long distance.

Abortion was not a potential for the 66.7% (n=28) of the women in their country, while the 33.3% (n=14) were given the option. Abortions take place in hospitals, clinics, at home by a doctor or at doctor’s private office. Usually medicine or herbs, like “bonto”, are used. Remarkable was the fact that the 42.9% (n=18) of the women had none knowledge concerning “abortions”.

The 40.5% (n=17) had a miscarriage in a previous pregnancy while the 59.5% (n=25) not. The 66.7% (n=28) had faced complications in previous pregnancy in their country and the 33.3% (n=14) not. Complications referred to hemorrhage, hypertension, preeclampsia, infection, hyperemesis gravidarum, hemorrhoids or/and gastrointestinal problems. The 52.4% (n=22) of the women visited a hospital, 21.4% (n=9) a health center, 14.3% (n=6) a private doctor, 2.4% (n=1) “other” and surprisingly, the 9.5% (n=4) did not contact a healthcare professional at all.

The 35.8% (n=15) of the women took vitamins/calcium/ferrum/folic acid after doctor’s consultation, 35.8% (n=15) after midwives’ consultation, 21.4% (n=9) after traditional birth attendants’ (TBAs) advice, while the 7% (n=3) answered “other”. It is noteworthy that over 35% of the African women had no supplement receipt in a previous pregnancy because they believed is “unsafe for the fetus”.

Moreover, it was reported that the 81% (n=34) of the women, in a previous pregnancy in their country, gave birth in hospital, the 9.5% (n=4) in a health center, the 7.1% (n=3) at home and 2.4% (n=1) answered “other”. This decision was taken in relation to accessibility towards the hospital for the 76.1% (n = 32) of the women, desire to be accompanied by family during labor for the 4.8% (n=2), tradition for the 4.8% (n=2), religion for the 2.4% (n=1) and finally, family’s and/or husband’s opinion for the 11.9% (n=5). Furthermore, women were asked the possible reasons for “not giving birth at a hospital”. The 59.5% (n=25) pointed out the distance as main reason, 23.9% (n=10) the refusal of their family, 9.5% (n=4) traditional beliefs and the 7.1% (n=3) answered “other”, which was mainly associated with lack of money and poverty, circumstances that usually prevail in African societies.

Characteristically:

A. said: “women in the villages prefer to give birth traditionally at home, while those in the cities prefer a hospital”.

X. stated: “the choice for the way we will give birth depends on the tribe we belong to.”

C. mentioned: “if the mother and grandmother know how to assist in labor, the woman prefers to be close to her family. Women living at the countryside prefer birth at home, but the husband also plays a crucial role in the decision.”

K. said disappointingly: “in the hospital if you do not have money they will not help you.”

Regarding the presence of TBAs, the 81% (n=34) answered that they exist in their country, while the 19% (n=8) answered that they do not exist or that they do not know about their existence. The 54.8% (n=23) of the women were supported during labor by a midwife, 30.9% (n=13) by an obstetrician, 11.9% (n=5) by TBAs and the 2.4% (n=1) by “other”.

Distinctively, X. explained with sadness: “many women prefer to give birth at home with TBAs because they have experience and cause in hospital you have to pay to be taken care of, otherwise they let you die. We prefer the hospital of the catholic church because they care for us. If we do not have money to pay them, afterwards, we will work voluntarily for them to repay.”

As far as complications during labor are concerned, the 54.8% (n=23) of the women acknowledged at least one complication, 33.3% (n=14) had no complications, whereas the 11.9% (n=5) “did not know”. Complications were resolved by medical, midwifery, traditional, “other” or “no” interventions in the percentage of 45.3% (n=19), 33.3% (n=14), 11.9% (n=5), 7.1% (n=3) and 2.4% (n=1) respectively.

Interestingly, the 92.8% (n=39) of the women felt uncomfortable and insecure to give birth at their country in home with TBAs, the 2.4% (n=1) not and the 4.8% (n=2) could not provide an answer. The 90.5% (n=38) felt safer giving birth in their country at a hospital because of the trained medical staff and the 9.5% (n=4) for other reason. At last, all women for their present pregnancy in Greece, preferred to deliver in hospital.

Perinatal Cultural Aspects

Quite fascinating was the report of traditional foods, like “abeduro”, “misili”, “zoomkom” or “puusakoomor” used by African women during pregnancy and birth, usually being solids, fruits or broth with great importance for themselves and their baby.

A. stated: “Okra helps us give birth more easily as the baby will slide in the vagina and we will avoid the caesarean section.”

In detail, the 26.2% (n=11) mentioned that the usage of these foods helps them give birth vaginally, 21.4% (n=9) relieve pain during birth, 21.4% (n=9) protect from intrapartum hemorrhage and 31% (n=13) mentioned “other”, like prevention of anemia during pregnancy, relief of constipation and increase milk production. The 76.2% (n=32) had the will to continue eating these traditional foods in Greece, if available, while the 23.8% (n=10) not. The consumption of culturally acceptable food during pregnancy and birth differed among the three African countries (Chart 1).

Chart 1.

Consumption of culturally acceptable food during pregnancy and birth among African countries (n)

The 57.1% (n=24) mentioned that traditions relating pregnancy and birth exist in their country, while the rest denied such fact. Women from Ghana reported only infant massage as tradition and from Cameroon prayers and circumcision. Apart from the above, women from Democratic Republic of the Congo described also customs like “herbal use” and “shower of mother and baby in conjunction”.

In addition, childbirth position was important for the 47,6% (n=20) of the women opposing the 52.4% (n=22) that did not consider it significant. As for culturally accepted disposal of placenta, the 47.6% (n=20) said they bury it, 23.8% (n=10) eat it, 16.7% (n=7) plant a tree over the burial spot, whereas the 11.9% (n=5) said the hospital incinerates it. Differences though, were observed among the three countries of origin (Chart 2).

Chart 2.

Culturally accepted disposal of placenta among African countries (n)

Particularly, G. stated: “we bury the placenta and plant a tree for the baby so as to have good luck and money in its life.”

Also D. said: “if the placenta is not buried is bad luck for the baby and if hospital staff disposes it, is like throwing the child’s future away.”

K. additionally mentioned a belief among African communities: “if the placenta is eaten by dogs then the child will develop brain damage.”

The 64.3% (n=27) stated that they would like to maintain the tradition regarding the placenta in Greece and the 35.7% (n=15) not. Some women from the latest percentage said that they would like to follow Greek traditions for placenta.

After childbirth, a ceremony for the baby was a common tradition among the African women. The 73.8% (n=31) of them mentioned rituals such as “naming ceremony” called “abendito”, “ceremony with songs and dances to welcome the baby”, “cut of hairs from neonatal head”, “apply cream/herbs on neonatal head” and “circumcision”.

The reference to the materials African women use for the care of the newborn’s navel was quite special. Some women reported shea butter, Vaseline or herbs, which they apply on the navel and then wrap in a bandage. Palm oil was mentioned as a very important product for the healing of the navel. Few women said they put ashes or their saliva. Finally, breast milk was the first meal for the baby for the 78,6% (n=33) of the women.

Characteristically, M. whispered “breast milk is my seal and my baby will be smart and healthy”.

DISCUSSION

African culture is consisted of a mixture of countries with various tribes. Each tribe has her own traditions, beliefs, values and practices. With this enormous linguistic, religious, and sociocultural diversity, found not only across different African countries but also within single ones (7), providing midwifery care through a cultural lens is of great importance, especially when vulnerable populations, such as refugees, are involved.

“Good health during pregnancy and at birth extends beyond the perinatal period and is an essential building block for later health” (8). That is the goal of all European health care systems and Greece, being a member of the European Union, serves that intention. Along with mother-centered and evidence-based midwifery care, the awareness and acceptance of other cultures from Greek midwives will lead to a high quality, culturally-sensitive midwifery approach for all refugee women in perinatal period.

In this study, refugee women from three different African countries resettled in Greece, were willing to share their perinatal cultural aspects. Besides, they referred to important issues regarding maternal health and addressed as well, the systemic root causes for adverse perinatal outcomes.

Early and regular attendance of antenatal care and access to qualified health providers, the right time, can reduce the risk of perinatal complications and give women a positive pregnancy experience. However, the women who took part in the study outlined factors that prevent African women from receiving or seeking care during pregnancy and childbirth. Such factors, supported also by previous studies (7,9,10,11), were multidimensional and interlinked, including lack of knowledge regarding maternal health services, socio-cultural factors, lack of understanding on the importance of skilled attendance at birth, financial difficulties and place of residence.

Although the World Health Organization identifies the availability of skilled birth attendants and provision of Emergency Obstetric Care as two of the most essential ingredients to be maternal mortality averted (12), traditional practices including preference for birthing at home under the supervision of TBAs, are still popular in African countries (13, 14). Predicators of place of delivery, in accordance with previous studies done in Africa (7, 14, 15, 16), were affected by economic, religious and socio-cultural dimensions, intra-household dynamics and urban residence. The majority of women recruited in that study (38/42), however, gave birth to a hospital or health center in their country.

Prior studies have shown that trust of African women lies in the presence of familiar faces, such as TBAs, rather than an unknown environment and healthcare staff (16, 17, 18). Apart from their role in childbirth, TBAs provide advice on family planning, nutrition, screening during pregnancy, infertility and reproduction. They provide also antenatal, perinatal and neonatal care, using both spiritual and physical methods, while in some African countries they have been integrated into the local health system (18, 19, 20). Preference for TBAs has been attributed to the fact that they provide affordable and accessible services (18), offer spiritual practices and prayers for effortless and safe birth (21, 22), dispose placenta according to traditions/beliefs/rituals of the family (23) and treat women compassionately, with culturally competent and acceptable way (24, 25, 26). Nevertheless, most women in that study (36/42) gave birth with the presence of a skilled health professional and most of them (39/42) admitted feeling uncomfortable and insecure to give birth at home in their country with TBAs.

Lastly, opportunity to access culturally acceptable food during pregnancy and labor, was important for the 32/42 participants of our study and had the desire to continue eating these traditional foods also in Greece, if available. This finding was similar to past studies which have highlighted that consumption of traditional foods is one of the main reasons that accounts for the decision to give birth at home under the care of TBAs (26, 27, 28).

CONCLUSION

Increased understanding of the pluralistic African perinatal cultural aspects is essential. Misunderstanding results in reduced maternal support and delayed antenatal/perinatal care. Ignoring cultural preferences and behaviors encourages African women to turn to traditional medicines and practices. Particularly, vulnerable refugee populations require culturally sensitive care at most, so as to foster trusting relationships between women and midwives. Awareness of barriers to the utilization of birth care services, inclusion of cultural insight and/or family members in decision making, midwifery-led interventions and implementation of training programs culturally-oriented for midwives to improve their skills and competency, can accomplish a vision of midwives: to fulfil women’s health, social needs and expectations.