Abstract
Objective:
The purpose of this study was to compare prenatal characteristics and postpartum outcomes among Somali and non-Somali women residing in Olmsted County.
Methods:
We reviewed medical records for a cohort of Somali women (≥18 years old; N = 298) who had singleton births between January 2009 and December 2014 and for an age-matched non-Somali cohort (N = 298) of women residing in Olmsted County, Minnesota. Logistic regression models which accounted for repeated measures were used to assess differences in prenatal and postpartum outcomes between Somali and non-Somali women.
Results:
Somali women had a significantly higher odds of cesarean section (adjusted OR=1.81; 95% CI=1.15, 2.84). Additionally, Somali women had a significantly lower odds of postpartum depression (adjusted OR=0.27; 95% CI=0.12, 0.63).
Conclusion:
The reported adverse postpartum outcomes have implications for interventions aimed at addressing perinatal care disparity gaps for Somali women immigrant and refugee populations.
Introduction
War and political unrest have displaced over 1.5 million Somalis worldwide, with a significant population of Somali refugees relocating to the US. Over 47,000 Somali refugees entered the US between 2010 and 2016, with a majority residing in Minnesota[1]. The estimated 80,000 Somalis that currently reside in Minnesota have specific and complex health needs. Multiple reports have identified significant health disparities affecting this immigrant population, including higher rates of anemia, diabetes mellitus, female genital mutilation, hepatitis viruses, obesity, hypertension [1, 2], and lower postpartum contraception[3]. Central to Somali culture is familial and community life; a woman’s status is often elevated by the number of children she has. The emphasis on family size likely explains the high fertility rate among Somali women, with an estimated average of 6 children per woman [4]. Somalia has one of the highest maternal and infant mortality rates, with 732 maternal deaths per 100,000 and 93 infant deaths per 1,000 [4]. There are no population data reported for most other pregnancy-related outcomes for women in Somalia, however, there is evidence of increased risk for adverse outcomes between Somali-born women who resettle outside of Somalia and receiving country-born women [5]. It is unclear whether adverse outcomes persist for Somali refugees in the US.
Substantial racial and ethnic disparities across multiple pregnancy-related health outcomes persist in the US. Some of the discrepancies in pregnancy outcomes may be attributable to differences in factors related to maternal and infant mortality. For example, among racial and ethnic minorities, there are significantly lower rates of breastfeeding [6, 7], higher rates of gestational diabetes [8, 9], hypertension [10, 11], preeclampsia [10], postpartum depression, cesarean sections [12–14], and low birth weight for infants [12, 15]. African American women have the highest burden of adverse pregnancy-related outcomes [16, 17], and African refugee groups often experience similar pregnancy complications due to their vulnerable status[18]. However, these factors may vary significantly across different racial and ethnic populations, and it is necessary to study individual populations to formally develop appropriate intervention strategies to improve pregnancy-related outcomes. The primary aim of this study was to address a gap in the literature, by providing prevalence estimates of critical perinatal outcomes among immigrant Somali women, with a particular focus on breastfeeding and postpartum depression. Additionally, we aim to compare outcomes between Somali and non-Somali women.
The conceptual framework used in this study draws from the social-ecological theory that asserts that multiple levels of influence across the lifecourse impact health outcomes; the pregnancy experience is not limited to biological processes but is also impacted by cultural and societal factors that impact access to care and decisions about care [19–21]. Figure 1 depicts an integrated model that includes established immigrant health predictors as well as gestational outcomes that result in postpartum outcomes. Studies have shown that immigrant status has an impact on peripartum outcomes such as increased cesarean deliveries and postpartum depression [5, 18, 22–24]. Additionally, outcomes, such as gestational depression and gestational diabetes have been found to be linked to adverse postpartum outcomes such as postpartum depression, low birth weight, and cesarean sections [25–28].
Figure 1.
Conceptual model linking socio-contextual factors with adverse pregnancy outcomes
Methods
Developed in 1966, the Rochester Epidemiology Project (REP) is a unique medical research infrastructure that links records between medical providers in Olmsted County, and allows researchers to follow subjects across different local medical centers across time. In this retrospective cohort study, medical records from the REP were reviewed for a cohort of adult women (≥18 years old) who had singleton births between January 2009 and December 2014. Details of the cohort identification have been described elsewhere [3]. A natural language processing algorithm was used to identify Somali patients from the REP medical records, which was confirmed by reviewing medical records. We originally identified 336 Somali patients who were age-matched to non-Somali women at their first pregnancy in the study time frame. Demographic data on age, race/ethnicity, marital status, birth origin, education, employment, language, interpreter use, history of substance abuse (tobacco, alcohol, drug), history of depression, and history of mental, physical, or sexual abuse were abstracted from these medical records by an abstraction team. Obstetrical outcomes were obtained for each singleton pregnancy in the study time frame and included baseline body mass index (BMI), gestational diabetes, gestational hypertension, preeclampsia, depression during pregnancy, substance abuse during pregnancy, breastfeeding, postpartum depression, low birth weight, and cesarean section. All pregnancies that occurred in our time frame were included in analyses of obstetrical outcomes.
Obstetrical outcomes were reported based on clinical diagnoses within medical records. Data on patient weight and height from the first pregnancy in the study were used to calculate standard Center for Disease Control and Prevention (CDC) BMI categories (underweight: <18.5 kg/m2, normal: 18.5–24.9 kg/m2, overweight: 25.0–29.9 kg/m2, obese ≥30.0 kg/m2). Gestational diabetes was clinically diagnosed during routine prenatal care and was defined as having a blood glucose level above pre-specified thresholds after a fasting and an oral glucose tolerance test. Gestational hypertension was clinically diagnosed when a woman without prior history of hypertension was found, defined as having two elevated blood pressures (at least 4 hours apart) after 20 weeks of gestation (systolic blood pressure was 140 mmHg – 159 mmHg, or diastolic blood pressure was 90 mmHg – 109 mmHg). Preeclampsia was defined as having gestational hypertension with either severe range blood pressures (above 159/109) or other evidence of organ damage. Depression and substance abuse during pregnancy (tobacco, alcohol, drugs) were reported on patient pregnancy records. Breastfeeding intentions and postpartum breastfeeding were self-reported by patient, and recorded on the pregnancy record. For our study, we defined breastfeeding as a dichotomous measure: those who only breastfed compared with those who supplemented with formula or used only formula. Postpartum depression was diagnosed using the Maternal Feelings Survey, the Patient Health Questionnaire-9 (PHQ-9), and the Edinburgh Postnatal Depression Scale. Low birth weight was defined as a newborn weighing <2500 grams. Finally, the type of birth (cesarean section versus vaginal) was reported on patient pregnancy records.
Data Analysis
Demographic characteristics were assessed for differences between Somali and non-Somali women using the chi-square or Fisher’s exact test for categorical variables, and Wilcoxon rank-sum test for continuous variables. Demographic data were reported from the first pregnancy for each patient in the study time frame. Gravidity and parity were compared at the final pregnancy during the study time frame. Logistic regression models which accounted for repeated measurements were used to assess differences in prenatal and postpartum outcomes between Somali and non-Somali women while accounting for multiple pregnancies per patient. Adjustment was made for age, education, BMI, and parity. Additionally, a final model for postpartum depression also adjusted for prenatal history of depression, stress or anxiety, a final model for cesarean section also adjusted for gestational hypertension, and a final model for postpartum feeding also adjusted for prenatal feeding intention. All analyses were conducted using SAS version 9.4 (SAS Institute Inc., Cary, NC). Study procedures were approved by the Institutional Review Board at Mayo Clinic and Olmsted Medical Center.
Results
Of the 336 women originally identified, we excluded 1 matched pair (2 women) because the control did not have research authorization; 10 matched pairs (20 women) because of misclassification; and 27 pairs (54 women) because they were found to have their first birth dated in 2015, outside of our study time frame. Our final sample consisted of 298 Somali and 298 non-Somali women (N = 596), and there were 474 pregnancies for Somali women and 387 pregnancies for non-Somali women between 2009 and 2014. There were significant differences observed across demographic characteristics between Somali and non-Somali women at the time of their first pregnancies (Table 1). Somali women were less likely to have higher education levels, less likely to be employed, more likely to have limited English proficiency, and more likely to use interpreter services. They were also less likely to have history of tobacco, alcohol, or drug use, and less likely to have a report of depression history.
Table 1.
Demographic comparison of Somali women with singleton birth versus non-Somali women* (2009 – 2014)
| Characteristic | Non-Somali | Somali | P† |
|---|---|---|---|
| N=298 | N=298 | ||
| Age (years) ** , N (%) | 0.94 | ||
| 18–29 | 163 (54.7) | 164 (55.0) | |
| 30–39 | 116 (38.9) | 117 (39.3) | |
| 40–49 | 19 (6.4) | 17 (5.7) | |
| Marital status, N (%) | 0.20 | ||
| Married | 207 (69.5) | 219 (73.5) | |
| Single | 68 (22.8) | 57 (19.1) | |
| Divorced/widowed/separated | 17 (5.7) | 14 (4.7) | |
| Living with partner | 4 (1.3) | 1 (0.3) | |
| Unknown | 2 (0.7) | 7 (2.3) | |
| Race, N (%) | <0.001 | ||
| White | 223 (74.8) | 0 (0.0) | |
| Black | 11 (3.7) | 297 (99.7) | |
| Asian | 30 (10.1) | 0 (0.0) | |
| American Indian | 4 (1.3) | 0 (0.0) | |
| Other/mixed/multiracial | 29 (9.7) | 1 (0.3) | |
| Unknown | 1 (0.3) | 0 (0.0) | |
| Birth origin, N (%) | <0.001 | ||
| US born | 239 (80.2) | 2 (0.7) | |
| Foreign born | 52 (17.4) | 294 (98.7) | |
| Unknown | 7 (2.3) | 2 (0.7) | |
| Education, N (%) | <0.001 | ||
| Less than high school | 12 (4.0) | 91 (30.5) | |
| High school/GED | 46 (15.4) | 94 (31.5) | |
| Some college/2-year degree | 84 (28.2) | 55 (18.5) | |
| 4-year college degree | 70 (23.5) | 23 (7.7) | |
| Post graduate studies | 72 (24.2) | 3 (1.0) | |
| Unknown | 14 (4.7) | 32 (10.7) | |
| Employment, N (%) | <0.001 | ||
| Employed | 229 (76.8) | 144 (48.3) | |
| Unemployed | 54 (18.1) | 127 (42.6) | |
| Student | 5 (1.7) | 19 (6.4) | |
| Unknown | 10 (3.4) | 8 (2.7) | |
| Language, N (%) | <0.001 | ||
| Non-English | 19 (6.4) | 202 (67.8) | |
| English | 274 (91.9) | 93 (31.2) | |
| Unknown | 5 (1.7) | 3 (1.0) | |
| Interpreter use, N (%) | <0.001 | ||
| No | 285 (95.6) | 157 (52.7) | |
| Yes | 9 (3.0) | 132 (44.3) | |
| Unknown | 4 (1.3) | 9 (3.0) |
Demographics are reported from the first pregnancy in the study time frame
Age at first delivery during the study time frame
Chi-square or Fisher’s exact test P value
Overall, Somali women had significantly higher gravidity (median = 4; interquartile range (IQR): 2, 6) and parity (median = 3; IQR: 2, 5) at the final birth in the study time frame compared with non-Somali women gravidity (median = 2; IQR: 2, 3) and parity (median = 2; IQR: 1, 3); p<0.001 for both comparisons. Table 2 reflects the characteristics of the study population during all pregnancies. Somali women had a significantly higher prevalence of obesity (31.0 vs. 22.5%; p<0.001) and gestational diabetes (12.9 vs. 7.2%, p<0.05; Table 2). Additionally, Somali women had a significantly lower prevalence of depression and substance abuse during pregnancy (Table 2). Finally, Somali women were less likely to report an intention to exclusively breast feed (32.7 vs. 71.3%; p<0.001; Table 2).
Table 2.
Prenatal characteristics among Somali women and non-Somali women (all pregnancies 2009 – 2014)
| Characteristic | Non-Somali | Somali | P† |
|---|---|---|---|
| N=387 | N=474 | ||
| Age (years), N (%) | 0.97 | ||
| 18–29 | 209 (54.0) | 260 (54.9) | |
| 30–39 | 155 (40.1) | 187 (39.5) | |
| 40–49 | 23 (5.9) | 27 (5.7) | |
| Body mass index, N (%) | <0.001 | ||
| Underweight (<18.5 kg/m2) | 9 (2.3) | 24 (5.1) | |
| Normal (18.5–24.9 kg/m2) | 183 (47.3) | 161 (34.0) | |
| Overweight (25.0–29.9 kg/m2) | 98 (25.3) | 128 (27.0) | |
| Obese (≥30.0 kg/m2) | 87 (22.5) | 147 (31.0) | |
| Unknown | 10 (2.6) | 14 (3.0) | |
| Gestational diabetes, N (%) | 0.01 | ||
| No | 356 (92.0) | 411 (86.7) | |
| Yes | 28 (7.2) | 61 (12.9) | |
| Unknown | 3 (0.8) | 2 (0.4) | |
| Gestational hypertension, N (%) | 0.65 | ||
| No | 354 (91.5) | 441 (93.0) | |
| Yes | 31 (8.0) | 30 (6.3) | |
| Unknown | 2 (0.5) | 3 (0.6) | |
| Preeclampsia, N (%) | 0.67 | ||
| No | 372 (96.1) | 453 (95.6) | |
| Yes | 12 (3.1) | 19 (4.0) | |
| Unknown | 3 (0.8) | 2 (0.4) | |
| Depression during pregnancy, N (%) | <0.001 | ||
| No | 307 (79.3) | 449 (94.7) | |
| Yes | 75 (19.4) | 20 (4.2) | |
| Unknown | 5 (1.3) | 5 (1.1) | |
| Substance abuse during pregnancy (tobacco, drug, alcohol), N (%) | <0.001 | ||
| No | 320 (82.7) | 467 (98.5) | |
| Yes | 62 (16.0) | 6 (1.3) | |
| Unknown | 5 (1.3) | 1 (0.2) | |
| Feeding intentions, N (%) | <0.001 | ||
| Breastfeeding only | 276 (71.3) | 155 (32.7) | |
| Breastfeeding and formula | 30 (7.8) | 9 (1.9) | |
| Formula only | 28 (7.2) | 258 (54.4) | |
| Unknown | 53 (13.7) | 52 (11.0) |
Chi-square or Fisher’s exact P value
Some pregnancy outcomes also differed between Somali and non-Somali women. Somali women were more likely to have a cesarean section delivery, and were less likely to be breastfeeding at the postpartum 6-week follow-up visit (Table 3). Somali women were less likely to be diagnosed with postpartum depression (2.3 vs. 10.1%; Table 3).
Table 3.
Differences in pregnancy outcomes between Somali and non-Somali women (all pregnancies 2009 – 2014)
| Characteristic | Non-Somali | Somali | P† |
|---|---|---|---|
| N=387 | N=474 | ||
| Cesarean section, N (%) | 0.05 | ||
| No | 313 (80.9) | 358 (75.5) | |
| Yes | 73 (18.9) | 116 (24.5) | |
| Unknown | 1 (0.3) | 0 (0.0) | |
| Low birth weight, N (%) | 0.58 | ||
| No (≥2500 grams) | 351 (90.7) | 438 (92.4) | |
| Yes (<2500 grams) | 25 (6.5) | 27 (5.7) | |
| Unknown | 11 (2.8) | 9 (1.9) | |
| Postpartum 6-week follow-up visit, N (%) | 0.13 | ||
| No | 75 (19.4) | 112 (23.6) | |
| Yes | 312 (80.6) | 362 (76.4) | |
| Feeding reported at postpartum 6-week follow-up visit, N (%) | <0.001 | ||
| Breastfeeding only | 153 (39.5) | 131 (27.6) | |
| Breastfeeding and formula | 79 (20.4) | 23 (4.9) | |
| Formula only | 45 (11.6) | 186 (39.2) | |
| Unknown | 110 (28.4) | 134 (28.3) | |
| Received postpartum depression screen, N (%) | 0.22 | ||
| No | 85 (22.0) | 117 (24.7) | |
| Yes | 222 (57.4) | 244 (51.5) | |
| Unknown | 80 (20.7) | 113 (23.8) | |
| Postpartum depression, N (%) | <0.001 | ||
| No | 327 (84.5) | 456 (96.2) | |
| Yes | 39 (10.1) | 11 (2.3) | |
| Unknown | 21 (5.4) | 7 (1.5) |
Chi-square or Fisher’s exact P value
The odds of adverse prenatal and postpartum outcomes for Somali women vs. non-Somali women are reported in Table 4. After adjustment for age, education, BMI, parity, and gestational hypertension, Somali women had a significantly higher odds of cesarean section (OR = 1.81; 95 % CI: 1.15 – 2.84). Additionally, Somali women had a significantly lower odds of postpartum depression (OR = 0.27; 95 % CI: 0.12 – 0.63 after adjustment for age, education, body mass index, parity, and prenatal history of depression, stress, or anxiety.).
Table 4.
Associations between postpartum outcomes for Somali versus non-Somali women
| PRENATAL OUTCOMES | Unadjusted | P | Adjusteda | P | Adjusteda | P |
|---|---|---|---|---|---|---|
| OR (95% CI) | OR (95% CI) | OR (95% CI) | ||||
| Gestational diabetes | 0.04 | 0.12 | ||||
| No | Reference | Reference | ||||
| Yes | 1.68 (1.01, 2.80) | 1.65 (0.88, 3.11) | ||||
| Gestational hypertension | 0.47 | 0.88 | ||||
| No | Reference | Reference | ||||
| Yes | 0.82 (0.47, 1.42) | 1.06 (0.51, 2.22) | ||||
| Preeclampsia | 0.45 | 0.14 | ||||
| No | Reference | Reference | ||||
| Yes | 1.34 (0.62, 2.87) | 2.07 (0.78, 5.48) | ||||
| Depression during pregnancy | <0.001 | <0.001 | ||||
| No | Reference | Reference | ||||
| Yes | 0.20 (0.11, 0.34) | 0.17 (0.09, 0.33) | ||||
| POSTPARTUM OUTCOMES | ||||||
| Postpartum depression | <0.001 | <0.001 | 0.002 | |||
| No | Reference | Reference | Reference | |||
| Yes | 0.20 (0.10, 0.42) | 0.16 (0.07, 0.36) | 0.27 (0.12, 0.63)b | |||
| Postpartum feeding | <0.001 | 0.02 | ||||
| Formula or some formula | Reference | Reference | Reference | |||
| Breastfeeding only | 0.49 (0.34, 0.69) | 0.62 (0.41, 0.93) | 1.10 (0.69, 1.73)c | |||
| Low birth weight | 0.57 | 0.61 | ||||
| ≥2500 grams | Reference | Reference | ||||
| <2500 grams | 0.84 (0.45, 1.55) | 0.80 (0.34, 1.89) | ||||
| Cesarean section | 0.12 | 0.01 | 0.01 | |||
| No | Reference | Reference | Reference | |||
| Yes | 1.34 (0.93, 1.93) | 1.78 (1.13, 2.80) | 1.81 (1.15, 2.84)d |
Abbreviations: CI, confidence interval, OR, odds ratio
Adjusted for age, education, body mass index, and parity
Adjusted for age, education, body mass index, parity, and prenatal history of depression, stress, or anxiety
Adjusted for age, education, body mass index, parity, and prenatal feeding intention
Adjusted for age, education, body mass index, parity, and gestational hypertension
Discussion
Somali women represent an understudied and vulnerable population in the US. To date, there are limited studies that examine Somali prenatal factors and their association with postpartum health within the US, and the lack of such studies may exacerbate disparities. Our analyses have identified gaps in perinatal health outcomes for Somali women compared to non-Somali women in Olmsted County. In particular, our data indicated that Somali women had significantly higher odds of cesarean deliveries and lower odds of postpartum depression.
Cesarean deliveries account for 32% of births in North America [29]. In our study, we found that Somali women had a greater odds of cesarean delivery compared to non-Somali women. Cesarean deliveries disproportionately affect racial-ethnic minorities in the US, and multiple studies have revealed that non-Hispanic Blacks are the most likely to deliver via cesarean [30]. Another study conducted in 2005 on a sample of Somali immigrants in Washington also found an increased risk of several adverse pregnancy outcomes, including cesarean deliveries due to fetal distress and failed induction of labor when compared to White and African American women in the study [22]. These results were also consistent with a study conducted across six other receiving countries – Australia, Belgium, Canada, Finland, Norway, and Sweden- which found that Somali women had higher rates of cesarean deliveries[31]. The limited research on the Somali population suggests that reluctance towards interventions such as an induction, prolonged gestation, and providers lacking familiarity with genital cutting and infibulation commonly found among Somali women may lead to higher rates of cesarean deliveries [22, 31]. Cesarean deliveries have been found to be associated with future subfertility, subsequent pregnancy risks such as placenta previa, uterine rupture, and stillbirth [32]. Decreasing the risk for cesarean deliveries in the Somali population may require a multi-faceted intervention.
Second, we found that Somali women were significantly less likely to be diagnosed with postpartum depression, even after adjusting for multiple prenatal characteristics. Our results conflict with a systematic review on the prevalence of postpartum depression within immigrant and refugee women, which reported that immigrant women were twice as likely to experience depressive symptoms in the postpartum period compared to non-immigrant women [33]. Lower levels of social support, poorer marital adjustment, perceived insufficient household income, and shorter length of residence in the destination country were just a few risk factors for postpartum depression in this review [33]. It is expected that refugees fleeing war, famine, and traumatic experiences would have significant stressors that would make these vulnerable populations at higher risk for postpartum depression[34, 35]; in fact, 42% of immigrant and refugee women are estimated to experience postpartum depression globally compared to around 10–15% of non-refugee women [36]. Our study reports only 2.3% of Somali women have diagnoses of postpartum depression compared to 10.1 % in non-Somalis. There is some concern that postpartum depression may be underdiagnosed, because discussion about mental health issues is stigmatized within the Somali community; often times, mental illness is discussed as physical symptoms (eg: stomach pain, headaches etc) [35, 37] and treated with medication to address only the physical aspects [38]. Mental health issues have been linked with negative terms such as “crazy”, “unstable”, or “demons”[39]. Additionally, qualitative studies have found that Somali patients preferred religious counsel rather than medical guidance for mental health issues [39, 40].
Given that Somali women are hesitant to discuss mental health concerns with their providers, it is critical to develop more effective strategies to destigmatize postpartum depression and to better understand the issues that Somali women face during and after pregnancy. For example, the postpartum experience in Somalia is vastly different compared to the American experience[41]. It is common in Somali culture for the extended family to rally around the new mom and baby to care and cook for them for an entire 40-day period[41]. In the US, the support structures from extended family do not exist, and women are more isolated. They may have to return immediately to caring for their homes and other children alone while their husbands return to work[41]. Instruments used to diagnose postpartum depression have not been adapted to reflect these unique experiences nor do they account for potential language and cultural barriers. This may contribute to underreporting of postpartum depression in this population.
Finally, we found that Somali women were less likely to exclusively breastfeed their children compared to non-Somali women. After adjusting for prenatal intention to breastfeed, this association was non-significant. Exclusive breastfeeding for the first 6 months of an infant’s life has been recommended by the American Academy of Pediatrics [42, 43], and has long been recognized as having important benefits to both mother and child. Studies have shown that babies who are breastfed are at reduced risk for infections, sudden infant death syndrome, obesity, and diabetes; and mothers are at reduced risk for breast and ovarian cancers, diabetes, and cardiovascular disease [42, 44, 45]. In the US, approximately 80% of all infants are breastfed initially, however only 21.9% are exclusively breastfed by 6 months. Non-Hispanic Black women (59.7%) [46] and American Indian Alaskan Native women (73.8%) [6] have the lowest rates of breastfeeding initiation nationally compared to White women (83.0%). To our knowledge, there are no national estimates on breastfeeding for Somali refugees in the US; 32.7 % of the Somali women in our sample had intention to breastfeed exclusively, compared to 71.3% of non-Somali women, revealing a significant gap. Several qualitative studies have described a cultural norm of supplementing with formula among Somali women which was often linked to beliefs and barriers including: the idea that supplementation leads to plumper and healthier babies, concerns about having to breastfeed in public, misconceptions about breastfeeding benefits, nurses’ and lactation consultants’ unconscious biases resulting in communication and trust barriers, and cultural norms surrounding formula use [47–49]. Additionally, the refugee experience of fleeing war and famine during a drought and the high infant mortality rate in Somalia has contributed to the idea that plump babies are healthy, leading to overfeeding with formula [48, 49]. Further inquiry into the underlying factors for this significant disparity is needed, in order to inform interventions that that would improve the rates of breastfeeding among Somali women. Prior behavioral intervention studies have linked prenatal breastfeeding intentions with breastfeeding behavior, and intentions have been found to be a product of maternal motivation, attitudes, subjective norms, and perceived behavioral control[50].
To address the low odds of breastfeeding and high cesarean deliveries we found in our study, it will be important for clinical practices to develop culturally appropriate communication strategies, in addition to providing access to translators. One effective strategy that has previously been shown to be successful at addressing multifaceted cultural norms and beliefs within the Somali community is “stories for change”, a community-based participatory research approach that produced health educational material for Somalis [51]. This program developed culturally appropriate digital stories that were used to educate about diabetes self-management. Furthermore, to better understand postpartum experiences and diagnose postpartum depression within the Somali population, it will be important for clinicians to collaborate with leaders within the Somali community to develop effective strategies to destigmatize mental health issues.
The use of medical records in a retrospective study has its limitations; the validity and reliability of our measures were dependent on clinical documentation completed by medical professionals not associated with our study. Additionally, we were unable to examine some of the extensive qualitative data on social factors surrounding pregnancy experiences reported in medical records that may have helped explain some of the differences across Somalis and non-Somalis, because these data were not consistently reported across the sample. Furthermore, these results are not necessarily generalizable to other African refugee populations, as this study was limited to a subset of Somali women receiving pregnancy-related medical care in Olmsted County, Minnesota. However, the large sample of Somali women who were age-matched to non-Somali women and the use of the REP make this a robust study.
Conclusion
Currently, there are limited studies that characterize perinatal complications for Somali immigrants in the US. Contributing to the challenge in understanding the pregnancy experience for Somali women are the lack of ethnic-specific data for this population, and efforts to better capture outcomes by ethnicity will be important to address gaps evidenced by this study. Further research might also explore the socioeconomic mechanisms in which Somali women develop adverse pregnancy outcomes in order to identify specific factors for intervention. The results of this study indicate that culturally-appropriate strategies may be helpful in reducing the health burden for this refugee population, and collaborative partnerships with the community will be critical in developing these strategies.
Funding
This study was funded through the Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery.
Footnotes
Ethics approval and consent to participate
Study procedures were approved by the Institutional Review Board at Mayo Clinic and Olmsted Medical Center. All accessed medical records received appropriate consent.
Competing Interests
There are no conflicts of interest to declare.
Data Access
The datasets used during this study are available from the corresponding author.
References
- 1.US Department of Health and Human Services, Somali Refugee Health Profile. 2018.
- 2.Njeru JW, et al. , High rates of diabetes mellitus, pre-diabetes and obesity among Somali immigrants and refugees in Minnesota: a retrospective chart review. Journal of immigrant and minority health, 2016. 18(6): p. 1343–1349. [DOI] [PubMed] [Google Scholar]
- 3.Cope A, et al. , Postpartum Contraception use in Somali Women: A Population-Based Study [5F]. Obstetrics & Gynecology, 2018. 131: p. 64S. [Google Scholar]
- 4.Central Intelligence Agency. The World Factbook: Somalia. 2016. [cited 2019 5/20/2019]; Available from: https://www.cia.gov/library/publications/resources/the-world-factbook/geos/so.html.
- 5.Small R, et al. , Somali women and their pregnancy outcomes postmigration: data from six receiving countries. Bjog, 2008. 115(13): p. 1630–40. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6.Jones KM, et al. , Racial and ethnic disparities in breastfeeding. Breastfeeding Medicine, 2015. 10(4): p. 186–196. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 7.Center for Disease Control and Prevention. Breastfeeding Facts. 2019. [cited 2019 September 9th]; Available from: https://www.cdc.gov/breastfeeding/data/facts.html.
- 8.Hedderson MM, Darbinian JA, and Ferrara A, Disparities in the risk of gestational diabetes by race-ethnicity and country of birth. Paediatr Perinat Epidemiol, 2010. 24(5): p. 441–8. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9.Ferrara A, et al. , An increase in the incidence of gestational diabetes mellitus: Northern California, 1991–2000. Obstetrics & Gynecology, 2004. 103(3): p. 526–533. [DOI] [PubMed] [Google Scholar]
- 10.Tanaka M, et al. , Racial disparity in hypertensive disorders of pregnancy in New York State: a 10-year longitudinal population-based study. American Journal of Public Health, 2007. 97(1): p. 163–170. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 11.Miranda ML, et al. , Disparities in maternal hypertension and pregnancy outcomes: evidence from North Carolina, 1994–2003. Public Health Rep, 2010. 125(4): p. 579–87. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 12.Martin JA, et al. , Births: final data for 2013. 2015. [PubMed]
- 13.Roth LM and Henley MM, Unequal motherhood: racial-ethnic and socioeconomic disparities in cesarean sections in the United States. Social Problems, 2012. 59(2): p. 207–227. [Google Scholar]
- 14.Janevic T, et al. , Disparities in cesarean delivery by ethnicity and nativity in New York city. Maternal and child health journal, 2014. 18(1): p. 250–257. [DOI] [PubMed] [Google Scholar]
- 15.Bryant AS, et al. , Racial/ethnic disparities in obstetric outcomes and care: prevalence and determinants. American journal of obstetrics and gynecology, 2010. 202(4): p. 335–343. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 16.Petersen EE DN, Goodman D, et al., Vital Signs: Pregnancy-Related Deaths, United States, 2011 – 2015, and Strategies for Prevention, 13 States, 2013–2017. 2019: MMWR Morb Mortal Wkly Rep,. p. 423–429. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 17.Mathews T, MacDorman MF, and Thoma ME, Infant mortality statistics from the 2013 period linked birth/infant death data set. 2015. [PubMed]
- 18.Dyer J and Baksh L, A Study of Pregnancy and Birth Outcomes among African-Born Women Living in Utah. 2016: Washington, D.C. [Google Scholar]
- 19.Golden SD, et al. , Upending the social ecological model to guide health promotion efforts toward policy and environmental change. Health Educ Behav, 2015. 42(1 Suppl): p. 8s–14s. [DOI] [PubMed] [Google Scholar]
- 20.Bronfenbrenner U, Friedman S, and Wachs T, Measuring environment across the life span: Emerging methods and concepts. Measuring environment across the life span, 1999: p. 3–28. [Google Scholar]
- 21.Behruzi R, et al. , Understanding childbirth practices as an organizational cultural phenomenon: a conceptual framework. BMC Pregnancy Childbirth, 2013. 13: p. 205. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 22.Johnson EB, et al. , Increased risk of adverse pregnancy outcome among Somali immigrants in Washington state. Am J Obstet Gynecol, 2005. 193(2): p. 475–82. [DOI] [PubMed] [Google Scholar]
- 23.Stewart DE, et al. , Postpartum depression symptoms in newcomers. Can J Psychiatry, 2008. 53(2): p. 121–4. [DOI] [PubMed] [Google Scholar]
- 24.Ganann R, et al. , Influence of maternal birthplace on postpartum health and health services use. J Immigr Minor Health, 2012. 14(2): p. 223–9. [DOI] [PubMed] [Google Scholar]
- 25.Lapolla A, et al. , Quality of Life, Wishes, and Needs in Women with Gestational Diabetes: Italian DAWN Pregnancy Study. Int J Endocrinol, 2012. 2012: p. 784726. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 26.Daniells S, et al. , Gestational diabetes mellitus: is a diagnosis associated with an increase in maternal anxiety and stress in the short and intermediate term? Diabetes Care, 2003. 26(2): p. 385–9. [DOI] [PubMed] [Google Scholar]
- 27.Lydon K, et al. , Psychological stress associated with diabetes during pregnancy: a pilot study. Irish medical journal, 2012. 105(5 Suppl): p. 26–28. [PubMed] [Google Scholar]
- 28.Silverman ME, et al. , The risk factors for postpartum depression: A population‐based study. Depression and anxiety, 2017. 34(2): p. 178–187. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 29.Betran AP, et al. , The Increasing Trend in Caesarean Section Rates: Global, Regional and National Estimates: 1990–2014. PLoS One, 2016. 11(2): p. e0148343. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 30.Roth LM and Henley MM, Unequal Motherhood: Racial-Ethnic and Socioeconomic Disparities in Cesarean Sections in the United States. Social Problems, 2014. 59(2): p. 207–227. [Google Scholar]
- 31.Small R, et al. , Somali women and their pregnancy outcomes postmigration: data from six receiving countries. BJOG: An International Journal of Obstetrics & Gynaecology, 2008. 115(13): p. 1630–1640. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 32.Keag OE, Norman JE, and Stock SJ, Long-term risks and benefits associated with cesarean delivery for mother, baby, and subsequent pregnancies: Systematic review and meta-analysis. PLoS medicine, 2018. 15(1): p. e1002494. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 33.Falah-Hassani K, et al. , Prevalence of postpartum depression among immigrant women: A systematic review and meta-analysis. J Psychiatr Res, 2015. 70: p. 67–82. [DOI] [PubMed] [Google Scholar]
- 34.Tobin CL, Di Napoli P, and Beck CT, Refugee and immigrant women’s experience of postpartum depression: a meta-synthesis. Journal of Transcultural Nursing, 2018. 29(1): p. 84–100. [DOI] [PubMed] [Google Scholar]
- 35.Gagnon A and Tuck J, A systematic review of questionnaires measuring the health of resettling refugee women. Health Care for Women International, 2004. 25(2): p. 111–149. [DOI] [PubMed] [Google Scholar]
- 36.Collins CH, Zimmerman C, and Howard LM, Refugee, asylum seeker, immigrant women and postnatal depression: rates and risk factors. Archives of women’s mental health, 2011. 14(1): p. 3–11. [DOI] [PubMed] [Google Scholar]
- 37.Warfa N, et al. , Post-migration geographical mobility, mental health and health service utilisation among Somali refugees in the UK: a qualitative study. Health & place, 2006. 12(4): p. 503–515. [DOI] [PubMed] [Google Scholar]
- 38.Bhui K, et al. , Traumatic events, migration characteristics and psychiatric symptoms among Somali refugees. Social psychiatry and psychiatric epidemiology, 2003. 38(1): p. 35–43. [DOI] [PubMed] [Google Scholar]
- 39.MN Department of Health, Somali Mental Health Project Findings and Recommendations. 2016.
- 40.Markova V and Sandal GM, Lay Explanatory Models of Depression and Preferred Coping Strategies among Somali Refugees in Norway. A Mixed-Method Study. Front Psychol, 2016. 7: p. 1435. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 41.Narruhn R, Perinatal profile for patients from Somalia. 2008, EthnoMed. [Google Scholar]
- 42.Perrine CG, et al. , Vital Signs: Improvements in Maternity Care Policies and Practices That Support Breastfeeding - United States, 2007–2013. MMWR Morb Mortal Wkly Rep, 2015. 64(39): p. 1112–7. [DOI] [PubMed] [Google Scholar]
- 43.Breastfeeding and the use of human milk. Pediatrics, 2012. 129(3): p. e827–41. [DOI] [PubMed] [Google Scholar]
- 44.Ip S, Chung M, and Raman G, Breastfeeding and maternal and infant health outcomes in developed countries. Evid Rep Technol Assess (Full Rep), 2007. 153(153): p. 1–186. [PMC free article] [PubMed] [Google Scholar]
- 45.Hauck FR, et al. , Breastfeeding and reduced risk of sudden infant death syndrome: a meta-analysis. Pediatrics, 2011. 128(1): p. 103–110. [DOI] [PubMed] [Google Scholar]
- 46.Control, C.f.D. and Prevention, Breastfeeding among US children born 2002–2012, CDC national immunization surveys. National Immunization Survey (NIS). Atlanta, GA, 2015. [Google Scholar]
- 47.TEXTOR L, TIEDJE K, and YAWN B, Mexican and Somali Immigrant Breastfeeding Initiation and Counseling. Minnesota medicine, 2013. [PubMed] [Google Scholar]
- 48.Steinman L, et al. , Understanding infant feeding beliefs, practices and preferred nutrition education and health provider approaches: an exploratory study with Somali mothers in the USA. Maternal & child nutrition, 2010. 6(1): p. 67–88. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 49.Carpenter S, Vaucher YE, and Brownlee A, Cultural Transition and Infant-Feeding Practices among Somali Immigrant Women in San Diego, California. Pediatric Research, 1999. 45(7): p. 279–279. [Google Scholar]
- 50.Raissian KM and Su JH, The best of intentions: Prenatal breastfeeding intentions and infant health. SSM Popul Health, 2018. 5: p. 86–100. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 51.Njeru JW, et al. , Stories for change: development of a diabetes digital storytelling intervention for refugees and immigrants to minnesota using qualitative methods. BMC Public Health, 2015. 15(1): p. 1311. [DOI] [PMC free article] [PubMed] [Google Scholar]